Healthcare institutions and associated organizations across the U.S. are required to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This federal law prevents protected health information (PHI) from being disclosed without a patient’s consent or knowledge. Between April 2003 and March 2021, 69% of 41,686 privacy complaints were classified as violations, and corrective actions were taken. Therefore, HIPAA compliance is a concern for many healthcare institutions. Let’s talk about how a trusted IT security partner could help your organization prepare for HIPAA audits and maintain your HIPAA compliance.
The Intricacies of HIPAA Compliance
The U.S. Department of Health and Human Services (HHS) provided the HIPAA Privacy Rule as a tool to implement HIPAA requirements. The HIPAA Privacy Rule protects patients’ health information while allowing necessary use of protected health information (PHI) to provide healthcare.
Which Organizations Need to be HIPAA Compliant?
The following entities must meet HIPAA compliance standards:
- Healthcare providers (of all size)
- Health plans or health insurance providers
- Healthcare clearinghouses
- Business associates that handle patients’ protected health information (PHI)
The HIPAA Security Rule
The HIPAA Security Rule protects a subset of protected health information (PHI) that the Privacy Rule safeguards. This subset refers to all individually identifiable health information that a covered entity creates, receives, stores, or transmits in an electronic format. Such data is called “electronic protected health information” (e-PHI).
HIPAA Security Rule compliance requires that all covered entities ensure the integrity, availability, and confidentiality of electronic protected health information (e-PHI). Furthermore, they must detect and defend against all cybersecurity threats and impermissible use and disclosure of the data and certify their workforce.
HIPAA Audit vs. SOC Audit
You should be aware of the two main types of healthcare audits:
Only a firm accredited by the AICPA can perform a SOC audit. These audits commonly use the HITRUST common security framework (CSF):
- HITRUST CSF validates your IT infrastructure and policy compliance with the HIPAA Security Rule.
- HITRUST CSF also verifies your business practices and third-party compliance with the HIPAA Security Rule by addressing IT security standards and regulations.
At Net Friends, we voluntarily subject ourselves to an independent SOC 2 Type II audit every year with KirkpatrickPrice, our third-party HITRUST CSF Assessor, to validate that our information security policies and practices meet the industry standards stipulated by the AICPA. Learn more about why we maintain our SOC 2 Type II certification year after year.
How Your IT Security Partner Can Help You Meet The OCR's HIPAA Audit Requirements
Any CIO knows that preparing for a HIPAA audit takes a lot of work. Your IT security partner should be a part of that preparation process, and they can help your organization to meet these requirements better:
1. Emphasize HIPAA Training
HIPAA compliance training for your management and staff is a critical component of audit preparation. You don’t want to risk failing your HIPAA audit due to employee shortcomings. Your IT security partner can help you perform these training sessions.
The Office of Civil Rights (OCR) requires evidence of this HIPAA compliance training. Document your training sessions as evidence of your commitment to employee instruction. A trusted managed services provider (MSP) can help you create and publish HR policies that prioritize training and education. During the audit, the OCR can question any member of your organization to verify that everyone understands the HIPAA regulations and compliance requirements.
At Net Friends, we have in-house Privacy Compliance & Risk Management Experts, who have been CRISC-certified to guide our own teams through an annual HIPAA compliance training, as well as consult our customers in their own training practices.
The CRISC certification ensures that IT security practitioners are following governance best practices for Information Technology Risk Management (ITRM) to mitigate risks and optimize resources. This certification prioritization is an extension of our Safe Networks Philosophy, which underpins our approach to managed services.
2. Perform a Risk Analysis
We recommend that you perform a thorough risk analysis to identify any security issues. A HIPAA audit requires that you document all your preparatory steps. Your IT security partner should have HIPAA experts to offer guidance about the security reports and other risk evaluation documentation that you need. Ensure that these documents are kept up-to-date and in an accessible location for easy retrieval.
3. Design a Risk Management Plan
The findings from your risk analysis will help you create the best risk management plan for your organization. Your IT security partner or MSP will also help develop and document your HIPAA compliance policies to meet the Privacy and Security Rules requirements. Your organization’s risk management plan should discuss the incident response, breach notification, IT security and firewalls, and physical security. This detailed documentation will help you pass the HIPAA audit and provide a clear roadmap to run your organization effectively.
4. Assign a HIPAA Privacy Officer
One of the HIPAA compliance requirements is assigning a privacy officer to manage each covered entity and business. You don’t need to worry about hiring a new person for this role, as you can assign an existing staff member (or your MSP). This person will ensure the security and privacy of your clients’ protected health information (PHI). They will also ensure that your organization meets the HIPAA regulations. Your privacy officer is also responsible for reviewing all your Business Associate Agreements (BAAs). The OCR will examine your organization’s third-party relationships that involve electronic protected health information (e-PHI).
Net Friends Pro-Tip: Your MSP can help you create a list of vendors and suppliers, and document their security measures as outlined in each Business Associate Agreement (BAA).
5. Review HIPAA Compliance Policies
The privacy officer should regularly review your organization’s HIPAA security policies. Your MSP is well-placed to conduct a thorough risk analysis on all your IT networks and data security systems. Record all breaches or incidents and your organization’s response in each case. The HIPAA auditors will be interested in these details as proof of your compliance.
When you document your policies and procedures, also show evidence of their implementation. The OCR will examine how your organization’s policies and procedures influence your daily operations and their consistent application. We recommend that you:
- Speak with your management and staff to determine the effectiveness of your policies. If there are any implementation difficulties, then analyze the issues and make the necessary adjustments.
- Document your implementation schedule as it may be requested during your HIPAA audit. The OCR likes to see how you implement your policy adjustments and procedures and your rate of progress in the implementation process.
6. Perform an Internal Audit
How about performing a dress rehearsal before your HIPAA audit? Your IT security partner can help you conduct an internal HIPAA audit, which not only helps you solve problems in advance, but it also keep your management and staff prepared for the actual review. This pre-HIPAA audit will help identify and fill gaps in your system before the big day.
Always try to review your policies and procedures like a HIPAA auditor. Consider if your policies meet the regulatory intent and if they improve patient privacy and security. When you critically analyze your framework, you will uncover areas for improvement in your business operations and HIPAA compliance requirements.
7. Design and Execute an Internal Remediation Plan
After you’ve completed the previous steps with your IT security partner, then you need to think about remediation. This remediation plan should address any vulnerabilities and minimize your organization’s risk profile. Yes, you also need to document this remediation plan! Documentation is critical to passing your HIPAA audit. Include a schedule that outlines the core elements of your remediation plan, and be prepared to discuss this plan with the HIPAA auditor.
Net Friends Pro-Tip: It’s crucial to view HIPAA as a continual process and not a one-time evaluation. Your institution’s remediation plan and schedule also helps you keep your business associations accountable and compliant, even when your operation is not under audit.
8. HIPAA Compliance & Cybersecurity
Your institution’s HIPAA compliance and cybersecurity protocols are closely intertwined. Preventing network security breaches will also safeguard your clients’ protected health information (PHI). An effective IT security partner will help you meet your regulatory requirements and build a strong cybersecurity culture.
Net Friends is Home to Your Top HIPAA Partners
Net Friends is committed to helping every organization we serve build a strong and sustainable cybersecurity culture. We have a long history of HIPAA expertise and our internal operations are SOC 2 Type II certified. We will help you safeguard your clients’ protected health information (PHI), generate timely security reports, and help you meet HIPAA compliance standards by implementing cybersecurity best practices. Contact Net Friends today and discover how we can simplify your preparation for HIPAA audits and cost-effectively maintain your HIPAA compliance.