HIPAA Audits 101: Your Compliance State Under Review

Written by Kevin L MabryHealthcare


Hello, HIPAA

The Health Insurance Portability and Accountability Act, better know as HIPAA, was passed by Congress in 1996 and called for the protection and confidential handling of protected health information (PHI). HIPAA still exists today, aiming to protect patients and their information, but it’s important to think about how far we’ve come in the ways we handle patient data since its enactment.

Look how far we’ve come

Think about this, the first iPhone was introduced in 2007; that’s 11 years after the introduction of HIPAA. This highlights the significant technological advancements our country has seen over the last 20+ years. We’re now living in a digital world. Not only has that made an impact on our personal lives, but also how organizations are able to conduct business. From financial institutions to medical practices, technology has brought new opportunities, and obstacles.

When HIPAA was created, a patient’s PHI was stored in a chart, on paper. There was no worrying about a hacker sneaking into the network and stealing their information. Nobody heard of phishing or ransomware.

Today, 23 years after HIPAA made its debut, it is far more common to see electronic protected health information (ePHI) than it is to see paper records. We have had tremendous advancements in patient care and treatment, which has led to new challenges for the protection and confidential handling of PHI.

Holes in HIPAA

While there have been some tweaks to HIPAA like the Omnibus Rule in 2013, by a large part, HIPAA has not seen much change since its introduction. With the vast changes to how we access and handle patient data, there is no denying the significant holes in the HIPAA rule and the need for a major update.

Compliance is non-negotiable

One thing that has not changed since 1996 – HIPAA compliance is here, and it is not optional.  In fact, it’s arguably more important than ever before to have your HIPAA compliance program in order. With the healthcare industry being favored by cybercriminals, human error accounting for most data breaches, the ease in filing a complaint against an organization, and more, your compliance program could come under review at any given time – and you must be ready.

What triggers an audit?

The Office for Civil Rights (OCR), is the department responsible for enforcing HIPAA. It seems there is a common misconception that audits by the OCR happen at random when the department decides to “pop in” on organizations to check on their compliance state. The reality is, the OCR is not staffed to audit organizations without just cause, meaning when an audit occurs, something triggered it.

Common audit triggers

  • Patient complaints – Patients could file complaints for any number of reasons. Maybe a patient was denied access to their records, or perhaps they saw a picture on social media with their medical chart in the background.
  • Employee complaints – Often times, disgruntled employees may file a complaint following termination of employment, but that’s not always the case. If an employee feels there has been wrongdoing, they could certainly file a complaint.
  • Employee mistakes – Employee mistakes or human error account for many audits. An employee falling for a phishing email, using weak passwords, and sending a patient the incorrect records are all examples of human errors.
  • Insider wrongdoing – Sometimes employees violate company policies maliciously, and other times they may just be curious. Employees could steal patient records for personal gain or could peek at a patient’s records because they’re curious about their visit.
  • Third-party mistakes – Mistakes caused by a Business Associate (BA) could also lead to an investigation of your organization. If your (BA) suffers a data breach, you may be audited as well.
  • Security incident – Common security incidents include lost or stolen devices, especially those devices that are unencrypted, as well as unpatched software that led to malware or ransomware exploits.

Many times, whatever triggered the audit, to begin with, is not the biggest problem or finding by the OCR. This is why having your HIPAA compliance program in order and continuously working towards your compliance is critical.

Bring on the questions

When a Covered Entity or Business Associate suffers a security incident, it needs to be reported, and once that happens, questions may start arising. Why didn’t you have a password on your Wi-Fi? Why was your server unlocked and underneath your reception desk? Aren’t your employees trained on how to spot a phishing email? Didn’t you have a policy in place for what’s permitted use of a workstation? Why didn’t you have a Business Associate Agreement with your transcription service?

These are just a few questions that could be posed by an auditor – but that’s just the beginning of what they will ask of you.

What will OCR look for in an audit?

What OCR may be looking for in an audit situation will vary, dependent on what triggered the audit in the first place. Below are some common items that your organization could expect to show an auditor in the event of an audit, all of which, are key components of a HIPAA compliance program.

  • Security Risk Assessment – An absolutely critical part of your compliance program. The Security Risk Assessment (also referred to as the SRA, or Security Risk Analysis) will look for gaps in your organization’s administrative, physical and technical safeguards that could pose a risk for protected health information (PHI). You must have documented proof of your SRA.
  • Remediation/Risk Management Plan – Once you’ve conducted your SRA, you’ll need to have a process in place to begin addressing your deficiencies, often referred to as a Risk Management Plan. This plan should cover how you plan to remediate all the security gaps discovered in your SRA.
  • Policies & Procedures – Not only does your organization need to have policies and procedures in place, but you also must ensure that employees understand those policies and have signed off on them. Employees can’t be expected to follow the rules if they are unaware of them, and the documented proof that they acknowledged the policies is vital in the event of a security incident.
  • Security Officer – Every organization needs to have an appointed Security Officer. This individual is responsible for ensuring policies and procedures are created, understood by all employees of the organization, and acknowledged by them with documented proof. The Security Officer should also ensure employees are trained on HIPAA routinely.
  • Routine HIPAA Training – Not only is HIPAA training a requirement, but it is also necessary to reduce the chances of an employee-error. HIPAA and cybersecurity awareness training should be conducted routinely so employees are kept updated on the latest threats, and to keep security best practices top of mind.
  • Business Associate Agreements – You must have a Business Associate Agreement (BAA) with any and all vendors that handle your patient data. A data breach caused by a Business Associate will also affect your organization, so make sure you are working with vendors who take HIPAA compliance seriously.

Proof of network vulnerability scans, penetration tests, and breach notification (in the event of a breach) are also common requests by the OCR.

The bottom line

It’s safe to say that in this digital age, HIPAA could use a refresh, but despite its flaws, your adherence to it is not up for discussion. An audit could be triggered by anyone, at any time. If you had a complaint filed against you tomorrow, would you be confident in your compliance state? If you can’t answer yes, it’s best to get to work – before it’s too late.


CEO, Author of the #1 Risk to Small Businesses

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