Audits and Breaches and Fines, Oh My! It’s time to make sure your HIPAA privacy and security compliance program has you covered


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 (followed by a discussion of what you can do to improve your program).

Meaningful use incentives. As part of its proposed rule to implement “meaningful use” incentives, the Centers for Medicare & Medicaid Services (CMS) dictated that 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 for “meaningful use.”

Breach notification. You probably know by now that your organization is obligated to report breaches of protected health information (PHI) to both affected individuals and Health and Human Services (HHS) (and, in some cases, the media). Existing breach notification laws at the state level have taught us that sending the requisite notifications often prompts a government investigation of privacy and security compliance and sometimes spawns lawsuits by affected individuals. Ensuring compliance prior to one of these events can mitigate its impact, in part by minimizing the risk of a government enforcement action and as a defense to a potential lawsuit.

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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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