Doing a HIPAA Security Risk Assessment

Doing a HIPAA Security Risk Assessment

Your organization’s annual HIPAA Security Risk Assessment and Analysis are only one element of the compliance process, and whether you’re a Business Associate or Covered Entity, your organization must also “implement security updates as necessary and correct identified security deficiencies”. In other words, you must act via a Corrective Action Plan (CAP) following the required risk assessment process.

Here are a few common Corrective Action Plan steps:

  • Implement technical policies and procedures to allow access only to those persons or software programs that have been granted access rights to information systems maintained.
  • Implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports.
  • Conduct accurate and thorough assessments of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI.
  • Develop a complete inventory of all its categories of electronic equipmentdata systems, and applications that contain or store ePHI, which will then be incorporated into its Risk Analysis, and must complete a Risk Management plan.

 

What happens if I fail to complete my Security Risk Assessment?

Failing to complete your annual Risk Assessment oftentimes means the organization will be required to complete a “robust” Corrective Action Plan (CAP) and often with at least two years of monitoring activity.

Have you ever doubted whether a small billing company or independent physician practice actually ever face penalties?

Well, keep in mind, a Business Associate is a ‘person’ or ‘entity’. This means that there is no billing company too small to have to comply with the Federal HIPAA regulations. Again, if you have not completed an accurate and thorough security risk assessment prior to that, you could also be penalized under ‘willful neglect’. This category alone is $50,000 per violation!

It is important for you to understand that every complaint or potential breach must be investigated by HHS/OCR. If you, a billing company, or another vendor suspects a breach, you must inform the covered entity (your client) and have a breach risk assessment completed to determine key factors and take action.

 

An EZClaim partner, Live Compliance, will help you to make checking off your compliance requirements extremely simple. They provide:

  • Completely online, our role-based courses make training easy for remote or in-office employees.
  • Contact-free, accurate Security Risk Assessments are conducted remotely. All devices are thoroughly analyzed regardless of location. Conducting an accurate and thorough Security Risk Assessment is not only required but is a useful tool to expose potential vulnerabilities.
  • Complete set of HIPAA Policies and procedures built directly into your portal. Includes actionability, change management documentation, and Incident Response Policy to assist with your Corrective Action Planning. Easily share policies with staff with one click.
  • Built directly into your portal, easily monitor where your workforce may be vulnerable with our Dark Web Breach Searches. Easily expose breach sources with ongoing searching of active employee email or domain ensuring continued awareness of potential breach exposure. Weekly automatic email notifications if new breaches are discovered.
  • Short, informative, privacy awareness videos covering technical, administrative, and physical safeguards with topics such as ransomware, phishing, the Dark Web, password protection, and more. All delivered monthly with no logins required, they empower your workforce to make conscious decisions when it comes to your organization’s privacy and security.

 

So, don’t risk your company’s future, especially when Live Compliance is offering a FREE Organization Assessment to help determine your company’s status. For more information, visit their website, e-mail them, or give them a call at 980.999.1585.


ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.

[ Contribution by Jim Johnson with Live Compliance ]

ONE Patient Complaint

ONE Patient Complaint

ONE patient complaint leads to $2.175 Million fine! AND 2 Years of OCR Monitoring.

Contributed by Jim Johnson, President of Live Compliance

One patient complaint, that’s all it takes. Have you ever read such headlines and doubted whether a small billing company or independent physician practice would ever face such seemingly insurmountable penalties? Actually, there should be no doubt! The Sentara Hospital violations are violations that every small billing company or independent physician practice would face, not just because Sentara is a hospital.

So what happened? In short, a complaint from an individual came from a person receiving a bill containing another individual’s billing statement. As a result of Sentara investigating this breach, Sentara reported a breach affecting 8 individuals, when in actuality, Sentara mailed 577 patient’s statements to the wrong addresses. This is an example of why you must perform and document a breach risk analysis as soon as you become aware of a potential incident. It is important that you understand what a breach is and the breach notification requirements.

The second issue discovered during the investigation revealed Sentara failed to have a business associate agreement in place with an entity that performed business associate services for Sentara. This reinforces the importance of having business associate agreements in place and your understanding that BAA’s are contracts that outline timeframes and provide your attestation to a satisfactory assurance of your ability to safeguard PHI among other things.

Maybe most importantly, you should know every complaint must be investigated by HHS/OCR. What that means is, if you improperly disclose protected health information, like sending a statement to the wrong patient, you, a billing company, must inform the covered entity (your client) and have a breach risk assessment completed to determine several key factors. Then the covered entity must take action based on these findings. If you haven’t completed an accurate and thorough security risk assessment prior to that, you could also be penalized under ‘willful neglect’. This category alone is $50,000 per violation! 

In fact, Texas Health received a $1.6 million fine for improperly disclosing ePHI. Texas Health failed to comply with several HIPAA requirements including failure to perform the HIPAA Security Risk Assessment.

The fines are huge, but the reputational damage to your billing company and the covered entity is expensive and difficult to overcome.

What we do is keep this from ever being a worry for you! In fact, we have a 100% audit pass rate since 2010! For example, Live Compliance has easy to understand HIPAA breach notification training. We perform your security risk assessment and manage all your requirements, including business associates, in a clean, organized cloud-based portal.

Don’t risk your company’s future, especially when we are offering a FREE Organization Assessment to help determine your company’s status. 

It’s easy, call us at (980) 999-1585, email me jim@LiveCompliance.com or visit LiveCompliance.com

Keep in mind, a business associate is a ‘person’ or ‘entity’. This means there is no billing company too small or too large to comply with the Federal HIPAA regulations.

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