Planet HIPAA – Beyond the Bite

By Dr. Danika Brinda, CEO, Planet HIPAA

Did you know that your practice’s website can reveal to the world that you are out of compliance with HIPAA?

A quick look around your website could reveal to a HIPAA auditor that your practice is struggling with HIPAA compliance. Wondering what I am referring to? It’s the Notice of Privacy Practices! The regulations state that your practice must ensure that the most current version of your Notice of Privacy Practices is posted on the practice’s website (if one exists). Here is the specific language from the regulations:

CFR 164.520(c)(3)(i) – A covered entity that maintains a website that provides information about the covered entity’s customer services or benefits must prominently post its notice (of privacy practices) on their website and make the notice available electronically through their website.

Go ahead, give it a try. Head on out to your website (or another practice’s). Try and find the Notice of Privacy Practices. Were you successful or did you find something that is called Privacy Policy? If you look through the Privacy Policy, most of the time the language is something specific to the privacy policy of the website and not the Notice of Privacy Practices. Keep searching for the Notice of Privacy Practices. If you are unsuccessful at finding it, the basic elements of the regulations are not met. If you found the Notice of Privacy Practices – great work! You are compliant, right? NOT NECESSARILY!

Even with your Notice of Privacy Practices posted on your website, you must make sure that the document is your most current version and matches the one available in your office. You also must make sure it meets all the requirements that were defined in the 2013 HIPAA Privacy Regulations and the 2013 HIPAA Omnibus Rule. If any of the following three statements are true, your website revealed that you are out of compliance with HIPAA:

Your Notice of Privacy Practices was not posted on your website.
Your Notice of Privacy Practices was dated prior to Sept. 23, 2013.
The Notice of Privacy Practices on your website isn’t the most up-to-date copy.

If you think the auditors will not be looking on your website to make sure your Notice of Privacy Practices is posted, think again. In the OCR 2016 HIPAA Desk Audit Guidance on Selected Protocol Elements, it states the covered entity must “upload the URL for the entity’s website and the URL for the posting of the entity’s notice.” In fact, the instructions for the HIPAA auditors state that they must:

“Determine whether the entity maintains a website. If so, observe the website to determine if the Notice of Privacy Practices is prominently displayed and available. An example of prominent posting of the notice would include a direct link from homepage with a clear description that the link is to the HIPAA Notice of Privacy Practices.”

Not only does it have to be posted on your website, but it must be in a location that is easy to find with an easy description!

The Notice of Privacy Practice is not a difficult area to comply with for the HIPAA regulations; however, it is a common area of non-compliance. To be compliant with this regulation, the following four items should be established:

Notice of Privacy Practices
Notice of Privacy Practices Policy and Procedure
Acknowledge Form of the Notice of Privacy Practices
Making the notice available on the practice’s website

The specific elements that need to be defined in the Notice of Privacy Practices are specifically defined in the regulations. More information can be found here.

Dr. Danika Brinda is the CEO of Planet HIPAA and has more than 12 years of experience in health care privacy and security practices. She also is a nationally recognized speaker on a variety of health care privacy and security topics, and specializes in helping dental organizations implement a HIPAA-compliance program.

This article was first published on Planet HIPAA on Sept. 5, 2016.

By Dr. Danika Brinda, CEO, Planet HIPAA

2016 is going to be a monumental year for HIPAA compliance. The Phase 2 HIPAA audits will be starting, and increased HIPAA enforcement is a guarantee. So far in 2016, we have seen multiple fines and HIPAA compliance enforcement that are setting the stage for the remainder of 2016. For many years, HIPAA compliance has been pushed off and ignored; however, if the first 2 months of 2016 is telling the story, now is the time to ensure your dental practice has established proper policies, procedures and practices for HIPAA compliance. Don’t get tangled up in a HIPAA audit with no confidence in your dental practice’s compliance with HIPAA!

It is easy to think that your practice is too small to get selected for a HIPAA audit or that audits will focus on large, integrated health care systems. However, looking at the findings from the pilot audits indicate that dental practices are just as desirable for a HIPAA audit as any other type of organization.

Some key findings from the HIPAA Pilot Audits are:

Smaller organizations tended to struggle with HIPAA compliance more than larger organizations.
The most common finding was that the entity was “unaware of the requirement.”
Of the total health care providers audited, NONE of them were 100 percent HIPAA compliant.
Incomplete implementation of the regulations was cited as a top finding from the audits.

We are at a stage with HIPAA compliance that the “I didn’t know” or “I was unaware” is no longer going to be an acceptable reason for non-compliance. In the past year, numerous data breaches were reported to the Department of Health and Human Services. In some of the dental data breaches reported, more than 500 individuals were impacted!

2,000 individuals impacted when an unencrypted portable device was stolen from a dental provider.
3,200 individuals impacted after an unencrypted server was stolen during a burglary of a dental office.
7,400 individuals impacted when dental records at an off-site storage were released by the storage company to unauthorized individuals.

With proper oversight of HIPAA and appropriate physical, technical and administrative safeguards, these data breaches could have been avoided.

Another common finding is false security that the vendor of your practice management system or electronic health record has all aspects of HIPAA compliance covered. Even when a third-party solution manages a system, not all aspects of HIPAA compliance are met. Additionally, you may find that some functionality of your systems does not actually meet HIPAA compliance. For example, your systems should be able to automatically log out after a specified time of inactivity. Your vendor may be the group responsible for creating the functionality, but you are responsible for the implementation in your dental organization. If your software system doesn’t have the functionality to automatically log out of the system with inactivity, you may be out of compliance with HIPAA. Don’t assume that compliance is met — verify it!

Don’t wait until a HIPAA audit comes to your dental practice to know that you are out of compliance. Immediate action is needed if you are not confident in your HIPAA compliance. HIPAA takes more than just putting a HIPAA manual on the shelf in your dental practice. Make sure your organization takes the steps NOW and prevents a bad outcome from a HIPAA audit or showing up on the HIPAA Wall of Shame.

Dr. Danika Brinda is the CEO of Planet HIPAA and has more than 12 years of experience in health care privacy and security practices. She also is a nationally recognized speaker on a variety of health care privacy and security topics, and specializes in helping dental organizations implement a HIPAA-compliance program.

This article was first published on Planet HIPAA on April 18, 2016.

Tag: Planet HIPAA

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