How to Prepare For Your Next HIPAA Audit
Proactive steps to be HIPAA audit ready
In the healthcare industry, compliance with the Health Insurance Portability and Accountability Act (HIPAA) is non-negotiable. HIPAA sets stringent standards for the protection of patients' sensitive health information and imposes hefty penalties for non-compliance. One crucial aspect of HIPAA compliance is undergoing periodic audits to ensure that healthcare organizations are meeting the required standards.
We’ll explore essential compliance measures that healthcare companies need to have in place to pass their next HIPAA audit successfully. From understanding the HIPAA audit process to implementing a comprehensive HIPAA compliance program, let's dive into the key steps to prepare for your next HIPAA audit.
Understanding the HIPAA Audit Process
Before diving into the specific compliance measures, it's essential to understand the HIPAA audit process. HIPAA audits can be conducted by the Office for Civil Rights (OCR), which is responsible for enforcing HIPAA regulations. These audits typically assess an organization's compliance with HIPAA's Privacy, Security, and Breach Notification Rules. The audit process may include a review of policies and procedures, on-site visits, interviews with staff and a thorough examination of systems and controls.
How to prepare for a HIPAA Compliance audit?
The best way to prepare for a HIPAA audit is to always be ready for one. Here are a few compliance measures healthcare companies can proactively take to stay HIPAA compliant all year round.
Hire and staff a HIPAA privacy and security officer
In the past, this role typically fell under your organization's IT Manager to handle any privacy or security requirements. However, with the continued innovation in health technology and AI, this has become a much larger role.
Today, the HIPAA rule mandates the appointment of a HIPAA Privacy officer for each Covered Entity and Business Associate of a Covered Entity. Here are some of the responsibilities this role would hold:
Responsible for ensuring that the organization complies with the HIPAA Privacy Rule and other relevant regulations regarding the protection of patients' health information.
Develop and implement policies and procedures related to the privacy of protected health information (PHI), including the Notice of Privacy Practices (NPP), to ensure that patient privacy is maintained.
Facilitates training for employees, contractors and volunteers on HIPAA Privacy Rule requirements and organizational policies related to the privacy and security of PHI.
Investigate complaints related to patient privacy breaches and unauthorized disclosures of PHI, taking appropriate corrective actions and reporting incidents as required by law.
Ensures that all privacy-related activities, including policies, training, incidents and audits are properly documented and reported to senior management and regulatory authorities as necessary.
Conduct HIPAA employee training
Your employees must be trained on HIPAA policies for proper handling and storing of PHI. By offering training, it ensures that every employee in your organization is up-to-date on HIPAA policies and any policy updates. Creating and facilitating this training is something your HIPAA privacy officer and HR team will collaborate on and own.
It’s important to note that training and education doesn’t stop at orientation. Healthcare organizations should continually notify employees of any policy updates and provide additional training if necessary.
Here is a checklist of what your employee HIPAA training should offer:
Understand the fundamental principles and requirements of HIPAA, including the Privacy, Security and Breach Notification Rule.
Review the basics of HIPAA law. Employees should understand their role in safeguarding PHI and recognize potential security threats and risks.
Become familiar with the organization's HIPAA policies and procedures. Training should emphasize adherence to these policies to ensure consistent compliance with HIPAA regulations.
Explain the consequences of HIPAA violations.
Cover the steps to take in the event of a security incident or breach, including reporting procedures, containment measures and notification requirements.
Conduct a risk assessment and create a risk management plan
A comprehensive risk assessment is the foundation of HIPAA compliance. They identify potential risks and vulnerabilities to the confidentiality, integrity and availability of protected health information (PHI) within your organization.
Depending on the healthcare organization, risk assessments can vary. Unfortunately, this means there’s no universal template for how to conduct one. Here are some general steps and guidelines that most organizations follow to get you started:
Analyze the flow of PHI within your system, including its creation, transmission, storage and exit pathways.
Identify potential threats, risks and vulnerabilities across your system, applications and processes, including risks posed by hackers, weak passwords and internal factors such as disgruntled employees.
Assess your HIPAA risk level thoroughly, considering both the likelihood and potential impact of potential threats.
Develop a comprehensive risk management plan, including regular testing of your environment through vulnerability scans, penetration tests and gap analysis.
Maintain detailed documentation outlining all aspects of your risk management efforts.
Develop policies and procedures and implement a periodic review
Establish clear policies and procedures that govern the handling of PHI in accordance with HIPAA regulations. These policies should cover areas such as data access controls, encryption methods, employee training, incident response protocols and breach notification procedures.
As your organization grows and changes, it’s important to implement periodic reviews of these policies and procedures to ensure everything is running smoothly. It’s also a great time to identify any needed updates or additional documentation.
Ensure the necessary HIPAA safeguards are in place
There are three types of safeguards you should be aware of:
Administrative
HIPAA's administrative safeguards require healthcare organizations to implement measures to manage and protect PHI. This includes designating a HIPAA Privacy Officer and Security Officer, conducting regular employee training on HIPAA policies and procedures, and implementing controls to limit PHI access to authorized personnel only.
Technical
Technical safeguards are essential for securing electronic PHI (ePHI) stored or transmitted by healthcare organizations. Implement encryption measures to protect ePHI both at rest and in transit, utilize secure authentication mechanisms to control access to systems containing ePHI and implement audit controls to monitor and track access to ePHI.
Physical
Physical safeguards focus on protecting the physical infrastructure where PHI is stored or processed. Implement measures such as access controls, security cameras, and secure storage facilities to prevent unauthorized access to PHI-containing areas.
Conduct regular HIPAA security audits
Regularly audit your organization's HIPAA security controls to identify any gaps or deficiencies. Take another look at those safeguards you have in place, are there any weaknesses to address or updates to be made? When was the last time you took a look at your documentation process? Are employees properly disposing of physical papers or files?
Be sure to address any findings from the internal audit promptly.
Develop a breach response plan
Despite best efforts, data breaches can still and have occurred. The most recent being UnitedHealth’s cybersecurity attack effectively halting all billing. Healthcare organizations must develop a comprehensive breach response plan outlining the steps to take in the event of a data breach, including notifying affected individuals, reporting the breach to the OCR and implementing remediation measures to prevent future breaches.
How long does a HIPAA audit take?
The duration of a HIPAA audit can vary depending on several factors, including the scope of the audit, the size and complexity of the healthcare organization being audited, and the specific focus areas of the audit. On average, a HIPAA audit may take anywhere from several weeks to several months to complete.
For instance, a desk audit, which involves a review of documentation and policies remotely, may take less time compared to an on-site audit, which includes interviews with staff and physical inspections of facilities.
Additionally, the OCR may conduct a more extensive audit encompassing multiple aspects of HIPAA compliance, such as privacy, security, and breach notification, which could extend the audit duration.
Types of HIPAA violations that would prompt an audit
Unauthorized disclosure of PHI
This can be as simple as an employee emailing a receipt with PHI to the wrong patient and now an unauthorized user has access to that patient's information.
Lack of safeguards in place
Business associates and entities must implement safeguards within their organization. A violation of this could look like an employee leaving their laptop open, displaying PHI for anyone to see.
No patient authorization
It is a HIPAA requirement to obtain authorization from the patient prior to disclosing any of their protected health data. This authorization must be given in writing and specifically state the uses or disclosures.
Improper disposal of PHI
PHI should be shredded, burned or destroyed so it cannot be read or reconstructed. It is up to your organization to put physical and technical safeguards in place to ensure the proper disposal of PHI.
Failure to notify patients of a breach
A breach is defined as an unauthorized use or disclosure of PHI that compromises its privacy or security. It is required under HIPAA law that if a breach occurs, patients must be promptly notified.
How can OpenLoop help you stay HIPAA compliant?
Preparing for a HIPAA audit requires a proactive approach and a comprehensive understanding of HIPAA regulations. Implementing the essential compliance measures before an audit ever comes is the best way to stay compliant and pass an audit.
At OpenLoop, we know keeping patient information safe is a top priority for every healthcare organization. Compliance is built into every one of our seven core service offerings. Our team of experts stay up-to-date on HIPAA laws and regulations, offering state-by-state regulatory and legal support to our clients. Additionally, our intuitive, HIPAA-compliant EHR platform offers the security and privacy you require with the customizability you want.
Interested in what we can do for your organization? Get in touch here!
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