Surviving a HIPAA Audit: Five Crucial Steps
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Spurred to action by HITECH, the U.S. Department of Health and Human Services has started to enforce HIPAA regulations through a series of random audits. In 2014 the audits are expected to extend to Business Associates. In this session, attorney Richard Wagner will cover the five crucial steps that Covered Entities and Business Associates alike will need to take now to survive an unexpected audit.
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Surviving a HIPAA Audit: Five Crucial Steps
- 1. 855.85HIPAA www.compliancygroup.com Industry leading Education Certified Partner Program • Please ask questions • For todays Slides http://compliancy-group.com/slides023/ • Todays & Past webinars go to: http://compliancy-group.com/webinar/ Get Involved. #cgwebinar
- 2. Surviving a HIPAA Audit: Five Crucial Steps RICHARD WAGNER
- 4. Quick Takeaway The HIPAA Audit program sounds scary Challenge – think of this as an opportunity ◦ IT/Security/Compliance: voice can be heard ◦ Providers: beHer serve your paIents in an increasingly unsecure environment Overall theme: tackle the priority items, then move onto the other issues
- 5. Agenda HIPAA Audit Program Overview Pilot Program Results and Discussion Five Steps to Surviving an Audit QuesIons
- 6. The HIPAA Audit Program Enacted into law in 2009 (ARRA/HITECH) Designed to combat ex post enforcement HHS’ Office of Civil Rights (OCR) oversees program, but most work contracted out to consultants Two pilot programs (2012 and 2013) Permanent rollout in 2014
- 7. Pilot: 2012-‐2013 Caveat: designed/implemented before Omnibus Rule ◦ Covered EnIIes only, no Business Associates ◦ Used old breach analysis, etc. OCR findings ◦ Many issues, even intenIonal misrepresentaIons ◦ Small providers had the most difficulty ◦ Security flaws dominated findings
- 11. Points of Emphasis: Privacy Rule Policies and procedures Minimum Use
- 12. Points of Emphasis: Security Rule Risk assessment, risk assessment, and risk assessment Mobile device security ◦ Data in moIon ◦ Data at rest Security incident procedures ◦ Ever more important a`er HIPAA Omnibus RegulaIons went into effect
- 13. HIPAA Audit Survival THE FIVE STEPS
- 14. Step #1 – OrganizaOon IniIal document request period: 10 days from the postmarked audit leHer Done by design: tesIng your response Ime Following this step also allows you to assess your documentaIon gaps Update old documents Establishing an audit trail
- 15. Quick Poll #2
- 16. Step #2 – Security Risk Assessment The most important document you need for HIPAA compliance ◦ Stressed by OCR and the HIPAA Audit process ◦ Also has great pracIcal value – a risk assessment is foundaIonal to proper risk management Does not have to be daunIng – scalable according to size What you need to assess ◦ PotenIal risks and vulnerabiliIes to the confidenIality, integrity, and availability of ePHI Other Ips
- 17. Step #3 – Plugging the PHI Holes Risk management – comes on the heels of your risk assessment Document everything ◦ Remember, the goal is to establish an audit trail PrioriIze risk miIgaIon acIons
- 18. Step #4 – Business Associate Agreements Update your BAA to reflect Omnibus changes ◦ The changes aren’t drasIc, but they need to be in there Make sure all vendors are under an agreement ◦ BAA terms and complexity needed can vary from provider to provider ◦ Consult your aHorney if necessary Get subcontractor assurances Related – vendor management procedures
- 19. Step #5 – Training Point of emphasis in the audits, so documentaIon is criIcal Don’t limit yourself to HIPAA training ◦ Security awareness should be included as well Use the training as an opportunity to gain informaIon
- 20. Conclusions Audits signal a major change in enforcement As worrisome as this might sound, this can be viewed as an opportunity Risk assessment: the foundaIon The more documentaIon, the beHer
- 21. QuesOons Richard Wagner richard@qliqso`.com
- 22. Free Demo and 60 Day Evaluation www.compliancy-‐group.com 855.85 HIPAA (855.854.4722) The Guard: One Simple, cost effective Compliance Tracking Solution that satisfies HIPAA, HITECH Risk Assessment, and Omnibus Compliance • Reduces Risk & Liability • Differentiates you from the competition • Retain Clients/Patients • Improve Revenue