HIPAA Security Overview of the Regulations

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "HIPAA Security Overview of the Regulations"

Transcription

1 HIPAA Security Overview of the Regulations

2 Presenter: Anna Drachenberg Anna Drachenberg has been assisting healthcare providers and hospitals comply with HIPAA and other federal regulations since Prior to HRM Services, Ms. Drachenberg held management positions at PacifiCare Senior Horizons, a Medicare insurance company; Apex Learning, an online education company; Microsoft and the Food and Drug Administration. Ms. Drachenberg has over fifteen years experience in software development, online training, healthcare and regulatory affairs.

3 HIPAA Risk Management Based in Fayetteville, AR with offices in Texas, Utah and California Healthcare regulatory consulting since 2008; rebranded to focus exclusively on HIPAA Security in 2013 Assisted over 100 covered entities with HIPAA Security including: Sole providers Multi-specialty clinics Multi-location specialties Hospitals Pharmacies Team of experts in IT Security and HIPAA Security including staff credentialed in Systems Security Certified Practitioner (SSCP), Certified Ethical Hacker (CEH), and EC-Council Certified Security Analyst (ECSA)

4 Data Security Doing Business in 2014

5 Electronic Health Record Breach

6 Employee Theft: Accessing Electronic Health Record

7 Stolen Laptop

8 Viruses and Hackers

9 Data Security is a Concern for Everyone

10 40 Million Credit/Debit Cards & PINs

11 Importance of HIPAA Security Stolen Credit Card = 50 Medical Identity = $50 Provider Identity = $$$$ A stolen medical identity can be used to bill tens of thousands in fraudulent claims before anyone notices. Stolen provider identities can be used to file millions of fraudulent insurance claims.

12 HIPAA Privacy vs. Security Privacy Conversations Files in plain view Release of Info Security Electronic Data Accidental Loss Malicious Theft

13 HIPAA Omnibus Rule Background

14 2009 HITECH Act & 2010 Interim Rule In 2009 the HITECH Act was passed to encourage all healthcare providers to adopt Electronic Health Records (EHRs) through the EHR Incentive Program. To address concerns regarding privacy and security of switching to electronic records and sharing data electronically, Congress increased the enforcement and penalties for failing to protect electronic health information HIPAA Penalties range from $100 to $50,000 per violation, with an annual maximum of $1.5 million. Violations can be assessed per patient record breached.

15 Final Rule Timeline 2013 HIPAA Omnibus Final Rule : Pilot audit program and breach investigations January 2013: Final Rule Published 180 Days to Comply: September 23, 2013 A few of the security changes in the HIPAA Omnibus Final Rule include: Business Associates can be held directly liable for breaches And a stricter definition of a breach and requirements for reporting breaches to OCR, patients and the media The Resource Guide includes a link to the HIPAA Omnibus Final Rule. This presentation focuses on the HIPAA Security Rule portion of the HIPAA Omnibus Final Rule

16 It s Not Too Late You need to start TODAY! Covered entities must be in compliance with the HIPAA Omnibus Final Rule by September 23, 2013, but just because you missed the date, doesn t mean it s too late to get into compliance. Remember: HIPAA Compliance Program takes time to implement Daily penalties can be applied Failure to start can lead to willful neglect penalties Ignoring it won t make it go away

17 Penalties, Breach Reporting & Enforcement

18 Up to $1.5 Million HIPAA Penalties Violation Minimum Penalty Maximum Penalty Individual did not know Reasonable cause Willful neglect (corrected) Willful neglect (not corrected) $100 per violation (Annual maximum $25,000 for repeat violations) $1,000 per violation (Annual maximum of $100,000 for repeat violations) $10,000 per violation (Annual maximum of $250,000 for repeat violations) $50,000 per violation (Annual maximum of $1.5 million) $50,000 per violation $1.5 million annual maximum $50,000 per violation $1.5 million annual maximum $50,000 per violation $1.5 million annual maximum $50,000 per violation $1.5 million annual maximum Maximum penalties are reserved for cases of willful neglect: conscious, intentional failure or reckless indifference to the obligation to comply

19 Breach Examples Stolen Laptop: $1.5 Million Massachusetts Eye & Ear Associates ~3,000 records Stolen Laptop: $50k Idaho Hospice Less than 500 records Firewall: $400k Idaho State University No firewall for 10+ months

20 Breach Notification & Reporting Notification to Patients and Media Some states (such as Texas) have state-level reporting requirements and regulations. Notification must include: o What happened o Information breached o What individuals should do to protect themselves o Steps covered entity is doing to investigate Notified in writing, by first-class mail as soon as possible If over 500 individuals affected, notice must also be sent to the Media Notification to Secretary of HHS If more than 500 individuals affected, within 60 days If less than 500 individuals, reported at the end of the year

21 HHS Breach Report Website As required by section 13402(e)(4) of the HITECH Act, the Secretary must post a list of breaches of unsecured protected health information affecting 500 or more individuals.

22 Sample Patient Notification our office was the victim of an internet hacker complimentary one-year membership of Experian s ProtectMyID Alert

23 Audits Start FY 2014 HIPAA Compliance Audits What HHS/OCR Will Look For in HIPAA Compliance Audits Red Flags: Deficiency in Risk Analysis Data Encryption We will have a robust program focused on high-risk areas and one thing they can absolutely count on is the risk analysis ~ Leon Rodriguez Director, OCR

24 The [HITECH Act] gave State Attorneys General the authority to bring civil actions on behalf of state residents for violations of the HIPAA Privacy and Security Rules OCR developed HIPAA Enforcement Training to help State Attorneys General and their staff use their new authority to enforce the HIPAA Privacy and Security Rules -HHS Press Release Other Investigations Breach Report Patient Complaint Enforcement Program You can watch the training videos here:

25 Complying with the HIPAA Security Rule

26 Reasonable Cause The amended definition of Reasonable Cause includes violations due to circumstances that: the covered entity should have known of the violation based on the exercise of ordinary business care and diligence the covered entity knows of a violation and lacks the conscious intent of willful neglect In order to demonstrate ordinary business care and diligence a covered entity must implement the current industry standards for the data security safeguards defined in the HIPAA Security Rule

27 Safeguards Safeguards are divided into 3 categories: Administrative, Technical & Physical. Below are a few of the 40+ safeguard sections. Administrative Risk Analysis Policies & Procedures Risk Management Plan User Training Technical Network/Firewall Passwords & Access Encryption Malware Protection Physical Locks Security System/Cameras Restricted Access The regulation (CFR) tells you what safeguards are needed. The National Institute of Standards and Technology (NIST) define the current standards for those safeguards.

28 Required v. Addressable If the specification is required it must be implemented. The concept of addressable implementation standard was developed to provide covered entities additional flexibility. Must do one of the following: Implement the addressable Security implementation standard Implement one or more alternative security measures to accomplish the same purpose Resources Not implement either addressable or alternative Must document decision based on risk analysis, risk mitigation strategy, what security measures are already in place and the cost of the implementation.

29 Have you: Review Your Compliance Assigned HIPAA Security Officer? Performed HIPAA Security Risk Analysis? Implemented Technical and Physical Safeguards? Implemented Administrative Safeguards? Policies & Procedures Contingency & Disaster Recovery Plan Incident Response Plan Staff Training Vetted Business Associates & Signed Agreements? Implemented Risk Management Plan?

30 Assessment Identify all of your systems and people that create, access, store and transmit Electronic Protected Health Information (EPHI). Computers o Servers o Workstations o Laptops o Tablets/mobile devices Storage/Media o External hard-drives o USB (thumb) drives o CD/DVD o Backups Printers/Faxes Software Network/Internet People Employees Contractors Business Associates

31 Risk Analysis Analyze Compliance Review all 40+ Safeguards Does it meet the NIST Standard? Is it required or addressable? Analyze Risk How likely is it to occur? Impact if it does occur? Level of Risk

32 Choose Safeguards Even Required safeguards my have several options for implementation that can affect cost and effort. Required o Administrative o Technical o Physical Addressable o Cost to implement standard o Other options for mitigation o Plan to manage risk if no safeguard is implemented

33 Implement Safeguards Administrative Policies and Procedures Workforce documentation and training Business Associates Physical Alarm system Metal keys/replace locks Technical Encryption Hardware and software Network configuration Document, document, document!

34 Risk Management Event Scheduled New Employee Terminate Employee Decommission Equipment Verify OS Updates Verify Anti-virus Scans Review network and application logs Document that you are staying in compliance with a comprehensive Risk Management Plan

35

HIPAA Secure Now! How MSPs Can Profit From Selling HIPAA security services

HIPAA Secure Now! How MSPs Can Profit From Selling HIPAA security services HIPAA Secure Now! How MSPs Can Profit From Selling HIPAA security services How MSPs can profit from selling HIPAA security services Managed Service Providers (MSP) can use the Health Insurance Portability

More information

HIPAA in an Omnibus World. Presented by

HIPAA in an Omnibus World. Presented by HIPAA in an Omnibus World Presented by HITECH COMPLIANCE ASSOCIATES IS NOT A LAW FIRM The information given is not intended to be a substitute for legal advice or consultation. As always in legal matters

More information

What Health Care Entities Need to Know about HIPAA and the American Recovery and Reinvestment Act

What Health Care Entities Need to Know about HIPAA and the American Recovery and Reinvestment Act What Health Care Entities Need to Know about HIPAA and the American Recovery and Reinvestment Act by Lane W. Staines and Cheri D. Green On February 17, 2009, The American Recovery and Reinvestment Act

More information

HIPAA and HITECH Compliance for Cloud Applications

HIPAA and HITECH Compliance for Cloud Applications What Is HIPAA? The healthcare industry is rapidly moving towards increasing use of electronic information systems - including public and private cloud services - to provide electronic protected health

More information

HIPAA and Mental Health Privacy:

HIPAA and Mental Health Privacy: HIPAA and Mental Health Privacy: What Social Workers Need to Know Presenter: Sherri Morgan, JD, MSW Associate Counsel, NASW Legal Defense Fund and Office of Ethics & Professional Review 2010 National Association

More information

Why Lawyers? Why Now?

Why Lawyers? Why Now? TODAY S PRESENTERS Why Lawyers? Why Now? New HIPAA regulations go into effect September 23, 2013 Expands HIPAA safeguarding and breach liabilities for business associates (BAs) Lawyer is considered a business

More information

OCR Reports on the Enforcement. Learning Objectives 4/1/2013. HIPAA Compliance/Enforcement (As of December 31, 2012) HCCA Compliance Institute

OCR Reports on the Enforcement. Learning Objectives 4/1/2013. HIPAA Compliance/Enforcement (As of December 31, 2012) HCCA Compliance Institute OCR Reports on the Enforcement of the HIPAA Rules HCCA Compliance Institute April 22, 2013 David Holtzman Sr. Health IT & Privacy Specialist U.S. Department of Health and Human Services Office for Civil

More information

OCR Reports on the Enforcement. Learning Objectives

OCR Reports on the Enforcement. Learning Objectives OCR Reports on the Enforcement of the HIPAA Rules HCCA Compliance Institute April 22, 2013 David Holtzman Sr. Health IT & Privacy Specialist U.S. Department of Health and Human Services Office for Civil

More information

HIPAA COMPLIANCE PLAN FOR 2013

HIPAA COMPLIANCE PLAN FOR 2013 HIPAA COMPLIANCE PLAN FOR 2013 Welcome! Presentor is Rebecca Morehead, Practice Manager Strategist www.practicemanagersolutions.com Meaningful Use? As a way to encourage hospitals and providers to adopt

More information

Are You Still HIPAA Compliant? Staying Protected in the Wake of the Omnibus Final Rule Click to edit Master title style.

Are You Still HIPAA Compliant? Staying Protected in the Wake of the Omnibus Final Rule Click to edit Master title style. Are You Still HIPAA Compliant? Staying Protected in the Wake of the Omnibus Final Rule Click to edit Master title style March 27, 2013 www.mcguirewoods.com Introductions Holly Carnell McGuireWoods LLP

More information

Heather L. Hughes, J.D. HIPAA Privacy Officer U.S. Legal Support, Inc. hhughes@uslegalsupport.com www.uslegalsupport.com

Heather L. Hughes, J.D. HIPAA Privacy Officer U.S. Legal Support, Inc. hhughes@uslegalsupport.com www.uslegalsupport.com Heather L. Hughes, J.D. HIPAA Privacy Officer U.S. Legal Support, Inc. hhughes@uslegalsupport.com www.uslegalsupport.com HIPAA Privacy Rule Sets standards for confidentiality and privacy of individually

More information

Understanding HIPAA Privacy and Security Helping Your Practice Select a HIPAA- Compliant IT Provider A White Paper by CMIT Solutions

Understanding HIPAA Privacy and Security Helping Your Practice Select a HIPAA- Compliant IT Provider A White Paper by CMIT Solutions Understanding HIPAA Privacy and Security Helping Your Practice Select a HIPAA- Compliant IT Provider A White Paper by CMIT Solutions Table of Contents Understanding HIPAA Privacy and Security... 1 What

More information

Security Is Everyone s Concern:

Security Is Everyone s Concern: Security Is Everyone s Concern: What a Practice Needs to Know About ephi Security Mert Gambito Hawaii HIE Compliance and Privacy Officer July 26, 2014 E Komo Mai! This session s presenter is Mert Gambito

More information

The Basics of HIPAA Privacy and Security and HITECH

The Basics of HIPAA Privacy and Security and HITECH The Basics of HIPAA Privacy and Security and HITECH Protecting Patient Privacy Disclaimer The content of this webinar is to introduce the principles associated with HIPAA and HITECH regulations and is

More information

What s new In the News Data Breach Discussion The 5 W s Risk Analysis: Why, What, how, When, and Who Common Issues Observed Q / A Session Purdue

What s new In the News Data Breach Discussion The 5 W s Risk Analysis: Why, What, how, When, and Who Common Issues Observed Q / A Session Purdue What s new In the News Data Breach Discussion The 5 W s Risk Analysis: Why, What, how, When, and Who Common Issues Observed Q / A Session Purdue Healthcare Advisors The # of data breaches is climbing The

More information

HIPAA COMPLIANCE AND DATA PROTECTION. sales@eaglenetworks.it +39 030 201.08.25 Page 1

HIPAA COMPLIANCE AND DATA PROTECTION. sales@eaglenetworks.it +39 030 201.08.25 Page 1 HIPAA COMPLIANCE AND DATA PROTECTION sales@eaglenetworks.it +39 030 201.08.25 Page 1 CONTENTS Introduction..... 3 The HIPAA Security Rule... 4 The HIPAA Omnibus Rule... 6 HIPAA Compliance and EagleHeaps

More information

HIPAA Audits: How to Be Prepared. Lindsey Wiley, MHA, CHTS-IM, CHTS-TS HIT Manager Oklahoma Foundation for Medical Quality

HIPAA Audits: How to Be Prepared. Lindsey Wiley, MHA, CHTS-IM, CHTS-TS HIT Manager Oklahoma Foundation for Medical Quality HIPAA Audits: How to Be Prepared Lindsey Wiley, MHA, CHTS-IM, CHTS-TS HIT Manager Oklahoma Foundation for Medical Quality An Important Reminder For audio, you must use your phone: Step 1: Call (866) 906-0123.

More information

Art Gross President & CEO HIPAA Secure Now! How to Prepare for the 2015 HIPAA Audits and Avoid Data Breaches

Art Gross President & CEO HIPAA Secure Now! How to Prepare for the 2015 HIPAA Audits and Avoid Data Breaches Art Gross President & CEO HIPAA Secure Now! How to Prepare for the 2015 HIPAA Audits and Avoid Data Breaches Speakers Phillip Long CEO at Business Information Solutions Art Gross President & CEO of HIPAA

More information

HIPAA Myths. WEDI Member Town Hall. Chris Apgar, CISSP Apgar & Associates

HIPAA Myths. WEDI Member Town Hall. Chris Apgar, CISSP Apgar & Associates HIPAA Myths WEDI Member Town Hall Chris Apgar, CISSP Apgar & Associates Overview Missed Regulatory Requirements Common HIPAA Privacy Myths Common HIPAA Security Myths Other Related Myths Finding the Right

More information

HIPAA Omnibus Rule Practice Impact. Kristen Heffernan MicroMD Director of Prod Mgt and Marketing

HIPAA Omnibus Rule Practice Impact. Kristen Heffernan MicroMD Director of Prod Mgt and Marketing HIPAA Omnibus Rule Practice Impact Kristen Heffernan MicroMD Director of Prod Mgt and Marketing 1 HIPAA Omnibus Rule Agenda History of the Rule HIPAA Stats Rule Overview Use of Personal Health Information

More information

Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH)

Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH) Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH) Table of Contents Introduction... 1 1. Administrative Safeguards...

More information

2011 2012 Aug. Sept. Oct. Nov. Dec. Jan. Feb. March April May-Dec.

2011 2012 Aug. Sept. Oct. Nov. Dec. Jan. Feb. March April May-Dec. The OCR Auditors are coming - Are you next? What to Expect and How to Prepare On June 10, 2011, the U.S. Department of Health and Human Services Office for Civil Rights ( OCR ) awarded KPMG a $9.2 million

More information

12/19/2014. HIPAA More Important Than You Realize. Administrative Simplification Privacy Rule Security Rule

12/19/2014. HIPAA More Important Than You Realize. Administrative Simplification Privacy Rule Security Rule HIPAA More Important Than You Realize J. Ira Bedenbaugh Consulting Shareholder February 20, 2015 This material was used by Elliott Davis Decosimo during an oral presentation; it is not a complete record

More information

Part 14: USB Port Security 2015

Part 14: USB Port Security 2015 Part 14: USB Port Security This article is part of an information series provided by the American Institute of Healthcare Compliance in response to questions we receive related to Meaningful Use and CEHRT

More information

HIPAA Compliance and the Protection of Patient Health Information

HIPAA Compliance and the Protection of Patient Health Information HIPAA Compliance and the Protection of Patient Health Information WHITE PAPER By Swift Systems Inc. April 2015 Swift Systems Inc. 7340 Executive Way, Ste M Frederick MD 21704 1 Contents HIPAA Compliance

More information

Health Care Information Privacy The HIPAA Regulations What Has Changed and What You Need to Know

Health Care Information Privacy The HIPAA Regulations What Has Changed and What You Need to Know Health Care Information Privacy The HIPAA Regulations What Has Changed and What You Need to Know Note: Information provided to NCRA by Melodi Gates, Associate with Patton Boggs, LLC Privacy and data protection

More information

Overview of the HIPAA Security Rule

Overview of the HIPAA Security Rule Office of the Secretary Office for Civil Rights () Overview of the HIPAA Security Rule Office for Civil Rights Region IX Alicia Cornish, EOS Sheila Fischer, Supervisory EOS Topics Upon completion of this

More information

What Every Organization Needs to Know about Basic HIPAA Compliance and Technology. April 21, 2015

What Every Organization Needs to Know about Basic HIPAA Compliance and Technology. April 21, 2015 What Every Organization Needs to Know about Basic HIPAA Compliance and Technology April 21, 2015 Who are these handsome fellas? Jamie Wolbeck (VP Of Operations) jamiew@sccnet.com Ron Shelby (Sr. Account

More information

HIPAA Security Rule Compliance

HIPAA Security Rule Compliance HIPAA Security Rule Compliance Caryn Reiker MAXIS360 HIPAA Security Rule Compliance what is it and why you should be concerned about it Table of Contents About HIPAA... 2 Who Must Comply... 2 The HIPAA

More information

HIPAA and the HITECH Act Privacy and Security of Health Information in 2009

HIPAA and the HITECH Act Privacy and Security of Health Information in 2009 HIPAA and the HITECH Act Privacy and Security of Health Information in 2009 What is HIPAA? Health Insurance Portability & Accountability Act of 1996 Effective April 13, 2003 Federal Law HIPAA Purpose:

More information

White Paper THE HIPAA FINAL OMNIBUS RULE: NEW CHANGES IMPACTING BUSINESS ASSOCIATES

White Paper THE HIPAA FINAL OMNIBUS RULE: NEW CHANGES IMPACTING BUSINESS ASSOCIATES White Paper THE HIPAA FINAL OMNIBUS RULE: NEW CHANGES IMPACTING BUSINESS ASSOCIATES CONTENTS Introduction 3 Brief Overview of HIPPA Final Omnibus Rule 3 Changes to the Definition of Business Associate

More information

HIPAA Omnibus Rule Overview. Presented by: Crystal Stanton MicroMD Marketing Communication Specialist

HIPAA Omnibus Rule Overview. Presented by: Crystal Stanton MicroMD Marketing Communication Specialist HIPAA Omnibus Rule Overview Presented by: Crystal Stanton MicroMD Marketing Communication Specialist 1 HIPAA Omnibus Rule - Agenda History of the Omnibus Rule What is the HIPAA Omnibus Rule and its various

More information

COMPLIANCE ALERT 10-12

COMPLIANCE ALERT 10-12 HAWAII HEALTH SYSTEMS C O R P O R A T I O N "Touching Lives Every Day COMPLIANCE ALERT 10-12 HIPAA Expansion under the American Recovery and Reinvestment Act of 2009 The American Recovery and Reinvestment

More information

HIPAA COMPLIANCE AND

HIPAA COMPLIANCE AND INTRONIS CLOUD BACKUP & RECOVERY HIPAA COMPLIANCE AND DATA PROTECTION CONTENTS Introduction 3 The HIPAA Security Rule 4 The HIPAA Omnibus Rule 6 HIPAA Compliance and Intronis Cloud Backup and Recovery

More information

HIPAA Myths. WEDI Regional Affiliates. Chris Apgar, CISSP Apgar & Associates

HIPAA Myths. WEDI Regional Affiliates. Chris Apgar, CISSP Apgar & Associates HIPAA Myths WEDI Regional Affiliates Chris Apgar, CISSP Apgar & Associates Overview Missed Regulatory Requirements Common HIPAA Privacy Myths Common HIPAA Security Myths Other Related Myths Finding the

More information

SECURITY RISK ASSESSMENT SUMMARY

SECURITY RISK ASSESSMENT SUMMARY Providers Business Name: Providers Business Address: City, State, Zip Acronyms NIST FIPS PHI EPHI BA CE EHR HHS IS National Institute of Standards and Technology Federal Information Process Standards Protected

More information

Community First Health Plans Breach Notification for Unsecured PHI

Community First Health Plans Breach Notification for Unsecured PHI Community First Health Plans Breach Notification for Unsecured PHI The presentation is for informational purposes only. It is the responsibility of the Business Associate to ensure awareness and compliance

More information

Are You Ready for an OCR Audit? Tom Walsh, CISSP Tom Walsh Consulting, LLC Overland Park, KS. What would you do? Session Objectives

Are You Ready for an OCR Audit? Tom Walsh, CISSP Tom Walsh Consulting, LLC Overland Park, KS. What would you do? Session Objectives Are You Ready for an OCR Audit? Tom Walsh, CISSP Tom Walsh Consulting, LLC Overland Park, KS What would you do? Your organization received a certified letter sent from the Office for Civil Rights (OCR)

More information

Nationwide Review of CMS s HIPAA Oversight. Brian C. Johnson, CPA, CISA. Wednesday, January 19, 2011

Nationwide Review of CMS s HIPAA Oversight. Brian C. Johnson, CPA, CISA. Wednesday, January 19, 2011 Nationwide Review of CMS s HIPAA Oversight Brian C. Johnson, CPA, CISA Wednesday, January 19, 2011 1 WHAT I DO Manage Region IV IT Audit and Advance Audit Technique Staff (AATS) IT Audit consists of 8

More information

HIPAA/HITECH PRIVACY & SECURITY CHECKLIST SELF ASSESSMENT INSTRUCTIONS

HIPAA/HITECH PRIVACY & SECURITY CHECKLIST SELF ASSESSMENT INSTRUCTIONS HIPAA/HITECH PRIVACY & SECURITY CHECKLIST SELF ASSESSMENT INSTRUCTIONS Thank you for taking the time to fill out the privacy & security checklist. Once completed, this checklist will help us get a better

More information

Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use

Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use Click to edit Master title style Decrypting the Security Risk Assessment (SRA) Requirement for Meaningful Use Andy Petrovich, MHSA, MPH M-CEITA / Altarum Institute April 8, 2015 4/8/2015 1 1 Who is M-CEITA?

More information

HIPAA Privacy and Security

HIPAA Privacy and Security HIPAA Privacy and Security Cindy Cummings, RHIT February, 2015 1 HIPAA Privacy and Security The regulation is designed to safeguard Protected Health Information referred to PHI AND electronic Protected

More information

6/17/2013 PRESENTED BY: Updates on HIPAA, Data, IT and Security Technology. June 25, 2013

6/17/2013 PRESENTED BY: Updates on HIPAA, Data, IT and Security Technology. June 25, 2013 Updates on HIPAA, Data, IT and Security Technology June 25, 2013 1 The material appearing in this presentation is for informational purposes only and should not be construed as advice of any kind, including,

More information

HIPAA Security Risk Analysis for Meaningful Use

HIPAA Security Risk Analysis for Meaningful Use HIPAA Security Risk Analysis for Meaningful Use NOTE: Make sure your computer speakers are turned ON. Audio will be streaming through your speakers. If you do not have computer speakers, call the ACCMA

More information

Healthcare and IT Working Together. 2013 KY HFMA Spring Institute

Healthcare and IT Working Together. 2013 KY HFMA Spring Institute Healthcare and IT Working Together 2013 KY HFMA Spring Institute Introduction Michael R Gilliam Over 7 Years Experience in Cyber Security BA Telecommunications Network Security CISSP, GHIC, CCFE, SnortCP,

More information

HOW TO REALLY IMPLEMENT HIPAA. Presented by: Melissa Skaggs Provider Resources Group

HOW TO REALLY IMPLEMENT HIPAA. Presented by: Melissa Skaggs Provider Resources Group HOW TO REALLY IMPLEMENT HIPAA Presented by: Melissa Skaggs Provider Resources Group WHAT IS HIPAA The Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub.L. 104 191, 110 Stat. 1936,

More information

HIPAA MYTHS: DON T ALWAYS BELIEVE WHAT YOU HEAR. Chris Apgar, CISSP

HIPAA MYTHS: DON T ALWAYS BELIEVE WHAT YOU HEAR. Chris Apgar, CISSP HIPAA MYTHS: DON T ALWAYS BELIEVE WHAT YOU HEAR Chris Apgar, CISSP 2015 OVERVIEW Missed Regulatory Requirements Common HIPAA Privacy Myths Common HIPAA Security Myths Other Related Myths Finding the Right

More information

Data Security and Integrity of e-phi. MLCHC Annual Clinical Conference Worcester, MA Wednesday, November 12, 2014 2:15pm 3:30pm

Data Security and Integrity of e-phi. MLCHC Annual Clinical Conference Worcester, MA Wednesday, November 12, 2014 2:15pm 3:30pm Electronic Health Records: Data Security and Integrity of e-phi Worcester, MA Wednesday, 2:15pm 3:30pm Agenda Introduction Learning Objectives Overview of HIPAA HIPAA: Privacy and Security HIPAA: The Security

More information

Trust 9/10/2015. Why Does Privacy and Security Matter? Who Must Comply with HIPAA Rules? HIPAA Breaches, Security Risk Analysis, and Audits

Trust 9/10/2015. Why Does Privacy and Security Matter? Who Must Comply with HIPAA Rules? HIPAA Breaches, Security Risk Analysis, and Audits HIPAA Breaches, Security Risk Analysis, and Audits Derrick Hill Senior Health IT Advisor Kentucky REC Why Does Privacy and Security Matter? Trust Who Must Comply with HIPAA Rules? Covered Entities (CE)

More information

HIPAA Security & Compliance

HIPAA Security & Compliance Creative Mind. Creative Heart. Creative Care. 2014 WALA Spring Conference HIPAA Security & Compliance Jeff Grady Thursday, March 27 10:30 am HIPAA Security & Compliance A TIME FOR ACTION Jeff Grady, Senior

More information

HIPPA Goes HITECH. Data Protection for Agents

HIPPA Goes HITECH. Data Protection for Agents HIPPA Goes HITECH Data Protection for Agents For agent information only. this material should not be distributed to the public or used in any solicitation. 13-0127 Course objectives Agents will be able

More information

Am I a Business Associate? Do I want to be a Business Associate? What are my obligations?

Am I a Business Associate? Do I want to be a Business Associate? What are my obligations? Am I a Business Associate? Do I want to be a Business Associate? What are my obligations? Brought to you by Winston & Strawn s Health Care Practice Group 2013 Winston & Strawn LLP Today s elunch Presenters

More information

HIPAA Compliance: Efficient Tools to Follow the Rules

HIPAA Compliance: Efficient Tools to Follow the Rules Bank of America Merrill Lynch White Paper HIPAA Compliance: Efficient Tools to Follow the Rules Executive summary Contents The stakes have never been higher for compliance with the Health Insurance Portability

More information

HIPAA Privacy, Security, Breach, and Meaningful Use. CHUG October 2012

HIPAA Privacy, Security, Breach, and Meaningful Use. CHUG October 2012 HIPAA Privacy, Security, Breach, and Meaningful Use Practice Requirements for 2012 CHUG October 2012 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Standards for Privacy of Individually

More information

New HIPAA Rules and EHRs: ARRA & Breach Notification

New HIPAA Rules and EHRs: ARRA & Breach Notification New HIPAA Rules and EHRs: ARRA & Breach Notification Jim Sheldon-Dean Director of Compliance Services Lewis Creek Systems, LLC www.lewiscreeksystems.com and Raj Goel Chief Technology Officer Brainlink

More information

Secure Endpoint Management. Presented by Kinette Crain and Brad Lewis

Secure Endpoint Management. Presented by Kinette Crain and Brad Lewis Secure Endpoint Management Presented by Kinette Crain and Brad Lewis Brad Lewis Brad Lewis - Service Specialist 14 years of IT experience In-House Support Manager Network Administrator Assessing Risk:

More information

Lessons Learned from HIPAA Audits

Lessons Learned from HIPAA Audits Lessons Learned from HIPAA Audits October 29, 2012 Tony Brooks, CISA, CRISC Partner - IT Assurance and Risk Services HORNE LLP AGENDA HIPAA/HITECH Regulations Breaches and Fines OCR HIPAA/HITECH Compliance

More information

Patient Privacy and Security. Presented by, Jeffery Daigrepont

Patient Privacy and Security. Presented by, Jeffery Daigrepont Patient Privacy and Security Presented by, Jeffery Daigrepont Jeffery Daigrepont, SVP No Financial Conflicts to Report Jeffery Daigrepont, Senior Vice President of The Coker Group, specializes in health

More information

INFORMATION SECURITY & HIPAA COMPLIANCE MPCA

INFORMATION SECURITY & HIPAA COMPLIANCE MPCA INFORMATION SECURITY & HIPAA COMPLIANCE MPCA Annual Conference August 5, 201 Agenda 1 HIPAA 2 The New Healthcare Paradigm Internal Compliance 4 Conclusion 2 1 HIPAA 1 Earning Their Trust 4 HIPAA 5 Health

More information

HIPAA Omnibus Compliance How A Data Loss Prevention Solution Can Help

HIPAA Omnibus Compliance How A Data Loss Prevention Solution Can Help HIPAA Omnibus Compliance How A Data Loss Prevention Solution Can Help The Health Information Portability and Accountability Act (HIPAA) Omnibus Rule which will begin to be enforced September 23, 2013,

More information

HIPAA Compliance Guide

HIPAA Compliance Guide HIPAA Compliance Guide Important Terms Covered Entities (CAs) The HIPAA Privacy Rule refers to three specific groups as covered entities, including health plans, healthcare clearinghouses, and health care

More information

The Impact of HIPAA and HITECH

The Impact of HIPAA and HITECH The Health Insurance Portability & Accountability Act (HIPAA), enacted 8/21/96, was created to protect the use, storage and transmission of patients healthcare information. This protects all forms of patients

More information

The Security Rule of The Health Insurance Portability and Accountability Act (HIPAA) Security Training

The Security Rule of The Health Insurance Portability and Accountability Act (HIPAA) Security Training The Security Rule of The Health Insurance Portability and Accountability Act (HIPAA) Security Training Introduction The HIPAA Security Rule specifically requires training of all members of the workforce.

More information

InfoGard Healthcare Services. 2015 InfoGard Laboratories Inc.

InfoGard Healthcare Services. 2015 InfoGard Laboratories Inc. InfoGard Healthcare Services 10 Steps To Protect My Covered Entity From Breach Your Presenters Alan Martin Account Manger Marvin Byrd Security Engineer Test and Certification Laboratory Healthcare Payment

More information

Privacy Officer Job Description 4/28/2014. HIPAA Privacy Officer Orientation. Cathy Montgomery, RN. Presented by:

Privacy Officer Job Description 4/28/2014. HIPAA Privacy Officer Orientation. Cathy Montgomery, RN. Presented by: HIPAA Privacy Officer Orientation Presented by: Cathy Montgomery, RN Privacy Officer Job Description Serve as leader Develop Policies and Procedures Train staff Monitor activities Manage Business Associates

More information

Policies and Procedures Audit Checklist for HIPAA Privacy, Security, and Breach Notification

Policies and Procedures Audit Checklist for HIPAA Privacy, Security, and Breach Notification Policies and Procedures Audit Checklist for HIPAA Privacy, Security, and Breach Notification Type of Policy and Procedure Comments Completed Privacy Policy to Maintain and Update Notice of Privacy Practices

More information

Lessons Learned from Recent HIPAA and Big Data Breaches. Briar Andresen Katie Ilten Ann Ladd

Lessons Learned from Recent HIPAA and Big Data Breaches. Briar Andresen Katie Ilten Ann Ladd Lessons Learned from Recent HIPAA and Big Data Breaches Briar Andresen Katie Ilten Ann Ladd Recent health care breaches Breach reports to OCR as of February 2015 1,144 breaches involving 500 or more individual

More information

Healthcare Compliance Solutions

Healthcare Compliance Solutions Healthcare Compliance Solutions Let Protected Trust be your Safe Harbor In the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), the U.S. Department of Health and Human

More information

HIPAA Hot Topics. Audits, the Latest on Enforcement and the Impact of Breaches. September 2012. Nashville Knoxville Memphis Washington, D.C.

HIPAA Hot Topics. Audits, the Latest on Enforcement and the Impact of Breaches. September 2012. Nashville Knoxville Memphis Washington, D.C. HIPAA Hot Topics Audits, the Latest on Enforcement and the Impact of Breaches September 2012 Nashville Knoxville Memphis Washington, D.C. Overview HITECH Act HIPAA Audit Program: update and initial results

More information

HIPAA Compliance The Time is Now Changes on the Horizon: The Final Regulations on Privacy and Security. May 7, 2013

HIPAA Compliance The Time is Now Changes on the Horizon: The Final Regulations on Privacy and Security. May 7, 2013 HIPAA Compliance The Time is Now Changes on the Horizon: The Final Regulations on Privacy and Security May 7, 2013 Presenters James Clay President Employee Benefits & HR Consulting The Miller Group jimc@millercares.com

More information

Reporting of HIPAA Privacy/Security Breaches. The Breach Notification Rule

Reporting of HIPAA Privacy/Security Breaches. The Breach Notification Rule Reporting of HIPAA Privacy/Security Breaches The Breach Notification Rule Objectives What is the HITECH Act? An overview-what is Protected Health Information (PHI) and can I protect patient s PHI? What

More information

What do you need to know?

What do you need to know? What do you need to know? DISCLAIMER Please note that the information provided is to inform our clients and friends of recent HIPAA and HITECH act developments. It is not intended, nor should it be used,

More information

HIPAA Compliance Guide

HIPAA Compliance Guide HIPAA Compliance Guide Important Terms Covered Entities (CAs) The HIPAA Privacy Rule refers to three specific groups as covered entities, including health plans, healthcare clearinghouses, and health care

More information

Sunday March 30, 2014, 9am noon HCCA Conference, San Diego

Sunday March 30, 2014, 9am noon HCCA Conference, San Diego Meaningful Use as it Relates to HIPAA Compliance Sunday March 30, 2014, 9am noon HCCA Conference, San Diego CLAconnect.com Objectives and Agenda Understand the statutory and regulatory background and purpose

More information

DATA SECURITY HACKS, HIPAA AND HUMAN RISKS

DATA SECURITY HACKS, HIPAA AND HUMAN RISKS DATA SECURITY HACKS, HIPAA AND HUMAN RISKS MSCPA HEALTH CARE SERVICES SEMINAR Ken Miller, CPA, CIA, CRMA, CHC, CISA Senior Manager, Healthcare HORNE LLP September 25, 2015 AGENDA 2015 The Year of the Healthcare

More information

HIPAA Final Rule Changes

HIPAA Final Rule Changes HIPAA Final Rule Changes What you need to know and do now Presented by Lucy A. Homans, Ed.D WSPA Director of Professional Affairs Prepared by the APA Practice Organization Introduction January 2013: U.S.

More information

Joseph Suchocki HIPAA Compliance 2015

Joseph Suchocki HIPAA Compliance 2015 Joseph Suchocki HIPAA Compliance 2015 Sponsored by Eagle Associates, Inc. Eagle Associates provides compliance services for over 1,200 practices nation wide. Services provided by Eagle Associates address

More information

HIPAA Security Series

HIPAA Security Series 7 Security Standards: Implementation for the Small Provider What is the Security Series? The security series of papers provides guidance from the Centers for Medicare & Medicaid Services (CMS) on the rule

More information

Meaningful Use and Security Risk Analysis

Meaningful Use and Security Risk Analysis Meaningful Use and Security Risk Analysis Meeting the Measure Security in Transition Executive Summary Is your organization adopting Meaningful Use, either to gain incentive payouts or to avoid penalties?

More information

Data Security Breaches: Learn more about two new regulations and how to help reduce your risks

Data Security Breaches: Learn more about two new regulations and how to help reduce your risks Data Security Breaches: Learn more about two new regulations and how to help reduce your risks By Susan Salpeter, Vice President, Zurich Healthcare Risk Management News stories about data security breaches

More information

OCR/HHS HIPAA/HITECH Audit Preparation

OCR/HHS HIPAA/HITECH Audit Preparation OCR/HHS HIPAA/HITECH Audit Preparation 1 Who are we EHR 2.0 Mission: To assist healthcare organizations develop and implement practices to secure IT systems and comply with HIPAA/HITECH regulations. Education

More information

VMware vcloud Air HIPAA Matrix

VMware vcloud Air HIPAA Matrix goes to great lengths to ensure the security and availability of vcloud Air services. In this effort VMware has completed an independent third party examination of vcloud Air against applicable regulatory

More information

By Ross C. D Emanuele, John T. Soshnik, and Kari Bomash, Dorsey & Whitney LLP Minneapolis, MN

By Ross C. D Emanuele, John T. Soshnik, and Kari Bomash, Dorsey & Whitney LLP Minneapolis, MN Major Changes to HIPAA Security and Privacy Rules Enacted in Economic Stimulus Package By Ross C. D Emanuele, John T. Soshnik, and Kari Bomash, Dorsey & Whitney LLP Minneapolis, MN The HITECH Act is the

More information

HIPAA TRAINING. A training course for Shiawassee County Community Mental Health Authority Employees

HIPAA TRAINING. A training course for Shiawassee County Community Mental Health Authority Employees HIPAA TRAINING A training course for Shiawassee County Community Mental Health Authority Employees WHAT IS HIPAA? HIPAA is an acronym that stands for Health Insurance Portability and Accountability Act.

More information

Compliance Challenges. Ali Pabrai, MSEE, CISSP (ISSMP, ISSAP) Member, FBI InfraGard. Increased Audits & On-site Investigations

Compliance Challenges. Ali Pabrai, MSEE, CISSP (ISSMP, ISSAP) Member, FBI InfraGard. Increased Audits & On-site Investigations Enabling a HITECH & HIPAA Compliant Organization: Addressing Meaningful Use Mandates & Ensuring Audit Readiness Ali Pabrai, MSEE, CISSP (ISSMP, ISSAP) Member, FBI InfraGard Compliance Mandates Increased

More information

Sample Business Associate Agreement Provisions

Sample Business Associate Agreement Provisions Sample Business Associate Agreement Provisions Words or phrases contained in brackets are intended as either optional language or as instructions to the users of these sample provisions. Definitions Catch-all

More information

University Healthcare Physicians Compliance and Privacy Policy

University Healthcare Physicians Compliance and Privacy Policy Page 1 of 11 POLICY University Healthcare Physicians (UHP) will enter into business associate agreements in compliance with the provisions of the Health Insurance Portability and Accountability Act of

More information

The HITECH Act: Implications to HIPAA Covered Entities and Business Associates. Linn F. Freedman, Esq.

The HITECH Act: Implications to HIPAA Covered Entities and Business Associates. Linn F. Freedman, Esq. The HITECH Act: Implications to HIPAA Covered Entities and Business Associates Linn F. Freedman, Esq. Introduction and Overview On February 17, 2009, President Obama signed P.L. 111-05, the American Recovery

More information

Written Information Security Programs: Compliance with the Massachusetts Data Security Regulation

Written Information Security Programs: Compliance with the Massachusetts Data Security Regulation View the online version at http://us.practicallaw.com/7-523-1520 Written Information Security Programs: Compliance with the Massachusetts Data Security Regulation Melissa J. Krasnow, Dorsey & Whitney LLP

More information

HIPAA PRIVACY AND SECURITY AWARENESS

HIPAA PRIVACY AND SECURITY AWARENESS HIPAA PRIVACY AND SECURITY AWARENESS Introduction The Health Insurance Portability and Accountability Act (known as HIPAA) was enacted by Congress in 1996. HIPAA serves three main purposes: To protect

More information

HIPAA: Understanding The Omnibus Rule and Keeping Your Business Compliant

HIPAA: Understanding The Omnibus Rule and Keeping Your Business Compliant 1 HIPAA: Understanding The Omnibus Rule and Keeping Your Business Compliant Introduction U.S. healthcare laws intended to protect patient information (Protected Health Information or PHI) and the myriad

More information

Hosting for Healthcare: ADDRESSING THE UNIQUE ISSUES OF HEALTH IT & ACHIEVING END-TO-END COMPLIANCE

Hosting for Healthcare: ADDRESSING THE UNIQUE ISSUES OF HEALTH IT & ACHIEVING END-TO-END COMPLIANCE Hosting for Healthcare: ADDRESSING THE UNIQUE ISSUES OF HEALTH IT & ACHIEVING END-TO-END COMPLIANCE [ Hosting for Healthcare: Addressing the Unique Issues of Health IT & Achieving End-to-End Compliance

More information

How to use the Alertsec Service to Achieve HIPAA Compliance for Your Organization

How to use the Alertsec Service to Achieve HIPAA Compliance for Your Organization How to use the Alertsec Service to Achieve HIPAA Compliance for Your Organization Alertsec offers Cloud Managed - Policy Controlled - Security Modules for Ensuring Compliance at the Endpoints Contents

More information

STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES BUSINESS ASSOCIATE ADDENDUM

STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES BUSINESS ASSOCIATE ADDENDUM STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES BUSINESS ASSOCIATE ADDENDUM BETWEEN The Division of Health Care Financing and Policy Herein after referred to as the Covered Entity and (Enter Business

More information

HIT Audit Workshop. Jeffrey W. Short. jshort@hallrender.com

HIT Audit Workshop. Jeffrey W. Short. jshort@hallrender.com HIT Audit Workshop Jeffrey W. Short jshort@hallrender.com 1 Audits and Investigations to be Discussed Meaningful Use Audits HIPAA Audits Data Breach Investigations Software Vendor Audits FTC Investigations

More information

HIPAA Security. 1 Security 101 for Covered Entities. Security Topics

HIPAA Security. 1 Security 101 for Covered Entities. Security Topics HIPAA SERIES Topics 1. 101 for Covered Entities 2. Standards - Administrative Safeguards 3. Standards - Physical Safeguards 4. Standards - Technical Safeguards 5. Standards - Organizational, Policies &

More information

HITRUST CSF Assurance Program You Need a HITRUST CSF Assessment Now What?

HITRUST CSF Assurance Program You Need a HITRUST CSF Assessment Now What? HITRUST CSF Assurance Program You Need a HITRUST CSF Assessment Now What? Introduction This material is designed to answer some of the commonly asked questions by business associates and other organizations

More information

Developing HIPAA Security Compliance. Trish Lugtu CPHIMS, CHP, CHSS Health IT Consultant

Developing HIPAA Security Compliance. Trish Lugtu CPHIMS, CHP, CHSS Health IT Consultant Developing HIPAA Security Compliance Trish Lugtu CPHIMS, CHP, CHSS Health IT Consultant Learning Objectives Identify elements of a HIPAA Security compliance program Learn the HIPAA Security Rule basics

More information

HIPAA Privacy and Security Requirements

HIPAA Privacy and Security Requirements 600 East Superior Street, Suite 404 I Duluth, MN 55802 I Ph. 800.997.6685 or 218.727.9390 I www.ruralcenter.org HIPAA Privacy and Security Requirements Joe Wivoda CIO and HIT Consultant June 19, 2013 Purpose

More information