What triggers a HIPAA audit?

The Office for Civil Rights (OCR), is the department responsible for enforcing HIPAA. It seems there is a common misconception that audits by the OCR happen at random when the department decides to “pop in” on organizations to check on their compliance state. In reality, that's not the case!

What is HIPAA?

The Health Insurance Portability and Accountability Act, better know as HIPAA, was passed by Congress in 1996 and called for the protection and confidential handling of protected health information (PHI). HIPAA still exists today, aiming to protect patients and their information, but it’s important to think about how far we’ve come in the ways we handle patient data since its enactment.

Compliance is Non-Negotiable

One thing that has not changed since 1996 – HIPAA compliance is here, and it is not optional.  In fact, it’s arguably more important than ever before to have your HIPAA compliance program in order. With the healthcare industry being favored by cybercriminals, human error accounting for most data breaches, the ease in filing a complaint against an organization, and more, your compliance program could come under review at any given time – and you must be ready.

What triggers an audit?

The Office for Civil Rights (OCR), is the department responsible for enforcing HIPAA. It seems there is a common misconception that audits by the OCR happen at random when the department decides to “pop in” on organizations to check on their compliance state. The reality is, the OCR is not staffed to audit organizations without just cause, meaning when an audit occurs, something triggered it.

Common audit triggers

  • Patient complaints – Patients could file complaints for any number of reasons. Maybe a patient was denied access to their records, or perhaps they saw a picture on social media with their medical chart in the background.
  • Employee complaints – Often times, disgruntled employees may file a complaint following termination of employment, but that’s not always the case. If an employee feels there has been wrongdoing, they could certainly file a complaint.
  • Employee mistakes – Employee mistakes or human error account for many audits. An employee falling for a phishing email, using weak passwords, and sending a patient the incorrect records are all examples of human errors.
  • Insider wrongdoing – Sometimes employees violate company policies maliciously, and other times they may just be curious. Employees could steal patient records for personal gain or could peek at a patient’s records because they’re curious about their visit.
  • Third-party mistakes – Mistakes caused by a Business Associate (BA) could also lead to an investigation of your organization. If your (BA) suffers a data breach, you may be audited as well.
  • Security incident – Common security incidents include lost or stolen devices, especially those devices that are unencrypted, as well as unpatched software that led to malware or ransomware exploits.

Many times, whatever triggered the audit, to begin with, is not the biggest problem or finding by the OCR. This is why having your HIPAA compliance program in order and continuously working towards your compliance is critical.

What will OCR look for in an audit?

What OCR may be looking for in an audit situation will vary, dependent on what triggered the audit in the first place. Below are some common items that your organization could expect to show an auditor in the event of an audit, all of which, are key components of a HIPAA compliance program.

  • Security Risk Assessment – An absolutely critical part of your compliance program. The Security Risk Assessment (also referred to as the SRA, or Security Risk Analysis) will look for gaps in your organization’s administrative, physical and technical safeguards that could pose a risk for protected health information (PHI). You must have documented proof of your SRA.
  • Remediation/Risk Management Plan – Once you’ve conducted your SRA, you’ll need to have a process in place to begin addressing your deficiencies, often referred to as a Risk Management Plan. This plan should cover how you plan to remediate all the security gaps discovered in your SRA.
  • Policies & Procedures – Not only does your organization need to have policies and procedures in place, but you also must ensure that employees understand those policies and have signed off on them. Employees can’t be expected to follow the rules if they are unaware of them, and the documented proof that they acknowledged the policies is vital in the event of a security incident.
  • Security Officer – Every organization needs to have an appointed Security Officer. This individual is responsible for ensuring policies and procedures are created, understood by all employees of the organization, and acknowledged by them with documented proof. The Security Officer should also ensure employees are trained on HIPAA routinely.
  • Routine HIPAA Training – Not only is HIPAA training a requirement, but it is also necessary to reduce the chances of an employee-error. HIPAA and cybersecurity awareness training should be conducted routinely so employees are kept updated on the latest threats, and to keep security best practices top of mind.
  • Business Associate Agreements – You must have a Business Associate Agreement (BAA) with any and all vendors that handle your patient data. A data breach caused by a Business Associate will also affect your organization, so make sure you are working with vendors who take HIPAA compliance seriously.

Proof of network vulnerability scans, penetration tests, and breach notification (in the event of a breach) are also common requests by the OCR.

The Bottom Line

It’s safe to say that in this digital age, HIPAA could use a refresh, but despite its flaws, your adherence to it is not up for discussion. An audit could be triggered by anyone, at any time. If you had a complaint filed against you tomorrow, would you be confident in your compliance state? If you can’t answer yes, it’s best to get to work – before it’s too late.

Have questions? Need help?

Call us at 859-245-0582 or click here to reach out to us.

You might also be interested in our other article on HIPAA Compliance, “What are the HIPAA standards for IT”. Click here to read it now.

Next Century Technologies has teamed up with HIPAA Secure Now to bring comprehensive HIPAA compliance solutions and advice, at a reasonable price, to establishments that fall under HIPAA. We thank our partners at HIPAA Secure Now for providing the content for this article. 

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Tracy Hardin

Tracy Hardin

Tracy Hardin is President and founder of Next Century Technologies in Lexington, KY. She has a bachelor's degree in computer science from the University of Kentucky and has earned certifications from Novell, Cisco and CompTIA. Her specialties in the field of IT are network design and security, project management and improving productivity through technology. She loves helping people by sharing her knowledge of tech.

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