Yesterday, the Office for Civil Rights (OCR) at the Department of Health and Human Services (DHHS) released its 2016-2017 HIPAA Audits Report. Although this seems outdated, it typically takes this long to compile the data.They reviewed selected covered entities (CE) and business associates (BA) for HIPAA compliance of the HIPAA Privacy, Security, and Breach Notification Rules.
DHHS is required by law under the HITECH Act to conduct periodic audits. The chances of a random audit are slim, but they do happen, and you must be prepared. Don’t be fooled by a slim chance of a random audit, you can be audited for many other reasons! This audit comprised of 166 covered entities and 41 business associates. The OCR publishes this report to share the overall findings.
A summary of the audit findings includes:
Most CEs met the timeliness requirements for providing breach notification to individuals.
Most CEs that maintained a website about their customer services or benefits satisfied the requirement to prominently post their Notice of Privacy Practices on their website.
Most CEs failed to provide all of the required content for a Notice of Privacy Practices.
Most CEs failed to provide all of the required content for breach notification to individuals.
Most CEs failed to properly implement the individual right of access requirements such as timely action within 30 days and charging a reasonable cost-based fee.
Most CEs and BAs failed to implement the HIPAA Security Rule requirements for risk analysis and risk management.
“The audit results confirm the wisdom of OCR’s increased enforcement focus on hacking and OCR’s Right of Access initiative,” said OCR Director Roger Severino. “We will continue our HIPAA enforcement initiatives until health care entities get serious about identifying security risks to health information in their custody and fulfilling their duty to provide patients with timely and reasonable, cost-based access to their medical records.”
During this pandemic, the Office for Civil Rights (OCR) relaxed some of the requirements for Telehealth. This has since been retracted. Make sure the service you are using is in fact HIPAA compliant and you have a business associate agreement (BAA) in place. We also encourage you and all your business associates (BA) to carry cyber liability insurance. Data breaches and mishaps are part of our everyday life it seems. Although your medical malpractice insurance may offer a token amount of coverage, it is probably not enough. Keep in mind, if you cannot determine WHICH patient’s data has been breached, you must notify all your patients. This is where is can be very costly. When selecting an agent, make sure they are well versed in this type of insurance, as we have seen some policies are not worth the paper they are written on. Read the exclusions!
Below are some HIPAA violation highlights from 2020. This is not meant to scare you, but to remind you of how important adhering to HIPAA really is. The Office for Civil Rights (OCR) enforcement actions are designed to send a message to the health care industry about the importance and necessity of compliance with the HIPAA Rules.
The OCR investigation found longstanding, systemic noncompliance with the HIPAA Security Rule including failure to conduct a risk analysis, and failures to implement information system activity review, security incident procedures, and access controls.
“The health care industry is a known target for hackers and cyberthieves. The failure to implement the security protections required by the HIPAA Rules, especially after being notified by the FBI of a potential breach, is inexcusable,” said OCR Director Roger Severino.
The OCR investigation discovered longstanding, systemic noncompliance with the HIPAA Privacy and Security Rules including failures to conduct a risk analysis, implement risk management and audit controls, maintain HIPAA policies and procedures, secure business associate agreements with multiple business associates, and provide HIPAA Privacy Rule training to workforce members.
“Hacking is the number one source of large health care data breaches. Health care providers that fail to follow the HIPAA Security Rule make their patients’ health data a tempting target for hackers,” said OCR Director Roger Severino.
The OCR investigation revealed that a former employee returned eight days after being terminated, logged into her old computer with her still-active user name and password. Additionally, OCR found that the former employee had shared her user ID and password with an intern, who continued to use these login credentials to access PHI after the employee was terminated. The investigation determined that the entity failed to conduct an enterprise-wide risk analysis, and failed to implement termination procedures, access controls such as unique user identification, and HIPAA Privacy Rule policies and procedures.
“Medical providers need to know who in their organization can access patient data at all times. When someone’s employment ends, so must their access to patient records,” said OCR Director Roger Severino.
The OCR investigation revealed that in addition to the impermissible disclosures, Aetna failed to perform periodic technical and nontechnical evaluations of operational changes affecting the security of their electronic PHI (ePHI); implement procedures to verify the identity of persons or entities seeking access to ePHI; limit PHI disclosures to the minimum necessary to accomplish the purpose of the use or disclosure; and have in place appropriate administrative, technical, and physical safeguards to protect the privacy of PHI.
“When individuals contract for health insurance, they expect plans to keep their medical information safe from public exposure. Unfortunately, Aetna’s failure to follow the HIPAA Rules resulted in three breaches in a six-month period, leading to this million-dollar settlement,” said OCR Director Roger Severino.
The OCR has settled twelve investigations for HIPAA Right of Access denials. This is not to be confused with a medical summary at the end of a patient encounter. A patient’s request for a copy of their medical record (their designated record set) either by them or from a third party must be handled in a timely manner.
“It shouldn’t take a federal investigation to secure access to patient medical records, but too often that’s what it takes when health care providers don’t take their HIPAA obligations seriously. OCR has many right of access investigations open across the country, and will continue to vigorously enforce this right to better empower patients,” said Roger Severino, OCR Director.
“No one should have to wait over a year to get copies of their medical records. HIPAA entitles patients to timely access to their records and we will continue our stepped up enforcement of the right of access until covered entities get the message,” said Roger Severino, OCR Director.
“The OCR is committed to enforcing patients’ right to access their medical records, including the right to direct electronic copies to a third party of their choice. HIPAA covered entities should review their policies and training programs to ensure they know and can fulfill all their HIPAA obligations whenever a patient seeks access to his or her records,” said Roger Severino, OCR Director.
“For too long, healthcare providers have slow-walked their duty to provide patients their medical records out of a sleepy bureaucratic inertia. We hope our shift to the imposition of corrective actions and settlements under our Right of Access Initiative will finally wake up healthcare providers to their obligations under the law,” said Roger Severino, OCR Director.
The OCR investigation determined that there was systemic noncompliance with the HIPAA Rules including a failure to encrypt ePHI on laptops after Lifespan ACE determined it was reasonable and appropriate to do so. OCR also uncovered a lack of device and media controls, and a failure to have a business associate agreement in place with the Lifespan Corporation.
“Laptops, cellphones, and other mobile devices are stolen every day, that’s the hard reality. Covered entities can best protect their patients’ data by encrypting mobile devices to thwart identity thieves,” said Roger Severino, OCR Director.
A breach report regarding the impermissible disclosure of protected health information to an unknown email account. The breach affected 1,263 patients. OCR’s investigation revealed longstanding, systemic noncompliance with the HIPAA Security Rule. Specifically, they failed to conduct any risk analyses, failed to implement any HIPAA Security Rule policies and procedures, and neglected to provide workforce members with security awareness training until 2016.
“Health care providers owe it to their patients to comply with the HIPAA Rules. When informed of potential HIPAA violations, providers owe it to their patients to quickly address problem areas to safeguard individuals’ health information,” said Roger Severino, OCR Director.
“All health care providers, large and small, need to take their HIPAA obligations seriously,” said OCR Director Roger Severino. “The failure to implement basic HIPAA requirements, such as an accurate and thorough risk analysis and risk management plan, continues to be an unacceptable and disturbing trend within the health care industry.”
HIPAA covered entities and business associates are required to conduct an accurate and thorough assessment of the risks to the ePHI it maintains. Identifying, assessing, and managing risk can be difficult, especially in organizations that have a large, complex technology footprint. Understanding one’s environment – particularly how ePHI is created and enters an organization, how ePHI flows through an organization, and how ePHI leaves an organization – is crucial to understanding the risks ePHI is exposed to throughout one’s organization. As technology changes, risk assessments must be updated and reflected in a risk management plan. Reviewing policies and procedures may also need to be updated depending on the type of changes in technology. As we get ready to close out 2020, set your schedule to review your updates and planned upgrades for 2021.
To read about enforcement and the resolution agreements, click on the link below:
While the nation was shut down and people were suffering, hackers were busy at work. It is coming to light how many organizations have had a data breach and have been hit with ransomware.
Now more than ever all organizations need to make sure their HIPAA Compliance Officer understands what is needed for data security. The FBI has stated cybercrime in 2020 has surpassed 2019 and we still have a few months to go. The problem is the hackers have become very sophisticated in their attacks. Whereas it used to be easy to spot a fake email, that is no longer the case. Between email and text efforts, they are gaining access to our information and we are the ones permitting it. Also, user credentials are compromised and used to gain access to your network or to send false emails to gather personal information. These scams typically involve a criminal that has hacked a legitimate email address. For example, a person would receive a message that appears to be from someone within their organization or a business associate with which that person knows. The message will request a payment, wire transfer, gift card purchase, or even a list of employees with social security numbers that seems legitimate. The compliance officer should be notified, and the transaction verified BEFORE it is completed. Every office needs to have a verification process in place before releasing ANY data.
We have said this before… if a stranger walked up to you and asked you to verify your identity would you give them any information? Of course not, but that is exactly what we are doing when we receive an email or text message from someone or somewhere, we trust. Trust, but verify.
With more and more people working remotely, that brings us to another vulnerability. Covered entities that utilize the services of business associates are required by HIPAA to ensure the business associate is in fact HIPAA compliant. The starting point is to ensure you have a business associate agreement in place with all your vendors that create, receive, maintain, or transmit protected health information (PHI). This agreement should include security requirements to ensure they are protecting your patient data. If a covered entity does not have a BA agreement in place and the vendor causes a data breach, the covered entity will more than likely receive the fine. With a BA agreement in place, it is still typical the covered entity bears the financial burden of the breach but may not receive the fines. That is why a BA agreement should include an indemnification and requiring the business associate to carry cyber liability insurance. Recently, a business associate was fined $2.3 million for a data breach that was caused by a hacking incident. If the covered entities did not have BA agreements in place, they could have been the ones who received this hefty penalty. Also, recently an orthopedic clinic was fined $1.5 million after a journalist notified them that a database of their patient information was posted for sale online. For this reason, we recommend covered entities should carry their own policies as well. “Hacking is the number one source of large health care data breaches. Health care providers that fail to follow the HIPAA Security Rule make their patients’ health data a tempting target for hackers,” said OCR Director Roger Severino. Many electronic and portable devices are used to process and store PHI. Anyone with access to such devices could potentially have the ability to change configurations, install malicious programs, change information, or access information that are not authorized to. Any of these actions has the potential to affect the integrity of patient information. HIPAA requires covered entities and their business associates to implement and follow policies and procedures to limit access to only those who are authorized.
Risk management should be at the top of everyone’s list. Preventing data breaches and securing patient data is everyone’s responsibility, but the OCR requires someone to be the point person, hence the HIPAA Security or Compliance Officer title. This responsibility is so much more than just a title. HIPAA Compliance Officers responsibilities include creating, maintaining, and enforcing compliance. This includes the staff, management, and even the medical providers.I hear too often that the compliance officer gets push back from the doctors or owners. This is so unfortunate since they are only trying to do their job that is required under state and federal law. They are the frontline defense in keeping your practice alive and well. The owners of the practice may suffer the financial loss, but sometimes everyone does if the practice closes. Let’s all work together to keep patient data safe and secure.
To find out more about how our automated HIPAA compliance platform can help your organization click here:
First, it is required under HIPAA that medical organizations and business associates ensure the confidentiality, integrity, and availability of ePHI. Part of a HIPAA compliance program requires an entity to conduct a HIPAA risk analysis to determine where ePHI is located and how it is protected. It is critical that all organizations understand how data flows in and out of their systems as well has how business associates access your data. Risk management is the key to protecting your data.
Here is a starting point after your risk analysis:
Create an inventory list. The list should include servers, computers, laptops, tablets, printers, scanners, fax servers/machines, and specialized equipment for your type of practice.
Include what type of encryption you have implemented or what type of anti-virus and anti-malware is utilized. Also, think about devices that are not onsite, remote users, cloud servers, and offsite backups. If smartphones are used, add those as well. Even if they are not company owned, just make a note of that.
The inventory list should also include software that is used to access or store ePHI. When the time comes to retire a device, this list could be used to determine how it is to be handled. For example, will it need to be destroyed or could be sanitized and reused?
Be sure to include the operating systems on your devices. This will alert you when systems are at the end of life and need to be replaced.
We also recommend adding assets that do not store or access ePHI, just in case they could be compromised and create a method of intrusion. This includes firewalls and routers.
Next, create a diagram of all technology and how ePHI flows through your system. Hackers can gain access to your systems through your vendors. You may need the help from your IT company. Keep in mind when selecting an IT vendor, they MUST be well versed in healthcare. Your security is more complex than the average small business, not to mention the heavy fines should you suffer a data breach.
When creating your network mapping, we suggest adding which devices store and/or access ePHI. Again, this is a visual reminder of how your data flows and can help you to understand how to protect your data. If possible, request a Visio Map from your IT vendor.
With all the data breaches that are happening, it is so important to know where your data is and how it is protected. Keeping up with your risk analysis and risk management plan demonstrates your on-going compliance efforts. This is a requirement under the HIPAA Security Rule. If you suffer from a data breach and you can provide documentation that you have reasonable and appropriate safeguards in place and that you have done the best you can to protect your data, more than likely you will not be fined.
To find out more about how our automated HIPAA compliance platform can help your organization click here:
As you know you HIPAA Compliance is not a once and done process. It continually changes and evolves as your organization grows and your technology changes. This is a reminder to review what you have in place to ensure it still adequately safeguards your data.
Here are some quick helpful tips:
Review your Notice of Privacy Practices. Have you implemented any new technology or added any new services that needs to posted? If you have a website make sure you update your NPP there as well.
If you have a “Contact us” or an “Appointment Scheduler” form on your website and your website is not HTTPS, we recommend placing a disclaimer advising patients not to send personal information via the form. If you do have an HTTPS site, make sure your hosting vendor understands HIPAA and review where the data is sent and stored.
Review your Technology Equipment. Have you added any new software or hardware? Do you regularly check your firewall settings? Are you reviewing your website security to ensure it is up to date? Are you documenting your IT efforts or reviewing your monthly IT vendor reports?
Have you reviewed your list of Business Associates to ensure you have BA agreement in place with ALL of your Associates?
Review your Inventory list. Have you added any new equipment or have you disposed of any?
Have you conducted your annual HIPAA training for everyone? Is it documented?
Have you tested your Contingency Plan?
Of course we could go on and on, but hopefully this will jumpstart your thinking process! Remember, your Risk Management Plan is a living document that needs to be updated on a continual basis. As you review your compliance efforts be sure to document this in your Plan.
For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.
“Protecting Organizations through Partnership, Education, and Support”
Many organizations have the attitude that they are too small to be a target for a data breach. Just because you don’t hear about small and medium sized practices being targeted doesn’t mean it is not happening.
Most medical practices are busy treating patients and are not aware of the severity behind this type of threat. Since small and even medium sized practices do not have the infrastructure in place to protect their data, they are a larger target than think. Data breaches can go undetected for months, if not years since they are not watching for it. For instance, if a Pediatric Practice is hacked, those social security numbers can be used for years before it will be discovered.
Many business associates are also targeted because they have access to medical records in different manner. Again, small and midsized organizations that do not have appropriate safeguards in place can wreak havoc in a medical environment. So what can you do?
First of all, conduct a Security Risk Analysis to understand what are your vulnerabilities. This is critical in order to mitigate risks.
Next, have a network security audit performed. Even if you access your data in the cloud and not through an onsite server, you can still be hacked.
Invest in monitoring your network. Know who is accessing your data.
TRAINING IS A MUST! Your employees can be your best asset or your largest liability.
Not only is this required under HIPAA, it is considered best practice in protecting patient data.
Contact Aris Medical Solutions at 877.659.2467 or click here to find out how we can protect your organization.
“Protecting Organizations through Partnership, Education, and Support”