All Posts Tagged: hipaa audits

false sense of security

Does HIPAA Compliance Give A False Sense of Security?

The fact that HIPAA compliance isn’t bulletproof – that cyber security frameworks around health information require a new level of vigilance – is now axiomatic.Perhaps owing to whatever legislative sausage-making gave birth to HIPAA, to protect the privacy and security of protected health information, the law offers no guidance on how to follow it.

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ransomware hackers steal hospital

Ransomware Hackers Steal A Hospital. Again.

A month after a hospital in Hollywood was shut down by a ransomware infection that encrypted all the files on its computers and computer-controlled instruments and systems, another hospital, this one in Kentucky, has suffered a similar fate.

The hacker who stole Hollywood Presbyterian asked for $3.6 million, but settled for a piddling $17,000 (40 bitcoin), presumably after they realized that their random infectious agent had kidnapped a giant, high-profile institution that would be able to motivate serious law-enforcement investigations that would move ever-closer to their true identity the longer the ransom negotiations continued.

Ransomware Hackers Steal Hospital Information, Again

Henderson, Kentucky’s Methodist Hospital has declared an “Internal State of Emergency,” having been shut down by a piece of ransomware called “Locky.” The hospital’s spokeslawyer, David Park, said that they’re addressing the ransomware attack using plans designed to help the hospital weather a tornado or other natural disaster.

The attackers are only asking for $1,600 (4 bitcoin) to unlock the hospital’s files.

Brian Krebs speculates that the attackers didn’t set out to hold a hospital to ransom, and have no real appreciation of how much they could be asking for (though the Kentucky hospital seems to have been less compromised than the one in Hollywood). He warns that in future, ransomware creeps will start targeting their attacks, aiming for victims who have more to lose, and more to spend, when their data is taken from them.

“We haven’t yet made decision on that, we’re working through the process,” with the FBI, he said. “I think it’s our position that we’re not going to pay it unless we absolutely have to.”

The attackers are demanding a mere four bitcoins in exchange for a key to unlock the encrypted files; that’s a little more than USD $1,600 at today’s exchange rate.

Park said the administration hasn’t ruled out paying the ransom.

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northwell health hipaa settlement

Northwell Health HIPAA Settlement-Agrees To Pay $3.9M

The Feinstein Institute for Medical Research has agreed to settle potential HIPAA violations with a $3.9 million payment and a substantial corrective action plan.

Feinstein is a biomedical research institute based in Manhasset, N.Y., that falls under the Great Neck, N.Y.-based Northwell Health enterprise. In 2012, Feinstein reported a data breach after a computer containing the electronic protected health information of nearly 13,000 patients and research participants was stolen from an employee’s car. Information stored on the laptop included names, birth dates, addresses, Social Security numbers, diagnoses, laboratory results, medications and other medical information.

Northwell Health HIPAA Settlement

HHS’ Office of Civil Rights launched an investigation into the breach and determined Feinstein’s security management processes to be incomplete and insufficient to address potential risks and vulnerabilities of electronic PHI, including failure to restrict access to unauthorized users and a lack of policies and procedures to govern the removal of laptops out of its facilities.

“Research institutions subject to HIPAA must be held to the same compliance standards as all other HIPAA-covered entities,” said OCR Director Jocelyn Samuels. “For individuals to trust in the research process and for patients to trust in those institutions, they must have some assurance that their information is kept private and secure.”

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okay to share hipaa

When It’s Okay To Share – HIPAA

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that sets rules about who can look at and receive an individual’s health information. “Covered entities” that must follow the HIPAA regulations include health plans, most healthcare providers, and healthcare clearinghouses. Business associates of covered entities also must follow parts of the HIPAA regulations.

“Business associates” are generally contractors, subcontractors, and other outside persons and companies that need to be able to access individual health records held by a covered entity to provide a service. Examples of business associates include:

  • Billing companies
  • Companies that help administer health plans
  • Lawyers, accountants, and IT specialists
  • Data management companies

These covered entities and business associates must follow HIPAA regulations or face heavy fines and other penalties. Generally, a covered entity cannot use or share an individual’s health information without written permission, unless the law allows for it.

Examples of when it;s okay to share HIPAA info/patient information without written consent include:

  • When the information is necessary to provide treatment.
  • When not disclosing it would interfere with a disaster relief organization’s ability to respond to an emergency.
  • As necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public.
  • To relay information about a patient’s location in the facility and general condition.

Providers also may share patient information to the extent necessary to seek payment for services rendered.

Original Content by H.H.S.

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Prepare for 2016 HIPAA Audits

7 Ways to Prepare for 2016 HIPAA Audits

Phase two of audits for the Health Insurance Portability and Accountability Act (HIPAA) are coming this year as the Office of Civil Rights looks to crack down on violations.

HIPAA was signed into law in August of 1996, and the Privacy and Security Rules were both implemented over a decade ago. Moreover, the Health Information Technology for Economic and Clinical Health Act (HITECH Act), which made significant changes to a variety of facets of HIPAA, passed in 2009. Section 13411 of the HITECH Act requires the Office of Civil Rights (OCR)–which is part of the U.S. Department of Health and Human Services (HHS)–to conduct periodic HIPAA audits.

Why is there so much emphasis on meeting standards that have been required for two decades in some instances? It’s due mainly to the increased use of technology in healthcare and accompanying cybersecurity risks. The purpose of this article is to provide an overview of the OCR audit program (phase 2), identify key areas of risk and provide suggestions on how to mitigate adverse findings.

Prepare for 2016 HIPAA Audits

OCR Audit Program

In 2011, OCR launched the requisite OCR Pilot Privacy, Security, and Breach Notification Audit Program. For the first phase, only covered entities were audited. This second phase includes business associates of covered entities.

Regardless of the type of entity, the time frames for the audit are the same. From the time the audit notification letter is sent from OCR, organizations should plan on a 30 day to 90 day process. Analogous to a Recovery Audit Contractor (RAC) audit, an entity has a certain period of time to produce the requested information. The information may be requested either on-site or as a desk audit, which is described below.

Next, OCR reviews the information provided and drafts a report. The entity then has the opportunity to review and respond to the draft report, after which OCR finalizes the report.
The scope of the phase 1 audits was limited to the federal Privacy, Security and Breach Notification Rules. This does not mean that a state law or international law provision may have been violated-it just was not addressed in the phase I audits.

Phase 2 audits will be more robust, in part due to a $4 million increase in OCR’s 2016 budget. Another area of difference will be the number of on site versus desk audits. During the phase 1 audits, covered entities were evaluated by a third party, who visited them on-site. Phase two audits will include a greater number of desk audits – entities responding to the audits from their desks by providing policies and documentation of privacy policies and procedures to HHS.

This serves as a signal —a key administrative area that will be looked at during the audits are the adequacy of policies and procedures. Therefore, the number of administrative and security violations could increase significantly.

Key Areas of Risk

A good place for practices to start is to look at the findings from phase 1, as well as recent penalties that were assessed by HHS for HIPAA violations. Violations occurred in the administrative, technical and physical realms. Primarily, policies and procedures were found to be inadequate; encryption of USB drives, laptops and email was found to be lacking; and inadequate employee security awareness and training were some of the major areas of vulnerability.

Suggestions to Mitigate Adverse Findings

The most prudent approach is to be prepared ahead of time, much like an IRS or Joint Commission audit. Whatever aspect of HIPAA compliance an organization is addressing, a good vantage point from which to start is the patient information. Every action should take into account the confidentiality, integrity and availability of the information. The way to make employees and contractors aware is through training. While the required way to hold business associates and subcontractors accountable is through the contractual obligations in a business associate agreement (BAA). Moreover, an annual risk assessment is a must. And, the HHS website is the ideal place to find explanations of what is set out in the laws and regulations.

Here are some tips to make sure that the practice is HIPAA compliant and avoid an adverse audit outcome:

  1. Begin compliance efforts from the vantage point of the government, who may “review pertinent policies, procedures, or practices of the covered entity or business associate and of the circumstances regarding any alleged violation”;
  2. Read Section 164.316 for what is required in relation to policies and procedures from an administrative, technical and physical aspect;
  3. Curtail policies and procedures to your individual practice;
  4. Know where the external and internal sources of protected health information are located;
  5. Encrypt everything both at rest and in transit and make sure that the level of encryption utilized is adequate;
  6. Train employees– Trustwave is a reputable vendor that has online training or various organizations offer live courses; and
  7. Perform due diligence on various third party risk assessors for expertise, price and quality.

OCR audits and HIPAA compliance should not be taken lightly. RAC audits also started with a pilot program more than a decade ago and now generate a substantial amount of revenue for the government, as well as serving as a check on providers’ claims submissions. Those submission, by the way, are also required to be HIPAA-compliant.

Conclusion

The overall goal of the phase 2 audits is to raise awareness and provide the opportunity for entities to correct their practices surrounding the creation, receipt, transmission and maintenance of protected health information.

The flip side, however, is that OCR may assess a penalty. Given that there are going to be more on site and business associate audits, the findings may translate into increased scrutiny by OCR on other fronts. Therefore, organizations of all types should look at the OCR audit like an IRS audit: a practice should be prepared for an audit. Failure to do so could be costly.

Original content by Modern Medicine Network

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911 dispatcher fired

911 Dispatcher Fired For Sharing Caller’s PHI on Facebook

A Catoosa County 911 dispatcher was fired Friday morning for sharing on Facebook the private information of at least one person who called 911.

Holly Dowis was terminated Friday following an internal investigation into her conduct while on the job.

A Channel 3 investigation found Dowis sent a screenshot to Facebook friends in a private chat of one man’s call to 911 requesting emergency assistance.

Sixty-year-old Ringgold resident Ron Darnell called Catoosa County dispatch on December 23rd when he had a blood clot which resulted in an “embarrassing” medical problem.

“I had a blood clot break loose and come out of my body,” he said. “I called to get emergency help and I almost died that day.”

911 Dispatcher FiredThe 911 dispatch screen detailing his call included his name, phone number, address and exact medical complaint. Dowis then took a photo of all that personal information and posted it to a Facebook group chat with some friends.

“A call I just took,” Dowis wrote.

Darnell fears he’s not the only victim. “If they put out mine, how many others have they put out of other people that don’t know it and just making fun of people?”

Dowis has worked with the county since 2007 and was named communications officer of the year in 2013.

“911 is an organization that we must rely on to keep information confidential and to communicate that information to law enforcement officials only and she has violated the public trust,” said Chattanooga Attorney Stuart James.

County Manager Jim Walker said Dowis was fired for misconduct and violating federal and county rules. The county learned of the allegations Tuesday, placed Dowis on administrative leave Wednesday, concluded its investigation Thursday and officially terminated her Friday morning at 11 a.m.

Walker said Dowis had committed similar offenses in the past, though not to this severity, and had been issued warnings.

Darnell told Channel 3 that her losing her job is not enough. He wants to see criminal charges filed against Dowis, which Chattanooga attorney Stuart James said is not far-fetched.

“There’s this thing called HIPAA that guarantees our medical records remain private and that they are private from other people seeing those records,” Stuart James said. “What I see here is not only did she discuss the medical condition the man was suffering from but also named his name, put his address of the Internet and it was a huge privacy concern for him, a huge HIPAA violation, and a huge problem for the 911 center down in Georgia.”

James said criminal charges would be up to a district attorney. But he said in terms of a civil lawsuit, there are issues of a man’s right to privacy, HIPAA violations, and possible libel and slander.

Channel 3 reached out to Dowis and left her a voicemail asking for her side of the story. She has not returned that call as of early Friday afternoon.

Original content by WRCBtv

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