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A devastating ransomware attack on health insurance giant Change Healthcare in early 2024 impacted the medical data of at least 190 million Americans, resulting in losses of over 1.5 billion for UnitedHealth Group. Complying with the Health Insurance Portability and Accountability Act isn’t just about fulfilling government regulations anymore; learning how to become HIPAA compliant is a priority for your organization to protect itself.
This guide walks you through the foundational steps to HIPAA compliance.
At its core, HIPAA compliance involves keeping patient data safe, secure, and private. The goal of HIPAA regulations is to safeguard protected health information — such as a patient’s medical records, payment information, SSN, and other personally identifiable information.
To achieve this seemingly simple objective, healthcare providers need to implement policies and systems for organizational technology, personnel, and practices. Becoming HIPAA compliant means designing a HIPAA framework that fits your business — and your patients — and putting it into practice.
Depending on the size of your enterprise, this process can be complex. There are legal and regulatory considerations at stake, which is why working with HIPAA professionals is so important.
HIPAA doesn’t have a long list of detailed procedures. Instead, this framework outlines general requirements in Security, Privacy, and Breach Notification Rules.
The Security Rule focuses on the safeguards that are necessary to protect ePHI against cyberattacks, breaches, ransomware, and other threats. This rule has four main objectives:
The tools and processes your organization uses to reach these objectives can vary. How complex your framework needs to be depends on factors such as your total personnel, the types of technology you use, likely risks and vulnerabilities, how many different locations you operate, and your company’s budget. In general, you always have to follow reasonable industry practices for physical and electronic security.
The Privacy Rule aims to limit the use and transmission of patient data to authorized individuals only. For example, doctors, nurses, and consulting physicians who care for the patient need access to the relevant medical records, but other employees don’t.
Health insurance providers can process ePHI (names, SSNs, test results, payment card information, etc.) as required for billing, but they can’t share information with third parties, such as advertisers. HIPAA guidelines allow patients to access their own data at any time, but unauthorized friends, family members, or strangers can’t.
HIPAA and HITECH (and the FTC in some situations) require healthcare organizations to have procedures in place for reporting breaches of healthcare information. When a data breach happens, HIPAA compliance means you must:
You have 60 days to comply with the Breach Notification Rule before risking severe penalties. HITECH updates make your organization responsible for managing data breach notifications, even if they happen to a third-party business associate, such as Zoom or Microsoft.
The process of becoming HIPAA compliant is similar to driving down a highway. Some enterprises start closer to the destination than others, but every driver needs a reliable map.
Your organization may already have some good cybersecurity habits, but no matter your experience and technology, HIPAA compliance requires changes. It’s an ongoing process, especially when it comes to your personnel.
The first step in putting together a HIPAA compliance program is knowing what you need to protect. PHI refers to any healthcare information that can identify someone, including all of the following:
Many medical records have ePHI, including lab reports, CT scans, X-rays, prescriptions, bills, and hospital admissions forms. Emails, phone records, and telehealth videos also have ePHI.
By performing a comprehensive audit, you learn what types of sensitive patient data your organization handles, processes, or saves. This is called your HIPAA compliance scope. Details like where you store ePHI and how you use it can help you craft effective compliance policies.
The HIPAA Privacy Rule and Security Rule require you to put responsible individuals in charge of monitoring compliance. Small businesses sometimes have the same person overseeing security and privacy processes. However, larger enterprises usually have three separate positions: a security officer, a privacy officer, and a HIPAA compliance officer. Each one of these positions involves creating the respective policies, assigning responsibilities, ensuring departments and employees follow through, and making any necessary changes for better results.
Once you have a rough outline of the departments and officers in charge of HIPAA compliance, the next step is to look for potential vulnerabilities, ePHI risks, and attack surfaces. Many enterprises partner with IT professionals or HIPAA specialists for this, but you can also follow your company’s established risk analysis process.
The most common vulnerabilities for HIPAA programs involve the human element:
Other threats include phishing attacks, dubious apps, slow software updates, weak administrator protections, no daily backups, and not using multi-factor authentication.
Knowing your weaknesses is a good thing. It alllows you to prepare strong defenses and policies that fit your organization’s day-to-day operations. That’s why you should always speak with a wide range of stakeholders when crafting procedures related to HIPAA compliance, from nurses to hospital maintenance personnel.
To protect ePHI, modern healthcare providers need three layers of security:
HIPAA compliance doesn’t mean you’re responsible for going to extreme lengths to prevent hacks. Instead, it requires you to take reasonable precautions and follow cybersecurity best practices. These are tools and policies that the majority of organizations should be using, given the rising threat of cybercrime. Not every company can invest in 24/7 network monitoring, for example, but the better your protection, the safer your data and patients are.
One of the most important areas for developing in-depth policies for HIPAA compliance is ePHI access control measures. Having detailed guidelines to prevent unauthorized access helps you avoid employee-related HIPAA violations and many cybersecurity risks.
The principle of least privilege means only allowing employees to access records that are necessary for their work. For example, billing department employees don’t usually need access to doctor-patient communications, and physicians don’t need access to a patient’s credit card data.
Correctly configured firewalls and network tools can also help. They can block suspicious traffic or alert admins if there are multiple failed password attempts.
A good privacy policy benefits your organization, your patients, and your employees. It tells patients how you use and store their data, for how long, and what steps they should take to request a copy. On the other hand, it gives your employees a quick reference they can check and follow for managing ePHI in a HIPAA-compliant manner.
Here’s an example: “At XYZ Health, we will never share your medical records with family members without your consent, either online or in person. To authorize a representative to receive documents on your behalf, please fill out our “Records Disclosure Consent Form.”
The HIPAA Privacy Rule gives patients the right to request copies of all ePHI, including billing records, scans, and doctor’s notes. This can impact your data storage practices.
Any records system you use must organize files by patient. You have to respond to records requests within 30 calendar days.
Hackers frequently target healthcare supply-chain businesses to bypass security measures. Instead of trying to breach your firewall directly, cyber attackers try infiltrating the systems of medical device manufacturers or accounting partners. Third-party attacks were involved in almost 60% of healthcare data breaches in 2023.
HIPAA compliance can help you. One requirement is to obtain a Business Associate Agreement from all vendors that come into contact with ePHI, including email hosting services like Microsoft Outlook. The BAA should indicate that the service provider is fully compliant with HIPAA regulations.
Hospitals and insurers often have dozens or hundreds of employees, which presents many opportunities for mistakes that can lead to data breaches. While creating thorough HIPAA compliance policies is a good first step, you also need to offer continual training so employees follow organizational guidelines every day. Pay special attention to anti-phishing training and device security practices.
Sadly, you can’t afford to trust that employees will always follow through on HIPAA policies. Some violations are even deliberate, including internal theft of financial information, leaks of confidential patient records, or uploading malware in exchange for payment.
The solution is to use a compliance platform such as Compyl. This versatile tool can help you minimize both accidental and deliberate HIPAA violations:
Tracking platforms can reveal trends or issues that you need to target ASAP.
HIPAA compliance only works if employees get involved. Create a culture of responsibility and support. Designate a responsible individual and channel for reporting HIPAA violations, suspicious activities, or strange messages. One of the best ways to avoid falling for phishing attacks is to train employees to reach out directly to you if they get an odd email, phone call, or text message.
HIPAA policies must include penalties for non-compliance. Employees must understand the seriousness of improperly accessing or carelessly disclosing patient data. Punishments should correspond to the level of the violation, ranging from friendly but firm reminders to fireable offenses for serious or repeated failures.
Despite your best efforts, evolving threats can succeed in evading your defenses. This doesn’t mean HIPAA is pointless. In fact, part of a robust HIPAA framework is having a contingency plan for “what ifs.” For example, by keeping an encrypted backup off the network, you may be able to recover more quickly from a ransomware attack.
HITECH and HIPAA guidelines don’t have an official certification process. Some independent auditing firms provide attestation, or you can pursue HITRUST CSF certification. Following through on compliance should always be your primary goal.
HIPAA and HITRUST costs vary widely based on the size and complexity of your business, risk profile, consulting services, technology costs, and IT needs. One thing is virtually guaranteed: The annual cost of compliance is far less than the estimated $11 million that a single healthcare data breach usually costs.
Minimize human error and maximize efficiency with HIPAA compliance automation. Compyl is one of the best ways to become HIPAA compliant, no matter how many employees or how much patient data you manage. Contact us today for expert assistance with HIPAA compliance.
