When Was Your Last HIPAA Risk Assessment?

Working in the healthcare industry means more than treating patients. In addition to patient care, your practice’s staff also has to maintain compliance with complicated, regularly updated HIPAA regulations — are you sure you’re compliant?

When Was Your Last HIPAA Risk Assessment?

BY Matthew Brown |May 10, 2021|BLOG

When Was Your Last HIPAA Risk Assessment?

Working in the healthcare industry means more than treating patients. In addition to patient care, your practice’s staff also has to maintain compliance with complicated, regularly updated HIPAA regulations — are you sure you’re compliant? Double-check with help from NST.

When it comes to security and compliance, a lot of smaller healthcare practices think they can get away with little to no effort.

Why?

Because they think they’re flying under the radar. Because they don’t think they have the resources to spend on better compliance and security solutions. Because they have a small staff that’s focused on what they believe to be more pressing matters.

Not only is this all untrue — it’s dangerous. Is your medical practice risking a data breach and HIPAA non-compliance fines?

The NST team understands how complicated HIPAA compliance is, and that organizations of your size need to focus their available personnel on treating patients. That’s why we’ll handle your HIPAA compliance assessment for you, and make sure you have a plan in place to address any identified non-compliance risks.

You Can’t Afford To Cut Corners On HIPAA Compliance

Failing to stay compliant can carry severe penalties.

Fines for HIPAA violations range from $100 to $50,000 and there’s a maximum penalty of $1.5 million for repeat violations. You can also end up with criminal charges resulting in jail time. HIPAA compliance isn’t something you can afford to overlook.

The fact is that noncompliance can cost you a lot.  How much? In theory, as much as $ 1.6 million.

That’s not an exaggeration — not too long ago, the Texas Health and Human Services Commission was hit with that big of a fine for failing to conduct an organization-wide HIPAA risk analysis, as well as for being generally non-compliant.

Long story short – failing to comply with HIPAA is expensive.

What Should Your HIPAA Compliance Strategy Include?

Whether you’re managing your HIPAA compliance on your own, or you’ve invested in healthcare IT solutions for your practice, you need to have a strategy in place.

Have you taken care of the following?

  • Develop A Plan: With roughly 50 “implementation specifications” split up into administrative, physical, and technical safeguards, the HIPAA Security Rule is a lot to take in. Instead of wading right into the specifics, take the time to understand the big picture. A resource like the HHS website can help you get started.
  • Give The Proper Responsibilities To The Proper Individuals: You’ll need to appoint a Privacy and a Security Officer as part of your HIPAA requirements. While not specifically asked for, you’ll also need to have members of your team handling compliance documentation.
  • Individuals with good organizational and writing skills are needed in this position, given that documenting your actions is a huge part of HIPAA compliance. A designated Security Officer and clear documentation are required to meet the Administrative Safeguards.
  • Make Sure Your Staff Contributes To Compliance: An effective HIPAA compliance plan has to teach your staff how to handle a range of potential situations:
    • How to participate in compliance best practices
    • How to identify and address suspicious emails, phishing attempts, social engineering tactics, and more.
    • How to use business technology without exposing patient data and other assets to external threats by accident.
    • How to respond when you suspect that your organization is noncompliant.
  • Plan Ahead For Future Audits and Reviews: You are required by HIPAA to regularly revisit your HIPAA compliance policies and procedures in order to make sure they keep in line with changes to regulations, and changes within your organization. The more meticulous and systematic your documentation is to start off with, the easier it will be to go back and make periodic reviews or make adjustments down the road.
  • Don’t Assume You’re Invulnerable: You’ll never be so compliant and so secure that you’re risk-free. This entire process is about minimizing, not eliminating risk. That’s why you need a plan in place for when you suspect you have experienced a breach or become noncompliant. Have contingencies in place for the worst-case scenarios, so that you’re never caught off guard.

When Was The Last Time You Double Checked Your HIPAA Compliance?

You are required by HIPAA to regularly revisit your HIPAA compliance policies and procedures in order to make sure they are still in line with changes to regulations, and changes within your organization.

While you could do so on your own, it’s smarter to have an expert third-party like NST assess your HIPAA risk potential.

This assessment should involve the following considerations:

  • It should consider any and all risks to any and all PHI, in terms of its privacy, availability, and integrity. It’s important to determine and document where the data is being stored, received, maintained, or transmitted.
  • Potential threats need to be identified and documented, as well as their probability of occurring, and the result of their occurrence. Using this information, a theoretical level of risk needs to be determined.
  • Your cybersecurity needs to be assessed and confirmed to be in line with HIPAA standards (if not stronger and more extensive).
  • All information involved in and resulting from the assessment needs to be documented, and formed in an Action Plan, to address any potential noncompliance and mitigate risks.

Why Can’t You Perform Your Own HIPAA Assessment?

While many healthcare organizations across the country often choose to manage their HIPAA assessments internally, it’s not recommended that you do so.

There are two key reasons why it’s smarter to outsource the process:

  • Unbiased Perspective On Your HIPAA Compliance: This is the inherent problem with any form of self-assessment — how can you have a truly unbiased view of your own organization? If you want the assessment to be effective and actually identify areas for improvement, there’s no better way to do so than with an independent third-party.
  • Scope And Scale Of The Assessment: Are you sure your internal team is aware of everything that falls under HIPAA compliance? Everyone knows to double-check processes involving ePHI, but what about physical and technical safeguards? HIPAA compliance means verifying safety measures including fire extinguishers, sprinklers, and more.
  • Freedom Of Focus: By outsourcing the process, you give your team the freedom to focus directly on their work. This serves to promote the highest quality of care for your patients, as there are no distractions for your staff.

Have You Made Progress Since Your Last HIPAA Assessment?

Did you know that, in addition to performing annual HIPAA audits, you’re also expected to implement improvements year to year?

This is an often-overlooked component of compliance. Organizations will perform a cursory self-assessment each year, check the boxes, and move on.

However, given that you need to keep past assessments on file for reference by the HHS, any sign that you’ve identified potential problems but failed to address them can result in serious fines. That’s why, in addition to the assessment, you need to have a process for implementing improvements as well.

Have Your HIPAA Compliance Assessed By NST

We know how complicated HIPAA compliance is, and how organizations like yours would rather be focusing on caring for their patients. That’s why we’ve developed a comprehensive compliance assessment service to help you stay in line with HIPAA.

When you choose to work with us, we will:

  • Conduct a risk assessment to identify gaps between your existing security measures and compliance requirements.
  • Implement the proper technical safeguards to address gaps and secure electronic protected health information.
  • Verify the often-overlooked physical aspects of compliance including fire extinguishers, locks, sprinklers, alarm codes, and more.
  • Assist in creating the policies and procedures needed to keep your staff operating in a way that’s compliant at all times.

NST Will Help You Double-Check Your HIPAA Compliance

No one said HIPAA compliance was easy. It’s a higher level of security and data governance that healthcare organizations have to follow.

Proactive healthcare organizations seek out support for their compliance from an expert third-party. It’s simpler and more effective than trying to manage an assessment internally.

With so much to consider, it’s vital that you have reliable and knowledgeable support from a third-party like NST to help you effectively maintain your HIPAA compliance posture. We have been helping healthcare facilities and practices throughout the region build reinforced IT strategies that work within their business model to make them more productive and efficient.

Our team understands how complicated HIPAA compliance is, and that organizations of your size need to focus their available personnel on treating patients. That’s why we’ll handle your HIPAA compliance for you.

On your behalf, we’ll conduct a risk assessment to identify gaps between your existing security measures and compliance requirements. Our HIPAA compliance consultants will make sure that best practice IT protocols are followed.

Get in touch with our team to schedule your assessment. 

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