Healthcare Law Blog

Plan for the Worst, Hope for the Best: Why You Must Have a HIPAA Risk Assessment

“The single biggest and most common compliance weakness is the lack of a timely and thorough risk analysis.” More >

Preparing for Round Two, Continued

Earlier this week, information about OCR Phase 2 HIPAA audits was provided. Today, let’s take a look at how to prepare if your entity is selected for an audit:

• Confirm that a recent comprehensive Risk Assessment has been completed and documented.
• Confirm that all action items identified in the Risk Assessment have received attention and have been completed (or are in the process of being completed).
• Verify that policies are up-to-date, including breach notification procedures, notice of privacy practices, and responses to patient requests.
• Ensure that a current list of business associates (and their contact information) is readily available.

Because Phase 2 does not consist of on-site visits, there will not be an opportunity for dialogue with auditors. Therefore, it is crucial to ensure that documentation alone shows a complete picture of an entity’s compliance efforts. All documents should be carefully reviewed, dated, and signed before turned over to an auditor. While providing extraneous information is not recommended, it is important to double-check that all requested and necessary information is submitted.

Phase 2 audits set to occur in 2016 will focus on the Security Standard’s encryption and decryption requirements, facility access controls, breach reports and complaints. It is never too early to start considering what protocols, training, and procedures will need to be implemented in anticipation of a possible audit related to these items.

In the event you are selected for a Phase 2 audit and have any questions about your responsibilities or what you can do to ensure a smooth process, contact a McBrayer healthcare attorney today.

Services may be performed by others.

This article does not constitute legal advice.

Are You Ready for Round Two?

In February 2014, the Health and Human Services Office of Civil Rights (“OCR”) announced its plans to send pre-audit surveys to between 550 and 800 entities during the summer in preparation for Phase 2 HIPAA compliance audits. After collecting information from those surveyed, OCR will select about 400 of those entities for actual HIPAA audits. Those audits will begin this fall – which is quickly approaching. More >

OCR Offers “Lessons Learned” Regarding HIPAA Compliance, Part II

On Tuesday, some of the details of OCR’s recently released Breach and Compliance Reports were discussed. In addition to detailing facts and figures from cases involving breaches in 2011 and 2012, the Breach Report includes an important “Lessons Learned” section that all covered entities and their business associates should review. Based upon reported breaches, the OCR has outlined some specific areas of concern, which include the following: More >

Electronic Data Breach Leads to Largest HIPAA Settlement to Date

Recently, the Office of Civil Rights (“OCR”) of the Department of Health and Human Services entered into a $4.8 million dollar settlement with two New York-based health care organizations after a data breach involving electronic protected health information occurred. The agreement is the largest HIPAA settlement thus far. More >

Coming to a Medical Practice near You: HIPAA and Hi-Tech Audits

On December 26, 2013, the U.S. Health and Human Services Office of Civil Rights (“OCR”) announced  its first settlement with a covered entity for not having policies and procedures in place to address the breach notification provisions of the Health Information Technology for Economic and Clinical Health (“HITECH”) Act. Adult & Pediatric Dermatology, P.C., (“the Practice”) of Concord, Massachusetts agreed to settle potential violations with a $150,000 penalty and corrective action plan. More >

Plan for the Worst, Hope for the Best: Why You Must Have a HIPAA Risk Assessment

“The single biggest and most common compliance weakness is the lack of a timely and thorough risk analysis.” More >

Tools for the Trade: Understanding HIPAA

As a result of the intricate details and requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), it comes as no surprise that HIPAA Privacy and Security Rules can cause challenges and confusion for even the most sophisticated providers. With this in mind, the U.S. Department of Health and Human Services (“HHS”) Office for Civil Rights (“OCR”) has recently provided tools meant to educate both consumers and providers on HIPAA. More >