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Compliance with the Health Insurance Portability and Accountability Act is critical for all healthcare organizations. Whether your organization has less than a dozen employees or hundreds, the penalties for HIPAA violations can have a major impact on your finances — as much as $50,000 per violation and $1.5 million per year depending on the seriousness of the breach. To avoid these devastating effects, it’s urgent to understand what a HIPAA officer is and what your next steps should be.
Put simply, a HIPAA officer is an individual who is responsible for coordinating, implementing, and monitoring compliance with HIPAA guidelines. The purpose of a HIPAA officer is to help your business meet HIPAA standards and stay compliant as time goes on. Depending on the size of your organization, you may choose a single HIPAA compliance officer or divide responsibilities between a security officer and a privacy officer.
The HIPAA Privacy Rule and Security Rule both have some overlap, so it makes sense for smaller organizations to have one person handle both aspects of compliance. That way, there are fewer risks of miscommunication, crossed wires, or compliance mistakes.
Things are different for large enterprises with many departments and employees to coordinate. Trying to keep tabs on both privacy compliance and security measures can be overwhelming for just one person, especially if the individual has other administrative responsibilities to care for.
The need for a HIPAA privacy officer is outlined in section 164.530 under “Administrative requirements.” The privacy official must ‘develop and implement’ organizational privacy policies that comply with HIPAA standards.
The HIPAA Privacy Rule deals with keeping PHI confidential and avoiding disclosure to non-authorized parties (including family members). Permissible disclosures, such as those for treatment, payment, or healthcare operations, are allowed under certain conditions, while unauthorized disclosures occur when PHI is shared without proper consent or authorization. At the same time, HIPAA compliance means making sure patients have access to and control over their data.
In section 164.308, the HIPAA Security Rule also requires your organization to “identify the security official who is responsible for the development and implementation of the policies and procedures required.” The HIPAA security officer is responsible for ensuring your organization has the security measures necessary to follow privacy practices related to PHI. Examples range from risk analysis to anti-malware software.
HIPAA guidelines leave it up to your organization to select the individual(s) responsible for compliance. You can choose a current employee or hire someone new to handle the role.
Even though it’s technically not a requirement, in practice, you want a person who understands HIPAA guidelines and has experience with compliance. There are no rules against the person taking care of other responsibilities besides HIPAA management, but HIPAA compliance is a full-time job in larger organizations.
In simple terms, a HIPAA officer’s job is to make sure your organization complies with the Privacy and Security Rules. This is more complex than it sounds.
The security officer’s role revolves around keeping electronic PHI safe. This includes preventing, containing, identifying, and resolving data breaches. The individual also has to establish and oversee healthcare information systems, such as secure data storage and platforms for telehealth.
Other responsibilities include implementing:
The HIPAA security officer also helps create organizational policies related to data storage and handling. For example, there should be policies in place that prevent unauthorized workers from accessing patient records. Security training includes teaching employees to lock their devices and to recognize and avoid phishing emails.
It’s also vital to create policies for responding to access violations, network security mistakes, and potential data breaches. One of the main factors that determines the cost of HIPAA violations is how your organization acts following a suspected breach. Quick action and the right safeguards are the difference between a small incident and massive headlines.
Beyond creating an organizational privacy policy that satisfies the HIPAA Privacy Rule — and updating it every year — the privacy officer is also responsible for monitoring compliance. This involves many smaller tasks:
In larger organizations, the HIPAA privacy officer often needs to coordinate closely with the security officer (and potentially the legal department). For example, telehealth appointments have both cybersecurity and privacy considerations under HIPAA rules.
Whether your healthcare practice has one HIPAA compliance officer or divides the work between a privacy and security officer, gathering documentation is one of the biggest responsibilities for each role. Documents are necessary to show:
In other words, following HIPAA policies isn’t enough. You also have to prove that your organization is HIPAA compliant. A compliance platform such as Compyl can make your workload much lighter by helping you track compliance goals and automate document creation.
Outsourcing HIPAA compliance isn’t the best idea, in our professional opinion. An in-house HIPAA officer is more aware of day-to-day operations and workflow changes that can impact compliance. Third-party providers can also be less willing to take corrective actions or recommend disciplinary measures for noncompliance.
A HIPAA officer doesn’t have to be perfect or an endless encyclopedia of IT security practices. The person just needs to have the right tools and professional support available. At Compyl, we’ve helped business professionals navigate HIPAA compliance successfully for a long time. Discover how it works.
