A Guide to Hipaa Basics and Security

HIPAA is a set of rules that protects the sensitive information of patients in the healthcare industry.

The Health Insurance Portability and Accountability Act of 1996 requires healthcare providers to keep patient information confidential and secure.

HIPAA applies to healthcare providers, insurance companies, and anyone else who handles patient information.

The law requires healthcare providers to have a clear policy for protecting patient information and to train their staff on HIPAA procedures.

Health care providers, including individuals and units, that provide, bill for, and are paid for health care and transmit Protected Health Information (PHI) are required to comply with the privacy and security regulations established by HIPAA and HITECH.

The primary purpose of HIPAA's privacy regulations is to protect the confidentiality of patient health information generated or maintained in the course of providing health care services.

The Privacy Rule governs how individuals can use and disclose confidential patient information called “Protected Health Information” or “PHI”.

Healthcare providers, health plans, and business associates have a strong tradition of safeguarding private health information, but the old system of paper records locked in cabinets is not enough in today's world anymore.

The Federal Security Rule establishes federal standards to ensure the availability, confidentiality, and integrity of ePHI, which includes written, spoken, or electronic information relating to an individual's health or condition, the provision of health care services, or the payment for such services.

Here are some key identifiers that are considered part of PHI:

HIPAA is a federal law that protects the confidentiality, integrity, and availability of health information. It was enacted in 1996 and consists of 5 Titles.

The law requires healthcare providers, health plans, and clearinghouses to comply with the privacy and security regulations established by HIPAA. This includes protecting patient health information, also known as Protected Health Information (PHI), from unauthorized disclosure or use.

The primary purpose of HIPAA's privacy regulations is to protect the confidentiality of patient health information generated or maintained in the course of providing healthcare services.

Healthcare providers must give patients a notice of their privacy practices and obtain patients' signatures to confirm receipt of the document.

The law requires healthcare organizations to post the Notice of Privacy Practices in a prominent position in a physical service delivery site and on a web page.

Here are some key points about HIPAA:

Record retention is a crucial aspect of HIPAA compliance. You must retain medical records for a specified period, which varies by state. For instance, in South Carolina, medical records must be retained for 11 years after discharge, while in Florida, they must be retained for five years after the last patient contact.

In Florida, hospitals must retain medical records for seven years after discharge. HIPAA requires covered entities to implement administrative, technical, and physical safeguards to keep ePHI secure at all times. This includes securing medical records from creation to disposal.

HIPAA-related documents must be retained for six years from the date they were created. Policies must be retained for six years from when they were last in effect. Insurance companies may be subject to FINRA laws, which cover the retention of certain records.

The Fair Labor Standards Act and the Employee Retirement Income Security Act require certain records to be retained. Healthcare providers must retain cost reports for five years after closure. Medicare managed care program providers must retain records for ten years.

Improper PHI Disposal is a serious issue that can lead to data breaches and fines. Disposing of PHI or ePHI improperly can result in serious consequences.

Paper records should be shredded, burnt, pulped, or pulverized to ensure they are unreadable and indecipherable. Electronic media should be cleared, purged, degaussed, or destroyed to prevent data recovery.

Proper disposal is crucial to protecting sensitive information.

Under the HIPAA Privacy Rule, individuals have certain rights when it comes to their protected health information (PHI).

You have the right to a notice of a Covered Entity's privacy practices, which means you'll receive information about how your PHI will be used and protected.

This includes the right to request restrictions and confidential communications concerning PHI, as well as the right to request a restriction to a health plan of a health care item or service for which you've paid in full out of pocket.

Here are your specific rights under the HIPAA Privacy Rule:

It's also worth noting that impermissible disclosures of PHI can occur when PHI is provided to a third party without consent, or when unencrypted portable electronic devices containing ePHI are stolen.

Security and compliance are crucial aspects of HIPAA. HIPAA requires covered entities to implement administrative, physical, and technical safeguards to ensure the confidentiality, integrity, availability, and security of electronic PHI.

A key aspect of security is assigning responsibility for security to a person or organization, as mandated by the Security Rule. This includes assessing security risks and determining the major threats to the security and privacy of PHI. Regular risk assessments and a risk management process are also critical to reducing risks to a reasonable and appropriate level.

Covered entities must implement access controls, such as encryption, context-based access, and role-based access, to ensure that only authorized individuals can access PHI. Additionally, mechanisms must be in place to restrict and terminate access as needed. The decision to implement encryption or alternative safeguards must be backed up by a risk assessment and documented in writing.

Encryption is an addressable implementation specification, but it's essential to consider its use, especially for portable devices and email containing ePHI. The National Institute of Standards and Technology (NIST) recommends using Advanced Encryption Standard (AES) 128, 192, or 256-bit encryption, OpenPGP, and S/MIME.

Here are some key security measures required by HIPAA:

Ultimately, security and compliance are ongoing processes that require regular monitoring and evaluation to ensure the confidentiality, integrity, and availability of ePHI.

Security is a top priority for any organization handling sensitive information, especially in the healthcare industry. HIPAA requires covered entities to establish national security standards to protect electronic PHI. This includes implementing administrative, physical, and technical safeguards to ensure the confidentiality, integrity, availability, and security of electronic PHI.

To achieve this, organizations must assign responsibility for security to a person or organization, assess security risks, and establish a program to address physical security, personnel security, technical security controls, security incident response, and disaster recovery. They must also certify the effectiveness of security controls and develop policies, procedures, and guidelines for the use of personal computing devices.

Organizations must also ensure mechanisms are in place to allow, restrict, and terminate access to electronic PHI, and implement access controls such as encryption, context-based access, role-based access, or user-based access. Audit control mechanisms, data authentication, and entity authentication are also required.

The HIPAA Security Rule lists conditions that must be in place for HIPAA-compliant storage and communication of ePHI. All security measures are generally required, unless there is a justifiable rationale not to implement a safeguard, or an appropriate alternative is put in place that achieves the same objective and provides an equivalent level of protection.

Here are some examples of required and addressable security measures:

Regular security awareness training is also a must for all members of the workforce, including management. This training should be provided regularly and the frequency should be determined by means of a risk analysis.

Password security is a crucial aspect of protecting sensitive information, especially in the healthcare industry. HIPAA-covered entities and their business associates must implement procedures for creating, changing, and safeguarding passwords.

HIPAA is vague when it comes to specific password requirements, but it's essential to follow current best practices. NIST recommends creating password policies based on current best practices.

A good password should be difficult to guess but also memorable. NIST advises against using highly complex passwords that are hard to remember, as employees often write them down. Instead, long passphrases are recommended.

Here are some password best practices to keep in mind:

The HHS' Office of Civil Rights is responsible for enforcing HIPAA's Privacy and Security Rules.

HIPAA establishes both civil monetary penalties and federal criminal penalties for the impermissible use or disclosure of unsecured PHI in violation of HIPAA's Privacy and Security Rules.

Civil penalties can range from $100 per violation per incident to $1,500,000 for all such violations of a single provision in a calendar year.

Criminal penalties include fines up to $250,000 and up to ten years imprisonment.

The HITECH Act granted State Attorneys General the authority to bring civil actions and obtain damages on behalf of state residents for violations of the HIPAA Privacy and Security Rules.

HIPAA's Privacy and Security Rules are enforced by the HHS' Office of Civil Rights (OCR), which can issue fines for non-compliance.

Civil penalties for violating HIPAA's Privacy and Security Rules can range from $100 to $1,500,000 for all such violations of a single provision in a calendar year.

The HITECH Act granted State Attorneys General the authority to bring civil actions and obtain damages on behalf of state residents for violations of the HIPAA Privacy and Security Rules.

Criminal penalties for impermissible use or disclosure of unsecured PHI include fines up to $250,000 and up to ten years imprisonment.

The penalty structure for HIPAA violations can lead to fines up to $68,928 per violation up to a maximum of $2,067,813 per year for violations of an identical type.

State attorneys general can also initiate lawsuits, which can result in fines of up to $250,000 per violation category.

Covered Entities and Business Associates may also be sued by victims of data breaches, adding to the financial burden of non-compliance.

A HIPAA violation can have serious consequences, and reporting requirements are in place to ensure transparency and accountability. A breach is defined as a use or disclosure of protected health information not permitted by the HIPAA Privacy Rule that compromises the security or privacy of protected health information.

If you're a HIPAA-covered entity or business associate, you must issue notifications to patients/health plan members without unnecessary delay, and no later than 60 days after the discovery of a breach. A media notice must also be issued if the breach impacts more than 500 individuals, again within 60 days.

The notice should be provided to a prominent media outlet in the state or jurisdiction where the breach victims are located. This is to ensure that those affected are informed and can take steps to protect themselves.

You must also notify HHS' Office for Civil Rights within 60 days of the discovery of a breach if it impacts 500 or more individuals, and within 60 days of the end of the calendar year in which the breach was experienced if it impacts fewer than 500 individuals.

Risk management is a critical aspect of HIPAA compliance. All risks identified during a risk analysis must be reduced to a reasonable and appropriate level through a HIPAA-compliant risk management process.

Risk analysis failures are a common HIPAA violation, so it's essential to conduct regular, organization-wide risk analyses to identify vulnerabilities to the confidentiality, integrity, and availability of PHI. This includes performing a comprehensive risk analysis that covers all aspects of your organization.

Implementing a security awareness training program is also a HIPAA requirement. This training should be provided regularly, and the frequency should be determined by means of a risk analysis.

Risk management is a critical aspect of HIPAA compliance, and failure to properly manage identified risks can have serious consequences. The HIPAA Security Rule requires covered entities and their business associates to conduct regular risk analyses to identify vulnerabilities to the confidentiality, integrity, and availability of PHI.

All risks identified during the risk analysis must be subjected to a HIPAA-compliant risk management process and reduced to a reasonable and appropriate level. This process is crucial to the security of ePHI and PHI.

Risk management failures are a common HIPAA violation, often resulting from inadequate risk analysis and management processes. This can lead to the compromise of sensitive patient information.

A comprehensive risk management process involves identifying, assessing, and prioritizing risks, as well as implementing controls to mitigate or eliminate them. This process should be ongoing and regularly reviewed to ensure continuous improvement.

The OCR has identified risk management failures as a significant issue in HIPAA compliance, highlighting the need for covered entities and business associates to prioritize risk management and security awareness.

Security awareness training is a crucial aspect of risk management, and its importance cannot be overstated. HIPAA requires covered entities and business associates to implement a security awareness training program for all members of the workforce, including management.

The frequency of HIPAA training is determined by a risk analysis, which should be conducted regularly. This ensures that the training program is tailored to the specific needs of the organization and addresses any potential security threats.

A well-designed security awareness training program should be provided regularly to all members of the workforce, including management. HIPAA training should be a continuous process, not a one-time event.

HIPAA violations and breaches can be costly and have serious consequences. Notifications must be issued to patients/health plan members without unnecessary delay and no later than 60 days after the discovery of a breach.

A breach is defined as a use or disclosure of protected health information that compromises the security or privacy of protected health information. Notifications are not required if a HIPAA-covered entity or business associate can demonstrate there is a low probability that PHI has been compromised, with that determination made through a risk analysis.

Fines for non-compliance can be substantial, with penalties up to $68,928 per violation and a maximum of $2,067,813 per year for violations of an identical type.

HIPAA violations are often discovered during investigations of data breaches and complaints filed through the OCR complaints portal. Ten of the most common HIPAA violations have been detailed, and they're worth knowing about to avoid costly mistakes.

These violations can lead to fines up to $68,928 per violation, with a maximum of $2,067,813 per year for identical type violations. The HITECH Act penalty structure has been adjusted annually to account for inflation.

Covered Entities and Business Associates may be sued by victims of data breaches, with fines of up to $250,000 per violation category possible. This highlights the importance of prioritizing data security.

The high cost of addressing data breaches, including breach notification correspondence, credit monitoring services, and regulatory fines, is a significant concern for healthcare organizations. This is far higher than the cost of achieving full compliance.

Organizations that have implemented mechanisms to adhere to HIPAA often see their workflows streamlined and the workforce become more productive. This allows healthcare organizations to reinvest their savings and provide a higher standard of healthcare to patients.

Delayed breach notifications can have serious consequences. HIPAA-covered entities must issue notifications to patients/health plan members without unnecessary delay, no later than 60 days after the discovery of a breach.

If a breach impacts more than 500 individuals, a media notice must also be issued within 60 days. This notice should be provided to a prominent media outlet in the state or jurisdiction where the breach victims are located.

A copy of the breach notices and documentation showing that notifications were issued must be retained. This is a crucial step in case of an audit or investigation.

HHS' Office for Civil Rights must be notified within 60 days of the discovery of a breach if it impacts 500 or more individuals.

Covered Entities often require third parties to provide services that require access to PHI, and prior to any disclosure of PHI, these third parties must enter into a business associate agreement (BAA) with the covered entity.

The BAA outlines the business associate's responsibilities to safeguard PHI and explains the permissible uses and disclosures of PHI.

A business associate agreement is a must-have for Covered Entities to ensure that their business associates handle PHI securely and in compliance with HIPAA regulations.

The BAA typically outlines the business associate's responsibilities to safeguard PHI, explains the permissible uses and disclosures of PHI, and other requirements of HIPAA.

By requiring a BAA, Covered Entities can protect their patients' sensitive information and maintain trust in their business relationships.

Covered Entities must ensure that their business associates enter into a BAA prior to any disclosure of PHI to safeguard patient data.

Healthcare organizations are required by law to give patients a notice of their privacy practices and get patients to sign to confirm receipt of the document. This notice must be posted in a prominent position in a physical service delivery site and on a web page.

A patient's rights include requesting their medical records whenever they like, and requesting the amendment of their medical records to correct errors.

A patient can also limit who has access to their personal health information and choose how their healthcare provider communicates with them.

Here are some key rights a patient has:

It's essential that any member of the workforce interacting with patients is aware of the procedures for responding to a patient's request for their medical records or restricting disclosures of PHI.

HIPAA violations can lead to significant financial penalties, with fines up to $68,928 per violation and a maximum of $2,067,813 per year for identical type violations.

Healthcare organizations that become targets for cybercriminals face exorbitant costs for addressing data breaches, including breach notification correspondence, credit monitoring services, and regulatory fines.

The cost of achieving full compliance with HIPAA may seem high, but it can lead to improved efficiency and savings over time.

Organizations that have already implemented HIPAA compliance measures often see streamlined workflows and a more productive workforce.

Covered Entities and Business Associates may be sued by victims of data breaches, and state attorneys general can also initiate lawsuits.

The high cost of addressing data breaches is a strong incentive for healthcare organizations to prioritize HIPAA compliance.