HIPAA / Healthcare Industry

The HIPAA Security Rule provides a structured framework to safeguard electronic protected health information (ePHI), ensuring its confidentiality, integrity, and availability to authorized individuals.

A critical component of HIPAA compliance is technical safeguards, which leverage technology to protect ePHI from unauthorized access, alteration, and transmission risks. These safeguards are essential for healthcare organizations to address modern cybersecurity threats effectively. This blog explores the critical aspects of technical safeguards and offers guidance on their implementation.

Stay Compliant with HIPAA Regulations in 2025
Since the 1990s, healthcare organizations and their business associates have followed HIPAA regulations to safeguard protected health information (PHI). While the core rules have remained largely unchanged, significant updates to the HIPAA Privacy Rule are scheduled for 2025, potentially adding complexity to compliance efforts.

The Health Insurance Portability and Accountability Act (HIPAA), signed into law on August 21, 1996, introduced sweeping reforms to protect the privacy and security of individuals’ health information.

The law is divided into five titles aimed at improving the portability of health insurance, streamlining administrative processes, and safeguarding protected health information (PHI).

Before HIPAA, it wasn’t always possible for someone who had declined coverage to sign up outside of that open enrollment window.

Generally accepted sets of cybersecurity solution standards or general requirements for protecting health information just didnt exist in the healthcare industry before HIPAA.

The implementation of HIPAA policies, procedures and rules ushered in a new era for the healthcare industry, giving patients peace of mind and instilling more faith in healthcare practitioners.

Unfortunately, HIPAA compliance is not being prioritized in some healthcare organizations. These entities instead seek out shortcuts to cut costs while putting patient protected healthcare information (PHI) at risk of being breached.

These breaches and the investigations in organizations that are not in compliance with HIPAA regulations have led to hefty fines as of recent years.

In 2016 alone, the U.S. Department of Health and Human Services Office for Civil Rights (OCR) collected a record-setting $23 million in HIPAA fines, greatly surpassing the previous record of $7.4 million in 2014.

Thats a lot of cheddar.

To keep your organization from violating HIPAA requirements and shouldering the weight of enormous fines and sanctions from the OCR, it is imperative that your organization educates itself on the types of violations that commonly incur these fines.

Understanding where other organizations went wrong in their negligent quest for HIPAA compliance will give you much more insight into how you can optimize your quest for HIPAA compliance in the future.

HIPAA Requirements

HIPAA is a series of laws that have required health care organizations to invest time and money into training for strict compliance.

HIPAA applies to covered entities that manage certain health plans, health care clearinghouses and health care providers as well as business associates such as service providers that create, receive, maintain or transmit Protected Health Information (PHI) for covered entities or other business associates.

Also Read: Top 5 Components of HIPAA Privacy Rule

Under HIPAA, participants could enroll in coverage if they meet certain criteria. For instance, if a marital situation changes or you move to a new location, HIPAA makes sure that you can get insurance without having to wait for open enrollment.

HIPAA covers different aspects of handling PHI such as creating, storing, transferring and sharing the data. It provides guidelines via its 5 titles and 5 rules on how to meet privacy and security requirements that will ensure the sustainable protection of your patients PHI. Without further ado, lets break down the 5 titles of HIPAA:

Title I: Health Care Access, Portability, and Renewability

Title I establishes rules on how a group plan handles a pre-existing condition. Before HIPAA, there were many people who were completely denied health insurance based on chronic medical conditions, regardless of how well the condition was controlled.

Today, group health insurance plans must follow rules regarding what’s considered a pre-existing condition and how long they can exclude coverage for these conditions.

Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform

Title II is broken up into 5 rules:

1. Privacy Rule
2. Transactions and Code Sets Rule
3. Security Rule
4. Unique Identifiers Rule
5. Enforcement Rule

Each of these 5 rules goes into considerable depth. Title II requires the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers.

Adopting these standards facilitates the improvement of efficiencies and effectiveness of the nation’s health care system by encouraging the widespread use of electronic data interchange across the healthcare industry.

Title III: Tax-related health provisions governing medical savings accounts

Title III provides for certain deductions for medical insurance, makes other changes to health insurance law, and establishes medical savings accounts for individuals. In laments terms, Title III standardizes the amount you can save per person in a pre-tax medical savings account.

Title IV: Application and enforcement of group health insurance requirements

Title IV addresses the application and enforcement of group health plan portability, access and renewability for those with pre-existing conditions, and modifies continuation of coverage requirements. It also clarifies continuation coverage requirements and includes COBRA clarification.

Title V: Revenue offset governing tax deductions for employers

Title V includes provisions related to company-owned life insurance, treatment of individuals who lose U.S. Citizenship for income tax purposes and repeals the financial institution rule to interest allocation rules.

HIPAA Requirements and Legal Framework

To understand how HIPAA violations occur, it’s essential to know what HIPAA requires.

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that mandates strict privacy and security standards for healthcare organizations. It applies to covered entities, such as health plans, healthcare providers, and healthcare clearinghouses, as well as business associates that handle protected health information (PHI) on behalf of those entities.

HIPAA introduced comprehensive rules for creating, storing, transferring, and sharing PHI, and it requires organizations to invest in training, safeguards, and documentation to remain compliant.

Here are five HIPAA rules

The Privacy Rule (circa 2000)

This rule addresses the use and disclosure of individuals health information called covered entities, as well as standards for individuals’ privacy rights to understand and control how their health information is used.

The OCR is responsible for implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and civil money penalties.

A major goal of the Privacy Rule is to assure that individuals health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public’s health and well-being.

The Transaction and Code Sets Rule (circa 2003)

This rule creates a uniform way to perform electronic data interchange (EDI) transactions for submitting, processing, and paying claims.

The standards inherent in this rule apply to any healthcare plan, health care clearinghouse, and/or health care provider that transmits PHI in electronic form in connection to the defined transactions.

The Security Rule (circa 2003)

This rule establishes national standards to protect individuals electronic personal health information that is created, received, used, or maintained by a covered entity.

The Security Rule requires implementation of three types of safeguards (administrative, physical, and technical) to ensure the confidentiality, integrity, and security of electronic PHI.

The National Provider Identifier (NPI) Rule (circa 2005)

This rule is focused on National Provider Identifiers (NPIs) which are unique identification numbers that covered health care providers must utilize during their administrative and financial transactions.

These NPIs must not carry other information about healthcare providers and must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.

The Enforcement Rule (circa 2006)

This rule establishes compliance responsibilities for covered entities with respect to cooperation in the enforcement process.

These rules govern the process and grounds for establishing the amount of a civil money penalty where HHS has determined that a covered entity has violated a HIPAA requirement.

Procedures for hearings and appeals for any challenges to a HIPAA violation determination are outlined in this rule as well.

What is a HIPAA Violation?

HIPAA violations are based on the level of negligence and the amount of infractions for non-compliance. Fines increase as the number of patients and the amount of neglect increases. Heres a breakdown of the types of violations and the financial consequences that come with each infraction:

VIOLATION TYPE	EACH VIOLATION	VIOLATIONS OF AN IDENTICAL PROVISION IN A CALENDAR YEAR
Individual didn’t know they violated HIPAA	$100 – $50,000	$1,500,000
Reasonable cause and not willful neglect	$1,000 – $50,000	$1,500,000
Willful neglect but corrected within time	$10,000 – $50,000	$1,500,000
Willful neglect and is not corrected	$50,000	$1,500,000

The consequences of HIPAA violations go far beyond the financial ramifications. Organizations can lose their good standing reputation, client/patient trust, and their ability to operate a business. It can take an organization months or even years to recover from a single HIPAA violation. The three common HIPAA violations that are outlined in the following sub-sections can be mitigated when you implement an effective compliance program that works for the needs of your organization:

PHI and ePHI Storage

Sensitive patient data is termed electronic protected health information (ePHI) and includes information like patient names, addresses, social security numbers, procedure codes, birth dates, and much more.

If PHI is stored on a laptop or smartphone, those safeguards must be implemented on the respective device. Encryption is considered an addressable specification, meaning covered entities are only required to implement it if it reduces the risk of ePHI data breach.

If you lose a laptop containing encrypted ePHI, the risk of an unauthorized user accessing the data is still low. However, the use of a laptop with unencrypted ePHI takes the risk of a data breach to a whole new level.

Data Breaches

Under HIPAA, organizations are required to report breaches that impact 500 or more individuals to federal regulators and affected individuals within 60 days. OCR treats data breaches severely when it finds that they’re the result of systematic neglect.

An organization that suffers a data leak despite consistently good security practices might get only recommendations on improving them.

One which is negligent, as in this case, could be made to give up a large amount of money and demonstrate improvement in its practices.

Below are the top 10 largest healthcare data breaches (listed by size, from largest to the smallest in terms of the number of individuals affected):

Number	Healthcare Provider	Individuals Affected	Date of Breach
1	Anthem Blue Cross	78.8 Million	Jan-15
2	Premera Blue Cross	11+ Million	Jan-15
3	Excellus BlueCross BlueShield	10+ Million	Sep-15
4	TRICARE	4.9 Million	Sep-11
5	University of California, Los Angeles Health	4.5 Million	Jul-15
6	Community Health Systems	4.5 Million	Jun-14
7	Advocate Health Care	4.03 Million	Aug-13
8	Medical Informatics Engineering	3.9 Million	Jul-15
9	Banner Health	3.62 Million	Aug-16
10	NewKirk Products	3.47 Million	Aug-16

Employee Training

HIPAA requires all covered entities to provide training to their employees in following HIPAA titles and rules. Covered entities are required to train all existing and new employees on HIPAA law, as well as providing a refresher course periodically.

Failure to provide this required training could mean major penalties for your organization. Most violations pertaining to employees can easily be prevented through the implementation of HIPAA policies and procedures to ensure that all individuals with access to PHI receive the proper training on how to safely handle it.

Even if an individual is negligent and engages in prohibited conduct such as knowingly obtaining or using HIPAA-protected information without authorization, they can still face criminal prosecution.

Even if they aren’t immediately aware that their actions are prohibited under the law, they are still held accountable for their negligence under HIPAA.

Ensuring that your materials are current, manuals are updated, and that you are conducting annual HIPAA training will put your organization in prime positioning to prevent potential violations.

HIPAA Violation Cases

Many HIPAA violations are discovered by HIPAA-covered entities through internal audits. Supervisors may identify employees who have violated HIPAA Rules and employees often self-report HIPAA violations and potential violations by co-workers.

The 5 Largest HIPAA Penalties to Date include:

Number	Healthcare Provider	Amount
1	Advocate Health Care Network	$5.55 million
2	Memorial Healthcare System	$5.5 million
3	New York-Presbyterian Hospital and Columbia University	$4.8 million
4	Cignet Health of Prince George County	$4.3 million (civil monetary penalty)
5	Fresenius Medical Care North America	$3.5 million

The second-largest HIPAA penalty to-date was the $5.5 million penalty perpetrated by Memorial Healthcare Systems across six hospitals and other facilities across the state of Florida. Unauthorized employees had access to ePHI through shared login credentials.

The reasons for the huge fine included failure to review access controls and examine audit logs. Credentials cannot be shared.

The July 2013 breach of more than 4 million patients confidential medical records that impacted Advocate Health Care Network ended up costing them a record $5.5 million in HIPAA violation penalties back in 2016.

This breach involved the theft of four desktop computers from Advocate Medical Groups administrative buildings along with two subsequent breaches within three months of the record breach.

The breach exposed demographic data, clinical data, health insurance information, payment card details, names, addresses, and dates of birth.

OCR investigators uncovered a catalog of HIPAA failures while investigating the 4+ million patient breaches at Advocate Health.

It was determined that Advocate Health had failed to implement HIPAA policies and procedures to control physical access to ePHI stored in its data support center. OCR investigators determined that if these HIPAA policies and procedures would have been implemented, the breaches would not have taken place.

Closing Thoughts

Patients entrust healthcare entities with their PHI, therefore it is of paramount importance that these entities must protect it against deliberate or inadvertent misuse or disclosure from internal and external sources.

Now that technologies are evolving and the healthcare industry is moving away from paper processes and relying more heavily on the use of electronic information systems, it is imperative for organizations to maintain their compliance with all facets of HIPAA.

With healthcare organizations receiving millions of dollars in fines for non-compliance, it goes without saying that the best course of action to protect your patients PHI and maintain their trust in your organizational data security is in consistent HIPAA compliance.

Stay ahead of HIPAA breaches download our   HIPAA Checklist and close your compliance gaps today.

Download Our HIPAA Checklist

The Health Insurance Portability and Accountability Act (HIPAA) mandates strict standards to protect the privacy and security of patients’ health information. A critical aspect of maintaining HIPAA compliance is conducting a thorough data breach analysis.

This process involves identifying, documenting, and mitigating breaches of protected health information (PHI). Here’s a step-by-step guide on how to conduct an effective HIPAA data breach analysis.

Understanding HIPAA Data Breaches

Before diving into the analysis process, it’s essential to understand what constitutes a data breach under HIPAA. A data breach is any impermissible use or disclosure of PHI that compromises its security or privacy. This includes unauthorized access, disclosure, alteration, or destruction of PHI.

Step 1: Immediate Response and Containment

When a data breach is suspected or detected, the first crucial step is to contain the breach. This involves several immediate actions to prevent further damage and preserve evidence for the investigation. One of the primary measures is disconnecting affected systems from the network to halt any unauthorized access or data exfiltration.

Additionally, changing passwords and revoking access for compromised accounts is essential to prevent further unauthorized use. Stopping any ongoing data transmissions is also critical to ensure that no more sensitive information is leaked. These containment steps are vital in minimizing further damage and maintaining the integrity of the evidence needed for a thorough investigation.

Step 2: Initial Assessment

Conduct an initial assessment to understand the scope and nature of the breach. Key questions to answer include:

• What data was compromised? Identify the types of PHI involved (e.g., medical records, social security numbers, financial information).
• How was the data compromised? Determine whether the breach resulted from hacking, employee error, lost or stolen devices, or other factors.
• Who is affected? Identify the number of individuals impacted and their relationship to the organization (e.g., patients, employees).

Step 3: Notification Obligations

HIPAA requires timely notifications to affected individuals, the Department of Health and Human Services (HHS), and sometimes the media. The specific requirements depend on the breach’s scope:

• Individual Notice: Notify affected individuals via first-class mail or email (if they have agreed to electronic communication). This must be done without unreasonable delay and no later than 60 days after discovering the breach.
• HHS Notice: For breaches affecting fewer than 500 individuals, notify the HHS annually. For breaches affecting 500 or more individuals, notify the HHS within 60 days of discovery.
• Media Notice: If the breach affects more than 500 residents of a state or jurisdiction, notify prominent media outlets within 60 days of discovery.

Step 4: Detailed Investigation

Conduct a detailed investigation to understand the breach’s root cause and full impact. This involves:

• Forensic Analysis: Engage cybersecurity experts to analyze affected systems and trace the breach’s origin. This helps identify vulnerabilities and how the breach occurred.
• Interviews and Audits: Interview employees and review system logs to gather additional information about the breach. Auditing access logs and system changes can provide valuable insights.
• Data Impact Assessment: Determine the extent of the compromised data. Identify specific records and the type of information breached.

Step 5: Risk Assessment

Conduct a comprehensive risk assessment to evaluate the breach’s potential harm. Start by assessing the sensitivity of the compromised information, considering details like medical history or financial records. Sensitive data can lead to significant repercussions, so it’s crucial to understand the nature of the PHI involved.

Next, evaluate the likelihood of the breached information being misused. This involves considering whether the data could be used maliciously, such as for identity theft or medical fraud. Estimating the potential impact on affected individuals is critical in this step, as it helps gauge the severity of the breach.

This risk assessment informs your mitigation strategies and helps prioritize response efforts. By understanding the potential harm and the likelihood of misuse, you can develop targeted actions to address vulnerabilities and protect affected individuals effectively.

Step 6: Documentation

Document every step of the breach analysis process meticulously. This documentation is crucial for compliance and potential legal actions. Key elements to include:

• Initial Report: Summarize the breach detection, initial response, and containment measures.
• Investigation Findings: Detail the forensic analysis, interviews, and audits conducted. Include findings on the breach’s cause and scope.
• Risk Assessment: Document the risk assessment process, including the factors considered and conclusions drawn.
• Notification Process: Record the notification process, including the dates and methods of notifications to affected individuals, HHS, and media.

Step 7: Mitigation and Remediation

Developing and implementing a mitigation plan is crucial for addressing vulnerabilities and preventing future breaches. A key component of this plan is strengthening security controls. This involves enhancing both technical and administrative safeguards to prevent similar incidents. Practical actions include updating firewalls, implementing multi-factor authentication, and enhancing encryption protocols to ensure data is protected against unauthorized access.

In addition to technical improvements, employee training is essential. Regular training sessions should be conducted to educate employees about data security best practices and breach response protocols. This ensures that all staff members are aware of their roles and responsibilities in maintaining data security and responding effectively to potential breaches.

Finally, reviewing and updating HIPAA policies and procedures is necessary to address any identified weaknesses. Regular policy updates help maintain compliance with current regulations and adapt to emerging threats. By incorporating these key actions into your mitigation plan, you can create a more robust defense against future breaches and ensure a swift, effective response if they occur.

Step 8: Post-Breach Review

After mitigating the breach, conduct a post-breach review to evaluate the effectiveness of the response and identify areas for improvement. Start by assessing the incident response process to pinpoint strengths and weaknesses, using this information to refine and enhance your response protocols. Documenting the lessons learned from the breach is also crucial, as it provides valuable insights that should be incorporated into future training sessions and policy updates.

Additionally, implement continuous monitoring to detect and respond to any future breaches promptly. Ongoing monitoring ensures that your organization remains vigilant and can quickly address potential threats, thereby strengthening your overall security posture and enhancing your ability to protect sensitive information.

Ensuring Comprehensive HIPAA Data Breach Analysis and Mitigation

Conducting a thorough HIPAA data breach analysis is essential for healthcare organizations to ensure compliance and protect sensitive patient information. By promptly containing the breach, performing a comprehensive risk assessment, and developing a robust mitigation plan, organizations can effectively manage the aftermath of a breach and minimize potential harm.

At RSI Security, we specialize in helping healthcare organizations navigate HIPAA compliance and data breach response. Our experts can assist with risk assessments, forensic analysis, and developing robust security controls. 

Stay ahead of HIPAA breaches, download our HIPAA Checklist and close your compliance gaps today.

Download Our HIPAA Checklist

HIPAA violations can have serious consequences for healthcare organizations, ranging from hefty fines to criminal charges. These laws are designed to safeguard patient privacy and ensure the integrity of healthcare services.

Even unintentional violations such as neglect or oversight can lead to penalties, employee terminations, and long-term reputational damage. In some cases, violations remain hidden for years, only to resurface with retroactive consequences that can severely impact an organization.

In this blog, we’ll explore common HIPAA violations and the serious consequences that can follow, helping you understand why HIPAA compliance is critical to healthcare operations.

For healthcare providers, securing electronic protected health information (ePHI) has become more complex with the widespread adoption of telemedicine.As ePHI is now transmitted in real time over digital platforms, the landscape of data protection and regulatory compliance has changed significantly.

If your organization provides services to healthcare entities, such as IT support, cloud storage, billing, or legal services—you may be legally required to sign a HIPAA Business Associate Agreement (BAA).

This agreement ensures that your organization complies with the Health Insurance Portability and Accountability Act (HIPAA) when handling or accessing protected health information (PHI).

Entering into a BAA means committing to partial or full HIPAA compliance, which includes conducting risk assessments, implementing security controls, and maintaining appropriate data protection policies.

Are you ready to fulfill the requirements of a HIPAA BAA? Schedule a consultation to find out!

HIPAA Business Associate Agreements 101

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) exists to define and safeguard protected health information (PHI). It applies primarily to covered entities within the healthcare field. However, it also contractually requires business associates to safeguard PHI.

Understanding and staying compliant as a business associate requires knowing:

• What a HIPAA business associate agreement is and to whom it applies
• Which requirements fall on parties to a business associate agreement
• What can happen if a business associate agreement is broken 

The big takeaway of business associate considerations under HIPAA is that the regulation applies beyond the boundaries of healthcare to many stakeholders adjacent to the industry.

What is a HIPAA Business Associate Agreement?

A HIPAA Business Associate Agreement (BAA) is a legally binding contract that requires business associates to follow certain HIPAA compliance standards.

These associates, such as IT providers, billing services, or consultants, must either fully comply with HIPAA or support their covered entity partners in maintaining compliance.

The HIPAA BAA extends HIPAA’s privacy and security requirements beyond healthcare providers, ensuring that any third party with access to protected health information (PHI) also handles it responsibly.

These agreements are mandated and regulated by the Department of Health and Human Services (HHS) as part of HIPAA’s goal to safeguard patient data across the entire healthcare ecosystem.

To fully understand why these agreements are necessary, it’s important to know what qualifies as PHI. Protected health information includes any data that identifies an individual in connection with their physical or mental health, treatments received, or healthcare payments, whether in full documents or individual data points.

HIPAA Covered Entities and Business Associates

Business associate contracts are made between covered entities and their business associates, requiring the latter to (at minimum) help the former meet their HIPAA requirements. As for who these parties are, the HHS has established three categories of HIPAA covered entities:

• Healthcare providers, such as hospitals, pharmacies, and doctors
• Health plan entities, such as administrators and insurance companies
• Healthcare clearinghouses that process standardized health information

Business associates are any organizations that work with these entities in a way that requires them to come into contact with PHI.

There is no explicit restriction on which kinds of partners are considered business associates, but common examples include third-party administrators, accounting and legal services providers, consultants, and benefits managers working on plans.

Covered entities are the parties who produce, use, and otherwise come into contact with PHI the most. Business associates also come into contact with it regularly, so it applies to them too.

Business Associate Agreement HIPAA Requirements

HIPAA explicitly requires covered entities who work with business associates to operate under a business associate contract.

The specific requirements for what it must include are sparse, so covered entities have discretion over the particular terms. The only guarantee is that the contract ensures a business associate helps the covered entity ensure HIPAA compliance.

Under a business associate contract HIPAA can essentially apply to business associates as though they are HIPAA covered entities.

The practical upshot is that business associates need to prepare for HIPAA compliance just like covered entities to avoid any future complications.

Privacy Rule Requirements for Business Associates

The HIPAA Privacy Rule is the first and most fundamental part of the entire HIPAA framework. It defines both PHI and covered entities, along with their (and their business associates’) essential responsibilities with respect to safeguarding PHI.

Namely, PHI needs to be made available to its subjects (persons identified within the PHI) at their request. But it also needs to be protected such that no unauthorized disclosures or uses, except for a set of permitted ones, can happen.

Some practical examples of permitted disclosures include using limited data sets for approved research or making certain information available for disease prevention or other public benefits.

See the HHS’s summary of the Privacy Rule for a comprehensive list of permitted PHI uses.

Security Rule Requirements for Business Associates

The Security Rule builds on the Privacy Rule, adding specific controls organizations need to apply to ensure the confidentiality, integrity, and availability of PHI.

There are two major kinds of measures the Security Rule requires covered entities and business associates to implement.

The first prescriptive requirement is programmatic risk analysis and management, including regular risk assessments that document, address, and ideally neutralize threats to PHI.

The other prescriptive requirement is implementing three sets of safeguards:

• Administrative safeguards

• • • Formalizing security management processes
    • Assigning security personnel and responsibilities
    • Systematizing information access management
    • Providing workforce training and management
    • Conducting evaluations related to PHI security

• Physical safeguards

• • • Limiting and controlling access to facilities
    • Limiting and controlling access to devices

• Technical safeguards

• • Installing system-wide access controls
  • Conducting and logging security audits
  • Ensuring integrity and change management
  • Securing PHI for network transmission

Originally, these protections applied only to electronic PHI (ePHI), but the HITECH Act extended its requirements to all PHI that covered entities and business associates come into contact with.

Breach Notification Requirements for Business Associates

Covered entities and business associates also need to comply with the Breach Notification Rule, which requires monitoring and communication infrastructure to be in place to report on breaches as swiftly as possible.

HIPAA considers a breach to have happened if identifiable PHI is accessed without authorization in any way beyond the permitted uses and disclosures.

If a breach has occurred, the covered entity or business associate who becomes aware of it needs to provide notice to one or more parties.

In particular, notice needs to be given to all pirates impacted by the breach. The secretary of the HHS must also be notified. And, if the breach impacts 500 or more people, media outlets serving their community must be notified.

If the breach is discovered by the business associate, their responsibility may be to provide these notices or to inform the covered entity proper to handle other required notices.

The business associate agreement will detail all specific responsibilities related to this rule.

The Stakes of Business Associate Compliance

Unlike some other regulatory contexts, HIPAA does not require a certification assessment to affirm compliance. Instead, the HHS mandates that organizations operating in the field are HIPAA compliant, and assessments happen if a breach or other non-compliance incident occurs.

If a covered entity (or business associate) is found to be in violation, one or both parties may be subject to HIPAA enforcement, including fines and criminal charges.

In particular, business associate contracts often distribute the liability for noncompliance issues between the business associate and covered entity, depending on the responsible party for the particular data breach or incident in question.

In practice, causing a HIPAA violation might be a breach of contract, and it can open the business associate up to the HHS’s enforcement arm.

To avoid these possibilities, covered entities and business associates are encouraged to work with third-party HIPAA advisors and assessors to optimize all elements of their cyberdefenses.

Achieve and Maintain Compliance

If your organization works directly in healthcare, or it partners with other organizations that are covered entities, you may need to comply with HIPAA—or at least help a partner comply. If that’s the case, you’ll need to ensure that your cyberdefenses meet HIPAA standards.

RSI Security has helped countless organizations in and adjacent to healthcare comply with HIPAA. We know that the right way is the only way to keep sensitive data and patients safe.

Protect your organization from costly HIPAA violations, download our   HIPAA Checklist today to ensure you’re fully compliant

 Download Our HIPAA Checklist

If your organization needs to comply with HIPAA, you’ll need to safeguard protected health information (PHI) and keep an eye out for:

• Identifiable records related to patients’ health conditions
• Identifiable records related to the provision of healthcare services
• Identifiable records related to payments for healthcare provided
• Methods for de-identifying PHI to lessen the scope of compliance
• Approaches to comprehensive HIPAA compliance implementation

Example #1: Records of Patients’ Health Conditions

The Health Insurance Portability and Accountability Act (HIPAA) exists to ensure that protected health information (PHI) is safeguarded. The kinds of information that can qualify as PHI are defined in the Privacy Rule.

The first of these is any record that contains or pertains to an individual’s past, present, or future health conditions—including physical and mental health.

The first example is the most straightforward and involves the least abstraction. Records that contain identifiable information about a patient (i.e., their name—see below) alongside any information about their health conditions can qualify as PHI.

One common pitfall in this respect is the mishandling of demographic data pertaining to individuals’ disabilities. Even if collected or used in good faith, this information needs to be safeguarded to protect these individuals’ rights.

Example #2: Records of Healthcare Services Provided

Closely related to the example above, yet distinct from it, PHI includes all records of healthcare services provided to an individual. The distinction is that the first example specifically hinges on whether or not a person is being identified alongside a condition (permanent or otherwise). But, in this case, a document is PHI if it associates an individual with a procedure they’ve received.

Common examples of service-provision PHI documents include:

• Records of medical procedures performed (i.e., operations)
• Records or notes pertaining to ongoing treatment (i.e., therapy)
• Records of medications or supplements prescribed or recommended

Any organization that is subject to HIPAA needs to de-identify and/or protect these kinds of documents, and any traces of this kind of information. See below for guidance on how.

Example #3: Records of Payment for Healthcare Services

In addition, according to the HIPAA Privacy Rule protected health information includes records of past, present, or future payment made in exchange for the provision of healthcare. If #2 is an abstraction of #1, this type of PHI further abstracts the individual from their health concerns, qualifying a document as PHI if it associates an individual with a payment made for healthcare.

One common instance of payment information qualifying as PHI under HIPAA is credit card and other transaction records being maintained digitally. Often, records of this nature are kept for standard bookkeeping or even for compliance with other regulatory frameworks.

However, if they include patients’ names and other identifiable criteria, they may qualify as electronic protected information (ePHI). If so, they need to be de-identified and/or safeguarded.

How to De-Identify PHI for HIPAA Compliance

Under HIPAA protected health information needs to be treated such that, if it were leaked or otherwise fell into the wrong hands, the individual it concerns could not be identified by it.

The Department of Health and Human Services (HHS) prescribes two de-identification methods:

• Expert Determination – An individual with substantial knowledge and training in threat and statistical modeling is able to demonstrate a negligible degree of identification risk.

• Safe Harbor – All categories of identifiable information (names, locations, dates, contact information, ID and related numbers, possessions, etc.) are removed from documents.

Organizations subject to HIPAA, including both covered entities and their business associates, should utilize one or both methods as much as possible to minimize the scope of identifiable PHI within their systems. HIPAA data breaches concern identifiable PHI exclusively.

How to Safeguard Identifiable PHI for HIPAA Compliance

All protected health information, identifiable or not, needs to be safeguarded according to HIPAA’s prescriptive rules. The Privacy Rule, noted above, requires controlling use and disclosure and preventing all but a select set of permitted disclosures while also ensuring information subjects have the ability to access PHI about or concerning them on demand.

The Security Rule augments the Privacy Rule, adding proactive protections and controls that organizations need to install. These include administrative, physical, and technical safeguards, along with programmatic risk assessments that often necessitate the use of penetration tests.

Finally, there is the Breach Notification Rule, which requires monitoring and communication infrastructure to identify and report on any breach of identifiable PHI as soon as possible.

Streamline Your HIPAA Compliance Process

Critically, PHI is a relatively wide category of information that includes both health-specific documentation and more generalized records, such as payment data.

Organizations in and adjacent to healthcare need to be aware of these common PHI types that they may come across so that they can de-identify and safeguard them to maintain HIPAA compliance.

RSI Security has helped healthcare organizations and their strategic partners steer clear of HIPAA enforcement for over a decade.

We believe that discipline up-front unlocks greater freedom to grow down the road, and we’ll help you rethink and optimize your compliance.

To learn more about protected health information and HIPAA, contact RSI Security today!

Download Our HIPAA Checklist

The rise of cloud computing has transformed how industries manage data, and healthcare is no exception. From electronic medical records to telehealth platforms, cloud solutions now play a critical role in modern care delivery.

However, with this advancement comes increased responsibility. Due to strict legal and regulatory requirements, organizations in or affiliated with healthcare must prioritize cloud security in healthcare, specifically by securing sensitive systems and protected health information (PHI).

Ensuring robust cloud infrastructure security is essential to maintain compliance, protect patient data, and reduce cybersecurity risks.