Complying with HIPAA regulations doesn’t have to be overwhelming. By following these four essential steps, organizations can ensure they meet federal requirements and protect sensitive patient data:
- Identify if Your Organization is a Covered Entity
Determine whether your organization qualifies as a covered entity under HIPAA rules, including healthcare providers, health plans, or healthcare clearinghouses. - Implement Required HIPAA Controls
Apply administrative, physical, and technical safeguards to comply with HIPAA’s prescriptive rules and protect patient health information (PHI). - Establish a Breach Notification Infrastructure
Ensure you have processes and systems in place to detect, respond to, and report data breaches within the required HIPAA timelines. - Streamline Compliance with a Unified Approach
Integrate HIPAA compliance efforts across your organization to reduce duplication, maintain accountability, and simplify audits.
Step 1: Check if HIPAA Applies to You
The Health Insurance Portability and Accountability Act (HIPAA), enforced by the U.S. Department of Health and Human Services (HHS), protects protected health information (PHI), including patients’ medical and billing records. If your organization handles PHI, HIPAA regulations likely apply.
While often associated with healthcare professionals, HIPAA regulations extend beyond the healthcare sector. Covered entities include:
- Healthcare providers, doctors, clinics, hospitals
- Health insurance plan administrators
- Healthcare clearinghouses
These entities frequently interact with PHI and are directly impacted by compliance requirements.
HIPAA also applies to certain business associates that work with covered entities. Through a Business Associate Agreement (BAA), organizations outside healthcare may also need to comply with HIPAA regulations if they handle PHI.
Ensuring your organization understands whether HIPAA applies is the first step in implementing the necessary controls and safeguarding sensitive data
Assess your HIPAA / HITECH compliance
Step 2: Implement Privacy and Security Protections under HIPAA Regulations
A critical part of HIPAA regulations is implementing the required privacy and security safeguards. The Privacy Rule and Security Rule together account for the majority of HIPAA compliance efforts.
Key Responsibilities Under the Privacy Rule:
- De-identify PHI by removing personal identifiers such as names, addresses, and social security numbers.
- Provide individuals access to their PHI upon request.
- Account for required disclosures to individuals or the HHS when requested.
- Restrict PHI access to specific permitted uses and disclosures:
- Disclosure to the individual who is the subject of the PHI
- Uses for treatment, payment, and healthcare operations
- Uses where the subject can agree or object
- Incidental disclosures during authorized activities
- Uses for public benefit or research initiatives
- Limited data sets for research or other approved activities
- Limit access to the minimum necessary for all permitted, non-required PHI.
Key Responsibilities Under the Security Rule:
- Ensure confidentiality, integrity, and availability of PHI and electronic PHI (ePHI).
- Implement Administrative Safeguards, including:
- Security management processes
- Security personnel and resources
- Information access management
- Workforce training and management
- Ongoing evaluation and monitoring
- Implement Physical Safeguards, including:
- Facility access and control
- Device and workstation security
- Implement Technical Safeguards, including:
- Access control
- Audit controls
- Integrity controls
- Transmission security
- Monitoring and addressing threats or vulnerabilities affecting PHI
Implementing these protections ensures your organization adheres to HIPAA regulations, reducing the risk of breaches, fines, and reputational damage.
Step 3: Prepare for Breach Notification Under HIPAA Regulations
A core component of HIPAA regulations is preparing for breach notification responsibilities. While many HIPAA safeguards aim to prevent unauthorized access to patient information, the Breach Notification Rule establishes protocols for responding if a breach occurs.
What Constitutes a HIPAA Breach:
A breach occurs when protected health information (PHI) is accessed, used, or disclosed without authorization. This includes PHI that was previously de-identified but is improperly re-identified or accessed.
Notification Requirements:
- Individual Notice:
- Must be provided in writing within 60 days of the breach.
- Individuals can opt to receive notice electronically.
- If contact information is unavailable for 10 or more people, post the notice on your organization’s website homepage for at least 90 days.
- HHS Reporting:
- Breaches affecting fewer than 500 individuals can be reported annually, no later than 60 days after the calendar year ends.
- Breaches affecting 500 or more individuals must be reported within 60 days to the HHS.
- Media Notification:
- For large-scale breaches (500+ individuals), covered entities must notify news outlets serving the areas where affected individuals reside.
- For large-scale breaches (500+ individuals), covered entities must notify news outlets serving the areas where affected individuals reside.
Preparing and executing these notifications promptly ensures compliance with HIPAA regulations, minimizes potential harm to patients, and reduces liability for your organization.
Assess your HIPAA / HITECH compliance
Step 4: Optimize Processes for Seamless HIPAA Compliance
Organizations navigating HIPAA regulations often face additional compliance requirements from other frameworks and laws. Overlapping requirements can lead to duplicated efforts, increased costs, and complex audits.
The HITRUST CSF addresses this challenge by aligning HIPAA guidelines with many other widely applicable regulations. For instance, organizations subject to the National Institute of Standards and Technology (NIST) frameworks or the Payment Card Industry Data Security Standards (PCI DSS) can implement controls that satisfy both HIPAA regulations and these standards simultaneously.
HITRUST offers multiple assessment types, each providing varying degrees of HITRUST Certification. At intermediate and advanced levels, organizations benefit from a “report once, assess many” approach, allowing a single audit to fulfill multiple compliance obligations.
By optimizing processes in this way, organizations can simplify audits, reduce costs, and maintain continuous compliance with HIPAA regulations while meeting other regulatory requirements.
Get Started with HIPAA Compliance Today
Whether your organization is new to HIPAA regulations or looking to refine existing systems, following the four-step plan above can help streamline your compliance efforts and safeguard protected health information (PHI).
At RSI Security, we’ve helped countless organizations achieve and maintain full HIPAA compliance. Our experts understand that proper implementation is essential not only for protecting PHI but also for safeguarding your business, partners, and clients.
Ready to simplify your compliance process and ensure adherence to HIPAA regulations? Contact RSI Security today to learn more about our HIPAA solutions and start protecting sensitive health information effectively.
