In today’s modern landscape, there are few aspects of our personal lives that haven’t been digitized and shared in one form or another. In fact, digital information sharing has become an important part of our society, leading to the development of better quality products and services.

However, as organizations collect greater amounts of personal information from their clients and user bases, the importance placed on how that information is regulated continues to grow. And this couldn’t be more representative of the creation of the HIPAA Privacy Rule.

But what exactly are the requirements of HIPAA, and to whom do they apply? Below, we’ll take a deeper dive into HIPAA regulations, what they’re composed of, and how your business can ensure it stays in compliance.

What is HIPAA?

HIPAA stands for the Health Insurance Portability and Accountability Act, enacted on August 21, 1996, by the United States Congress. The purpose of HIPAA was to help set strict standards on how personal health information (PHI), obtained by healthcare and healthcare insurance industries, was being collected and shared in a professional setting. 

Over the past 20 years, the move from paper to digital has been an essential evolution for nearly all sectors of the health industry. However, while this transition has afforded many positive strides towards a more flexible and scalable health care system, it has also introduced potential risks to personal security. HIPAA was formed to help address these risks by implementing higher levels of accountability to the organizations that collect and store sensitive health information.

The 5 Rules of HIPAA Compliance

HIPAA is a legislative act made up of five rules that address and mandate how organizations need to comply with various aspects of the law. Below, we’ll take a more in-depth look into each one of these rules:

Privacy Rule

The HIPAA Privacy Rule was put in place to protect the individual medical records of clients and patients by limiting how companies can legally obtain and utilize their personal information. Along with enforcing best security practices when storing and protecting personal information, HIPAA gives patients' rights over their records, as well as guarantees that information cannot be collected without their consent and that they’re able to request corrections to it over time.

Security Rule

While the “Privacy Rule” was created to govern organizations on how to collect and transmit personal health information properly, the HIPAA “Security Rule” was designed to ensure they adequately protect that same information. To simply say “your information is safe with us” is not enough to comply with HIPAA regulations. Organizations are expected to deploy specific safeguards to ensure a client or patient’s privacy rights are protected, and these include:

•    Administrative Safeguards – Companies are expected to document and implement specific policies and procedures designed to protect against potential data breaches.

•    Physical Safeguards – These policies ensure that due diligence is taken to protect sensitive information stored in public and private areas physically. These safeguards include active security systems, adequate storage locks, and video surveillance where applicable.

•    Technical Safeguards – Organizations are held accountable to protect and digital personal records they have from unauthorized access. This can include the deployment of cybersecurity tools and services to monitor and protect the information from outside sources actively.

Transactions and Code Set Rules

HIPAA Transactions and Code Set Rules are designed to standardize how health information is shared via EDI (Electronic Data Interchange) protocols. When information moves from one computer to the next without human intervention, the Transactions and Code Set rules governs how these transactions need to take place.

Unique Identifiers Rule

To promote better consistency and efficiency of HIPAA regulations, three separate identifiers are to be used during reporting:

•    Standard Unique Employer Identifier – Used to identify employer information and entity type.

•    National Provider Identifier (NPI) – A unique identifier for health-care providers

•    National Health Plan Identifier (NHI) – Adequately identifies different health plans and payers.

Enforcement Rule

In alignment with HIPAA requirements, the Enforcement Rule specifies how regulators determine if healthcare providers are compliant or not. This rule outlines the process of investigations, hearings, and penalties when violations are present. It also lists the various fine amounts based on the severity of each violation that is found.

Who Does HIPAA Apply To?

HIPAA regulations apply to any organization that collects and transmits personal health information electronically, or within any other standard outlined by the Department of Health and Human Services (HHS). In most cases, these standards apply to healthcare providers, health insurance companies, and entities that process nonstandard health information on behalf of another health organization.

However, the HSS also stipulates that “business associates” can also be considered as a “covered entity,” meaning that your organization doesn’t necessarily need to be a health organization to be accountable to HIPAA regulations. For example, IT companies, attorneys, and accountants who have access to personal health information through their clients might also be audited for HIPAA compliance.

What are the Penalties for Non-Compliance?

Regulated through HIPAA’s Enforcement Rule, there are a variety of non-compliance penalties enforced on organizations found to violate HIPAA regulations. Depending on the level of negligence, the severity of these penalties can vary, ranging from $100 to $50,000 per violation and with a maximum penalty of $1.5 million per year. More than just the financial impact, however, certain violations can also result in criminal charges when proven under the right circumstances.

Develop a HIPAA Compliance Checklist

While every organization has its own unique challenges when auditing for and ensuring HIPAA compliance, there are necessary steps every company can take to minimize non-compliance issues. Here is a checklist of items to proceed with when ensuring your own organization’s HIPAA compliance:

1. Get Consent Forms

Any time your organization collects, transmits, or uses personal health information, consent must be given and documented. This is an essential first-step in verifying HIPAA compliance.

2. Restrict Access

When your organization houses personal information from clients and patients, accountability to safeguard that information passes over to you. It’s your responsibility to restrict access to this information administratively, physically, and technologically.

3. Designate a Compliance Officer

HIPAA requires that a dedicated Compliance Officer is put in place to develop or manage and organizations privacy program. This can either be a part-time or full-time position, but an individual must be assigned to keep up-to-date with relevant state and federal laws while keeping internal policies and procedures in compliance.

4. Invest in Breach Safeguards

With today’s cybersecurity threats, maintaining HIPAA compliance standards requires active measures to be taken to the personal health information of clients and patients. SIEM (Security Information and Event Management) solutions are a great way to achieve this by providing regular security monitoring and protection of networked systems and databases.

5. Be Prepared for Audits

HIPAA regulation audits can happen at any time, and it’s vital that you maintain accurate, up-to-date compliance reports throughout the year. These reports not only help to ensure you avoid costly non-compliance penalties but also help your organization maintain the best security practices.

HIPAA regulations were designed for the protection of everyone, and health organizations and business associates are responsible for strictly upholding these standards. By better understanding the requirements of HIPAA and how it applies to your organization, you’ll be able to create a safe and sustainable business environment for your client’s information.

ArmorPoint is an out-of-the-box compliance reporting solution that quickly and easily demonstrates HIPAA compliance while maintaining advanced endpoint security protection throughout your entire network. Using a unified administrative dashboard, companies can have the transparency they need to improve security efficiencies within their organization, ensuring they maintain the strictest compliance standards 24/7. Reach out today for your free trial of ArmorPoint’s advanced SIEM solution.

About ArmorPoint

ArmorPoint is a security information and event management solution that provides a cost-effective and reliable way to continually protect your business from emerging threats. Through its customizable service pricing model, ArmorPoint’s cost-effective packages and dynamic levels of expert management support the security strategies of all companies, regardless of available budget, talent, or time. And since ArmorPoint offers 24/7 security support with a team of dedicated specialists, they can provide you with the manpower you need to expertly manage all of your cybersecurity initiatives. See how ArmorPoint can make a difference in your security posture with a risk-free 30 day free trial