HIPAA Audits and Enforcement — Being prepared helps prevent violations and penalties

01:00 PM EDT | 10:00 AM PDT | 12:00 PM CDT Duration 90 Minutes

Webinar Includes : All the training handouts , certificate ,Q/A and 90 mins Live Webinar

"Hear By Jim Sheldon-Dean award-winning, best-selling commercial utility software; and mission-critical, fault-tolerant communications satellite control systems"

HIPAA audit and enforcement programs and how they work, and discuss the areas that caused the most issues in prior audits and enforcement actions.


HIPAA Audit and Enforcement activity are on the increase, with new expansions of the HIPAA Audit program and new attention to reported violations of HIPAA. It is easy to become the target of a compliance investigation, and essential to be prepared in advance.

HIPAA Compliance requires that you be prepared to handle Protected Health Information properly and follow the requirements in the HIPAA Privacy, Security, and Breach Notification Rules. If there is a problem that comes to the surface, an enforcement action can result, including financial settlements that can reach into the millions of dollars, and Corrective Action Plans that can take years to complete and can cost many times the expense of the monetary settlements.

HIPAA enforcement and audits are now a significant reality, and settlements for violations are being announced more and more frequently. Now, with the increases in breach reporting and the new random audit program under way, enforcement of HIPAA is something that every HIPAA entity and business associate needs to be aware of and prepared for, by taking the proper steps in advance to have your compliance in order and the documentation to prove it.

Knowing what questions are likely to be asked and what documentation is necessary to show compliance are key to preparations for HIPAA compliance inquiries, and this session will explore a number of sets of questions and the issues they revealed, leading to enforcement action.

Every entity under the HIPAA regulations needs to know why the enforcement actions took place and what could have been done differently to prevent the violations that led to enforcement, so they can avoid those issues and their significant impact. Failure to do so can lead to financial settlements, fines, and/or corrective action plans that can severely impact your organization.

In this session we will discuss the HIPAA audit and enforcement programs and how they work, and discuss the areas that caused the most issues in prior audits and enforcement actions. We will explore what kind of issues 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 become a target for auditors in the next round.

We will review the contents of the HIPAA Audit Protocol used in 2016 to show what documentation needs to be on hand should your organization be selected for an audit in the new round. We will present methods for using the contents of the HIPAA Audit Protocol to build your own compliance plan by relating your compliance activities directly to the questions that might be asked.

In this session we will discuss the HIPAA audit and enforcement regulations and processes, and how they apply to HIPAA covered entities and business associates. 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.

We will discuss what information and documentation must be prepared in advance so that you can be ready for an audit or enforcement review at any time, including sample information request forms and questions asked at prior audits. The session will also cover how to know if you may become the subject of an audit or enforcement action, and what you can do to help limit your exposure. We will discuss how most enforcement actions come about and what can be done to prevent incidents that lead to enforcement activity.

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.  

Areas Covered

•    Find out what the audit process is, what HHS OCR is likely to ask you if you are selected for an audit or compliance review, and what you'll have to have prepared already when they do.
•    Learn how to make the HIPAA Audit Protocol useful to you as a way to organize and track your compliance work, and collect your documentation references.
•    Find out what you'll need to have documented to survive an audit or compliance review and avoid fines.
•    Learn how to use an information security management process to evaluate risks and make decisions about how best to protect PHI and meet patient needs and desires.
•    Find out what policies and procedures you should have in place.
•    Learn about the training and education that must take place and be documented to ensure your staff uses health information properly and does not risk exposure of PHI.
•    Find out the steps that must be followed in the event of a breach of PHI.
•    Learn about how the HIPAA audit and enforcement activities are now being increased and how you must be prepared or risk significant penalties.

Who will Benefit

Attendees should include Compliance Officers, Privacy and Security Officers, and leadership and staff in health information management, information security, and patient relations, as well as staff in patient intake and front-line patient relations and any others that are involved in, interested in, or responsible for, patient communications, information management, and privacy and security of Protected Health Information under HIPAA, including:
•    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

At the conclusion of the session, participants will be able to:

1.   Understand how to use texting and mobile devices for business and professional communications.
2.   Understand the difference between business use, professional use involving Protected Health Information, and communications with patients, and the rules surrounding each type of communication.
3.   Know how to consider the use of staff-owned devices in communications.
4.   Know when secure communications and devices are required and what must be done to secure communications and mobile devices

Speaker Profile

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. 

Sheldon-Dean serves on the HIMSS Information Systems Security Workgroup, has co-chaired the Workgroup for Electronic Data Interchange Privacy and Security Workgroup, and is a recipient of the WEDI 2011 Award of Merit. He is a frequent speaker regarding HIPAA and information privacy and security compliance issues at seminars and conferences, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference in Washington, D.C. 

Sheldon-Dean has more than 30 years of experience in policy analysis and implementation, business process analysis, information systems and software development. His experience includes leading the development of health care related Web sites; award-winning, best-selling commercial utility software; and mission-critical, fault-tolerant communications satellite control systems. In addition, he has eight years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician. Sheldon-Dean received his B.S. degree, summa cum laude, from the University of Vermont and his master’s degree from the Massachusetts Institute of Technology.

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