HIPAA Help: Your Top Compliance Questions Answered
January 29, 2025 Managing HIPAA compliance for your practice can be challenging. Given the overwhelming number of laws, requirements, and procedures to navigate, you likely have questions about ensuring compliance. Other practices likely have the same questions as yours. Learn more about the most common questions healthcare practices have and how you can ensure compliance. Who Needs to Do HIPAA Training? One of the most important HIPAA requirements is making sure staff members complete training. When facing a HIPAA investigation or audit, the Office for Civil Rights (OCR) will ask for documentation proving your practice has been properly trained. However, many questions might arise around this, including: How often should staff members train? How long should I keep training records? Who in my practice has to complete HIPAA training? First, HIPAA training is required for all staff that have access to Protected Health Information (PHI). PHI includes information like names, Social Security numbers, medical records, and more. Staff with access to sensitive data need to understand the foundation of HIPAA and how thorough data management protects patients. As staff members learn about vital skills such as breach management, compliant patient communication, and handling sensitive information, they become better equipped to manage PHI. Documentation of this training is required for each individual, such as each staff member receiving a completion certificate. This completion certification, or whatever proof that training has been completed, must be saved for at least six years. When being investigated, the OCR can and will ask for multiple years of training proof, so ensure your training program documentation is properly organized. This training needs to be completed at least annually, and it is recommended that new staff be trained as soon as possible before handling PHI. Staff should also be retrained should a breach occur, refreshing staff on proper procedures. What is a Business Associate Agreement? When entrusted with PHI, it is crucial that any third-party vendors working with your practice implement appropriate safeguards to protect sensitive data. This is where a Business Associate Agreement (BAA) comes in. The BAA is a document that holds both parties responsible for the protection of PHI. This document includes what PHI is defined as and how both parties have to uphold its protection. HIPAA requires this document to be signed by any Business Associate (BA) with access to PHI. Some common examples of BAs include shredding companies, billing companies, and more. If your BA doesn’t want to sign this agreement, that’s a bad sign, and it’s recommended that your practice works with another vendor. The OCR also recently proposed strengthened requirements for BAs. This would require businesses work with a cybersecurity expert to prove adequate safeguards for patient data are in place. What Should I Do with Patient Consent Forms? The HIPAA Authorization for Use or Disclosure of Health Information Patient Consent Form must be provided to the patient before you can work with them. Consent forms allow patients to understand and authorize how their health information is shared. This includes granting access to specific individuals. Patients can decline to sign this form and still be treated by the practice, but it must be noted in their records. It is also always best practice to review these consent forms with patients every three years, ensuring that the information is still current. What’s Next? From staff training and business associate agreements to patient consent forms, staying HIPAA compliant requires attention to detail. Smart software solutions with expert teams and simplified compliance can help alleviate this burden and allow you to easily check your compliance status. HIPAA compliance may seem daunting, but by taking these steps and utilizing the right tools, you can protect your practice and your patients. Ready to learn more? Watch our latest webinar, which addresses even more of the top questions healthcare professionals have when it comes to healthcare compliance.
