HIPAA. Just saying it will send chills down the spines of healthcare legal teams across the United States.
If this is your first run-in with it, though, it stands for the Health Insurance Portability and Accountability Act, and it's the law of the land when it comes to protecting medical data.
It's one of the most important pieces of legislation ever passed in the healthcare industry. And it's kind of intimidating.
Protecting patient data is at the core of the regulation, and mistakes can be extremely costly. But don't let all that scare you off — we got your back.
We've put together a comprehensive HIPAA compliance checklist that'll help keep you and your team safe from the regulatory powers that be.
- Complying with HIPAA regulations is necessary in order to protect your patients' personal healthcare data.
- Noncompliance can carry some steep fees and result in reputational damage to your business.
- Keeping the regulators at bay is easier than you might think as long as you’ve got a proper plan in place.
What Is HIPAA Compliance?
HIPAA compliance is the process of making sure you, your team, and your business associates are adhering to all regulations outlined in the Health Insurance Portability and Accountability Act.
So who has to be compliant?
The short answer is: everyone. The longer answer, however, includes:
- Healthcare providers such as doctors, dentists, psychologists, psychiatrists, chiropractors, and pharmacists
- Health insurance providers
- Healthcare clearinghouses
And covered entities, or everyone they do business with, including but not limited to:
- Data storage firms
- Cloud service firms
- Billing companies
The entire point of HIPAA is to protect patients from unauthorized use or disclosure of their protected health information (PHI) or electronic Protected Health Information (ePHI). So while compliance can be a little bit of a hassle, it's most certainly a good thing.
Now let’s get into the nitty-gritty. There are five basic rules of HIPAA compliance:
HIPAA Privacy Rule
Patients must have access to and control over their own health information, and covered entities must have measures to protect that data and the transmission of that data..
HIPAA Security Rule
Healthcare providers and covered entities must meet the administrative, physical and technical standards for the storage and protection of PHI and ePHI.
HIPAA Omnibus Rule
All HIPAA-covered entities must provide a notice of privacy practices to their patients.
HIPAA Breach Notification Rule
Covered entities are required to notify individuals when there is an unauthorized use or disclosure of their PHI.
HIPAA Enforcement Rule
Covered entities must have a process in place to investigate and address any complaints of noncompliance.
To be HIPAA compliant, you’ll need to take appropriate measures to ensure that your organization is meeting these requirements.
Why HIPAA Compliance Is Important
Well, for one, it's the right thing to do. By adhering to the requirements of HIPAA, you're protecting your patients.
If you ask your legal team, though, they might mention that there is another pretty big reason to remain compliant: noncompliance is expensive. Like, really, really expensive.
Noncompliance can also damage your organization's public image. After all, patients want to know that their health data is safe and secure.
Accidents happen — and they can be costly. But individuals knowingly violating HIPAA regulations for personal gain could face even steeper penalties. We’re talkin’ up to 10 years in the clinker.
If you don't keep up with HIPAA regulations, you're not only putting your patients at risk, but you’re also risking massive fines and a potential loss of business.
The Ultimate HIPAA Compliance Checklist
Wondering how you can make sure your organization is compliant with HIPAA regulations? Don't worry, we're here to help.
We've put together a handy HIPAA compliance checklist to make sure you cover all the bases:
1. Do a Risk Assessment
The first step to HIPAA compliance is conducting a comprehensive risk assessment based on the five rules we mentioned above.
This means evaluating the technology and devices you use, assessing your policies and procedures, analyzing the data that flows in and out of your system, and understanding how to secure sensitive patient information.
- Patients must have access to their PHI
- PHI must be stored securely
- You must provide a notice of privacy practices to all patients
- You need a process in place to notify patients if their PHI is compromised
- You need a comprehensive procedure in place to investigate complaints of noncompliance
Risk assessments should be repeated on a regular basis so you can make sure you're up to date with the latest regulations and best practices.
Here are a few questions you can ask in your HIPAA risk assessment:
2. Implement Security Safeguards
Once the risks to PHI have been identified, you must develop a comprehensive security plan to address them. This security plan should include physical and digital safeguards designed to protect PHI and ePHI from unauthorized access, use, or disclosure.
- Physical safeguards are things like locked doors and file cabinets, security cameras, and shredders for destroying confidential information.
- Digital safeguards include things like software with bank-level security, contract management solutions that allow you to set permissions and roles, password protection, two-factor authentication, encryption, and firewalls.
You'll also want to perform due diligence on your business associates like cloud storage providers, vendors, or anyone else that may have access to or be in charge of PHI to ensure they're complying with these safeguards. Make sure security provisions are outlined in contracts and review them regularly in case you need to update them.
Here are a few questions you can ask to ensure your HIPAA security safeguards are satisfactory:
3. Establish Administrative Policies and Procedures
Written policies and procedures are the lifeblood of organizational compliance.
Create a policy for routine system maintenance and monitoring, incident reporting, and how to handle violations.
You'll also want to outline appropriate sanctions for employees who violate HIPAA rules. Make sure everyone in the organization knows who is responsible for ensuring compliance and when any audit reports or assessments must be completed.
Finally, arm your compliance officers and contract managers with top-tier contract management software.
Software with the ability to set permissions and roles for specific documents will ensure that PHI is safe from prying eyes and allow you to terminate access when employees change roles, leave the organization, or move on to another patient.
Here are a few questions you can ask to make sure your policies and procedures are adequate:
4. Create a Contingency Plan
We all know Murphy's Law: Anything that can go wrong will go wrong.
That's why it's important to prepare for anything and everything that could put PHI at risk.
Here are four key goals every HIPAA contingency plan should accomplish:
- Establish clear lines of communication: Define who will be responsible for contacting the proper authorities, communicating with patients and healthcare providers, and notifying employees in the event of a violation.
- Outline appropriate responses: Have a plan for responding to violations, taking corrective action, and responding to media coverage.
- Guarantee quick response times: Set deadlines for responding to violations and resolving issues as quickly as possible. Delaying action runs the risk of further damage and could result in more expensive fines.
- Test your plan regularly: Conduct drills and tabletop exercises with your staff. By testing your plan regularly, you can identify any weaknesses and make necessary adjustments before an actual emergency occurs.
Here are a few questions you can ask to make sure your contingency plan is sufficient:
5. Train Your Employees on HIPAA Compliance
Ever heard this one? “For the best return on your money, pour your purse into your head.”
When Ben Franklin said that, he wasn't talking about HIPAA, though he could have been!
Not only is training required under HIPAA law, but it's also got a great ROI.
Remember, a data breach could result in an eight-figure loss, so training your team on how to prevent a breach, or mitigate the damage if one does occur, could help you save a pretty penny.
So, who needs training? Everyone! That includes employees and business associates who handle PHI. And it shouldn’t be a one-off onboarding session, either. You’ll need to make sure you have routine refreshers as well. Here's a quick list of topics your training should cover:
- Overview of HIPAA rules
- Guidelines for keeping data secure
- Proper handling of PHI
- Reporting security breaches
- How to use HIPAA-compliant software
- Cybersecurity best practices
- Risk assessment protocols and procedures
6. Document Everything
Hansel and Gretel left breadcrumbs to find their way home. You might consider taking a page from their book!
When it comes to keeping your organization compliant, having a paper trail and a secure, organized repository is everything.
Compliance audits are inevitable, so compiling regular reports showcasing your compliance efforts is a must.
These reports should cover things like:
- All training that has taken place
- Policies and procedures
- Security measures
- Incident reports and complaints
- Any disciplinary actions taken for noncompliance
Hansel and Gretel made it home safely, and if you audit-proof your organization, you will, too!
Here is a quick checklist to ensure you’re documenting everything you need to be documenting:
7. Use the Right Software
You know that old saying, “you’re only as good as your tools”? Well, it couldn’t be truer when it comes to HIPAA compliance.
And these days, it's all about software. HIPAA-compliant software.
Whether you're managing contracts or organizing patient files, you need a system that fulfills at least a few basic requirements:
- Secure against unauthorized access
- Able to encrypt or otherwise protect sensitive data
- Accurately track who has accessed the data and when
- Accessible by only authorized personnel
- Ensures the confidentiality and integrity of all PHI
- Backs up all ePHI to ensure it can be accessed by patients in case of emergency
Remember: If you’re using a third party as your technology provider, you will need to do your due diligence to make sure their systems are in tip-top shape and following the best practices outlined by the Department of Health and Human Services.
Here’s a quick checklist to ensure you’re following the best tech practices possible:
HIPAA Compliance Has Never Been Easier
Contract management software makes HIPAA compliance a walk in the park. With automated processes, detailed reports, user permissions and roles, and a secure, centralized digital repository for all your HIPAA documents, you can be sure you’re meeting the standards of compliance.
Want to see how you can beef up your compliance efforts today? Poke around ContractSafe's healthcare-specific contract management features during a free trial!