When considering what to focus on for compliance and internal audits, there is no better source of information about issues to avoid than the list of enforcement actions taken in HIPAA compliance that have resulted in penalties for the violators. The details of the enforcement actions, including the reasons, penalties, and corrective action plans involved with each, provide indicators of issues to be on the lookout for, that can cause significant pain if left unaddressed.

In addition, the maximum penalties for HIPAA violations have been revised, so that the maximums for each tier of a violation more closely reflect the maximums identified in the HITECH Act, and are now related to the culpability of the organization. Organizations that try to meet requirements will receive lower maximum fines than those that are negligent. And the maximums have also been revised to reflect a cost-of-living increase.

The random HIPAA Compliance Audit program had a year of trial audits in 2012 and a second round of audits, this time including HIPAA Business Associates, concluded in 2017. The law calls for a permanent Audit program, but HHS has indicated that the HIPAA audit program will be on hold for at least the time being, and that the next product will be a report on best practices learned in the audits conducted so far. But that doesn’t mean there will be no enforcement of the HIPAA rules. In fact, preparing for a HIPAA Audit is one of the best ways to be ready to respond to any enforcement action, and going through an internal HIPAA Audit will help you find issues before they become problems that can lead to penalties.

In this session we will review the enforcement actions taken by HHS and state Attorneys General to illustrate the issues concerned and explain how to avoid them, and the penalties that can result when they are not avoided. Issues will be explored in depth in several areas in order to explain the regulatory requirements and the means for meeting them.

We will also discuss the HIPAA audit program and how it works, and discuss the areas that caused the most issues in the 2012 audits and the areas that were targeted in the 2016 audits. We will explore what kind of issues were most prevalent and what kind of entities had the most problems, and show where entities need to improve their compliance the

most. We will also explore the typical risk issues that lead to breaches of health information and see how those issues may be targets for auditors and enforcement action in the future.

Knowing what questions are likely to be asked and have been asked at prior HIPAA compliance audits can make preparing for and surviving a HIPAA audit or enforcement review much easier. USDHHS has published an updated, July 2018 protocol for the HIPAA audits, so it is possible to know how to prepare for an audit or enforcement review. Nearly any health care covered entity may be subject to an audit or enforcement investigation; all entities need to know what kinds of questions they’ll be asked, what information they'll need to provide and how to prevent issues that could lead to violations and fines.

We will examine the updated 2018 HIPAA Audit Protocol as well as other questionnaires that have been used in the past and may be used to help prepare an organization for a future review. We will present methods for using the contents of the HIPAA Audit Protocol to build your own compliance plan by extracting the contents and relating your compliance activities and documentation directly to the questions that might be asked, thereby creating a compliance management tool to ensure continued compliance improvement.

We will review the contents of the 2018 HIPAA Audit Protocol to show what documentation needs to be on hand should your organization be selected for an audit or enforcement action. We will explain the enforcement regulations and the recent changes that increase fines and create new penalty levels, including new penalties for willful neglect of compliance that begin at $10,000. Documentation requirements for compliance will be explored.

The results of prior HHS audits and enforcement actions (and their penalties) will be discussed, including recent actions involving multi-million-dollar fines and settlements. A plan for attaining compliance will be presented. The steps to follow to prepare for an audit and respond to an audit request will be outlined. In addition, upcoming trends in information security risks will be discussed so you can start to plan for the work you'll need to do to stay in compliance and keep patient information private and secure.

Webinar Takeaway

  • Fines and penalties for violations of the HIPAA regulations have been updated to reflect the culpability of an organization and cost-of-living increases, and now include mandatory fines for willful neglect of the rules that begin at $10,000 minimum and can reach $50,000 per day, with maximums over $1.7 million.
  • HIPAA enforcement actions resulting in settlements or penalties of up to $16 million will be discussed, explaining the type of each violation and its impact.
  • The key issues driving each enforcement action will be explained, including such topics as breaches, communications, ransomware, and privacy rule violations.
  • Find out what HHS OCR is likely to ask you if you are selected for an audit or enforcement review, and what you'll have to have prepared already when they do.
  • The HIPAA Audit Protocol will be examined along with the sets of questions asked at other HIPAA audits previously.
  • Find out what the rules are that you need to comply with and what policies you can adopt that can help you come into compliance.
  • Learn how having a good compliance process can help you stay compliant more easily.
  • Find out what you'll need to have documented to survive an audit or enforcement review and avoid fines.
  • Learn how to use the contents of the HIPAA Audit Protocol as the foundation of your compliance activities and documentation.

Who will Benefit

  • Compliance director
  • CEO
  • CFO
  • Privacy Officer
  • Security Officer
  • Information Systems Manager
  • HIPAA Officer
  • Chief Information Officer
  • Health Information Manager
  • Healthcare Counsel/lawyer
  • Office Manager
  • Contracts Manager

Industries who can attend

This 180-minute online course is intended for professionals in the Healthcare Industry.

Faculty Jim Sheldon-Dean

Faculty Jim Sheldon-Dean

Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities. He is a frequent speaker regarding HIPAA, including speaking engagements at numerous

regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference. Sheldon-Dean has more than 19 years of experience specializing in HIPAA compliance, more than 37 years of experience in policy analysis and implementation, business process analysis, information systems and software development, and eight years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician.

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