HIO-301 Free PDF - Certified HIPAA Security Updated: 2023
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Exam Code: HIO-301 Certified HIPAA Security Free PDF November 2023 by Killexams.com team|
HIO-301 Certified HIPAA Security
Exam: HIO-301 (Certified HIPAA Security)
- Number of Questions: The exam consists of multiple-choice questions.
- Time: Candidates are typically given a specified amount of time to complete the exam.
The Certified HIPAA Security (CHS) course is designed to provide candidates with in-depth knowledge and skills related to the security aspects of the Health Insurance Portability and Accountability Act (HIPAA) regulations. The course outline includes the following topics:
1. Introduction to HIPAA Security
- Overview of HIPAA Security Rule
- Security standards and requirements
- Roles and responsibilities
2. Administrative Safeguards
- Security management process
- Risk analysis and risk management
- Security policies and procedures
3. Physical Safeguards
- Facility access controls
- Workstation and device security
- Disposal of PHI
4. Technical Safeguards
- Access controls and user authentication
- Audit controls and monitoring
- Encryption and data protection
5. Incident Response and Disaster Recovery
- Incident response planning
- Business continuity and disaster recovery planning
- Security incident handling
The HIO-301 exam aims to assess candidates' knowledge and skills in implementing and maintaining HIPAA security measures to protect electronic protected health information (ePHI). The exam objectives include:
1. Understanding the requirements and provisions of the HIPAA Security Rule.
2. Applying administrative safeguards to manage security risks and establish policies and procedures.
3. Implementing physical safeguards to protect facilities and devices that store or transmit ePHI.
4. Utilizing technical safeguards to control access, monitor systems, and protect ePHI.
5. Developing incident response and disaster recovery plans to address security incidents and ensure business continuity.
The exam syllabus covers the following topics:
- Introduction to HIPAA Security
- Administrative Safeguards
- Physical Safeguards
- Technical Safeguards
- Incident Response and Disaster Recovery
Candidates are expected to have a comprehensive understanding of these courses and demonstrate their ability to apply HIPAA security measures effectively. The exam assesses their knowledge, practical skills, and proficiency in implementing and maintaining HIPAA security compliance.
|Certified HIPAA Security|
Other HIPAA examsHIO-201 Certified HIPAA Professional
HIO-301 Certified HIPAA Security
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Certified HIPAA Security
This field in an X.509 digital certificate identifies that each certificate issued by a
particular Certificate Authority is unique:
A. Kerberos ticket ID
B. PA ID number
C. CA ID number
D. Sender ID
E. Serial number
Which the most widely accepted format for digital certificates is:
An example of a major VPN tunneling protocol is:
A hospital is setting up a wireless network using “Wi-Ei” technology to enable nurses
to feed information through it onto the corporate server instead of using traditional
paper forms. As a HIPAA security specialist, what would you do as the first step
towards, protecting the wireless communication?
A. Set up a message digest infrastructure to enable secure communication.
B. Configure intrusion detection software on the firewall system.
C. Protect the wireless network through installation of a firewall.
D. Enable use of WEP keys that are generated dynamically upon user authentication.
E. Configure TCP/IP, with a static IP address for all the clients having gateway
address of the server..
Dr. Alice needs to send patient Bob a prescription electronically. Dr. Alice wants to
send the message such that Bob can be sure that the sender of the prescription was in
fact Dr. Alice. Dr. Alice decides to encrypt the message as well as include her digital
signature. What key will Bob use to be able to decrypt the session key used by Dr.
A. Dr. Alice’s private key
B. Dr. Alice’s public key
C. Bob’s public key
D. Bob’s private key
E. Dr. Alice’s session key
Statement 1: A firewall is one or more systems, that may be a combination of
hardware and software that serves as a security mechanism to prevent unauthorized
access between trusted and un-trusted networks. Statement 2: A firewall refers to a
gateway that restricts the flow of information between the external Internet and the
internal network. Statement 3: Firewall systems can protect against attacks that do not
pass through its’ network interlaces.
A. Statement 1 is TRUE, Statement 2 is TRUE and Statement 3 is TRUE
B. Statement 1 is TRUE, Statement 2 is TRUE and Statement 3 is FALSE
C. Statement 1 is TRUE, Statement 2 is FALSE and Statement 3 is TRUE
D. Statement 1 is FALSE, Statement 2 is TRUE and Statement 3 is TRUE
E. Statement I is FALSE, Statement 2 is FALSE and Statement 3 is TRUE
During your discussions with one of the clients, you need to explain the meaning of a
Virtual Private Network. Select the best definition:
A. A VPN enables a group of two or more computer systems or networks, such as
between a hospital and a clinic, to communicate securely over a public network, such
as the Internet.
B. A VPN is used within the organization only and a firewall is needed to
communicate with the external network.
C. A VPN requires a private dedicated communication between the two end points.
D. A VPN may exist between an individual machine and a private network but, never
between a machine on a private network and a remote network.
E. A VPN is a “real” private network as opposed to a “virtual” network.
This is one of the areas defined in the ISO 17799 Security Standard.
A. Operational policy
B. Risk analysis
C. Computer and network management
D. Application management
E. Security procedures
A hospital has contracted with Lorna’s firm for the processing of statement generation
and payment activities of its patients. At the end of the day, the hospital sends three
different files to Lorna, one having new charges, the second one having updated
addresses of the patients and third one having information related to payments
received. The hospital wants to implement a secured method of transmission of these
files to Lorna’s firm. What would be the best option for the hospital?
A. Implement a Virtual Private Network (VPN) between the hospital and Lorna’s firm
and support it with strong authentication.
B. Audit Lorna’s firm every quarter and check all log files.
C. Deploy intrusion detection software on Lorna’s network.
D. Encrypt the files and then send it in a CD
E. Send the source data files in a CD via courier in the evening.
Statement 1: The IEEE 802.1 lb standards for wireless network define two types of
authentication methods, Open and Shared key. Statement 2: The range of “Wi-Fi”
products is within 30 feet of the router. Statement 3: A VPN can be setup over a
A. Statement 1 is TRUE, Statement 2 is TRUE and Statement 3 is TRUE
B. Statement 1 is TRUE, Statement 2 is TRUE and Statement 3 is FALSE
C. Statement 1 is TRUE, Statement 2 is FALSE and Statement 3 is TRUE
D. Statement I is FALSE, Statement 2 is TRUE and Statement 3 is FALSE
E. Configure Statement 1 is TRUE, Statement 2 is FALSE and Statement 3 is FALSE
The CTQ of a clearinghouse wants to implement a security mechanism that can alert
the systems administrator about any hacker attempting to break into the electronic PHI
processing server system. As a security advisor to the OTO, what mechanism would
you recommend? Select the best answer.
A. Deploying a VPN.
B. Deploy SSL for all connections to the server.
C. Installing an IDS solution on the server.
D. Deploying a PRI solution.
E. Installing a firewall to allow pass through traffic only to the allowed network
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Donna Davis, Ph.D., the director of the Oregon Reality Lab in Portland, Oregon, and an expert in virtual reality therapy (VRT), explains that VRT is used in a computer-generated or 3-D environment. She explains that VRT is completely different from teletherapy. While teletherapy is talk therapy performed virtually (such as over Zoom), VRT revolves around the use of a virtual world, such as a computer game or headset. Itâ€™s also important to note that a licensed therapist must be involved for it to be considered therapy. Apps or YouTube videos that are meant for relaxation or to enhance meditation are not technically VRT since a therapist is not involved.
There is a specific type of VRT called virtual reality exposure therapy (VRET), which immerses someone in a 3-D environment that feels extremely real. Often, but not always, this is done using a headset. One example of this type of therapy is that if someone is afraid of heights, the 3-D environment may depict a glass elevator, and can be used to help them conquer their fear. VRET is also used to help individuals with other types of phobias, as well as post-traumatic stress disorder (PTSD) and victims of violence.
But VRT is not always immersive to this level. Dr. Davis says that another form of VRT is talking to a therapist under the guise of an avatar in a computer-generated environment. For example, Dr. Davis has worked with a virtual reality support group for people with Parkinsonâ€™s disease on the online platform Second Life, in which users can create a 3-D character in an alternate universe. The group has been â€śmeetingâ€ť regularly for over 10 years. â€śPeople in the group create an avatar and they feel more comfortable opening up while their true physical identity is not revealed,â€ť she says.
Since VRT is still new, there are not as many therapists trained in using it as there are for more common forms of therapy. Because of this, it can be hard to access. Dr. Davisâ€™s advice is to do a Google search for clinical therapists in your area and see if the providers have VRT or VRET training. Virtual Reality International is another helpful resource with a database of VRT therapists.
How Successful Is Virtual Reality Therapy?
Lucy Dunning, a licensed professional counselor in Marietta, Georgia, who uses VRET in her counseling practice, says because the concept is relatively new, the data is still emerging in terms of how successful it is long-term. But early research points to promising results. â€śIt has especially been shown to be successful for people with PTSD, anxiety and chronic pain,â€ť she says.
Virtual reality therapy in the form of VRET has a reported success rate of between 66% and 90% for those with PTSD when used to enhance cognitive behavioral therapy (CBT), according to 2022 research in JMIR Serious Games . It has also been shown to significantly help with pain relief in place of medications. In one study in Annals of Behavioral Medicine, burn victims were transported to a snowy world, interacting with snowmen and throwing snowballs. This reduced their physical pain between 35% and 50% . Scientific studies have also shown success for overcoming fear of spiders and positive results for treatment for people with eating disorders.
Most existing research on VRT focuses on VRET; there is less known about how successful therapy using avatars in a virtual world is. One scientific article in Frontiers in Psychiatry found that using CBT in a virtual reality setting is an effective way to treat people experiencing depression, who may be reluctant to seek traditional therapy . Another in JMIR Mental Health highlights that VRT could be used as an alternative form of treatment to in-person therapy for people with social anxiety .
Based in Green Bay, Wisc., Jackie Lohrey has been writing professionally since 2009. In addition to writing web content and training manuals for small business clients and nonprofit organizations, including ERA Realtors and the Bay Area Humane Society, Lohrey also works as a finance data analyst for a global business outsourcing company.
As a healthcare provider, you should make patient data security and privacy as much a priority as the patientsâ€™ health. Patients may not want all their healthcare information to be widely available â€“ and they have a legal right to healthcare data security and privacy.
The primary law governing healthcare data security is the Health Insurance Portability and Accountability Act, or HIPAA. The wide-ranging law covers any devices that contain or transmit protected health information (PHI), including data collected by your customer relationship management software. The benefits of CRM software can be significant for healthcare organizations, but only if these solutions are properly secured and monitored.
After all, healthcare organizations are increasingly prime targets for cyberattacks. In 2020, the number of cyberattacks targeting the healthcare industry â€“ already a common target for malicious hackers â€“ spiked by 45%.
The benefits of a HIPAA-compliant CRM are many, but only if you monitor, detect and mitigate any cyberattacks threatening your patientsâ€™ PHI. Below, weâ€™ll walk you through CRM usage in healthcare and the importance of finding a HIPAA-compliant CRM.
CRM in healthcare
A healthcare CRM with data analytics can help you determine which of your patients might need additional care or identify patients who are behind on their follow-ups and tests. You can also use your practiceâ€™s CRM to manage patient prescriptions and appointments.
Increasingly, healthcare CRMs are adding remote patient-monitoring capabilities. If you own a medical practice and install a CRM with remote patient-monitoring tools, you can log in to your CRM to see a patientâ€™s vitals in real time. Youâ€™ll first need to prescribe the patient remote monitoring tools, such as blood pressure pumps and glucose tests that they can use at home, and then you can check their vitals at any time.
Additionally, a CRM can help you navigate the complexities of medical billing, Improve your practiceâ€™s workflows, and report on patient complaints and internal challenges. Some healthcare facilities also use CRMs for marketing campaigns to attract new patients.
In healthcare, CRMs are used for patient monitoring and have additional applications in billing, managing, reporting and marketing.
When do you need HIPAA-compliant CRM software?
All CRM software used in healthcare must comply with HIPAA, because the law applies to all patient data with which healthcare providers interact. Title II of HIPAA specifies the guidelines that healthcare providers must follow regarding patient data and has one rule each for transactions, identifiers, enforcement, privacy, and security.
If your business is a covered entity under HIPAA, it always needs HIPAA-compliant CRM software.
What makes a CRM HIPAA-compliant?
A CRM software platform is HIPAA-compliant if it ensures that all patient data remains confidential, backed up and securely stored. You must only transmit encrypted data and have complete control over the data in your CRM â€“ that means no unauthorized intake, access, creation, storage or sharing of data. To be safe, you might also want to see if your CRM has been certified by an organization specializing in information security and privacy.
A HIPAA-compliant CRM keeps all patient data demonstrably secure and private.
What to look for in a HIPAA-compliant CRM
These are the most important features to seek in a HIPAA-compliant CRM:
When looking for a HIPAA-compliant CRM, you should check for data and employee access safeguards, scalability, automated data backup, references, and additional cybersecurity features.
Top CRM systems for HIPAA compliance
The following are some of the best-regarded HIPAA-compliant CRM software programs.
Keap is a HIPAA-compliant, user-friendly CRM software platform thatâ€™s well suited for new and small healthcare organizations. You can use Keap to store and organize your patientsâ€™ information in a system that your team can access as needed. Itâ€™s also useful for patient acquisition, and as of January 2021, Keap has added over 2,000 apps to its library of compatible integrations.
Popular CRM platform Freshworks has an additional suite for healthcare providers. The Freshworks Healthcare CRM is HIPAA-compliant by nature. You can use it at your practice to store schedules and patient data in one location rather than across several programs. Freshworks says that with this centralized data hub, your patient satisfaction and internal workflows (including billing) are likely to improve.
Salesforce has long been a leader in the CRM field, and the Salesforce Health Cloud offshoot is no exception. You can use it to personalize the care and messages your patients receive from your practice. It can also help establish one-on-one connections between your staff and your patients and make your data more actionable. Note that payers, not just providers, can use Salesforce Health Cloud, so it can streamline the payment process between you and your patients or their insurance providers.
NexHealth is a HIPAA-compliant CRM that facilitates online scheduling, telehealth appointments, waitlists and appointment reminders. It integrates with most major electronic health record (EHR) vendors and includes reporting features and patient payment portals. The NexHealth tiers have different features; some even have capabilities for marketing campaigns and automated follow-up appointment outreach.
PatientPop is a HIPAA-compliant CRM with both internal and external features. It enables automated appointment emails, flexible online booking, patient surveys, and a stronger online presence for your practice. It also fully integrates with most EHR, electronic medical record (EMR) and practice management platforms. As such, PatientPop is equally useful for enhancing the patient experience and finding brand-new patients as it is for streamlining your internal workflows.
Caspio is a HIPAA-compliant CRM solution geared toward larger healthcare organizations. It allows for easy CRM customization without in-depth coding operations or modification. Itâ€™s a great choice if you want to grow your practiceâ€™s services beyond standard medical appointments. For example, if you want to expand into healthcare industry consulting or other non-patient-facing fields, Caspio facilitates this growth. Thatâ€™s because its easy customization allows the creation of numerous interrelated online databases.Â
The best HIPAA-compliant CRMs are Keap, Freshworks, Salesforce,Â NexHealth, PatientPop and Caspio.
Choose your healthcare CRM wisely
Before studying this article, you were likely aware that HIPAA compliance poses additional challenges when youâ€™re choosing a CRM. Now that you know what those challenges are, youâ€™re one step closer to thorough patient data security and privacy in your medical practice.
HIPAA requires hospitals and health systems to sanction employees who don't comply with the healthcare privacy law, DataBreaches.net reported Oct. 20.
The website cited an October HHS cybersecurity newsletter. "An organization's sanction policies can be an important tool for supporting accountability and improving cybersecurity and data protection," the agency wrote. "Sanction policies can be used to address the intentional actions of malicious insiders, such as the stealing of data by identity-theft rings, as well as workforce member failures to comply with policies and procedures, such as failing to secure data on a network server or investigate a potential security incident."
HHS noted that sanction policies are required by both the law's privacy rule and security rule.Â
For simple infractions, the penalties could include a written warning for the first sanction, a week's suspension without pay for the second, and a dismissal for the third, according to TotalHIPAA.
Photo: Al David Sacks/Getty Images
The U.S. Department of Health and Human Services' Office for Civil Rights has settled with MedEvolve for $350,000 over potential HIPAA violations regarding a data breach in which a server containing protected health information was left unsecure and accessible over the internet.
MedEvolve provides practice management, revenue cycle management and practice analytics software services to covered healthcare entities. OCR's investigation found that a 2018 data breach left the protected health information of 230,572 people exposed â€“ a potential HIPAA violation. The HIPAA Privacy, Security, and Breach Notification Rules apply to most healthcare breaches and set the requirements that HIPAA-regulated entities must follow to protect the privacy and security of health information.
The potential violations in this case include the lack of an analysis to determine risks and vulnerabilities to electronic protected health information across the organization and the failure to enter into a business associate agreement with a subcontractor, said OCR.
The HIPAA Rules require that covered entities and business associates â€“ a person or entity that has access to protected health information as part of their relationship with a covered entity â€“ enter into contracts that generally document the permissible uses and disclosures of protected health information, and ensure appropriate safeguards will be implemented, and that the covered entity will be notified of any breaches.
In addition to the monetary settlement, MedEvolve agreed to implement a corrective action plan to better shore up its data security.
WHAT'S THE IMPACT
The investigation was initiated in July 2018, following a breach notification report stating that a server containing electronic protected health information was openly accessible to the internet. The information included patient names, billing addresses, telephone numbers, primary health insurer and doctor's office account numbers, and in some cases Social Security numbers.
OCR investigates such breaches if they involve the protected health information of 500 people or more. Hacking/IT incidents was the most frequent (79%) type of large breach that was reported to OCR in 2022. Network servers are the largest category by location for these breaches.
THE LARGER TREND
As part of the settlement, MedEvolve will be monitored for two years to ensure HIPAA compliance.Â
The organization has also agreed to take a number of steps, including conducting a risk analysis and developing a risk management plan to identify security risks.
MedEvolve will also maintain and revise its written policies and procedures, augment its existing HIPAA and Security Training Program for all MedEvolve workforce members who have access to protected health information, and report to HHS within 60 days days when workforce members fail to comply with the written policies and HIPAA rules.
ON THE RECORD
"Ensuring that security measures are in place to protect electronic protected health information where it is stored is an integral part of cybersecurity and the protection of patient privacy," said OCR Director Melanie Fontes Rainer. "HIPAA regulated entities must ensure that they are not leaving patient health information unsecured on network servers available to the public via the internet."
Before EMRs digitized patient charts, physicians often ran out of physical storage space and had to destroy certain records. However, even EMRs donâ€™t have unlimited storage and memory, so the need to destroy records hasnâ€™t entirely disappeared. Keep in mind that destruction practices in violation of medical records retention laws are grounds for lawsuits. Below, learn how to retain and destroy medical records in compliance with the law. [Read related article: How to Implement an Electronic Health Records System]
What is medical records retention?
Medical records retention is the act of keeping your patient charts and other medical information on file. When you retain your records, you develop a track record of your treatment plans and quality of care. Proper medical records retention is advisable for successful long-term patient treatment. Itâ€™s also helpful when dealing with medical malpractice suits, licensing board complaints and medical billing audits.Â
How long must medical records be retained?
Several factors determine the number of years for which you must retain medical records.Â
These federal laws pertain to medical record retention:
Most states have extensive regulations of their own regarding retaining or destroying medical records. Consult experts in your state about these laws and how they affect your medical records retention. Below are a few examples of state medical records retention guidance:
Case law is a subset of state law concerning medical malpractice suits. It determines how long after the stateâ€™s statutory period a patient may file suit if they discover that medical malpractice led to their current complaints. Case law exists because some injuries or conditions arenâ€™t immediately obvious signs of medical malpractice, which means that medical malpractice suits can sometimes be exempt from statutory limits. Confer with experts in your state to learn more.
Consult other practitioners and medical law experts in your area to determine which state and case laws govern your medical records retention.
Best practices for keeping and maintaining medical records
To keep your medical records retention in line with the guidance above, follow these best practices:
1. Know which types of information to record.
A patientâ€™s medical records should include the following information:
To learn more about these types of information, read Business News Dailyâ€™s guide to patient charts.
Retain any records that physicians and certified outside your practice send you for your own use with a patient, according to the same retention timeframes as your own records. Keep your practiceâ€™s medical billing documents regarding the patient too, so you can track which services were performed and paid for.
2. Record and store information the right way.
Several doâ€™s and donâ€™ts of medical recordkeeping can ensure that your patient charts are easily usable for any future purposes.Â
3. Prioritize confidentiality except when necessary exemptions arise.
In almost all cases, you need a patientâ€™s written consent to share their medical records with other parties. Given this privacy concern, medical records retention is as much about keeping records on file as it is about securing them from unauthorized access. HIPAA-compliant EMRs, such as those weâ€™ve reviewed on our medical software best picks page, come with safeguards that make this protection of connected medical devices seamless. [Read related article: EMR vs. EHR]
In the U.S., limited exceptions exist to regulations regarding medical record sharing and confidentiality. Some portions of U.S. law can allow the sharing of medical records without the patientâ€™s consent if the following conditions are met:
4. Make medical records accessible to patients.
Although the burden of retaining medical records falls on your practice, all records belong to the patients named in them. So, set up your medical records in ways that make patient access easy. Medical software such as EHR systems and medical practice management system (PMS) patient portals streamline this access. Note that you must comply with all patient requests to share their medical records with any parties whom they request.
Since patients are ultimately the owners of their medical records, you must store your records in ways that patients can easily access, ideally through medical software.
5. Destroy medical records appropriately.
Eventually, all medical records will exist long enough that youâ€™re no longer required to keep them. In this case, follow destruction best practices:
Retention isnâ€™t the only portion of medical recordkeeping subject to laws and regulations â€“ so is the destruction of medical records.
Medical record retention FAQs
Who owns electronic medical records?
Technically, patients own their electronic medical records. You remain responsible for storing them, but patients can demand access at any time. Patients can even demand that you hand over their records without retaining any copies.
What happens to medical records when a practice closes?
If your practice closes, you canâ€™t just destroy your patient records and call it a day. After all, records belong to patients, not you. Notify your patients of your impending closure and inform them of their right to designate another practitioner as the holder of their records. Alternatively, you can release the patientâ€™s records directly to them.
Can a doctor refuse to release medical records?
In almost all circumstances, doctors cannot refuse to release medical records when patients request them. Extremely limited exceptions may exist in certain states or localities, but itâ€™s best to assume that when a patient demands their records, you should hand them over.Â
However, you donâ€™t have to release a patientâ€™s medical records to a third party unless you receive direct authorization from the patient first. Getting the patientâ€™s explicit permission for record release is best. This way, you avoid breaching the patientâ€™s confidentiality and winding up with a lawsuit on your hands. After all, thatâ€™s one of your biggest reasons for following medical records retention guidelines in the first place.
In the healthcare industry, patient data is considered sensitive and, as such, is subject to certain privacy and security requirements to ensure it remains confidential. Some employers may find themselves handling this protected health information (PHI) and could be required under federal law to manage that data in a specific way. All employers need to understand the federal law known as HIPAA and how it applies (or doesnâ€™t apply) to them.
What is HIPAA?
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that establishes privacy standards by which healthcare organizations are required to protect sensitive patient information. Since its signing in 1996, HIPAA has been updated periodically to evolve alongside technology and has adapted to include cybersecurity standards required of all â€ścovered entitiesâ€ť and their business associates.
What is the HIPAA Privacy Rule?
The HIPAA Privacy Rule is the section of the law that specifically relates to the confidential handling and transmission of patient healthcare data. Measures in the Privacy Rule include an enumeration of individualsâ€™ rights under the law, such as how they can control and access their own healthcare information.
Moreover, the Privacy Rule prescribes how healthcare organizations and other covered entities and business associates must handle protected health information. This includes requirements that govern both process and technology; not only must protected health information be handled properly, but it must also be stored securely.
â€śIt requires you to protect and maintain the security of PHI, which is a defined term that deals generally with health information that can be identified and tied to a specific individual,â€ť Paul Starkman, an employment attorney for Clark Hill, told us. â€śIt deals with how the information must be protected in terms of encryption, password protection and things like that. It also deals with transmission â€¦ and it has some other requirements too in terms of disposing [of] PHI once it is no longer needed.â€ť
Starkman said this includes information from paper files, digital files, machines and pieces of equipment that become outdated or are no longer in service.
â€śThose need to be disposed of in accordance with HIPAA guidelines,â€ť he said.
Which types of employers does HIPAA apply to?
The stringent requirements set forth in HIPAA donâ€™t apply to all employers â€” just those that fall into a particular category.
The term â€ścovered entitiesâ€ť refers to organizations that must comply with the rules set out under HIPAA. Covered entities include doctorsâ€™ offices, hospitals, insurance companies, insurance plans and clearinghouses. The U.S. Department of Health and Human Services maintains a complete list of covered entities on its website.
â€śHIPAA is primarily going to apply to covered entities,â€ť said Jarryd Rutter, an HR coach at Paychex. â€śThat is where HIPAA is most impactful: for those industries and obligations, not only to customers but their employees.â€ť
Rutter noted that Paychex does not provide its clients legal advice and recommended that businesses consult with legal counsel if they are concerned about their HIPAA obligations.
HIPAA also applies to organizations that do business with covered entities and handle or process patientsâ€™ protected health information in some way. These organizations are known as â€śbusiness associatesâ€ť under the law and are also required to abide by HIPAA regulations.
â€śSometimes we get pushback from a client we are helping because they are hesitant to send documents out of concern they are violating HIPAA when, in fact, they are not,â€ť Rutter said. â€śA non-covered entity doesnâ€™t have to be concerned with HIPAA; itâ€™s really limited to if they offer health insurance plans and the handling of that health insurance info.â€ť
Other employers are generally not covered by HIPAA and, therefore, are not required to abide by the strict privacy and security regulations included in the law. However, Rutter said, non-covered entities likely have some privacy and security obligations under other federal laws, such as the Americans with Disabilities Act (ADA) or the Family and Medical Leave Act (FMLA).
Whether youâ€™re legally obligated to or not, itâ€™s always wise to implement several levels of protection to safeguard sensitive employee information.
When does HIPAA apply to non-covered entities?
Although HIPAA doesnâ€™t apply to most businesses, there is one unique circumstance under which employers should be aware of the lawâ€™s requirements. Employers that provide a self-funded health insurance plan are technically operating a covered entity: the health plan itself. This means the health insurance plan is subject to all of the requirements in HIPAA, while the primary business is not.
â€śBecause that self-funded plan â€¦ is viewed as a covered entity, the health plan falls under HIPAA,â€ť said Matt Fisher, partner at Mirick Oâ€™Connell and chair of the firmâ€™s Health Law Group. â€śYou end up having to wall off the information used for maintenance and operation of that plan. But, on the whole, HIPAA will really not apply to the general employer and employee relationship.â€ť
Another common way employers come into contact with an employeeâ€™s PHI is through workersâ€™ compensation claims, Fisher said. In these instances, clinical documentation from medical appointments might be required to support the workersâ€™ compensation claim, and employers would need access to that information.
However, just because an employer can access this data does not necessarily mean HIPAA applies.
â€śGenerally, the health information employers get through the employment relationship is not going to be covered by HIPAA,â€ť Starkman said. â€śIt may be covered by other state privacy laws.â€ť
In the example of a workersâ€™ compensation claim, HIPAA would govern the healthcare providerâ€™s handling of protected health information and its release to the employer; the employee would be required to consent to this transmission of their healthcare data. Once that consent is given and the employer receives the information, HIPAA no longer applies. [Read related article: Guide to the Workersâ€™ Compensation Claim Process]
What are examples of HIPAA violations?
HIPAA violations can be costly, so it is essential to avoid even unintentional violations. Civil penalties for HIPAA violations can exceed $50,000 per violation. Violations committed with malicious intent could result in criminal charges â€” in the most egregious cases, up to 10 years in prison and $250,000 in fines.
The first step in avoiding HIPAA violations is knowing some of the most common ones.
Unreported data breaches
Healthcare organizations are a major target for cybercriminals attempting to breach the networks and steal sensitive healthcare data. Covered entities must report data breaches to the individuals affected, the secretary of the Department of Health and Human Services and sometimes the media.
To avoid data breaches, ensure that youâ€™re using highly rated antivirus software that is up-to-date and that all data is encrypted in storage and transmission. Update your software on all connected devices regularly to patch vulnerabilities hackers exploit. Decommission outdated devices and remove them from your network; dispose of them per HIPAA regulations.
If you are unsure whether your sensitive network information is protected, conduct a cybersecurity risk assessment on your company to see where potential weak points may occur.
Loss of devices
Any given hospital houses thousands of connected medical devices, all of which contain protected health information. The loss or theft of these devices could lead to the loss of sensitive data unless they are properly password-protected and encrypted in accordance with HIPAA. A failure to do so that results in a data breach is a HIPAA violation that could easily be avoided.
Employees who access data they do not need or are not authorized to access usually constitute a HIPAA violation. To avoid this problem, implement authorization systems that require employees to confirm their identities before accessing restricted information. Establish clear policies and procedures around authorizations and consequences for accessing information fraudulently.
Failure to encrypt data
Under HIPAA, all data must be encrypted. The law does not specify a precise standard, but the National Institute of Standards and Technology recommends Advanced Encryption Standard (AES) 128 at a minimum. Failure to encrypt devices, data in storage and data in transit likely constitutes a HIPAA violation. Avoid this by ensuring that all data in your network is encrypted to the highest possible standard.
Various laws govern how and for how long you must store employee data, including healthcare information. Check out our article on employee personnel files if you are interested in learning more about document storage and retention.
HIPAA compliance checklist
If you are a covered entity or a business associate of a covered entity, HIPAA regulations apply to you. To ensure you remain compliant, follow this helpful HIPAA compliance checklist from HIPAA Journal:
Following this checklist and establishing a clear set of policies and procedures regarding HIPAA compliance can put your organization in a better position to meet the strict privacy and security requirements included in the law.
Skye Schooley contributed to this article. Source interviews were conducted for a previous version of this article.
Photo: Lulis Alvarez/Getty Images
The Office of Civil Rights is providing a 90-day transition period for Â healthcare providers to come into compliance with the HIPAA Rules regarding telehealth, according to the Department of Health and Human Services OCR.Â
The transition period will be in effect beginning on May 12 and will expire at 11:59 p.m. on August 9.
OCR said it would continue to exercise its enforcement discretion and not impose penalties on covered providers for noncompliance during the 90- day transition period.Â
During the public health emergency, providers did not have to be licensed in the state where the patient was located. They were allowed to treat patients in other states.Â
Also under the PHE, non-HIPAA compliant platforms were allowed as long as they were not public facing.
Both of these flexibilities are coming to an end with the PHE on May 11, with providers now getting a 90-day grace period.
Other telehealth provisions expire at the end of 2023 and 2024.
WHY THIS MATTERS
HIPAA Enforcement Discretion is expiring with the end of the COVID-19 Public Health Emergency on May 11, according to the OCR notice on April 11.Â
OCR issued four Notifications of Enforcement Discretion that applied to certain violations of HIPAA rules during the PHE. These were related to community-based testing sites; using protected health information for public health; scheduling appointments for COVID-19 vaccinations; and telehealth.Â
THE LARGER TREND
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act during the COVID-19 public health emergency will expire at 11:59 pm on May 11, with the expiration of the COVID-19 public health emergency.
In 2020 and 2021, OCR published four Notifications of Enforcement Discretion in the Federal Register regarding how the Privacy, Security, Breach Notification, and Enforcement Rules of HIPAA would be applied to certain violations during the COVID-19 nationwide public health emergency.Â
These Notifications and the effective beginning and ending dates are:Â
The Notice of Expiration of Certain Notifications of Enforcement Discretion Issued in Response to the COVID-19 Nationwide Public Health Emergency may be found at: https://public-inspection.federalregister.gov/2023-07824.pdf - PDF.
ON THE RECORD
"OCR exercised HIPAA enforcement discretion throughout the COVID-19 public health emergency to support the healthcare sector and the public in responding to this pandemic," said Melanie Fontes Rainer, OCR Director. "OCR is continuing to support the use of telehealth after the public health emergency by providing a transition period for healthcare providers to make any changes to their operations that are needed to provide telehealth in a private and secure manner in compliance with the HIPAA Rules."
Glen Tullman will offer more detail in the HIMSS23 session "Views from the Top: Existential Crisis or Inflection Point Opportunity? An Industry Maverick's Perspective." It is scheduled for Tuesday, April 18, at 3 p.m. â€“ 4 p.m. CT at the South Building, Level 1, room S100 B.
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