Audits and Breaches and Fines, Oh My! — Part I It’s time to make sure your HIPAA privacy and security compliance program has a heart


Have you ever had that nagging feeling that you needed to take care of something, but you just didn’t have time so you let it go, probably for too long? I usually feel that way about two things: exercise and yard work. Some HIPAA-covered entities feel that way about compliance with the HIPAA Privacy and Security Rules. They are cumbersome, dense, and difficult to fully implement. And even if you have implemented policies and procedures to address each requirement, your compliance program can’t be a tin man. To effectively reduce risk of compliance problems and security incidents, you need to make sure the program actually functions, has been meaningfully implemented, and is refreshed periodically to address any compliance gaps created by changes in the law and your own operations. Breathing life into your compliance program takes real work, but doing so will have tangible rewards as the program becomes a living part of your organization’s daily functions.

If you don’t feel confident about your organization’s HIPAA privacy and security compliance, now is a good time to undertake a refresher. Here are a few reasons why.

“Meaningful Use” Incentives

Let’s start by discussing the carrot in this bunch. As part of the 2009 economic stimulus package, CMS was directed to provide incentive payments to eligible professionals and hospitals that make “meaningful use” of electronic health record technology and participate in Medicare and Medicaid. As part of their proposed rule to implement this requirement, CMS identified a series of “health outcome policy priorities” to be met, including “ensuring adequate privacy and security protections for personal health information.” As a Stage 1 measure, eligible professionals and hospitals must “[c]onduct or review a security risk analysis…and implement security updates as necessary.” If you comply with the HIPAA Security Rule, you will have met this Stage 1 requirement.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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