Preparing for HIPAA audits

In recent years, the Office of Civil Rights (OCR) has intensified its audio efforts to ensure healthcare providers comply with HIPAA regulations.

This trend is expected to continue, with a particular focus on the HIPAA Security Rule. This rule, one of the key components of HIPAA compliance, mandates comprehensive risk analyses and management plans. It requires healthcare providers to implement physical, technical and administrative safeguards to protect electronic protected health information (PHI). Chiropractic clinics must be fully prepared for potential audits initiated by the OCR.¹

Understanding HIPAA and its importance

HIPAA, established in 1996, sets strict standards for protecting PHI. The law mandates that all healthcare providers, including DCs, implement comprehensive policies and procedures to safeguard patient data. Noncompliance can result in significant financial penalties, such as:

Tier 1: Penalties now range from $137 to a whopping $68,928 per violation, with an annual cap of more than $2 million.

Tier 2: You’re still looking at penalties between $1,379 and $68,928, with the same annual cap as Tier 1.

Tier 3: Willful neglect violations (rectified within a month) bring fines ranging from $12,045 to $68,928 with the same annual cap.

Tier 4: When these violations aren’t rectified promptly, the minimum penalty is $68,928, and the maximum is more than $2 million.²

Critical components of HIPAA compliance

Train team members: Every team member who handles PHI must be well-versed in HIPAA complience. This includes understanding what constitutes PHI, how it should be protected and the consequences of noncompliance. Regular training sessions and updates are essential to keep everyone informed about current best practices and regulatory changes.

Use secure technology: Technology plays a critical role in protecting PHI. DCs must use secure systems to store and transmit patient information. This involves implementing strong passwords, encryption and firewalls to prevent unauthorized access.

Limit access to PHI: Access to PHI should be restricted to only those team members who need it to perform their duties. This minimizes the risk of data breaches and ensures sensitive information is only accessible to authorized personnel.

Use secure storage solutions: PHI should be stored securely on paper or electronically. Paper records must be kept in locked cabinets. In contrast, electronic records should be stored on secure servers with robust access controls.

Obtain patient consent: Patients must be informed about how their PHI will be used and shared. Clinics should have patients sign consent forms that explain their rights under HIPAA and give the clinic permission to use and share their information.

Develop a privacy policy: A comprehensive privacy policy should outline how PHI is protected. This policy must be communicated to all team members and patients, ensuring everyone knows their roles and responsibilities.

Conduct regular audits: Regular audits are crucial to ensure HIPAA compliance. These audits should review access logs, system configurations and training records to identify and address any potential vulnerabilities.

Respond to breaches: In a data breach, immediate action is required to mitigate the impact. Clinics must follow legal requirements for notifying affected patients and the relevant authorities and document the breach, along with mitigation steps, in the clinic’s compliance manual.

The most common HIPAA healthcare violations are caused by data breaches, and the “lost or stolen laptop” is probably the number one cause. Data breaches are 100% unplanned; however, the impact caused by the data breach or any HIPAA compliance violation is in direct proportion to the amount of planning that happened before the breach.³

Steps to prepare for an audit

Conduct a risk assessment: The first step in preparing for a HIPAA audit is conducting a thorough risk assessment. This involves identifying potential risks to PHI and implementing measures to mitigate those risks. Regularly update the risk assessment to address new threats and vulnerabilities.

Review and update policies: Clinics should review their HIPAA policies and procedures regularly to ensure they are up-to-date and comprehensive. This includes policies related to data security, patient consent and breach notification.

Implement robust security measures: Ensure all electronic systems used to store and transmit PHI are secure. This includes encryption, multi-factor authentication and regular software updates to protect against cyber threats.

Document everything: Documentation is critical in demonstrating compliance during an audit. Clinics should maintain detailed records of all HIPAA training sessions, risk assessments and policy updates. This documentation should be readily accessible in the event of an audit.

Prepare for the unexpected: Data breaches can happen despite the best preventive measures. Have a response plan in place to help minimize the impact of a breach. This plan should include steps for notifying affected patients and the OCR and detail what measures to take to contain and mitigate the breach.⁴

Real-world examples and lessons learned

The OCR often requests detailed information following a data breach, such as the type of PHI exposed, which can include a patient’s name, address, social security number and medical history, investigation reports, corrective measures taken and breach risk assessments. DCs must be prepared to provide this information promptly, as it is crucial in demonstrating compliance and mitigating potential penalties.

For instance, if a laptop containing patient information is stolen, the OCR will ask for a detailed list of the exposed PHI, notes from internal investigations and evidence of corrective actions. Clinics that cannot provide this information face significant fines and penalties.

The importance of ongoing compliance

HIPAA compliance is not a one-time effort but an ongoing process. Regular audits, continuous training and proactive risk management are essential to maintaining compliance and protecting patient information. DCs must stay informed about changes in HIPAA compliance regulations and adjust their practices accordingly. This includes regularly reviewing and updating policies and procedures, conducting staff training sessions and staying updated on the latest security measures and best practices.

Final thoughts

Preparing for HIPAA audits requires a proactive approach. DCs can ensure compliance and protect their patients’ sensitive information by conducting thorough risk assessments, implementing robust security measures and maintaining comprehensive documentation. Regular training and audits are critical to identifying and addressing potential vulnerabilities, ensuring clinics are always ready for an audit.

The increasing focus on HIPAA audits underscores the importance of compliance in healthcare. DCs who take the necessary steps to protect PHI will avoid hefty fines and build trust with their patients by demonstrating their commitment to privacy and security.

RAY FOXWORTH, DC, FICC, is founder and CEO of ChiroHealthUSA. For more than 35 years, he worked “in the trenches” facing challenges with billing, coding, documentation and compliance. He is a former medical compliance specialist and currently serves as chairman of the Chiropractic Summit, an at-large board member of the Chiropractic Future Strategic Plan Committee, a board member of the Cleveland College Foundation and an executive board member of the Foundation for Chiropractic Progress (F4CP). He is a former staff DC at the GV Sonny Montgomery VA Medical Center and past chairman of the Mississippi Department of Health.

References

1. Alder S. New HIPAA Regulations in 2023-2024. The HIPAA Journal. April 28, 2024. https://www.hipaajournal.com/new-hipaa-regulations/. Accessed July 22, 2024.
2. The Increase in HIPAA and OSHA Fines in 2024. Abyde. January 30, 2024. https://abyde.com/the-increase-in-hipaa-and-osha-fines-in-2024%EF%BB%BF/#:~:text=HIPAA%3A%20Your%20Data%2C%20Your%20Dollars,Ouch. Accessed July 22, 2024.
3. Necela T. What This Audit Letter Shows About Your Chiropractic Practice. The Strategic Chiropractor. htts://strategicdc.com/what-this-audit-letter-shows-about-your-chiropractic-practice/. Accessed July 22, 2024.
4. How to Prepare for a HIPAA Audit. TotalHIPAA. https://www.totalhipaa.com/how-to-prepare-for-a-hipaa-audit/. Accessed July 22, 2024.