HIPAA compliance Archives

What does being HIPAA Compliant actually mean anyway?

Suze Shaffer July 15, 2019February 2, 2024

We are always talking about HIPAA compliance because that is what we do! Sadly many practices think just having a patient sign they received your Notice of Privacy Practices is all that is needed. There is so much more to HIPAA than that! After we go over a client’s risk analysis they realize this and are anxious to get their compliance in place. Then you get busy and it is pushed off to the next week, then the next, and then you realize it never was implemented!

Being HIPAA compliant means MANY things, and I could write about this for hours, but here are some basic reminders:

Work on your Risk Management plan, implement your policies and procedures and mitigate risks. Policies and procedures are necessary so employees understand what is and is not permitted. The enforcement of your sanction policy and being consistent for those employees who violate HIPAA can help you avoid fines and penalties.
Monitor your audit logs. Know who is doing what within your systems. Whether it is an employee or a business associate, you must know who and how users access ePHI. This is critical in preventing or stopping a data breach.
Make sure your HIPAA compliance officer is informed and educated on any security incidents that may occur. This can help them to determine if and when a data breach occurred when they are reviewing the audit logs. The HIPAA compliance officer is required under federal law to report data breaches, large and small. The only difference is timing. Large data breaches must be reported within 60 days (state law could be more stringent) and smaller breaches within 60 days after the end of the year in which the breach occurred.
Check the OIG exclusions list before you hire a new employee which can save you from being required to return payments you received from CMS in the event you hired someone on this list. Also, conducting a thorough criminal background check can prevent you from being stolen from! Conducting and documenting annual HIPAA training as well as when new employees are hired will educate them on patient privacy and data security. Make sure the method of training you choose covers both areas.
Make sure everyone uses their own login credentials and never share their passwords. If someone signs in under another person, then that person that is logged in could be held liability for anything that is done under their credentials! Remember to use strong passwords and change them often. If possible, implement a secondary authentication in addition to using just a username and password. This is extremely helpful in protecting information for business and personal. All online accounts, even email should use a two-step of some type.
Since we work in healthcare we have the ability to look at anyone’s medical record in our system. Keep in mind, you should only look at records that you have a need to do so. This means that if a patient is being seen by another provider or medical staff member and you do not have the need to view the record, you are NOT permitted to do so.
When it comes to technology, many people think if it’s not broke, don’t fix it. This is NOT true! As our systems age, unless they are updated and upgraded, your information may be at risk of a data breach. Firewalls, computers, servers, and software all must be maintained. Firewalls are your first line of defense. Would you put up a fence and never bother to lock it? I have said this many times in the past, in the old wild wild west you could see danger coming towards your town and prepare. The world wide web is the new wild wild west, but the intruders are invisible. You must have several layers of security to secure your data. NOTE: Microsoft Windows 7 will no longer be supported after January 14, 2020. I have always liked this operating system, but now we must prepare for those computers to be updated or replaced.

HIPAA is much more than just these items, but this should help you to remember some important steps!

If you haven’t implemented HIPAA privacy and security policies and procedures, now is a good time to start to ensure your employees understand how to protect your data. If you would like more information, contact us at 877.659.2467 or complete the contact us form.

Do you have all of your HIPAA training documented?

Suze Shaffer January 7, 2019June 29, 2022

What do you know about HIPAA enforcement?
Just imagine you were investigated by CMS or the OCR, what would they find?
How confident are you in your medical and/or HIPAA documentation?
Do you have the appropriate documentation to protect your organization?

The Office for Civil Rights (OCR) is very serious about ensuring your organization is educating employees on patient rights and securing PHI. During a recent investigation in Florida an organization was fined $100K for each year they could not produce documented HIPAA training. The first year they only had 3 employees! They were fined for five years, $500K. Once you are under investigation, they review ALL of your documentation, not just what they originally requested. You do not want to end up being in the willful and wanton neglect category. This is where the big fines are calculated.

If you have a patient complaint or suffer a data breach, the best advice is to document, document, AND document! OH, did I mention… DOCUMENT? Next, cooperation. If they ask for something, give it to them. Nothing more, nothing less, but give them what they ask for. Show the OCR you are trying to do the right thing. After all, how would you like it if the information that was compromised was yours? Wouldn’t you want the organization to do what they could to stop the breach or prevent another one from happening?

Remember the MD Anderson in Texas fines? They had multiple devices lost containing unencrypted ePHI. They claimed that they were not obligated to encrypt its devices, and stated that the ePHI that was involved was for “research,” and thus was not subject to the HIPAA non-disclosure requirements. They challenged the OCR and the Judge ruled in favor of the OCR and MD anderson was ordered to pay $4,348,000 in civil money penalties. The quote from OCR Director Roger Severino: “OCR is serious about protecting health information privacy and will pursue litigation, if necessary, to hold entities responsible for HIPAA violations”.

At the NIST/OCR conference in Washington DC, the director along with other members of the OCR staff reminded organizations about enforcement. This is NOT going away. Patient information is extremely valuable to criminals. The days of just a slap on the wrist because you didn’t conduct risk assessment, conduct HIPAA training, or you can’t prove your HIPAA compliance is over. Every organization that has anything to do with patient information must get on board and understand HIPAA. There is NO certificate to prove you are HIPAA compliant, the proof is in your documentation. So I ask one more time… How well do you trust your HIPAA documentation?

To find out more about how our automated HIPAA compliance platform can help your organization click here:

https://arismedicalsolutions.com/aris-hipaa-service-automated-platform/

Or to schedule a demo click the contact us tab and scroll down.

“Simplifying HIPAA through Automation, Education, and Support”

Passwords – why you need to change them and not reuse previous ones!

Suze Shaffer August 20, 2018June 29, 2022

Just as the eyes are the window to our soul, passwords are the gateway to our inner most kept secrets.
Passwords are used to gain access to YOUR information, but what happens when your passwords are responsible for other people’s information? Did you know that by having your email hacked, you could potential expose not only your personal information but that of others?

Recently, I receive a text from a friend of mine saying “LOL, your email was hacked, just got a fake email from you!” Since she knows that I work in medical offices and with HIPAA compliance, she thought this was funny. However, the problem was, it was HER email that was hacked and they spoofed my address in hopes that she would fall for it. This is just one of the many ways that hackers “get in”. Some hacks start with this type of phishing email that someone falls for, depending on the hackers intentions… the sky’s the limit!

Did you know that a hacker that could get into your email would have the ability to change your access codes to many different resources and you not even know it? Many sites verify your identity through your email address. For instance, if you use the same password across different platforms, once they gain access to your email, they can try that password on other sites. Then they can change YOUR credentials and even change banking information.

So.. what can you do to protect your information and that information that you are responsible for…

Here are some suggestions that you may use. Maybe not all of them, but incorporate as many as you can.

Use STRONG passwords, preferably pass phrases.
Change them at least them at least every 90 days.
Do not share your passwords.
Do not use the same password/phrase phrase across multiple platforms.
Do not reuse the same passwords.
Enable two step authentication wherever offered.
Utilize an encrypted file and copy/paste passwords instead of typing them each time.
Make sure the network that you are accessing information from is secure.

Although nothing in this day is 100% safe, by simply adding a few precautionary measures you can protect yourself and the patient information that you are responsible for as much as possible!

If you would like to schedule a HIPAA training course customized to your facility, or if you need to update any of your HIPAA security needs call 877.659.2467 or complete the contact us form.

“Simplifying HIPAA through Partnership, Education, and Support”

Cost of cyber attacks on healthcare are steadily rising

Suze Shaffer August 1, 2018June 29, 2022

Why are so many medical offices being attacked? Simple, this is a one stop shop for everything needed for identity theft and many medical practices do not have appropriate safeguards in place. Business associates have even been the target or the entry point. HIPAA requires certain security safeguards to be in place to ensure the safety and security of Protected Health Information (PHI).

There have been 188 data breaches of 500 or more patient records in the first 6 months of this year, and in April alone there were 42. Thirteen of the 188 have already been resolved. https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf
These breaches include small medical practices, business associates, and hospitals. Small and large. Paper and electronic. No one is immune. Many organizations think they are too small to get hit, but the fact is the most common problem is untrained staff that unknowingly cause this to happen. Education is the key to avoiding this catastrophe from destroying your reputation. Of course you still need to certain technical safeguards in place, but even then it only takes one click of a mouse to bring your network down.

Here are some areas to consider:

How would you process a data breach?
How would you handle the reputation management of the breach?
How would you pay for the cost of breach and the investigations?

Having a breach notification plan in place before a breach occurs is critical to reducing the damage. You must have processing in place to shut the system down, continue manually, and report to the appropriate authorities.

Consider the lack of trust from your patients since their information was compromised from your office. No matter if it was your fault or that of a business associate this could have a negative impact on your patient database.

Breaches are costly on many fronts, the first being the cost of the notification of the patients, investigations, downtime, and the mitigation of the source of the breach. In 2013 the Ponemon Institute reported that a data breach cost $233 per medical record, now in the 2018 the report states a healthcare breach can cost on average $408 per medical record.
https://www.ibm.com/security/data-breach

Keep in mind if you do not know which records were breached then everyone must be included in the notification process. What could turn out to be the most costly is the fines and penalties associated with the breach. Depending on how and when you processed the breach is one determining factor. Also once the investigation is complete, if it is discovered this was an ongoing problem and was not mitigated, then you could be found in willful and wanton neglect. This is NOT a place you want to find yourself! The Office for Civil Rights (OCR) can also fine you for not conducting a thorough enough risk analysis thus leaving vulnerabilities untouched. How well do you trust your efforts in securing your data? Have you conducted a risk assessment to determine if what you have in place is sufficient?

How can Aris help?

First of all we conduct a thorough risk analysis that uncovers vulnerabilities and create a risk management plan so that you can mitigate those risks.
Since written documentation is also part of HIPAA compliance, we provide the necessary privacy and security policies, procedures, and documentation needed for state and federal regulatory requirements.
We also offer HIPAA training that includes privacy and security and any custom requests.
If you are one of the many organizations that simply do not have the time to implement your HIPAA program, we can do that for you as well. Month to month, no long term contracts!

If you would like a free HIPAA checkup call 877.659.2467 or complete the contact us form.

“Simplifying HIPAA through Partnership, Education, and Support”

Software Patches and Updates – Why they are so important.

Suze Shaffer July 17, 2018June 29, 2022

Whether you work in a medical office or are a business associate, they all rely heavily on the software they use for patient care. The reason software developers send out periodic updates is because more than likely a vulnerability has been discovered and the “patch” or “update” will mitigate the issue. Vulnerabilities come in a variety of types including electronic health records (EHRs), operating systems, custom software, databases, email, and even Java and Adobe Flash. Each program will have its own type of vulnerabilities. Unpatched software poses to a threat to ePHI and updating is required under HIPAA. Routers, phones, servers, and even some refrigerators have firmware that must be updated as well.

When discussing routers, it is important to mention that all routers come with default settings, including a username and password. These must be changed, otherwise they can be hacked. Routers also need to be rebooted or reset sometimes, depending on the type of vulnerability that has surfaced. Malware can infect not only your phone and computers, but also your router. It is imperative that you have an experienced IT professional that is current on these issues. Long gone are the days of plug and play. Although it is not difficult to set up a computer or a network, securing it is a whole new game.

Even if you utilize a cloud based system, the devices you use to access your system can be compromised. If you haven’t done so already, you should invest in a qualified IT vendor that will secure and monitor your computers and network. The data that your patients have entrusted you with is sought after in many areas. It is required under HIPAA to have reasonable and appropriate safeguards in place, but besides that… it’s the right thing to do!

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467.

“Simplifying HIPAA through Partnership, Education, and Support”

Workstation Security

Suze Shaffer June 19, 2018June 29, 2022

HIPAA Compliance is more than just about a patient’s right to access their information. Although the HIPAA Privacy Rule is how most of this began, it is so much more now! The HIPAA Security Rule outlines administrative safeguards, physical, and technical security. Most organizations are so busy trying to figure out how to protect themselves from the unknown (technical concerns) that they forget about the actual physical security. We are not just talking about building security systems, but how you secure the individual devices that are utilized within your facility and those who travel with portable devices.

Here are some helpful ideas to review with your particular situation:

Although utilizing a security system that has motion sensors is better than nothing, using security cameras usually discourages theft.
Conduct a walk through of your facility and create an inventory list of all devices that access or store ePHI. Knowing what you have, where it is located, and if it contains ePHI is essential in securing your data. This includes portable devices and small electronic media. Remember, printers, copiers, and scanners can store data as well.
Review the location of all devices that access or store ePHI. Ensure they are not located in an area that could be easily accessed by an unauthorized person or utilize cable locks. If screens are viewable and cannot be relocated, the use of privacy screens are highly recommended. Encryption is recommended on any device that contains ePHI. If the devices are transported they should be encrypted even if they do not contain ePHI. If they are ever lost or stolen and the encryption is engaged, it would not be a reportable breach.
If your USB drives are not used, locks should be installed. This is an inexpensive method to protect the network. If your workstations utilize CD/DVD drives, these should be disabled as well. Another option would be to configure this through a Microsoft Group Policy.
Make sure paper PHI is not left in areas that could be accessed by another as well. This includes where you store your excess paper charts. These areas should be locked when not in use. It is also recommended to utilize signage instructing “Employees Only”.
Employees can be your biggest asset or your largest liability. Training your employees on computer security is an ongoing process. Annual HIPAA training should include the HIPAA privacy rule and HIPAA security rule. Also, add monthly security reminders to keep HIPAA fresh in their minds. Continuing education is the key to safety.
HIPAA Policies and procedures are the backbone of an organization. Properly trained employees know and understand what is required and needed. The data that a health care provider has in its possession is priceless. This data must be secure physically and technically. All of this is necessary to avoid a data breach.

If an organization fails to secure patient information the Office for Civil Rights (OCR) will open an investigation and the organization can end up with massive fines. These fines have ranged from $250K to $3.5M. Although the fines are based on the organization’s ability to pay, the days of receiving just a $50K fine seems to be over. Best practices would be to review your HIPAA risk analysis and make sure it is thorough. Some online risk assessments unfortunately do not uncover all of your vulnerabilities. The OCR could consider this as willful neglect even though you didn’t know. Make sure you update your risk management plan and mitigate those vulnerabilities. Small oversights could cost you a fortune.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467.

“Simplifying HIPAA through Partnership, Education, and Support”

General Data Protection Regulation: What does this mean to the US

Suze Shaffer April 15, 2018February 2, 2024

By Aris Medical Solutions

You may have already heard about the GDPR (General Data Protection Regulation) from the EU (European Union) that will affect many organizations here in the United States.

Our personal information has been being sold for years. Some with and some without our knowledge. Many organizations require a person to “accept” their terms and conditions with long legal agreements that we must agree to before using their software, joining their network, or downloading an app to name a few. Most people do not read this very important disclosure because it is simply too long and too legal. They collect data from us in order to enter a sweepstakes, win a prize, or simply to gain access to a forum. This information can be sold to other organizations so they can market their good and services to us. I will be explaining in my next notification how to poison this information and make it useless. For now we need to concentrate on how to understand this new regulation.

With the GDPR from the EU becoming effect May 25, 2018, organizations must become compliant by May 25, 2018.

Here is a basic summary of what you need to know:

Organizations that provide goods or services to anyone located within the European Union regardless of where the company is located must adhere to this new regulation. This also includes companies that process and store personal data of an EU citizen. This is similar to our individual state laws we currently have in the United States.
Personal data is anything that can be used to identify a person, directly or indirectly. This includes name, photo, email address, bank details, medical information, computer IP address, and even posts on social media.
You must have clear full consent to use a person’s information. No lengthy vague legal forms; just clear plain language. Nothing short of an opt-in will be acceptable.
Just like HIPAA, there is a tiered sanction policy. Organizations can be fined up to 4% of annual global income for breaching the GDPR. This is for severe violators. Organizations can be fined up to 2% for not having their records in order, not notifying a supervising authority, not notifying the person that is affected by a data breach, or not conducting an impact assessment.
These rules will apply to both cloud data controllers and processors and will not be exempt from GDPR enforcement.
Data breaches must be reported within 72 hours.

What do you need to do to prepare:

Review your client/patient database.
Do you have any European clients/patients?
Review where all of your data is stored.
Do you use a cloud system?
Do you have a BA agreement in place with the data processor/center?
Update your breach notification plan.

For more information on the GDPR: https://www.eugdpr.org/

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467.

“Protecting Organizations through Partnership, Education, and Support”

How well do you trust your compliance efforts?

Suze Shaffer April 10, 2018February 2, 2024

By Aris Medical Solutions

HIPAA encompasses many aspects. Risk assessments, risk management, and your policies, procedures, documentation are the backbone of compliance.

Most medical providers don’t think about compliance until they are audited. By that time it is too late to mitigate any issues that you may have. The main misconception is that “it will never happen to me”.

A random audit is possible but relatively a low probability. A compliance audit is typically initiated by a disgruntled employee, a patient that feels their privacy has been violated, or a data breach. Once the HIPAA violation is reported then the Office for Civil Rights (OCR) will determine if the complaint will need to be investigated. If it does, depending on the documentation that you provide, will determine whether or not a desk audit will be issued. This is where your policies and procedures are critical. If your employees understand what they need to do, how to do, and what needs to be documented, your chances of a desk audit is greatly reduced. The OCR understands that people make mistakes, but if you don’t learn from them, they will fine you heavily!

Note to self… if you recognize a problem, address it, correct it, and learn from it.

You can survive a audit with proper documentation!

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data click here call 877.659.2467.

“Protecting Organizations through Partnership, Education, and Support”

Do HIPAA Fines go away when a practice or business closes?

Suze Shaffer March 26, 2018February 2, 2024

By Aris Medical Solutions

Many medical practices and business associates have the misconception that if they are fined they can simply close their doors and not be obligated to pay the fines or penalties. We have been asked if this will work many times. The Office for Civil Rights (OCR) has answered this haunting question.

Three years ago the OCR received an anonymous complaint against Filefax, Inc. that transported 2,150 patient files to be shredded. These files were left in an unlocked truck in their parking lot, or by granting permission to an unauthorized person to remove the files from Filefax, and leaving the Protected Health Information (PHI) unsecured outside the Filefax facility.

Although Filefax shut their doors during the course of the OCR’s investigation they were still obligated under the law. In 2016, a court in unrelated litigation appointed a receiver to liquidate its assets. In addition to a $100,000 monetary settlement, the receiver has agreed, on behalf of Filefax, to properly store and dispose of remaining medical records found at Filefax’s facility in compliance with HIPAA.

The first step in protecting your practice or business is to conduct a thorough security risk assessment and identify vulnerabilities and workflow. From there you can develop a risk management plan to ensure you document your compliance efforts and mitigate risks.

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”