HIPAA (Health Insurance Portability and Accountability Act) is a US federal law enacted in 1996 that establishes national standards for protecting sensitive patient health information. It applies to any business that handles protected health information (PHI). So, what is the key to HIPAA compliance?
| “Many organizations who require HIPAA compliance aren’t aware that they do. However, that doesn’t make the repercussions for violations any less severe.” – Brian Leger, Co-Founder of InfoTECH Solutions |
If HIPAA is required for your organization, consistently meeting security standards is a big deal. The penalties for violations can range anywhere from $137 to $68,928 per infraction, which means that simply doing your due diligence can make thousands of dollars worth of difference.
To help you avoid these costly violations, this article will help you understand how to be HIPAA compliant. Please treat this article as your starting point. Use the advice you will receive as guidance for how to speak to cybersecurity experts and your compliance officer.
Who Needs to Maintain HIPAA Compliance?
You don’t need to be a healthcare organization to require HIPAA. Any business that handles protected health information (PHI) must follow these standards. PHI includes any health-related information that can be tied to a specific individual – including medical records, health insurance details, and any emails containing health details.
Therefore, any business that may have access to this information will be subject to HIPAA requirements, regardless of whether you are a care provider. For example, if your law firm processes any documents that qualify as PHI for legal cases, you will need to follow HIPAA.
In fact, organizations that handle PHI who are not in the healthcare industry are often the biggest risks to healthcare data. 54% of healthcare-related data breaches begin at such organizations. Part of the reason why is an assumption that HIPAA only applies to healthcare providers.
Enjoy 24/7 Protection From a Team With 17+ Years of Experience
What Is & Isn’t PHI?
Not all health-related data qualifies as PHI. To be considered PHI, the record must meet 2 criteria.
- It relates to an individual’s health, healthcare, or payment for healthcare (past, present, or future).
- It includes one or more personal identifiers that could be used to trace the individual.
The record must meet both criteria to be considered PHI. So, if a health-related record is not traceable to a specific person, it would not be considered PHI. Here is an overview of some examples.
| PHI | Not PHI |
| A medical record with a patient’s name | A step count from a fitness tracker |
| A doctor’s appointment schedule with patient names | Anonymized health statistics in a research study |
| A prescription linked to an individual | A grocery store receipt listing over-the-counter medications |
| A health insurance claim with a policy number | A general health tip article from a website |
| An X-ray image with a patient ID | A personal journal entry about symptoms |
| A hospital bill with a name and date of service | A wellness app’s sleep tracking data |
| A phone call recording about a patient’s treatment | A workplace attendance record showing sick leave |
What Does It Mean to be HIPAA-Certified?
HIPAA certification refers to the process of training and validating an organization’s or individual’s understanding of HIPAA requirements.
The US Department of Health and Human Services (HHS) does not endorse or recognize any official HIPAA certification. Instead, third-party training programs offer certifications to demonstrate compliance with HIPAA’s privacy, security, and breach notification rules.
Because there is no official recognition of certifications, HIPAA certification does not automatically mean your organization is fully compliant. Treat HIPAA certification as a step in your compliance program, not as the final requirement.
How to Meet & Maintain HIPAA Compliance in Your IT Systems
Conduct Regular HIPAA Risk Assessments
Regularly assess your IT systems to identify possible risks to any PHI you may store. Evaluate vulnerabilities in data storage, transmission, and access points. A risk analysis helps identify potential security gaps that could lead to unauthorized access or data breaches. Knowing where risks exist allows you to take proactive measures before an incident occurs.
Implement Audit Controls & Logging
Enable system logging to track access, modifications, and transmission of PHI. Use security information and event management (SIEM) tools to monitor and analyze security events in real-time. Logging and audit controls provide a detailed record of who accessed data and when.
Maintain Business Associate Agreements (BAAs)
Ensure all third-party vendors handling PHI sign a Business Associate Agreement (BAA) outlining their HIPAA obligations. Review vendor security measures and conduct periodic compliance audits. Third-party vendors can introduce compliance risks. A BAA holds them accountable for maintaining HIPAA-compliant cybersecurity standards.
Regularly Update & Patch IT Systems
Implement a patch management policy to apply security updates for operating systems, applications, and network devices. Automate updates where possible and conduct vulnerability scans. Outdated systems are common targets. Regular updates help minimize security risks and maintain compliance.
| Read Our Blog For More Cybersecurity Insights What Is Zero Trust Network Segmentation & Why Do You Need It? What is an Information Security Policy & How Do You Create One? What Does Data Breach Insurance Cover? |
Establish Secure Data Backup & Recovery Processes
Maintain encrypted, offsite backups of critical PHI and regularly test disaster recovery plans. Use automated backup solutions that meet HIPAA’s data retention and integrity requirements. Secure backups ensure that PHI remains available in case of cyber attacks, hardware failures, or accidental deletions.
Train Employees
Provide annual employee training for all staff handling PHI, including how to recognize phishing attempts, securely handle data, and report security incidents. Human error is a major cause of HIPAA violations, but regular training helps you prevent them.
Develop an Incident Response Plan
Create an incident response plan detailing steps for detecting, containing, and responding to a security event involving PHI. Test the plan with drills and update it as threats evolve. A strong response plan helps mitigate damage from cyber attacks or unauthorized access and ensures compliance with HIPAA’s breach notification rules.
| Ask Louisiana’s Leading IT Consultants About Maintaining HIPAA Compliance | ||
| New Orleans | Baton Rouge | Lafayette |
Work With Cybersecurity Professionals Who Can Help You Meet HIPAA Standards
InfoTECH Solutions offers comprehensive services to help organizations achieve HIPAA compliance. Our expertise includes tailored compliance support, regular audits, and risk prevention strategies. We also provide cybersecurity consulting to strengthen your organization’s defenses against potential threats.
Contact us today to ensure your IT infrastructure aligns with HIPAA standards.
