Understanding the Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA) is essential for healthcare practices and facilities. These standards outline the disclosure and use of patients’ protected health information. Covered entities, such as healthcare providers or health insurance providers, and business associates like management firms, accountants, billing companies, and more must reach compliance. Failing to maintain compliance could result in various penalties that range in severity depending on the situation.
In this introduction to HIPAA training, you can learn more about compliance, including different rules and regulations, how to obtain certification, and possible penalties for common HIPAA violations.
HIPAA basics for healthcare professionals
Achieving HIPAA certifications in healthcare ensures your organization properly protects the privacy, security, and integrity of each patient’s information. HIPAA protects paper and digital records, and strict rules and regulations exist for disposing, storing, and using this information. These rules outline how to safeguard protected information and ensure patients can access records regarding their health conditions, treatments, medications, transactions, and more. Failing to adhere to these rules can result in financial or reputational damage.
Creating a compliance program empowers organizations to satisfy these requirements and highlight their organization as reputable and trustworthy. A successful compliance program involves conducting risk assessments, developing corrective actions, delivering training, and considering cyber risks from malware or phishing, as these threats are on the rise in the industry. These programs often feature officers to oversee the program and ensure your organization stays up-to-date on new regulations or changes.
Security officers can ensure the integrity, availability, and confidentiality of protected information. These team members can implement measures to safeguard from potential security breaches and train workers who handle this information regularly. Privacy officers manage and oversee privacy concerns. These team members are an excellent resource for workers to ask questions to ensure compliance.
Healthcare industry HIPAA regulations and rules
HIPAA consists of many rules and regulations. Rules your organization must adhere to include:
- Security Rule: This rule regards the transmission, handling, and maintenance of patient information. Organizations must put administrative, physical, and technical safeguards in place to ensure the safety and integrity of the data. Some rule requirements include modifying and reviewing measures, identifying threats, and analyzing security risks. Staff needs annual training with proper documentation to demonstrate compliance.
- Privacy Rule: The HIPAA Privacy Rule applies to covered entities and discusses a patient’s right to access their information, the use and disclosure or release forms, and a provider’s right to deny information access. All workers must also receive annual training regarding these policies and procedures. Under this rule, patients can request corrections and restrict access to some treatments. The Privacy Rule prohibits workers from sharing information or documents regarding a patient’s name, address, health conditions, previous care, payments, and similar. This rule also requires workers to notify patients about how they use patient data.
- Breach Notification Rule: In the event of data breaches, organizations must have a set of standards to report it. This rule enforces organizations to notify affected patients, the U.S. Department of Health and Human Services (HHS), and sometimes the media in particular cases. Each organization must report any breach that occurs, regardless of the size, but there are specific protocols for reporting breaches of differing sizes. HIPAA outlines the appropriate actions for different-sized breaches (U.S.) – those affecting fewer than 500 people and those impacting more than 500 people in a single jurisdiction.
- Omnibus Rule: This rule is an addendum to the other regulations. This rule requires business associates to maintain HIPAA compliance and outlines the necessary contracts between associates to allow information shares or transfers.
Along with these rules, there are several national regulations that business associates and covered entities must follow. These regulations include:
- Self-audits: Organizations must conduct audits to assess any gaps in HIPAA standards. Security Risk Assessments are inadequate for compliance, so entities must perform and annual audit each year.
- Remediation plans: Remediation plans help organizations reverse violations and address gaps they identified in their self-audits. You must document these plans and provide dates for when you will remedy the gaps.
- Employee training: Along with consistently updating policies and procedures, organizations must administer annual training for workers. Employees must attest that they have understood each policy and procedure related to their organization.
- Incident management: This regulation enforces the proper way to notify essential persons and document data breaches should one occur.
- Business associate management: Organizations must document every vendor with whom they share patient information with. Business Associate Agreements are essential for ensuring the secure handling of protected information and mitigating liability. Entities must review their agreements annually, make adjustments, and deliver agreements before sharing any protected information.
Steps to HIPAA certification
Effective compliance programs feature several essential elements to provide guidance and maintain consistency. Implementing written procedures, designating a compliance committee and officer, conducting training, ensuring communication, enforcing standards, and responding to offenses quickly are the minimum requirements for an effective program.
Our HIPAA compliance roadmap will provide the details and steps necessary to achieve and maintain compliance for a safer workplace. Here’s how your organization can reach certification and compliance:
Provide understanding and select a compliance officer
All healthcare workers must understand the importance of compliance and the essential steps for successful implementation. Selecting a compliance officer can benefit some organizations because these people can evaluate potential threats or gaps in infrastructure and ensure consistency. Large organizations may have a compliance officer and security or data protection officer, while small entities may combine these responsibilities into one role.
These officers understand the HIPAA Privacy and Security Rules, empowering them to identify gaps and threats. Privacy officers can answer questions about regulations, and security officers can train employees and implement strategies to prevent unauthorized access or breaches.
Some entities may also utilize a compliance committee for efficiency and effectiveness. These committees can contain workers from various departments, including legal, IT, operations, and finance. Compliance team members meet regularly to discuss recent environmental changes, organizational risks, and regulation updates.
Perform regular risk assessments
The HIPAA Security Rule requires organizations to perform annual risk assessments. These assessments empower organizations to identify and address potential pain points within the organization. A risk assessment protocol should evaluate every area of the organization and closely monitor how the organization uses mobile devices and email.
A HIPAA risk assessment should include steps like:
- Determine the scope of analysis: Risk analysis should include your organization’s protected information, regardless of its location, source, or electronic media you use for transmitting, maintaining, creating, or receiving it. This analysis should discuss all reasonable risks regarding information availability, integrity, and confidentiality. These risks include human error, malicious workers, and external factors.
- Collect your data: Gather accurate information regarding information disclosure and use. You can achieve this by analyzing project inventory, performing interviews, reviewing documents, or using other gathering techniques as needed.
- Assess vulnerabilities and threats: Consider all anticipated threats for each piece of data and include factors unique to your environment. For example, if you utilize an external cloud solution, you should research the risks associated with that specific solution.
- Consider your current measures: Evaluate any safeguards you have already implemented. Consider measures and non-technical measures such as encryption, auditing, access control, policies, physical security, and procedures. Analyze whether each measure is appropriate and effective to reduce associated risks.
- Determine threat impact: Assess every possible threat and detail possible outcomes. For example, threats could lead to a loss of financial flow, reputational damage, unauthorized disclosure or access, or temporary or permanent loss or corruption. Assign these threats a risk level to determine which risks may have the highest impact and most probability of occurring.
- Create or security measures: Identify how to reduce risks to a reasonable level and consider the requirements for implementation. Document all findings and create a routine for conducting a risk assessment and reviewing policies annually. Track any change at the end of the assessment and make updates as necessary.
Update and create procedures and policies
Entities should also establish written procedures and policies regarding information handling. Organizations will need to review and update these documents regularly to ensure consistency and accuracy. These policies and procedures should cover actions or measures regarding authorization, uses, disclosures, administration, physical strategies, and technical efforts. Organizations should have an efficient way to share updates with workers and provide easy access for each worker to review when necessary.
Provide adequate training
It can take months to create an effective compliance program, and ongoing threats and vulnerabilities require constant supervision. Allowing adequate time for proper training is essential for maintaining compliance. Every current worker and new hire should receive the same training and be able to access the same information. Whenever your organization makes a change to policies or procedures, all workers should receive immediate training to make adjustments and maintain compliance.
Maintaining HIPAA compliance with a checklist
Although a checklist is not an effective risk assessment, it can provide a baseline for organizations to better understand their obligations and the obligations of their business associates and partners. You can create checklists to satisfy each HIPAA rule or document a comprehensive list for your committee or officers to review. Below, you can find rule-specific checklists.
HIPAA Privacy Rule checklist
HIPAA Privacy Rule checklists could include actions such as:
- Designating a privacy officer to develop, implement, and enforce compliance policies.
- Identifying risks and implementing safeguards to minimize impact.
- Distributing a notice explaining how your organization uses patient information.
- Training employees on all relevant policies and procedures for their role.
- Documenting a contingency plan detailing response actions in the event of an emergency that damages systems of locations maintaining protected information.
- Reviewing Business Associate Agreements and update or revise as necessary.
- Developing procedures for obtaining authorization and allowing people to object or agree when necessary.
HIPAA Security Rule checklist
Include the following steps on your Security Rule checklist:
- Assign a security officer.
- Establish which systems transmit, receive, or create protected information and block unauthorized access.
- Establish measures and strategies for mitigating phishing, malware, and ransomware threats.
- Create a system for identifying workers to satisfy workstation security and physical access requirements.
- Monitor device inventory for information access and create a system for recording any media or device movement.
- Train workers on proper reporting actions or escalating concerns.
- Provide security awareness training for every employee.
- Create a contingency plan for any risk that could impact the availability, integrity, or confidentiality of protected information.
- Review Business Associate Agreements and replace any that are not compliant.
Best practices for a HIPAA compliance program
Regulations and rules are constantly evolving in the healthcare industry, and it’s essential for your organization to stay up-to-date on changes that impact your operations. Although your business may find some actions more necessary than others, there are several basic tips to keep in mind when creating your program. Essential tips for creating an effective compliance program include:
- Developing procedures and policies that comply with the Breach Notification, Security, and Privacy Rules.
- Implementing technical, physical, and administrative safeguards while considering risks and flexibility.
- Considering any threats you can reasonably anticipate to impact protected information.
- Ensuring communication lines allow employees to report violations, concerns, and breaches.
- Monitoring compliance and providing updates when necessary.
- Responding to advice requests and violation reports promptly while enforcing a sanctions policy fairly.
Penalties for lacking HIPAA compliance training in healthcare
HIPAA violations refer to any breach in a compliance program that impacts the integrity of protected information. Although not every data breach is a HIPAA violation, data breaches can become so when the risk is the result of incomplete, ineffective, or outdated HIPAA programs or a direct policy violation.
Many violations often fall into one of several categories: use and disclosure, access controls, improper security measures, and notice of privacy practices. Common HIPAA violations include:
- Stolen devices such as USBs, laptops, or phones
- Malware incidents
- Ransomware attacks
- Facility break-ins
- Failing to complete risk assessments
- Hacking incidents
- Inappropriate social media posts
- Sending information to the wrong contact or patient
- Business associate breach
- Discussing patient information outside of the facility
Penalties for violations can range in severity for financial and reputational damages. Organizations may face civil or criminal penalties (American). Civil penalties could result in fines between $100 and $50,000 for each Unknown Penalty. Willful neglect violations could result in a $10,000 to $50,000 fine per violation.
Criminal penalties could result in fines as well as imprisonment. Depending on whether the organization committed an offense under false pretenses, attempted or intended to sell information, or knowingly disclosed information, they could face fines between $50,000 and $250,000 and up to 10 years of imprisonment.
Navigating HIPAA certifications with Rectangle Health
HIPAA compliance requirements are constantly changing, and it’s important your business can keep up. At Rectangle Health, we understand the importance of maintaining HIPAA data protection in healthcare. We’ve empowered healthcare facilities to access innovative solutions for nearly 30 years. Security is our priority, so you can spend more time providing quality care and less time on business tasks.
We offer a compliance solution for organizations to conduct risk assessments, review checklists, and ensure teams have accurate and current information regarding HIPAA policies and procedures. Allow us to show you how we can simplify the business side of the healthcare industry. Contact our team for more information about our solutions or request a demo to see our solution in action.
References
American Medical Association. (n.d). HIPAA violations & enforcement. ama-assn.org. Retrieved from https://www.ama-assn.org/practice-management/hipaa/hipaa-violations-enforcement
U.S Department of Health and Human Services. (2023, February 24). Breach reporting. HHS.gov. Retrieved from https://www.hhs.gov/hipaa/for-professionals/breach-notification/breach-reporting/index.html
