4 Key HIPAA Requirements and Compliance Best Practices

What Is HIPAA? 

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law enacted in 1996 in the United States. Its primary purpose is to protect protected health information (PHI) from being disclosed without the patient’s consent or knowledge. HIPAA sets guidelines for maintaining the privacy and security of individuals’ medical information, ensuring that personal health details are handled with care by all entities involved.

HIPAA encompasses various rules and regulations that healthcare providers, insurance companies, and other entities dealing with health information must follow. The law mandates the standardization of electronic health transactions and requires safeguards to protect health information, ensuring patient confidentiality and data security. Compliance with HIPAA is crucial for healthcare organizations to avoid legal repercussions and maintain trustworthiness in handling medical data.

What Kind of Organizations Need to Adhere to HIPAA Compliance? 

Providers and Creators of PHI

Organizations that provide medical services or create PHI as part of their business activities are required to adhere to HIPAA compliance. This includes hospitals, clinics, doctors’ offices, and any other healthcare facilities. These providers handle sensitive patient data regularly and must ensure the privacy and security of PHI by implementing appropriate safeguards, training staff on HIPAA policies, and conducting regular audits. Failure to comply with HIPAA can lead to significant legal penalties and damage to the organization’s reputation.

Insurance and Finance

Entities in the insurance and finance sectors that deal with PHI also need to comply with HIPAA regulations. This includes health insurance companies, Medicare and Medicaid programs, and other organizations that process health-related claims and payments. These entities must protect the integrity and confidentiality of PHI by establishing robust security measures, ensuring that employees are trained on HIPAA requirements, and managing the risks associated with electronic health transactions.

Supply Chain Providers Transmitting PHI

Organizations involved in the healthcare supply chain that transmit PHI must comply with HIPAA. This includes third-party service providers such as billing companies, cloud storage services, and other vendors that handle PHI on behalf of covered entities. These providers must implement adequate security measures to protect PHI, enter into Business Associate Agreements (BAAs) with covered entities, and ensure that their subcontractors also comply with HIPAA requirements. Effective management of these relationships is essential for maintaining the privacy and security of health information throughout the supply chain.

Understanding the Key HIPAA Requirements 

1. The HIPAA Privacy Rule

The HIPAA Privacy Rule, enacted in 2003, establishes federal standards for safeguarding individuals’ medical records and other personal health information (PHI). It applies to covered entities such as healthcare providers, health plans, and healthcare clearinghouses, as well as their business associates who handle PHI on their behalf. The Privacy Rule aims to ensure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high-quality healthcare and protect public health and well-being.

Key components of the Privacy Rule include the requirement for covered entities to develop and implement policies and procedures to protect PHI. These policies must limit the use and disclosure of PHI to the minimum necessary to accomplish the intended purpose. For example, a healthcare provider should only access the parts of a patient’s medical record that are necessary for their specific job function.

The Privacy Rule also grants patients significant rights regarding their health information. Patients have the right to request access to their medical records and obtain copies. They can request amendments to their records if they identify inaccuracies or incomplete information. Additionally, patients have the right to receive an accounting of certain disclosures of their PHI made by the covered entity.

2. The HIPAA Security Rule

The HIPAA Security Rule, effective since 2005, specifically addresses the protection of electronic protected health information (ePHI). It requires covered entities to implement a series of administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and availability of ePHI:

• Administrative safeguards involve the implementation of policies and procedures designed to manage the selection, development, implementation, and maintenance of security measures to protect ePHI. This includes conducting regular risk assessments to identify potential vulnerabilities and implementing security management processes to address these risks. Entities must also designate a Security Officer who is responsible for developing and overseeing security policies and procedures.
• Physical safeguards are measures to protect electronic systems, equipment, and the data they hold from threats such as unauthorized access and natural disasters. This includes controlling physical access to facilities where ePHI is stored, ensuring that workstations are protected from unauthorized access, and implementing policies regarding the proper disposal of ePHI.
• Technical safeguards are the technology and related policies and procedures used to protect ePHI and control access to it. This includes implementing access controls like unique user IDs, emergency access procedures, automatic logoff, and encryption. Technical safeguards also involve the use of audit controls to record and examine activity in systems that contain ePHI.

3. The HIPAA Breach Notification Rule

The HIPAA Breach Notification Rule, established in 2009, requires covered entities and their business associates to provide notification following a breach of unsecured PHI. A breach is defined as an impermissible use or disclosure of PHI that compromises its security or privacy. The rule is designed to ensure that affected individuals are promptly informed of breaches, enabling them to take steps to protect themselves from potential harm.

Under the Breach Notification Rule, covered entities must notify affected individuals without unreasonable delay and no later than 60 days following the discovery of a breach. The notification must include a description of the breach, the types of information involved, the steps individuals should take to protect themselves, what the entity is doing to investigate the breach and mitigate harm, and contact information for further inquiries.

If a breach affects 500 or more individuals, the covered entity must also notify the Department of Health and Human Services (HHS) and prominent media outlets serving the affected area. For breaches affecting fewer than 500 individuals, entities are required to maintain a log of breaches and submit an annual report to HHS.

4. The HIPAA Omnibus Rule

The HIPAA Omnibus Rule, implemented in 2013, introduced changes to HIPAA regulations, enhancing and clarifying existing requirements. Here are some of the important changes introduced by the Omnibus Rule:

• Expansion of direct liability to business associates of covered entities. Business associates and their subcontractors are now directly liable for compliance with certain HIPAA requirements, making them accountable for safeguarding PHI.
• Stronger limitations on use and disclosure of PHI for marketing and fundraising purposes. Covered entities are prohibited from selling PHI without individual authorization, and they must obtain permission from patients before using their information for marketing.
• Enhancing individuals’ rights to access their health information. Patients can now request electronic copies of their medical records, and covered entities must comply within 30 days. Patients can also instruct providers to restrict disclosures of their information to health plans if they pay out-of-pocket in full for the services.
• Revision of the HIPAA Breach Notification Rule, requiring an objective assessment of the probability that PHI has been compromised. This means that any unauthorized use or disclosure of PHI is presumed to be a breach unless a risk assessment demonstrates a low probability that the PHI has been compromised.

How to Adhere HIPAA Compliance Requirements 

Self-Audits

Conducting self-audits is essential for organizations to ensure they are HIPAA compliant. These audits involve a review of the entity’s policies, procedures, and practices to identify any areas of non-compliance. Regular self-audits enable organizations to address potential issues before they result in breaches or violations.

During self-audits, organizations should examine various aspects such as how PHI is stored, accessed, and transmitted. Identifying vulnerabilities and implementing corrective measures helps maintain compliance with HIPAA’s requirements. Self-audits also serve as documentation of the organization’s efforts to remain compliant, which can be crucial in the event of an investigation or audit by regulatory authorities.

Remediation Plans

After identifying areas of non-compliance through self-audits, organizations must develop and implement remediation plans. These plans should outline specific steps to address the gaps and enhance HIPAA compliance. Effective remediation plans include setting timelines, assigning responsibilities, and ensuring that corrective actions are prioritized based on the potential risk to PHI.

Remediation efforts may involve updating policies and procedures, enhancing security measures, and providing additional training to staff. Regular monitoring and reassessment ensure that the remediation efforts are effective and that the organization continues to adhere to HIPAA requirements.

Policies and Procedures

Creating and implementing policies and procedures is crucial for HIPAA compliance. These documents provide a framework for how an organization handles PHI, ensuring that all staff members are aware of their responsibilities. Policies should address various aspects such as access control, data encryption, and incident response.

Regularly reviewing and updating policies and procedures is essential to adapt to changing regulations and emerging threats. Organizations should also ensure that staff are trained on these policies, fostering a culture of compliance. By establishing and maintaining policies and procedures, entities can effectively safeguard PHI and comply with HIPAA regulations.

Business Associate Management

Managing business associates is an important component of HIPAA compliance. Covered entities must ensure that their business associates, who handle PHI on their behalf, comply with HIPAA regulations. This involves executing Business Associate Agreements (BAAs) that outline the responsibilities of business associates in protecting PHI.

Regularly reviewing and updating BAAs is essential to address any changes in regulations or the scope of services provided. Organizations should also conduct due diligence to ensure that business associates have adequate safeguards in place. By managing business associates effectively, covered entities can maintain compliance and protect PHI throughout the information chain.

Incident Management

Effective incident management is critical for responding to potential breaches or security incidents involving PHI. Organizations must have a clear incident response plan that outlines the steps to be taken in the event of a security breach. This includes identifying and containing the breach, mitigating its impact, and notifying affected individuals and regulatory authorities as required by the HIPAA Breach Notification Rule.

Regularly testing and updating the incident response plan ensures that the organization is prepared to handle various types of security incidents. Training staff on their roles and responsibilities during an incident is also essential. Effective incident management helps minimize the consequences of breaches and ensures that organizations comply with HIPAA’s reporting requirements.

Maintain Records and Documentation

Maintaining detailed records and documentation is a key aspect of HIPAA compliance. Organizations must document all policies, procedures, and actions taken to protect PHI. This includes records of self-audits, training sessions, and breach notifications. Proper documentation demonstrates the organization’s commitment to compliance and provides evidence in the event of an audit or investigation.

Accurate documentation also helps organizations track their compliance efforts and identify areas for improvement. By keeping thorough records, entities can ensure that they are meeting HIPAA requirements and are prepared to respond to any inquiries from regulatory bodies. Effective record-keeping is indispensable for long-term compliance and risk management.

HIPAA Compliance with Exabeam

Noncompliance with HIPAA can result in heavy fines from OCR and other consequences. When patch management, access controls, and monitoring are not fully implemented with the right solution stack, it leaves the organization vulnerable to ransomware and other attack vectors that can impact patient care. 

Exabeam Security Operations Platform telemetry combines logs with context, security intelligence feeds, and AI analysis to identify anomalous behaviors that indicate potential attacks. Pre-built Dashboards make HIPAA Compliance reporting easier. Whether you are using a framework like NIST or MITRE ATT&CK^Ⓡ, Exabeam offers a clear path to track your compliance and governance request needs — while all establishing what normal looks like in your environment and for every entity logged in. 

The Outcomes Navigator offers continuous visualization and insight into your detection coverage and improvements made, which provides suggestions for improvements in log parsing as well as showing which sources and detections are most effective against which parts of the ATT&CK framework and use cases are most indicative of network penetration, persistence, and lateral movement.