February 24, 2025 Welcome to the third installment of Abyde’s HIPAA Investigation Survival Series. We’ve reviewed the initial breach and the letter itself, and now we will review those steps you need to take when organizing documentation to send back to the OCR. As discussed in our last blog post, you must start organizing documentation immediately after receiving an investigation letter. Since the turnaround is usually 30 days, it’s important to have documentation sent promptly to your investigator. Proper organization of documents is essential for a successful practice. How Should I Organize Documentation? The OCR will specify the documentation required in the initial investigation letter. For instance, if your practice experienced a ransomware attack, the OCR will likely ask specific questions about your practice’s cybersecurity safeguards. This response can be sent either through traditional mail or by email. If using email, ensure that the email is properly encrypted if any Protected Health Information (PHI) is mentioned. When responding to the OCR, being thorough and specific is crucial. The OCR expects you to provide relevant policies, procedures, your practice’s Security Risk Analysis (SRA), and other important documentation. Having this documentation readily available for your practice is essential. With only 30 days or less, you don’t have time to scramble. There isn’t an exact number of questions the OCR will ask about your practice. It all depends on what information the OCR currently has about your practice. As investigation documentation will likely span hundreds of pages, providing an index and table of contents is vital. Organize your documentation by ensuring it directly answers the specific question being asked. When compiling documentation, reference the question to maintain organization. The pages should also be numbered and match the index provided at the beginning of the response. If you have questions when organizing documentation, you can contact your investigator. Working with a third party, such as a HIPAA software solution provider or a lawyer, who has experience navigating an investigation is also recommended. Lastly, review your documentation carefully, ensuring all questions have been comprehensively answered. Then, send in the requested documentation to your HIPAA investigator with your OCR case number labeled appropriately. What’s Next? After the initial submission, the OCR might ask for additional information. That’s why answering questions thoroughly is vital to streamlining the investigation process. It could take months before the OCR responds. Once all necessary documentation is received, the OCR may close its investigation. Your practice could be found compliant or face monetary penalties and government monitoring. The need to quickly gather and organize documentation during an investigation highlights the importance of proactive document management. Easy access to documentation promotes a transparent culture of compliance within your practice. This organization also reduces stress in stressful situations, such as investigations. By utilizing an intelligent software solution, your practice can organize all documentation within the software, easily downloading and compiling all required documents for an investigation. Software solutions can also include incident response programs, providing healthcare practices with expert guidance when navigating a HIPAA investigation. To learn more about how your practice can ace an investigation, schedule a consultation with one of our experts today. To visit our first installment of this series, which is focused on the breach, please visit here, and to learn more about the audit letter, visit here. To finish the series, learn more about the potential outcomes of an investigation here.
Decoding the HIPAA Investigation Letter: What to Expect and How to Respond
February 17, 2025 Welcome to the second installment of Abyde’s HIPAA Investigation Survival Series. We’ve reviewed the initial breach, which usually sparks an investigation. Still, the actual start of an investigation is when a practice receives an official investigation letter. The investigation letter is usually sent by mail to a practice. However, depending on what information the Office for Civil Rights (OCR) has, this letter could also be sent by email. Knowing how to read and understand a HIPAA investigation letter is vital to the success of your practice. What’s in an Investigation Letter? A HIPAA investigation letter might be overwhelming to receive at first, but it’s important to keep calm. Getting a letter doesn’t necessarily mean you’ll be fined. It is solely a data request from the OCR if you can prove your due diligence in protecting patient data. An investigation letter begins with official letterhead from the Department of Health & Human Services—OCR. It will also provide an OCR Transaction Number, which will be used in all communications regarding this situation. This letter will also include the contact information for the OCR investigator assigned to your case. The letter will begin with the current information presented. For example, if the OCR receives a breach report about a stolen device, it will be mentioned alongside potentially violated HIPAA legislation due to that breach. The first part of the letter sets the scene for what the OCR currently has information about. The second part of the letter is the data request form. In addition to the information previously shared in a breach report (or what was provided by a patient complaint), the OCR requires more information about your current practices regarding securing Protected Health Information (PHI). As stated in the previous installment of this series, sometimes breaches happen, no matter how many precautions your practice takes. Your practice being breached is not the reason for a fine, but your practice’s inability to showcase adequate safeguards in place is. The OCR can and will ask thorough questions. The data request will ask you to provide proof of the compliance standards you have in place. Common questions include proof of an up-to-date and accurate location-specific Security Risk Analysis (SRA), what safeguards you have in place (encryption, antivirus, access logs, etc.), and training completed by staff. These questions all depend on the situation, but overall, they will ask about preventative measures taken, how the situation was handled, and what your practice is currently doing to avoid a similar breach. After the initial questions, the OCR will provide instructions on correctly submitting documentation. The documentation can be sent electronically (and must be encrypted if there’s any PHI) or through mail to the investigator. The letter then concludes with potential enforcement. Potential enforcement includes monetary fines, government monitoring, and, depending on the severity of the violation, criminal time. What’s Next? Upon receiving the letter, it’s time to gather documentation. The timeline documentation that needs to be received is also included in the initial letter. Most often, documentation must be returned to the investigator within 30 days of receiving the letter. Following the initial submission, more documentation might also be requested, so it’s vital to answer the questions thoroughly and provide as much information as possible. Due to how serious a HIPAA investigation is, it’s important to outsource HIPAA compliance for your practice. By having a third party assist in your compliance program, like a smart software solution, you can also be provided a team of compliance experts for support throughout an investigation. By working with a team, their experience is vital to navigate an investigation. To learn more about getting compliant for your practice, schedule a consultation with one of our experts today. To visit our first installment of this series, which is focused on the breach, please visit here. To learn more about organizing documentation for a HIPAA investigation, read the next part of this series. To finish the series, read about the potential outcomes of an investigation here.
Is Your Practice Prepared for a HIPAA Breach?
February 10, 2025 Welcome to Abyde’s HIPAA Investigation Survival Series. HIPAA investigations can last for years, making it one of the most stressful experiences a practice can endure. It’s vital your practice understands the investigation process. The first step of the HIPAA investigation is the breach itself. Experiencing a data breach is pretty common in healthcare and can affect organizations of all sizes. For example, the Change Healthcare breach, a subsidiary of UnitedHealthcare, exposed at least 100 million patients’ data. While they might be common, it’s still your practice’s responsibility that the proper precautions are put in place to mitigate risks. What is a Breach? A breach is any impermissible disclosure of Protected Health Information (PHI) without authorization. PHI is data that can individually identify a patient, including information like Social Security numbers, birth dates, medical records, and more. Healthcare faces significant data breaches due to various threats, including stolen computers and unauthorized access. However, the largest threat by far comes from ransomware and cybercrimes. Ransomware reports to the Office for Civil Rights have increased 264% in the last five years. Ransomware can infect systems through several channels, like email. Successful phishing attempts are the most common way malicious actors hack healthcare systems. That’s why it’s imperative to provide proactive training to staff, ensuring they are aware of common phishing scams and how to handle spam emails when they arrive, such as forwarding them to IT or immediately sending them to spam. If my practice is breached, what do I do? If your practice is breached, handling the situation calmly is important. Time is of the essence when it comes to HIPAA breaches, with every second pivotal for a hacker to leak more information. When becoming aware of a HIPAA breach, your practice must take the infected device offline and review the scope of the hack. In situations like these, Based on the size of your organization, it’s important to have an in-house or outsourced IT team to navigate you through the technical process. A breach report needs to be filed as well. This can depend on the size of the breach, with breaches impacting less than 500 needing to be filed within 60 days from the end of the year and large breaches, or 500+, needing to be reported to the OCR within 60 days of discovering the breach. This report needs to be filed here. The state where a breach occurs is a crucial factor, as some states have stricter requirements, including shorter timelines. In either situation, affected patients need to be notified. Under the Breach Notification Rule, patients must be notified within 60 days of discovering the breach. For large breaches, media notice is required, usually in the form of a press release, to ensure impacted patients are aware their health information was put at risk. Once again, depending on the state, different parties, like the State Attorney, need to be notified. What’s Next? The OCR may investigate your practice to ensure you had the proper protocols in place before and if the response after a breach is sufficient. This investigation would take place after breach recovery efforts are completed, such as restoring systems and notifying the necessary parties. A common misconception is a HIPAA fine is due to a cyber attack. Sometimes, breaches occur no matter how many safeguards you have in place. Fines are levied on practices that did not take the proper precautions before an event, such as training staff, having antivirus software, or having a Security Risk Analysis (SRA) in place. The fine is not due to the breach itself, but it triggers an investigation, where fines can be levied for lack of preventative measures. During an investigation, the government looks to see that your practice has taken steps to mitigate and prevent cybersecurity issues before they escalate into a breach. That’s why it’s imperative to implement protective measures for your practice before a breach occurs. Getting compliant can be overwhelming, but with the right tools, you can easily streamline your HIPAA program. Smart software solutions can serve as a comprehensive compliance hub, allowing you to see your practice’s vulnerabilities and offer steps to fix them. To learn more about HIPAA compliance for your practice, meet with a compliance expert today. Read the second installment of the series, focused on the HIPAA Investigation letter here. Read the third installment of the series, focused on organizing documentation for a HIPAA Investigation here. Finish the series here to learn about the potential outcomes of a HIPAA investigation.
HIPAA in Eye Care: Are You Doing Enough?
February 6, 2025 Running your eye care practice presents a unique set of challenges. From patient care to handling intricate technology, the workload can be demanding. Even though working in eye care keeps you busy, HIPAA compliance must be maintained. While taking care of your patients’ vision is your first priority, their data health is also important. HIPAA, or the Health Insurance Portability & Accountability Act, is a federal law that defines what Protected Health Information (PHI) is and what your eye care practice needs to do when ensuring data security. The Office for Civil Rights enforces HIPAA compliance and has levied monetary fines and other penalties against eye care practices. In fact, an eye care center was fined $250,000 last year after a major ransomware attack revealed its inadequate compliance practices. When getting your compliance program in order, knowing where to start is vital. How Can I Achieve HIPAA Compliance for My Eye Care Practice? HIPAA consists of several major rules and regulations, including the Security Rule, the Privacy Rule, and the Breach Notification Rule. The Security Rule focuses on the administrative, technical, and physical safeguards a practice needs to deploy to secure patient data. Some common precautions examples include antivirus software, door alarms, and employee ID badges. A significant component of the Security Rule is the Security Risk Analysis (SRA). The SRA is a comprehensive assessment of your eye care practice’s current efforts to protect patient data. This analysis is the foundation of a compliant practice and allows your practice to identify and address vulnerabilities. The OCR has also increased enforcement surrounding missing this document with the Risk Analysis Initiative. This rule, as of January 2025, is currently being updated. The proposed Security Rule updates are focused on modernizing the legislation, requiring more safeguards to protect patient data. For an in-depth analysis of the updates, please read here. The Privacy Rule focuses on limiting how patient data is shared. One part of this rule is the Minimum Necessary Standard, which requires practices to share only the necessary amount of information when handling PHI. Another component of the Privacy Rule is the Right of Access standard. This requires practices to give patients access to their medical records within 30 days. In some states, this timeline is even shorter. Lastly, the Breach Notification Rule dictates how affected patients and the OCR need to be notified after a breach. How a breach is handled can vary depending on the severity of the incident. The OCR must be notified of breaches affecting fewer than 500 people within 60 days of the end of the year. Breaches affecting 500 or more patients must be reported within 60 days of the incident. Affected individuals must be notified within 60 days. Depending on the state, some of these timelines may be shorter, and the state attorney may also need to be notified. These announcements are usually sent out as press releases and provide credit monitoring and more to impacted patients. What’s Next? While HIPAA compliance might feel overwhelming, there are ways to streamline compliance. Utilizing smart software solutions can alleviate the stress of compliance, allowing your practice to focus on providing quality eye care. To learn more about how you can streamline HIPAA compliance in your eye care practice, schedule a consultation with one of our experts today. x
OSHA 2025: What Healthcare Professionals Need to Know
February 3, 2025 We’ve already seen that 2025 will be a year of major healthcare compliance changes, with the OCR releasing the long-awaited updates to the Security Rule proposal. Similar to how HIPAA laws are being updated, OSHA will likely update key legislation for healthcare workers. Healthcare workers experience the highest rates of workplace injuries, with an average of 3.6 injuries for every 100 employees. Healthcare environments can present many hazards, so it is essential that your staff knows how to prevent and mitigate dangerous situations. While some OSHA initiatives have not been finalized, OSHA has already started the year with legislation that impacts healthcare workers. Increased Penalty Costs As seen in previous years, OSHA has once again increased its fine cost. OSHA has increased the penalty for serious and other-than-serious violations from $16,131 to $16,550 per violation due to inflation. The maximum penalty for repeated and willful violations also has been increased from $161,323 to $165,514 per violation. This highlights that OSHA is dedicated to setting an example with monetary punishment. It’s safe to say that this adjustment will continue to be an annual increase. Consolidating COVID-19 Regulations It’s an understatement to say that COVID-19 devastated and transformed healthcare. Nearly five years since it was classified as a pandemic, proposed healthcare OSHA COVID-19 regulations were officially scrapped as of early January. Over the past years, COVID-19 regulations have been altered. Emergency Temporary Standards required distinctive protocols to follow, which expired. A proposed rule for COVID-19 mitigation in healthcare settings was waiting to be passed for years. Now, specific OSHA COVID-19 legislation in healthcare will be rolled into a broader infectious disease rule, which is expected to be finalized in 2025. This comprehensive rule is expected to require COVID-19 recordkeeping log, but not much else focused on specifically COVID-19. The anticipated comprehensive rule will likely mandate a COVID-19 recordkeeping log. Federal Workplace Violence Legislation Healthcare workers are five times more likely to be attacked at work than workers in any other industry. We’ve seen state-level legislation announced requiring specific logs, training, heightened penalties, and more to mitigate workplace violence in healthcare, but federal legislation is still being drafted. Currently, workplace violence falls under OSHA’s General Duty Clause, requiring organizations to maintain “a place of employment which are free from recognized hazards.” This federal legislation is expected to be announced in 2025. It will likely mirror what state legislation requires, so please review your state’s legislation regarding workplace violence prevention in your practice. What’s Next? As new legislation is announced, it’s vital for your practice to maintain an organized OSHA program. New laws, especially focused on workplace violence prevention, will require additional training, logs, and more. Turning to smart software can allow for your practice to simplify and streamline compliance. Cloud-based software automatically updates with the latest legislation, providing your practice with a clear path to compliance. To learn more about how your practice can achieve OSHA compliance, meet with our experts today.