Before we get into the actual guide, the first thing you should know about HIPAA is that it’s HIPAA, and not HIPPA or HIPPO. Although, you might face a similar wrath for not respecting a hippo, as you would with being non-compliant.
Data security and privacy are increasingly top of mind these days, especially regarding sensitive data, such as our health information. If you’re a covered entity or business associate, transmitting health information, it is critical that you ensure you’re HIPAA-compliant.
Non-compliance can result in serious penalties, such as costly fines and imprisonment. In addition, 79% of all reported breaches occur in the healthcare industry, and these breaches continue to increase every year. One thing is clear: non-compliance with HIPAA is not an option.
The purpose of this comprehensive guide to HIPAA compliance is to take a deep dive into HIPAA, help you avoid data breaches, and ensure you are fully compliant with all HIPAA requirements.
What is HIPAA and what is its purpose?
HIPAA is a federal law that requires compliance with HIPAA standards, ensuring all protected health information (PHI) is protected and managed responsibly.
PHI, which stands for Protected Health Information, is a type of data regulated by HIPAA, the Health Insurance Portability and Accountability Act of 1996. PHI is any data related to a person’s health or treatment that can be used to identify them. This includes information such as medical treatments and diagnosis, healthcare providers, insurance information, medications, allergies and more.
The HIPAA Privacy Rule works to protect the security and privacy of PHI. It outlines certain standards for the data’s use, disclosure, and access to help protect individuals’ health information from falling into the wrong hands.
It requires certain entities to have specific safeguards in place to protect the privacy and security of PHI. These entities include, but are not limited to, healthcare providers, health plans, employers, and healthcare clearinghouses who process or store PHI.
The HIPAA Security Rule is another set of regulations related to PHI security and privacy, and is designed to help protect the confidentiality, integrity, and security of electronic Protected Health Information (ePHI). The Security Rule requires any covered entity to have administrative, physical and technical safeguards in place to ensure the security, privacy, and confidentiality of ePHI, which we will go into further detail down below.
Is it an audit, is it self-assessed?
While HIPAA does not require official audits of these organizations, as HIPAA is a federal law. And so, HIPAA does not hand out certifications for those who are HIPAA compliant – instead, HIPAA is a self-assessment. Only when there is a breach or suspicion of a breach, is when there will be an official audit conducted.
Remember, with HIPAA, there is no one action, training program, or software that makes your organization HIPAA-compliant.
In order to fully comply with HIPAA, you must implement the relevant HIPAA controls, and live a “complete HIPAA lifestyle”. Your compliance plan doesn’t just end once you’re officially compliant, as you need to make sure you are compliant every year.
What does it mean to be HIPAA compliant and why is it so important?
In spite of the fact that no healthcare organization wants sensitive data exposed or healthcare information stolen, without HIPAA, healthcare organizations would not be required by law to safeguard data – and repercussions would not be imposed if they do not have information security best practices in place.
Compliance with HIPAA ensures that patients’ health information remains private and secure. Personal health information includes test results, medical records, and insurance information. Importantly, it ensures that you do not violate the HIPAA law and set your organization up for heavy fines.
How do you get started with HIPAA compliance?
As mentioned, the HIPAA Rule requires covered entities to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting e-PHI.
Some HIPAA compliance requirements include:
- Policies on how to collect, use, and store information.
- Processes for handling patients’ requests to access their information.
- Training for your employees on these policies and procedures.
Specifically, covered entities must:
- Ensure the confidentiality, integrity, and availability of all e-PHI they create, receive, maintain or transmit;
- Identify and protect against reasonably anticipated threats to the security or integrity of the information
- Protect against reasonably anticipated, impermissible uses or disclosures; and
- Ensure compliance by their workforce.
What are the HIPAA compliance requirements?
Let’s dig a little deeper into what type of safeguards need to be in place:
- Administrative
- Physical
- Technical
Administrative safeguards
Administrative safeguards are the policies and procedures that organizations must follow in order to comply with HIPAA. These guidelines include training all employees on HIPAA’s regulations, safeguards, code of conduct and policies and procedures.
Organizations must also maintain a security risk assessment to ensure they have an adequate security system in place and regularly monitor it for any risks or gaps.
Physical safeguards
Physical safeguards are measures to ensure the physical security of protected health information. These measures include having a restricted-access facility, as well as implementing policies to protect data from environmental hazards and unauthorized access.
Organizations must limit access to the premises, implement security systems such as intrusion prevention and detection, and have control of workstations and devices used to access protected health information.
Technical safeguards
Technical safeguards are measures to ensure the security of protected health information sent over networks. These measures include implementing access control measures, such as user authentication and authorization, as well as encryption and integrity-checking technologies. Organizations must also maintain audit trails of all access attempts of protected health information and use appropriate technologies to transmit data.
Organizations must adhere to these administrative, physical and technical safeguards to comply with HIPAA. Remember, compliance with HIPAA is not an option; organizations that do not adhere to these requirements may face significant fines, regulatory action, and even legal action.
It sounds like a lot, but, would you prefer to undergo the HIPAA compliance process rather than the hefty fines you’d be liable for with a HIPAA violation?
What are the penalties for non-compliance with HIPAA?
Non-compliance with the Health Insurance Portability and Accountability Act (HIPAA) can result in stiff financial penalties, such as civil and/or criminal fines. Generally speaking, companies or individuals found to be in violation of HIPAA regulations will be subject to financial penalties based on the severity of the violation, which is measured per incident.
If you don’t comply with HIPAA, the penalty could be a slap on the wallet! Civil penalties can range from $100 to $50,000 per incident, with a maximum yearly penalty of $1.5 million. Crimes which involve the intentional misuse of a person’s personally identifiable information (PII) or PHI can carry much harsher penalties, including fines up to $250,000 and/or even imprisonment.
In addition to financial penalties, companies or individuals found to be in violation of HIPAA regulations are also subject to corrective actions.
Corrections include implementing the correct HIPAA-compliant software and security practices, updating or revising policies or procedures to make them consistent with HIPAA regulations, providing additional employee training on HIPAA regulations, or requiring an audit to ensure HIPAA compliance.
There’s no such thing as a slap on the wrist. The goal of penalties associated with HIPAA regulations is to ensure that companies and individuals are aware of the importance
By ensuring that HIPAA regulations are followed, we can protect the privacy and security of personal information and promote confidence in the healthcare system.
Who needs to be HIPAA-compliant?
HIPAA (Health Insurance Portability and Accountability Act of 1996) is a federal law that requires certain organizations and individuals to maintain the security and privacy of protected health information.
As such, the following organizations and individuals must abide by HIPAA compliance guidelines:
Covered Entities: all individuals, businesses, or organizations that work directly with protected health information. Organizations and individuals who are defined as covered entities (CEs) fall into three main categories:
- Healthcare providers
- Healthcare plan provider
- Health care clearinghouse
Business Associates: This includes any third party that provides services to a covered entity and has access to protected health information. Examples include billing services, transcription services, and data storage companies.
Overall, HIPAA compliance is an absolute must for organizations that are responsible for handling protected health information. Failure to comply with HIPAA regulations can result in hefty fines and penalties.
The HIPAA compliance checklist: Your very own ‘am I doing it right’ form
HIPAA compliance requires coverage of multiple business areas, which can be a huge challenge, and the work to maintain compliance never ends. But, something that could aid you along your journey is a HIPAA compliance checklist to make sure you are ticking all those HIPAA boxes.
Some important aspects to keep in mind when undergoing HIPAA:
- Dedicated, responsible personnel: HIPAA compliance is easiest to manage when responsible people are in charge of it. You need someone to be accountable and not “lackadaisy.”
- Develop a HIPAA compliance administration plan: HIPAA has several rules that an organization must follow to remain compliant. Outline a plan to tackle them all.
- Make sure your IT infrastructure meets the required standards
- Evaluate the current risk level of your environment: the only way to stay compliant is through periodic risk assessments and mitigation of any security gaps detected.
- Plan for emergencies: develop an action plan to counteract a cyberattack.
- Make sure you conduct annual HIPAA training for all your staff.
- Get signed HIPAA policies and procedures from all members of staff.
Automate HIPAA and demonstrate compliance to your customers!
I know it may have seemed like you just read ‘Lord of the HIPAAs’—but that’s where streamlining your HIPAA compliance comes in.
Simply put: you can’t afford to get HIPAA wrong. But luckily, by automating HIPAA processes and being guided by HIPAA veterans, you’re all set to managing PHI according to HIPAA standards and preventing any violations from occurring.
Check out our blog: How Automation Can Help with Data Compliance in Healthcare
