A Definitive Guide to HIPAA Audit Checklist For Your Healthcare Business

Posted in Healthcare Management

Overview: HIPAA Audit Checklist

HIPAA is the Health Insurance Portability & Accountability Act which is the federal law passed in 1996. HIPAA demands the development of national regulations for ensuring the protection of patients’ health data. It requires the protection of data from breaching or disclosing without the knowledge or consent of the patients. According to the stats of 2018, ten companies paid up to $28.7 million fines for not being able to comply with HIPAA compliance.

This means that complying with HIPAA regulations is mandatory for all healthcare facilities including hospitals, clinics, and private practitioners because getting fined is the last thing one wants. For every healthcare facility, HIPAA audit and HIPAA compliance services have become a crucial matter. In this article, we are sharing a guide for HIPAA audit compliance. This guide will ensure that your healthcare facility is able to protect the crucial Patient Health Information (PHI) in compliance with HIPAA regulations. So, let’s see the checklist and guide!

HIPAA Audit Services & Being HIPAA Compliant

To begin with, the HSS-OIG (Office of Inspector General) provides the compliance resource portal. According to this portal, seven elements derive effective and high-end compliant healthcare programs. The elements listed by the portal include the following;

1. Procedures, policies, and standards
2. Evaluation and screening of the physicians, employees, agents, and physicians
3. The administration of the compliance program
4. Training, communication, and education on the compliance standards
5. The preventive and investigation measures
6. Internal reporting systems and auditing and monitoring systems
7. Discipline for the non-compliance

The above-mentioned HIPAA audit checklist acts as a guiding resource for all healthcare facilities to remain HIPAA audit compliant and thereby needs to be practiced across all healthcare institutions in the country.

How to prepare for HIPAA audit?

HIPAA audit policies were designed to guarantee patient privacy and the protection of health records. HIPAA ensures health service practitioners take into account patient safety, confidentiality, and integrity of personal health records.  It is set according to international standards to assist in the exchange of medical information. Preparation for HIPAA Audits can be done by using successful approaches for hl7 integration implementation.

 An organization or healthcare provider can prepare themselves for a HIPAA Audit by encrypting all files containing sensitive information. It is also necessary to ensure all cloud-based platforms use encryption too. Healthcare networks can be protected from hackers using prevention methods and systems such as firewalls, employee training against phishing scams through proper identification, and regularly using complex passwords. It is also essential to have an immediate information backup in case of a glitch, changes, or accidental deletion.

It is essential to prevent mistakes during data entry by double keying and timely updating documentation on technologies and networks.

HIPAA Audit Programs

There are multiple HIPAA Audit programs designed for the benefit customers and patients. These programs make it easier to review HIPAA policies and review their implementation. One of the most commonly used programs is Epic. It is well known for being easy to use and highly accurate in providing information regarding policy implementations.

HIPAA Audit Compliance Cost

HIPAA compliance auditing is a one-time investment. The price for the software is usually $1,680 to$2,220. This cost is generally included in the investment required for a telemedicine startup.

HIPAA Compliance Services Checklist For 2023

Previously, we outlined the essentials that must be achieved by the healthcare facilities for becoming compliant with HIPAA audit services. However, it is important to note that HIPAA compliance and standards have been around for more than two decades. And the legislation and prerequisites have been altered various times with the advancement in technology to meet the changing need of the industry. The four primary amendments to HIPAA compliance services include;

• The security rule amendment from 2003 includes the administrative, physical, and technical precautions
• The breach notification rule from 2009
• The privacy rule amendment from 2003
• The final omnibus rule from 2013

The Security Rules and Audit Requirements

The security role by HIPAA defines the electronic health information’s protection. It’s often referred to as security. It includes multiple technical measures.

• It includes the network encryption that’s responsible for encrypting the ePHI for meeting the cryptographic standards of NIST. The technical measures also include the control of access with which the users are assigned with an exclusive PIN code and username, and the login credentials are controlled centrally
• The security rule includes the authentication of ePHI that demands the identification and authentication of ePHI while ensuring protection from destruction, unlicensed changes, and corruption.
• It demands the healthcare facilities encrypt and decrypt the data; it applies to laptops and mobiles.
• There is control of activity audits that demands in-depth logging for tracking the access attempts.
• It demands the users log out of the app or system within thirty seconds to three minutes.
  The covered entity uses cross-examination techniques and other procedures on the available information to protect ePHIs to stay in line with the 3 major things addressed in the HIPAA law.

HIPAA Physical Security Audit Checklist

• It includes the controlled facility access with which the individuals with access to data storage must be tracked. The tracking not only applies to engineers but the custodians and repair staff as well. It demands the blockage of unlicensed entries.
• The healthcare facilities must manage the workstations. The policies must be developed to control access to the data and how the information is guarded, along with apt utilization of the workspace.
• The healthcare facilities must endorse the mobile device policy, which deletes the data before it’s circulated to other users.
• The healthcare facilities must ensure the complete backup of data before changing the servers

The Administrative Rules 

• The first factor is risk assessment, with which the risks are identified and analyzed for devising the actions to mitigate risks.
• It includes the systematic risk management with which the risk assessment processes are implemented at regular intervals with risk reduction measures. It involves the development of sanctions for employees who don’t comply with the HIPAA standards.
• The administrative rules also demand employee training on ePHI access protocols. It must outline the potential risks from a cybersecurity point of view, such as hacking and phishing.
• The healthcare facilities must build the contingencies to achieve streamlined operations and effective response to the mishaps.
• After the development of contingencies, the facilities must check them with regular interims to check if it implies suitably with shifting dynamics.
• The unauthorized access must be blocked, and the associate agreements must be signed with the stakeholders.
• The security incidents must be documented, and the reports must be developed.

Privacy Audit Checklist

To ensure the organization is complying with all applicable laws, it must have a privacy audit system protecting all sensitive information. 

The privacy audit will assess how the organization collects the following data.

• Whether information is collected properly via means such as electronic messages, websites, and paper documents.
• What personal and security-sensitive information is being collected.
• How much and what highly sensitive information is being collected.
• The position or relation of the owners of the information collected to the organization such as customer, employee, or third party.
• Whether and what kind of monitoring is carried out by the organizing, such as a computer or GPS trackin
• Where and how the personal information collected is stored.
• Security measures and access limitations for sensitive information.
• For what purpose the collected information is by the organization.

The list provided simply states the most common effects of a privacy audit. The system can be tailored according to the user or organization’s needs.

OCR HIPAA Audits

HIPAA is managed by the HSS, the department of health & human services, while the endorsement is done through the office for civil rights. With the increased cases of data breaches and cybersecurity threats, OCR launched the first phase of the notification HIPAA audit program of privacy, security, and breach in 2014. Furthermore, the second phase was launched in 2016, and the third phase was launched in 2017, with which the on-site audits were launched.

That being said, the OCR has the capacity to check the HIPAA compliance of the organization or individual without prior notice. The primary objective of maintaining the HIPAA compliance checklist can be deciphered as providing the proof for HIPAA compliance for the OCR audit. Nonetheless, even if not for the OCR audit, HIPAA compliance is a crucial need of the hour for all healthcare facilities to ensure the protection of Protected Health Information (PHI).

Audit Protocol

For ensuring that checklists comply with HIPAA standards, the organizations or individuals can utilize the audit protocol. The audit protocols explain the areas that are usually assessed during the OCR audits. It outlines various audit types and outlines the key activities.

Audit Protocol Example

Phase 2 of the HIPAA audit program reviews procedures and policies regarding HIPAA Audit employed by the organization or covered entity and whether it meets the security standards, breach notification rules, and privacy.     

The most commonly used HIPAA Audit program focuses on employee training and generates a risk management plan while conducting a risk analysis. 

Next, the focus shifts to selecting a privacy officer and a security assessment in charge. The focus is then shifted to reviewing policy implementations. An internal audit is conducted, and an internal remediation plan is created.

HIPAA audit protocols need to be strictly employed by all healthcare organizations and private practitioners as non-compliance can result in heavy fines, data loss, and leakage of sensitive information.

HIPAA Audit Controls

Audit controls are essential for a healthcare provider or organization. It dramatically reduces the risk of inappropriate access to information and unauthorized tracking and disclosure of protected health information (PHI).  The HIPAA audit controls require business associates to install software, hardware, and procedural mechanisms to protect electronic PHI. 

There are multiple HIPAA Audit controls that can be used:

• Application Audit Controls- These are designed to monitor hall application activities carried out by the user, such as reading, editing, deleting, and creating any information related to ePHI. 
• System-level audit controls- These monitor successful and unsuccessful log-ins, devices used for logging in, data and time of each usage attempt, and the log-in username/ID.
• User audit controls- These monitor user activities in an application or ePHI system by recording all commands initiated on the system, including log-in attempts with authentication and accessing resources.

HL7 Integration With HIPAA 

While we talk about the HIPAA Audits and relative standards set for information exchange (administrative, security, and physical rules), it’s hard not to speak about HL7 integration since it’s another set of standards for medical information exchange. For those who don’t know, HL7 is the Health Level-7 and is the international set of standards that creates the network for transferring and sharing the EHRs between the healthcare sector and software systems. In addition, it provides guidance on sharing medical data between different healthcare providers.

The set of standards was designed by HL7 International, a non-profit organization that develops the standards and frameworks that support electronic data sharing and retrieval. HL7 is applicable in over 55 countries, and ANSI accredited it in 1941 to govern the medical standards. In addition, it offers the frameworks and formats for data exchange promotion in healthcare systems.

Coming back to the point, HL7 and HIPAA integration has become the rising point for healthcare organizations. Multiple software solution providers offer this integration service with which the healthcare organizations can access the HL7 and HIPAA messages. It can transform the data on a simultaneous basis. These integrated systems can convert the files into a usable format and are exchanged with clinical applications or data warehouses.

With HIPAA-compliant and HL7 data exchange and transformation, the healthcare facilities can cut down the deployment costs and gain access to standard formatting. In addition, these systems offer access to high-quality data. However, it’s best to find a software company, such as Folio3, to get the integration software that meets the HIPAA regulatory requirements. Such integration solutions can offer insights into batch processing and data lineage to ensure seamless data sharing.

To give you an idea, the integration solutions provide access to scalability applications, HL7 and HIPAA libraries, document processors for data extraction, predesigned transformations, and more.

FAQs:

What is HIPAA Audit?

The OCR tends to work with the healthcare businesses and healthcare providers to ensure they are compliant with the HIPAA standards, regulations, security, and privacy. These audits are conducted to track the progress on HIPAA compliance. Besides, it also outlines the areas that can be improved.

Why is it important for healthcare companies to have HIPAA audit compliance?

HIPPA audit compliance guarantees the safety and protection of patients’ health records. That is to say, the compliance with HIPAA audit ensures that patients trust the healthcare facilities. It’s essential to note that trust is a foundation for every healthcare facility, so if the organization has HIPAA audit compliance, the patients always prefer your healthcare facility as the go-to healthcare provider.

What are some key HIPAA audit compliance services?

Some keys of HIPAA audience compliance services include the integrity, confidentiality, and availability of PHI through timely implementation of the security, physical, and administrative rules.

Can HIPAA features be added to the hospital system?

Yes, the HIPAA compliance features can be added to the hospital system, and it actually prevents triggering the HIPAA audit. For instance, the UX for medical devices can be made more secure to ensure safe data storage and transmission.

Who must comply with the security rule HIPAA ?

HIPAA audit protocols need to be strictly employed by all healthcare organizations and covered entities as non-compliance can result in heavy fines, data loss, and leakage of sensitive information.

Organizational heads need to comply with the HIPAA security rules by training all employees holding access to sensitive information on how to deal with phishing scams and handle sensitive information while following the right protocols to ensure the safety of the data.

The organization further needs to monitor the employees strictly and restrict the areas containing sensitive information as demanded by the HIPAA security procedures. IT heads are also required to ensure timely backup and updates of the data to avoid irregular or invalid data information.

About the Author