With the resurrection of the HIPAA Audit program in 2016, 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.
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HIPAA Audit and Enforcement activity are on the increase, with new expansions of the HIPAA Audit program under way 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.
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. 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 be a target for enforcement and auditing in 2017.
- We will review the contents of the HIPAA Audit Protocol published in 2016 to show what documentation needs to be on hand should your organization be selected for an audit or compliance investigation. We will present methods for using the contents of the HIPAA Audit Protocol to build your own compliance plan by extracting and updating the contents and relating your compliance activities directly to the questions that might be asked.
- 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; most of the recent settlements with HHS OCR have been in the multiple millions of dollars.
- 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:
Information Systems Manager
Chief Information Officer
Health Information Manager
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 30 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. 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.