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HIPAA Compliance

The Health Insurance Portability and Accountability Act (HIPAA) establishes security standards for safeguarding sensitive personally identifiable patient data, known as Protected Health Information (PHI). Enforced by the Office of Civil Rights (OCR), a division of the Department of Health and Human Services (HHS), HIPAA compliance aims to ensure health insurance portability, eliminate job lock due to preexisting medical conditions, and combat healthcare fraud and abuse by enforcing strict standards for the security and privacy of personal health information

 

Methodology

The HIPAA regulation delineates two main types of organizations:

Covered Entities

These encompass organizations that electronically gather, create, or transmit personal health information (PHI). Primarily, this category includes healthcare entities such as insurance carriers and healthcare service providers.

Business Associates

These are organizations that come into contact with PHI in any capacity while working on behalf of a covered entity under contract. Examples include billing companies, third-party consultants, IT providers, and cloud storage services.

HIPAA Security Rules

The primary security, maintenance, and handling protocols apply to both covered entities and business associates.

HIPAA Privacy Rules

It sets forth the guidelines regarding patients’ rights to Protected Health Information (PHI) and is applicable to covered entities.

HIPAA Breach Notification Rules

This includes both companies and business associates and must be adhered to in the event of a data breach.

Expertise

Our Approach

Secnora streamlines HIPAA compliance for clients by providing a team of professionals who develop customized Policies and Procedures tailored to their existing infrastructure. Our documentation adheres to HIPAA guidelines, including essential policies like;

 

Information Security Policy

Cyber Crisis Resiliency Program

Incident Management Procedure

Privacy Statement

Data Protection Policy

Privacy Impact Assessment

We aid the organization in assessing the impact of privacy controls and identifying existing gaps in privacy procedures. Subsequently, we initiate the Privacy Control Implementation process based on this assessment. This process includes conducting a data protection impact assessment (DPIA) to ensure comprehensive privacy management.

Centralized Process

During this phase, we develop and construct centralized procedures tailored to our clients’ needs and assist in their implementation across their organizations. Key processes essential for HIPAA compliance include:

  • Data Subject Request handling.
  • Management of Data Subject consent.
  • Creation of breach inventory for incidents that have occurred.

Controls Framework

In this phase, we establish and oversee the implementation of all necessary controls within the organization. Additionally, we conduct Awareness Sessions for our clients to guide them through the implementation of each control in accordance with HIPAA requirements.

Risk Register

During this phase, we analyze the current system of the company in alignment with HIPAA requirements to pinpoint existing risks. We collaborate with our client to identify these risks comprehensively and then guide them in implementing the requisite controls and policies to mitigate these risks effectively.

Yearly Audit Framework

At this stage, we outline the plan for the Yearly Audit and execute it in collaboration with the organization. Following the implementation of all regulations and processes, the organization must undergo annual auditing, a service we provide to assist our customers.

Security Rules for HIPAA

HIPAA mandates that covered entities and Business Associates adhere to several security rules:

Safeguard the confidentiality, integrity, and availability of all electronic protected health information (e-PHI) they handle

Identify and mitigate foreseeable threats to the security or integrity of this information.

Prevent improper uses or disclosures that could reasonably occur.

Ensure compliance among their employees with these regulations.

Frequently Asked Questions

  • Privacy – Ensuring patients’ rights to Protected Health Information (PHI)
  • Breach Notification – Mandatory steps to take in the event of a breach
  • Security – Implementing physical, technical, and administrative security measures

  • Hacking
  • Inadequate records disposal practice
  • Insufficient Employee Training
  • Unauthorized Information Disclosure
  • Device Theft Due to Lack of Security

Any covered entity (CE) or business associate (BA) handling, processing, transmitting, maintaining, or encountering protected health information (PHI) must ensure compliance with HIPAA regulations.

Both the healthcare organization and individual employees with access to Protected Health Information (PHI) bear liability. The organization holds the responsibility for ensuring HIPAA compliance through the implementation of all
necessary safeguards.

SECNORA® is a CREST Accredited cyber security focused consulting firm with expertise in Information Security and Governance, Risk, Compliance.

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