Don’t Ring in the New Year with a HIPAA Audit – Safeguard Yourself Now

1 Indest-2008-1By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Here’s a scary reminder: There are people attempting to hack into electronic health systems every second of every day. Thankfully, most of these attempts are unsuccessful due to the preventive technologies in place to safeguard such information. However, electronic data will never be 100 percent secure.

Electronic health records promised was intended to be a tool for doctors to share patient data, reduce prescription drug errors, and allow patients convenient access to their records. However, since the transition to digital medical records, there have been concerns from patients about privacy, security and identity theft.

Recently, the Office for Civil Rights (OCR) announced that the agency will ramp up its Health Insurance Portability and Accountability Act (HIPAA) privacy and security audit program in 2015 for covered entities and business associates. These audits will focus on device encryptions, media controls, data transmission security protocols, and staff training on HIPAA policies and procedures.

Now is the time to ensure compliance.

Real World Privacy Breaches Happen All the Time.

On December 2, 2014, OCR and Anchorage Community Mental Health Services, Inc. (ACMHS), settled alleged violations of the HIPAA Security Rule. OCR started an investigation into ACMHS’s compliance with HIPAA after receiving a notification about a breach of unsecured electronic patient information affecting 2,743 individuals. The breach resulted from malware that compromised ACMHS’s information technology resources. According to the settlement, ACMHS must pay a $150,000 fine and enter into a resolution agreement and corrective action plan (CAP).

In November 2014, Beth Israel Deaconess Medical Center in Massachusetts agreed to a $100,000 settlement after a physician’s laptop was stolen from the hospital. The computer was not issued by the hospital and had not been encrypted in accordance with the hospital’s policies. However, the hospital was aware that the physician used the device. The laptop contained the health information and personal information, including Social Security numbers, of nearly 4,000 individuals. It’s alleged the hospital took three months to notify affected patients about the breach, which is a violation of HIPAA. (HIPAA requires such notifications to take place within 60 days.)

Tips to Protect Yourself and Your Business.

Again, the HIPAA audit program will be resuming after the first of the year. Accordingly, hundreds of covered entities and business associates will be receiving inquiries that could lead to an onsite audit. The audit requirements will be very difficult for organizations that have not planned in advance. Here are three easy-to-implement steps to prepare your practice.

1. Review the latest HIPAA policies and procedures. Make sure your office is meeting the latest privacy and security criteria. Identify gaps, update documents, and retrain staff on HIPAA policies and procedures. Don’t forget to document your educational efforts. Click here for a link to the latest policies and procedures.

2. Contact your business associates. Ask each of them to provide your practice with an updated Business Associate Agreement and list of all subcontractors they use. For business associates, the 2015 HIPAA audits will focus on risk analysis, risk management and updated policies and procedures for breach notification.

3. Have a risk assessment performed on your practice. To learn more about risk assessments, click here for a previous blog.

Also, a violation of the HIPAA privacy and security provisions does carry civil and criminal penalties. Anyone who is a health care professional or facility, should be aware of these legal provisions. Click here to read my previous blog.

HIPAA is Not One Size Fits All.

Protecting patient data is not a one-size-fits-all method, meaning that security measures and access to electronic records should not necessarily be uniform. There needs to be processes and check points in place at practices to ensure that the electronic health record system and its many users consistently meet HIPAA policies and procedures. Health care practices must be vigilant that when they integrate other medical practices and facilities into their organization that they extend these measures to incorporate new employees, new sites and locations, and various technologies.

As demonstrated throughout this blog, the risks of non-compliance simply outweigh the costs of sound preparation. If you’d like more information, contact a health law attorney experienced in these matters.


Are you worried about the next round of HIPAA audits? Are you concerned about HIPAA violations? How are you ensuring compliance within your practice? Please leave any thoughtful comments below.

Contact a Health Law Attorney Experienced in Defending HIPAA Complaints and Violations.

The attorneys of The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other health care providers and institutions in investigating and defending alleged HIPAA complaints and violations and in preparing Corrective Action Plans (CAPs).

For more information about HIPAA violations, electronic health records or corrective action plans (CAPs) please visit our website at or call (407) 331-6620 or (850) 439-1001.


Van Terheyden, Nick and Faix, Rob. “Digital Health Records: Pain and Gain.” Orlando Sentinel. (December 12, 2014). From: The Orlando Sentinel News Section on page A20.

“Beth Israel Agrees To Pay $100K To Settle 2012 Data Breach Case.” iHealthBeat. (November 25, 2014). From:

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
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