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HIPAA Compliance: The Best Practices and Principles

Lumiform's HIPAA guide will demonstrate the benefits/importance of HIPAA compliance, and the step-by-step procedures to file for HIPAA certification.

What Is HIPAA Compliance?


HIPAA stands for the Health Insurance Portability and Accountability Act, which was a federal law passed by the U.S. Congress in 1996. Its purpose is to increase the portability of health insurance coverage and to ensure the security of people’s protected health information (PHI), like names, social security details, addresses, and more.


In a nutshell, HIPAA compliance means that patients or employees’ healthcare data is always kept safe and secure. This mandate requires all healthcare providers and health insurance companies to follow strict guidelines and confidentiality rules when handling patient data, as mandated by the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR).


If your company is HIPAA compliant, it means that you have a system in place to keep those records confidential and secure from any unauthorized access. Some essential components that companies must follow if they want to be HIPAA compliant are the following:


  • Keep all patient information confidential at all times
  • Mandate password protection on all devices storing patient information
  • Create a policy for employees accessing confidential patient data or other sensitive information online
  • Have regular training sessions on protecting patient information


In this article, we will discuss the following:


1. The benefits of getting an HIPAA compliance certificate


1. A step-by-step guide on how to get a HIPAA certification


2. The industries where HIPAA compliance is most useful


3. The entities that must be HIPAA compliant


4. The five rules of HIPAA


5. The different types of HIPAA violations


6. The pros and cons of a HIPAA compliance audit


7. The best practices to get the most out of HIPAA compliance



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What Are the Benefits of Getting an HIPAA Compliance Certificate?


Many companies will wonder why HIPAA is even important, and the answer, of course, is found in its payoff. At its core, the benefits of HIPAA compliance for business owners, managers, and employees revolve around mitigating the expensive costs of data breaches and protecting all employees or patients from identity theft and other malicious intent.


Here are the more specific benefits of HIPAA compliance audits:


  • Employees: HIPAA compliance protects employees from identity theft and fraud, as well as the privacy of patients, employees, and other individuals who come into contact with the business. This means that your personal information as an employee will remain completely private and you won’t have to worry about, for example, someone trying to take out credit cards in your name or using your identity for fraudulent purposes. When employees feel confident that their data is safe, they can be more productive at work and less distracted by concerns about their personal security.

  • Managers: HIPAA compliance protects managers from lawsuits if something were to happen to employee information as a result of negligence on the part of the company. Compliance helps to protect managers by keeping patient records safe and secure. By providing managers with adequate data protection when needed, they are less likely to run into problems with patients or their families filing lawsuits against them for negligence.

  • Employers: It protects business owners from discrimination complaints and other costly lawsuits. Your HIPAA audit report template should require employers to protect the privacy and confidentiality of employee health information. This means that companies can’t discriminate against employees based on their medical history or their disability status. Many times, this can help people get jobs or keep their jobs when they otherwise might not have been able to do so. It also helps to keep your business compliant with state laws regarding healthcare providers and insurance companies. These regulations vary from state to state so it’s important that you understand what they are before hiring or firing employees who might need access to private information.


How Do I Get HIPAA Certification?


Getting an HIPAA certification means keeping your company always up-to-date and compliant with current regulatory measures on data privacy and patient information protection. You may be thinking, “how do you even make sure I’m HIPAA compliant, and what are the consequences of violating compliance? Let’s explore those questions below.


Here are the first initial steps that you or your quality managers have to incorporate when applying for HIPAA compliance, regardless of how you customize your workflow according to your unique business structure:


  1. Establish Privacy Policies and Security Procedures
  2. Privacy policies cover what your business will and won’t do with patient information to avoid HIPAA noncompliance implications. For example, if you don’t have an established privacy policy, then an employee may be able to access someone else’s medical records simply by asking for them. In order to prevent this kind of unauthorized disclosure, it’s essential that all employees understand what constitutes “reasonable effort” when it comes to protecting patient privacy.


    This step should include: ensuring confidentiality and accessibility of all e-PHI for proper use, abiding by the current HIPAA security and privacy rules, detecting threats to private information, and distributing a “Notice of Privacy Practices” (NPP) form for patients as consent for their medical records to be accessed by third parties.


  3. Choose and Train a Safety Officer
  4. A HIPAA compliance audit requires all covered entities name a Privacy or Safety Officer who is responsible for ensuring that the use of electronically protected health information (ePHI) complies with HIPAA. The Privacy Officer must be given written instructions on how to fulfill their duties, which include training employees on how to comply with HIPAA and overseeing the entity’s policies. The security officer should be trained in information security practices and should oversee the implementation of those practices within the organization.


    This step should include self-performed audits in regular intervals by the Privacy Officer, as well as creating a system to keep up with any changes in HIPAA regulations.


  5. Annual Risk Assessment and Business Associate Agreements
  6. The third step to getting certification is to do a HIPAA Risk Assessment. This is to help you identify weaknesses in your system that could lead to a breach of patient or customer data. It also helps to put together a game plan with business associates for preventive measures, especially on what to do if a breach happens.


    This step should include establishing business associate contracts with vendors regarding data privacy, and creating administrative, physical and technical inventory safeguards for business associates and other involved entities.


  7. Establish Breach Notification Systems for Urgent Responses
  8. It’s important for businesses to have an alert system or plan in place for notifying affected parties should there be a breach. If something happens, who should urgently be contacted? Should there be a hotline set up for people who think their information may have been breached? Should there be additional resources available on the website or in person? These are all questions that you need to have well thought-out and answered for your notification system.


    Businesses need to provide training and education for employees to address such contingencies. They should understand what the company policy is regarding breaches and can act appropriately if one occurs during a HIPAA compliance audit.


    This step should include setting up an immediate response system to a data breach, implementing a way to report the breach to patients and employees, and noted continuous efforts to improve HIPAA compliance in your company.



Application and Use Cases: Who Must Be HIPAA Compliant?


Covered entities and business associates must be HIPAA compliant. This includes healthcare providers, billing companies, EHR platforms, accountants, lawyers, healthcare clearinghouses, and all other third-party entities that collect, process, create or transmit PHI information electronically.


To know more about successful HIPAA compliance and what sort of entities must be HIPAA-compliant, you can read the complete guide from the official HHS government website.


Is a HIPAA Compliance Audit Mandatory?


HIPAA compliance is a must for anyone providing treatment, payment, and/or healthcare operations. Some permitted uses and disclosures of PHI without the individual’s authorization include: situations where entities want to object or agree to the disclosures of PHI, payment of healthcare operations, cadaveric organ donation, research for public health reasons, law enforcement, and victims of abuse or domestic violence.



What Are the 5 Rules of HIPAA?


It can be hard to keep track of what HIPAA’s exact rules and provisions are, let alone how to follow them. Here are the five main rules of HIPAA:


  • Privacy Rule: This rule protects the privacy of health information and applies to covered entities and business associates. The Privacy Rule generally requires covered entities to adopt policies and procedures designed to protect health information from impermissible uses and disclosures.

  • Security Rule: This rule requires covered entities and business associates to implement administrative, physical, and technical safeguards on electronically protected health information (e-PHI).

  • Breach Notification Rule: This rule requires covered entities to notify individuals whose protected health information has been breached. The breach notification must be made without unreasonable delay, but in no case later than 60 calendar days after discovery of the breach.

  • The Enforcement Rule: This rule sets up an administrative process for enforcing compliance with HIPAA. It also specifies how violations should be handled, including civil HIPAA non-compliance penalties and criminal prosecution. The rule gives people who were harmed by a violation of HIPAA a way to file suit against the person or organization responsible for their injury.

  • The Identifiers Rule: This rule states that you must protect all patient information from being released without consent in any way that would identify them by name or other personal identifiers, such as their home address or social security number. This includes both paper and electronic records.


What Are the Different Types of HIPAA Violations?


Legal experts studying HHS have identified five types of HIPAA compliance inspection violations. They are as follows:


  • Lack of reasonable administrative safeguards, business associate agreements, risk analysis, risk management, and security training.

  • Breaching, losing, or exposing of unsecured protected health information (PHI).

  • Conducting impermissible uses, release or disclosures of PHI.

  • Improper PHI access logs, access termination, and dissemination.

  • Failing to comply with the Breach Notification Rule’s requirements for reporting breaches of protected health information.


Pros and Cons of a HIPAA Compliance Audit


HIPAA Compliance has been around for decades, and it’s even gaining in popularity as more companies wake up to the expensive costs of non-compliance. However, while HIPAA compliance benefits outweigh the costs, it also has its own share of drawbacks.


We’ve compiled a list of the pros and cons that managers, employees, and business owners must not dismiss during and after HIPAA Compliance certification in their workplace:


The Pros

  • Better protection of patient privacy.
  • Improved efficiency in healthcare delivery.
  • Better coordination between providers, insurers, and patients.
  • You may be eligible for tax benefits if your business is compliant with HIPAA.
  • It helps ensure that your company is in compliance with state laws related to health insurance privacy protection.
  • It helps protect patient information from falling into the wrong hands.

The Cons

  • High cost of compliance for small businesses due to lack of resources for implementation.
  • Cost of software and/or hardware needed to protect patient information from hackers.
  • Risk of lawsuits against your company If there is ever a breaching incident.
  • Compliance requires significant changes in the way healthcare organizations operate.

For more details about HIPAA’s pros and cons, read this comprehensive article from Vittana.



female employee on laptop ensuring HIPAA compliance smiling

Indispensable Tips and Best Practices to Get the Most Out of Your HIPAA Compliance


A common question surrounding HIPAA is whether it is difficult to get HIPAA compliance certification with an already-established business; after all, it’s likely these individuals are very familiar already with the ins and outs of the company’s workflows and processes. That might be true, but the problem is that it’s easy to get complacent. To avoid any costly mistakes in complacency and faulty HIPAA compliance, here are some dos and don’ts, industry-vetted tips, and best practices for your company to follow:


  1. Start Simple:
  2. In trying to be as compliant to HIPAA standards as possible, start with changes that are easy to implement and measure, and will have an immediate impact on your employees’ data. This will allow you to meet HIPAA compliance requirements faster, see real results, and build momentum toward larger changes later on.


  3. Use Simple but Powerful HIPAA Security Risk Assessment Checklists:
  4. For best execution and faster certification, find a simple but powerful app or checklist maker that can itemize everything you need to assess in your PLG strategy. Make sure the software or app is trusted and can be accessed anywhere, anytime, by anyone on the team, like Lumiform.


  5. Execute a Risk Assessment:
  6. Successful HIPAA compliance means identifying where your company is most vulnerable to HIPAA breaches and violations. The easiest way to do this is by conducting a risk assessment within your organization. From there, you can make changes to reduce those risks and improve compliance with HIPAA rules.


  7. Ensure Employees Understand Roles in Protecting Patient Data:
  8. Employees who understand how important it is to protect patient data privacy will be more likely to take steps toward protecting that information. They’re more efficient than employees who don’t understand why it matters or how it’s protected in their daily workflows.


  9. Learn From Other Companies’ HIPAA Compliance Mistakes:
  10. A missed opportunity is failing to learn from other businesses mistakes—and sometimes those lessons come at a steep price. The best way to avoid similar mistakes is by learning from others’ failures and asking questions about their processes and procedures (and making sure you’re following or avoiding them).


  11. Exhaust All Options to Protect Data Privacy:
  12. Implement physical safeguards specific to the regulations, as well as provide technical and data protection so that you can continue operating smoothly while keeping your patients’ information safe from a breach. This means you should always keep your records secure and not leave them lying around or easily accessible by unauthorized people.


    Data officers must keep the company’s assessment records in a locked drawer, filing cabinet, or in a secure encrypted cloud drive at all times so that no one can access them without permission. They also need to ensure that all of your employees have access only when they need it and only when they are authorized by law to have said access.


  13. Create Processes for Deleting Data:
  14. This is so important because of how easy it can be for sensitive information to get into the wrong hands if left unchecked. Take account of the hardware inventories and transfer/relocation processes when changes happen in your organization, like job or role changes, so that information is protected data is never left available on devices it shouldn’t be.


    To prevent physical access, meddling, and loss, properly assign who has access to the physical workstation where data is stored. Classify the implementation for utilizing desktops and related media, including moving, storing, discarding, and recycling digital communication, for specified organizations and business partners.


To sum it up, HIPAA compliance is a must for businesses that handle sensitive patient or employee health information. The HIPAA Privacy Rule is a complex set of regulations that govern how and when healthcare providers, health plans, and their business associates can use and disclose an individual’s protected health information (PHI).


In other words, when it comes to adhering to HIPAA compliance, the best thing you can do is be prepared and proactive. Educating yourself and your employees on this topic will go a long way toward preventing any potential breaches of information that can land the reputation or your company in hot water.


If you have more questions about how your company can become compliant with HIPAA regulations, visit the HHS Health Privacy Information Page.



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