What Does HIPAA Stand For?

HIPAA stands for Health Insurance Portability and Accountability Act. Enacted in 1996, it is comprehensive healthcare reform legislation that aims to protect the privacy and security of patient health information (PHI).

What is the Concept of HIPAA?

HIPAA defines three categories of covered entities that must implement appropriate administrative, technical, and physical safeguards—health plans, healthcare providers, and business associates. It encompasses multiple regulations, but the HIPAA Privacy Rule is the cornerstone of patient data protection, outlining the following key principles:
  1. Patients must provide explicit authorization before any entity can utilize or disclose their HI for purposes that differ from providing healthcare services.
  2. The scope of PH data collection and usage should be limited to the bare minimum required to accomplish the desired objective.
  3. Patients hold the authority to access, verify, and rectify their PHI, and receive a detailed account of disclosures made regarding their PHI.
  4. Covered entities are mandated to establish robust security measures to safeguard PHI from unauthorized access, use, disclosure, disruption, modification, or destruction.

How to Achieve HIPAA Compliance: A Checklist

Here’s a comprehensive HIPAA compliance checklist to guide you through the process:
  1. Determine your covered entity status
  2. Identify your PHI (electronic, paper, and oral forms)
  3. Implement policies and procedures
  4. Designate a Privacy Officer (PO)
  5. Implement administrative safeguards (e.g., workforce security, incident reporting, and business associate relationships)
  6. Implement physical safeguards (e.g., secure facilities, locked storage)
  7. Implement technical safeguards (e.g., data encryption, access controls, and secure software practices)
  8. Conduct risk assessments
  9. Embrace vulnerability management
  10. Secure data in transit and storage (think of TLS/SSL)
  11. Dispose of PHI properly (e.g., shredding paper documents and securely erasing electronic data)
  12. Provide employee training
  13. Run annual HIPAA compliance reviews
  14. Seek external guidance (such as from experienced HIPAA consultants or attorneys)
  15. Stay updated on HIPAA changes
As you can see, achieving HIPAA compliance is an undertaking that requires a multifaceted approach.

How Can You Obtain HIPAA Certification?

Training programs are the most common way to obtain HIPAA certification. There are many different initiatives available, including both online and in-person courses. Third-party assessments, on the other hand, are less common, but they are becoming increasingly popular. Third-party assessors are independent organizations that evaluate an organization’s HIPAA compliance program and issue a certification if the program meets certain standards. Some of the most reputable third-party assessors include The Joint Commission, HIMSS, and OCR with its HIPAA self-assessment toolkit. Regardless of how you obtain your HIPAA certification, it is important to ensure that the program or assessor is reputable and recognized by the industry. You should also make sure that the program or assessor provides you with the training or assessment you need to effectively protect patient health information.

Who is Responsible for Enforcing HIPAA?

Non-adherence to HIPAA standards can expose covered entities to hefty fines and potential litigation. The Office of Civil Rights (OCR) within the U.S. Department of Health and Human Services (HHS) is the body that enforces HIPAA regulations. OCR investigates reported violations, conducts compliance audits, and imposes penalties ranging from corrective action plans to millions of dollars in fines.

What is a HIPAA Release Form, and When is It Needed?

Through a HIPAA release form, patients can officially consent to their healthcare providers sharing their PHI with other parties for specified purposes. PHI is any information about a patient’s past, present, or future health or condition, including their medical history, treatment records, and billing information. To be valid, a HIPAA release form must be in writing, voluntary, specific, and time-limited. Here are some examples of when a HIPAA release form is needed:
  • A patient wants their doctor to share their medical records with their new doctor.
  • A patient wants their therapist to share their mental health records with their employer.
  • A patient wants their dentist to share their dental records with their life insurance company.
  • A student wants their school nurse to share their immunization records with their college.
  • A patient wants their doctor to share their PHI with a law enforcement agency to report a crime.

What Constitutes a HIPAA Violation?

What is a HIPAA violation, then? In plain English, it is any breach of the Act’s provisions. Here are some examples:
  • Disseminating sensitive PHI without proper authorization to individuals or entities not legally granted access to it
  • Misusing PHI
  • Obstructing patients’ access to their PHI
  • Implementing inadequate access controls to protect PHI
  • Neglecting to encrypt PHI to safeguard its confidentiality
  • Failing to dispose of PHI in a secure manner
  • Skipping risk assessments to identify potential threats
  • Delaying breach notifications beyond the 60-day timeframe, potentially jeopardizing patient privacy and security
  • Providing incomplete or inaccurate information about breaches to affected individuals, hindering their understanding and ability to take protective measures
  • Failing to document breaches thoroughly and take timely corrective actions to prevent future incidents

What is the HIPAA Minimum Necessary Rule?

The HIPAA Minimum Necessary Rule is a requirement that mandates covered entities to limit the protected health information (PHI) collected, used, and disclosed to the minimum volume necessary to accomplish a specific purpose. This rule applies to all covered entities, including healthcare providers, health plans, and business associates. It also applies to all forms of PHI handling, including electronic, paper, and oral.