How to survive a HIPAA audit

Just as healthcare data has become very valuable to cybercriminals, compliance with the regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) has become a mandatory part of any secure healthcare operation. Despite HIPAA being written in the ’90s, compliance with its regulations remains the pinnacle and litmus test of any data privacy and security program.

This is because HIPAA emphasizes the need for measures to secure data healthcare data or Protected Health Information (PHI). These measures include administrative, physical, and technical safeguards, as well as organizational requirements and documentation standards. Data security plans and IT infrastructure are essential to this need. This is where many healthcare providers struggle.

What is a HIPAA security audit?

The Office of Civil Rights (OCR) is responsible for ensuring that healthcare providers and similar entities comply with HIPAA regulations. Audits are conducted to track progress on compliance and identify areas where improvement is needed.

A typical HIPAA security audit of an organization consists of evaluating administrative, physical, and technical safeguards for the PHI that it either creates, receives, processes, maintains or transmits. It also evaluates the organization’s policies, procedures, and overall readiness to manage a data breach.

Audits only begin after a security event has occurred at a healthcare provider or any other HIPAA-covered organization. This event can be a data breach, a HIPAA violation report, or one of the following:

  • A security event attributed to human error, such as an employee opening a phishing email, using a weak password, or inputting the wrong email address when sending PHI
  • Unpatched software where many malware and ransomware exploits can occur
  • Insider wrongdoing and the lack of a business associate agreement
  • A lost or stolen device

How can my organization prepare for a HIPAA security audit?

This question is not the right one to ask. If your organization gets audited, it means you’re doing something wrong. It is best to keep an audit from happening. So how does one do that? Make sure the privacy and security of PHI at your healthcare organization are without issue or risk.

The Office of the National Coordinator for Health Information Technology (ONC) provides a guide for this. It carefully lays out steps on how to ensure that your organization or business complies with HIPAA. These steps will help any healthcare organization avoid a security audit. Pay attention to these critical elements outlined in the guide:

  • Have a designated security assessment and privacy officer
    HIPAA requires a security and privacy officer responsible for all things security. Either an employee or consultant, they are tasked with developing security policies and procedures that are compliant with HIPAA. They also conduct employee training to ensure that each staff member is familiar with the security and privacy rules.
  • Conduct a security risk analysis
    This process reviews the existing security of PHI in your organization to assess the potential threats and vulnerabilities to the confidentiality, integrity, and availability of PHI. It looks for any security risks potential to your organization. These findings will inform your risk mitigation plan or become the foundation for any strategy to address security problems.
  • Create a risk management plan
    With the problem areas identified, your organization can create a risk management plan or a strategy for precisely how it intends to remediate those issues. This plan isn’t just a one-time action. The analysis must be completed yearly to identify new risks and enhance the risk management plan in order to address issues better.
  • Ensure business associate agreements are in place
    Business associate agreements (BAAs) are essential to ensure HIPAA compliance. BAAs ensure vendors or care partners such as electronic health record (EHR) developers handle PHI correctly.
  • Conduct routine HIPAA training
    Human error is the primary cause of events that lead to a security audit. To avoid a lot of these problems, employees must understand the basic HIPAA principles. Training is critical to understanding HIPAA compliance requirements, especially for employees who don’t have experience with compliance regulations. Neglecting this increases the risks.

To avoid expensive violations and fines, your organization needs to have an effective strategy to protect PHI. For years now, SpectrumWise has been helping healthcare providers and other organizations that handle PHI become HIPAA-compliant, making sure their IT infrastructure and security is up to par with HIPAA standards. Call us today to start providing healthcare without fear of penalties.


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