OCR Archives

Office for Civil Rights (OCR) Self Reporting – Should you do it?

Suze Shaffer October 18, 2017February 1, 2024

By Aris Medical Solutions

If you have a minor breach (under 500 records) you are required to self report this breach within 60 days after the end of the calendar year in which the disclosure occurred. If you report it, you run the risk of being investigated. So many times I hear organizations say… why would I “report” myself, that would be insane! If you do not report it and it is discovered at a later date, the fines will be increased and they will investigate heavily to determine if you have concealed any other breaches. So, the answer is YES; you should self report.

Understand that the different agencies like the Office for Civil RIghts (OCR) who enforces HIPAA, Federal Trade Commission (FTC), Department of Justice (DOJ), and Centers for Medicare and Medicaid (CMS) more than likely communicate with each other. If you are audited or investigated by one agency, they are looking at your organization as a whole and may report their findings to other agencies. In one scenario that we recently were made aware of the organization was expecting an investigation from the Office for Civil Rights and the Department of Justice showed up! These agencies can decide how and what to investigate based on the information they have received.

The best way to protect your organization is to make sure you have a complete and thorough risk analysis. This will uncover potential vulnerabilities and give you the opportunity to mitigate them BEFORE something happens. Next, make sure you have a risk management plan that dates/documents what you have implemented/corrected based on your risk analysis. Policies, procedures, and documentation are the foundation of all organizations. Your employees need clear and concise procedures so they understand what they need to do. This always insulates you from misunderstanding. Above all, it demonstrates your compliance efforts!

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”

1557 Discrimination Law – is your practice at risk?

Suze Shaffer April 3, 2017February 2, 2024

By Aris Medical Solutions

Section 1557 is the nondiscrimination provision of the Affordable Care Act (ACA). The law prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. Section 1557 builds on longstanding and familiar Federal civil rights laws: Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975. Section 1557 extends nondiscrimination protections to individuals participating in:

Any health program or activity any part of which received funding from HHS
Any health program or activity that HHS itself administers
Health Insurance Marketplaces and all plans offered by issuers that participate in those Marketplaces.

Section 1557 has been in effect since its enactment in 2010 and the HHS Office for Civil Rights has been enforcing the provision since it was enacted.
This provision goes much further than most practices are aware of including the fact this rule became effective July 18, 2016.

Take steps to ensure 1557 has been addressed:
Assign a Civil Rights Coordinator;
Revise your policies and procedures;
Incorporate a general assessment evaluation;
Review the patient intake process;
Track all requests for auxiliary aids and services;
Monitor performance of interpreter services to ensure effective communication;
Review your complaint process;
Post a Notice of Nondiscrimination;
Post a Nondiscrimination Statement; and
Conduct mandatory training for all staff.

Title II of the Americans with Disabilities Act of 1990 (Title II), Section 504 of the Rehabilitation Act of 1973 (Section 504) and Section 1557 of the Affordable Care Act of 2010 (Section 1557) requires an entity to take steps to ensure communication with individuals with disabilities is as effective as communication with others through the use of appropriate auxiliary aids and services. This includes people with as well as language barriers.

OCR has modified the notice requirement in § 92.8 to exclude publications and significant communications that are small in size from the requirement to post all of the content specified in § 92.8; instead, covered entities will be required to post only a shorter nondiscrimination statement in such communications and publications, along with a limited number of taglines. OCR also is translating a sample nondiscrimination statement that covered entities may use in fulfilling this obligation.
In addition, with respect to the obligation in § 92.8 to post taglines in at least the top 15 languages spoken nationally by persons with limited English proficiency, OCR has replaced the national threshold with a threshold requiring taglines in at least the top 15 languages spoken by limited English proficient populations statewide.

Samples can be downloaded here:
https://www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources/index.html

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”

Storing Patient Records

Suze Shaffer July 15, 2016February 2, 2024

By Aris Medical Solutions

Since most medical practices are going electronic, it may be time to free up some of that precious space in your office. Make sure when, how, and where you decided to store your data is secure.

Some practices move excess patient charts to a self storage unit. It’s cheap and if you have an patient chart inventory list you should be safe… right?
What happens if the facility burns down?
What if someone breaks in and it is not discovered for months?
What if you don’t have an inventory list of which records are in there?

Did you know that PHI is considered PHI until after a person has been deceased for 50 years! That means even if the person isn’t alive, it is still a reportable breach!
Did you know that if you can’t determine if ANY records or WHICH records were stolen, you would have to report all of them.

Self storage units may sound like a good deal. That good deal could cost you more in the end. If the unit burns or if it is vandalized, you could be charged for wilful neglect for NOT securing the records. Not to mention, you may be required to report this as a data breach and cost you nearly $350.00 per record! Are you willing to accept that risk? After all, the OCR doesn’t specifically state what is or is not HIPAA compliant. If you suffer a data breach, THEN they will determine if you had reasonable and appropriate safeguards in place.

Now I will ask you.. Wouldn’t it make sense to spend about the same amount of money and have a professional company store your records? That’s right; for about $50.00 per month you can store approximately 100 boxes of records! Of course pricing will depends on your location and how many you need to store. When organizing the records, we suggest by year and alphabetize them. This makes it much easier when the time comes to destroy them!

If you need assistance with a Risk Analysis, Risk Management Plan, or implementing a full set of HIPAA Policies and Procedures, call Aris at 877.659.2467 or click here to schedule a demo. We offer a full range of services from a Do-It-Yourself HIPAA program to a Full HIPAA Implementation package.

“Protecting Organizations through Partnership, Education, and Support”

OCR clarifies amount that can be charged for copies of PHI

Suze Shaffer June 10, 2016February 2, 2024

By Aris Medical Solutions

The Office for Civil Rights (OCR) announced the clarification in the Fact Sheet they released earlier this year. The maximum amount that can be charged for patients that request a copy of their Protected Health Information (PHI) under the right of access is not $6.50. Rather, charging a flat fee not to exceed $6.50 is an option available to those entities that do not want to go through the process of calculating the actual or average costs for requests for electronic copies of PHI maintained electronically. Entities may choose the fee calculation method that is most appropriate for their circumstances, of course within the boundaries of what is permissible under the Privacy Rule.

The new FAQ may be found at: New Clarification – Up to $6.50 Flat Rate Option. Additional information regarding permissible fees and other aspects of the individual right of access may be found at: http://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html
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”

Do you have your ALL of your Business Associate Agreements in place?

Suze Shaffer May 14, 2016February 1, 2024

By Aris Medical Solutions

The Omnibus Rule that became effective March 26, 2013 was a game changer in many ways. One area was requiring Covered Entities to ensure that Business Associate Agreements (BAA) were in place with all of their business partners by September 23, 2013. If a Covered Entity had agreements already in place, Covered Entities had until September 22, 2014 to replace them with new ones that had all of the required elements of the new Omnibus Rule.

Did you know that if a Covered Entity (Medical Practice) releases Protected Health Information (PHI) to person or an entity and the practice does not have a signed BAA in place, the Covered Entity can be fined? In the eyes of HIPAA, you have disclosed PHI to an unauthorized user. Yes, this is TRUE!

Did you know that if a medical practice’s software vendor has a data breach and you as the Covered Entity do not have a BA agreement in place you could be fined as well? I know what you are thinking… it’s THEIR responsibility, not yours. True, but it is YOUR responsibility to have an agreement in place. Have you reviewed your BA agreements to ensure the documents have all of the required elements and it protects YOU the Covered Entity? These are very important documents and since it is the responsibility of the medical practice to protect patient data, the practice dictates when this information can be shared. The practice also has the responsibility to have assurances that the entity understands how to protect the data before it is released.

The Office for Civil Rights (OCR) recently imposed a $750K fine for such an offense. A Raleigh Orthopedic practice released 17,300 x-rays films to a Business Associate (BA) that promised to transfer the images in exchange for the silver in films. Unfortunately the practice forgot to have the entity sign a Business Associate Agreement.

Make sure you do not make the same mistake…

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”