HIPAA Compliance for Medical Practices
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HIPAA Compliance for Medical Practices
HIPAA Compliance and HIPAA Risk management Articles, Tips and Updates for Medical Practices and Physicians
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5 Steps for Implementing a Successful HIPAA Compliance Plan 

5 Steps for Implementing a Successful HIPAA Compliance Plan  | HIPAA Compliance for Medical Practices | Scoop.it

HIPAA Compliance is key to thwarting cyber attacks, but more importantly, this Plan will tell your employees, Business Associates and patients (and HHS, if they should come calling) how you secure Protected Health Information (PHI). Just as important is effectively communicating the plan to your staff.  

So, where do you begin? The purpose of this blog is to highlight what goes into making your plan. 

Five Key Steps

Step 1 – Choose a Privacy and Security Officer

We will be talking in later blogs about what to consider when selecting these HIPAA leaders.

For a smaller practice, your Privacy and Security Officer may be the same person. For larger practices, these duties will probably be split between two people. These are the folks who are going to be spearheading your Compliance Plan.  If you don’t have someone designated to fill this role, you are not compliant.

Step 2 – Risk Assessment

This step requires you to review your workplace and electronic devices to assess the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic Protected Health Information (ePHI) held by the Covered Entity or Business Associate. According to Atlanta healthcare attorney Daniel Brown, “a Risk Assessment extends not only to the accessibility of ePHI -- such as passwords -- but also to threats to your access of ePHI caused by natural risks, such as hurricanes and tornadoes, and even human risks, such as malicious hacking.”

You can perform the Assessment yourself or hire an outside contractor to come in and complete the process for you. If you're thinking about performing the assessment yourself, HHS has developed a Risk Assessment tool to help you get started.

The first option is obviously the cheapest and the second can be costly, or you can use a combination of the two. The key is to be very detailed and identify where all your potential Privacy and Security issues may lie. This will include listing all computing and mobile devices, where paper files are stored, how you will secure your offices when you are closed, etc. This is not a one-time event and will change over time as technology and risks change. You will want to revisit your Risk Assessment anytime you have a Breach, theft, or major change in hardware or software, but at a minimum every 2-3 years.

Step 3 – Privacy and Security Policies and Procedures

After completing your Risk Assessment, it’s time to create your blueprint for achieving HIPAA Compliance. The Compliance Plan should include Policies and Procedures - ensuring the Privacy of Protected Health Information and the Security of such information. The Security Policies and Procedures deal with ePHI (electronic PHI) and how you will protect that information.

Policies and Procedures need to be updated regularly and any changes need to be clearly documented and communicated to your staff. As you saw in the Penalties Section of our last blog, “I didn’t know” isn’t an acceptable defense!

Step 4 – Business Associate Agreements

Most of you use vendors or contractors to help run your practice or business. Under HIPAA, persons or entities outside your workforce who use or have access to your patient’s PHI or ePHI in performing service on your behalf are “Business Associates” and hold a special status in the Privacy equation. Some examples of Business Associates include third-party billing agents, attorneys, laboratories, cloud storage companies, IT vendors, email encryption companies, web hosts, etc. This list can get pretty long, and should be documented in your Risk Assessment.

Make sure you do an audit of your Business Associates before you accept a signed Agreement from them. We’ve seen a lot of folks sign these Agreements, and have no clue what they’ve agreed to. Auditing means looking at their Compliance Plan. They have to have one, or you can’t do business with them. Your legal counsel should have an Agreement you can use, or you can use a third party Agreement from a HIPAA compliance company.

Step 5 – Training Employees

You’ve got your Risk Assessment, Privacy and Security Policies and Procedures and Business Associate Agreements in hand. You’re all good, right? NO! Employees are many times your weakest link.

You need to annually train your employees on the HIPAA Rule and communicate information about your Privacy and Security Policies and Procedures that you’ve worked so hard to create. What good is all the work you’ve done on a Compliance Plan when no one knows about it, or how to use it? Train employees both on the HIPAA Law and your specific plan. In addition, you must keep records that they have been trained.

Technical Dr. Inc.'s insight:
Contact Details :

inquiry@technicaldr.com or 877-910-0004
www.technicaldr.com

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How to Assess Practice Risk to HIPAA and the HITECH Act?

How to Assess Practice Risk to HIPAA and the HITECH Act? | HIPAA Compliance for Medical Practices | Scoop.it

Since President Obama signed the HITECH Act (Health Information Technology for Economic and Clinical Health Act) in February 2009, the relationship between and influence of the Act on HIPAA (Health Information Portability and Accountability) has drawn physician and practice manager attention to effective risk assessment.

 

American Health Lawyers Association Recommendation

This group recommends that practice professionals approach risk assessment regarding HIPAA and HITEC as a component of an Enterprise Risk Management (ERM) program. ERM, used by public and private corporations around the globe, is an ongoing decision-making program. In the healthcare industry, the board of directors or executive administrators typically design, install and use their plan to assess and reduce risk of all areas of patient care, compliance and to maximize the return on investment.

The Association reminds executives and administrators that Section 6401 of the Affordable Care Act requires that medical providers establish a compliance program as a condition of enrollment in the coming affordable healthcare legislation.

 

Risk Assessment Parameters

The core fundamentals of risk assessment programs, common to most businesses, regardless of industry, are familiar to many veteran executives. Components include the following items.

  • Written policy and procedure manuals.
  • Designating a Compliance Officer and/or Compliance Committee.
  • Providing staff with thorough training and education.
  • Disciplinary standards that are clearly defined.
  • A workable monitoring and auditing program.
  • Written response plan to mitigate losses.

Your risk assessment and compliance program should be as specific as you can make it. While it is impossible to address every possible eventuality, noting every potential risk you can identify in your policy and procedure manuals helps your staff manage their daily responsibilities more efficiently—with less risk.

Have the Compliance Officer or Committee monitor staff to be sure they follow the procedures your program mandates. Spend the time to write a plan to respond to increased risks your Compliance Officer discovers. This encourages fast action by your Compliance Officer or Committee to lower losses and quickly solve perceived risk issues.

The CMS (Centers for Medicare & Medicaid Services) Manual outlines the risk assessment compliance program guidelines, which emphasize the following issues.

  • Prevention, detection and correction of non-compliance conditions.
  • Identifying and reducing fraud, abuse and waste.

 

Evaluating Risk Involving HIPAA and the HITECH Act

Compliance program guidelines specify three assessments providers should conduct. These actions also fit ERM parameters and guidelines, along with being specified by the Code of Federal Regulations (C.F.R.).

  • Security Evaluation. This is required under the Security Rule section and applies to providers, business associates or partners and subcontractors alike. All must “perform periodic technical and nontechnical evaluations . . .” when responding to environmental or operational changes affecting the security of electronic health information protected by law.
  • Risk Assessment of Specific Items. This is required under Security Rule stated at 45 C.F.R. (Code of Federal Regulations), section 164.308(a)(a)(ii)(A). Highly technical, this requirement should be performed per NIST SP800-30, Revision 1 Guide for Conducting Risk Assessments.
  • Risk of Harm Assessment. A requirement of the Breach Notification Rules, the practice must address “the implications and notification requirements” that are part of its ERM program.

The bottom line is that physicians must complete these three assessments and design an overall ERM plan that addresses as many risk issues as they can identify for their specific practices. It is vital that all medical providers create an organizational risk assessment program that encourages long-term compliance with HIPAA, the HITECH Act and all other regulations that apply.

Designing an ERM plan, as described, makes assessing potential practice risk of and avoiding HIPAA, HITECH Act and other regulation violations become normal operating procedure instead of compliance or loss practice crises.

Technical Dr. Inc.'s insight:
Contact Details :

inquiry@technicaldr.com or 877-910-0004
www.technicaldr.com

more...
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