HIPAA Audits are Back: 86% of Practices Miss This Crucial Requirement (And How to Fix It)

May 29, 2024

The random HIPAA audits are officially back. Melanie Fontes Rainer, Director of the Office for Civil Rights (OCR), confirmed in a recent interview that the OCR is proactively conducting audits as part of a series of improvements. 

Following a five-year hiatus from proactive audits, the Office for Civil Rights (OCR) has been updating key HIPAA regulations. For instance, the OCR is also releasing an updated Security Rule by the end of the year to better reflect innovation since its original publication over twenty years ago. 

As the OCR continues to advance HIPAA rules, it’s vital to be prepared with a foundation of a compliant practice. 

At the base of this foundation is the Security Risk Analysis (SRA), a commonly missing HIPAA requirement. During the last round of proactive audits, 86% of Covered Entities could not show a properly documented SRA for their practice. 

What is a Security Risk Analysis (SRA)? 

The OCR defines an SRA as “an accurate and thorough assessment of potential risks and vulnerabilities to confidentiality, integrity, and availability of electronic Protected Health Information (ePHI).”

The SRA is focused on protecting ePHI. It is a continuous requirement and needs to be updated when significant changes occur to your practice. It’s best practice to complete the SRA at least annually. 

An SRA is a complete evaluation of how PHI is protected. Questions include encryption practices, staff training, disposal of PHI, and more. 

Why is the SRA Important? 

The SRA documents proof that a practice has appropriate safeguards to protect sensitive patient data. It requires practices to conduct self-audits and identify risks and vulnerabilities before they become issues. This means anticipating vulnerabilities and implementing preventative measures before sensitive data is compromised.

If followed correctly, the SRA acts as a vital line of defense, helping prevent data breaches, ensuring patient privacy, and building trust within the healthcare system. 

How do I complete an SRA? 

Completing an SRA is crucial for protecting sensitive patient data. The good news is that several approaches are available, each with varying costs and timelines.

Before starting an SRA, it is essential to have an HCO, or HIPAA Compliance Officer, in place to manage HIPAA documentation and the SRA process. 

You can complete the SRA internally using online resources provided by the OCR. While there are free resources, this option is less intuitive than others, can be time-intensive, and requires significant team effort. Manual audits can take weeks to months to complete. 

You could also hire an external auditor or consultant to complete your SRA. Hiring a consultant might reduce the burden on your team but can be costly. The average price of an external auditor is in the thousands, with some costing upwards of $20,000. Additionally, these external audits can take months. 

An alternative option is intelligent compliance software, which provides significant benefits for meeting the SRA requirement and more. It allows you and your practice to navigate the SRA cost-effectively and efficiently. While a manual audit usually takes weeks to months, an audit assisted by software can be completed in significantly less time, simplifying the SRA process, and saving your practice substantial costs and assuring protection.  

Why Should I Use Compliance Software?

As the Security Rule is updated, your compliance program also deserves an upgrade. 

Intelligent software solutions can help you easily fulfill complex HIPAA requirements, prepare for potential risks and vulnerabilities, and protect patient data. Many organizations overlook the SRA, but software solutions can streamline the process and protect your practice.

To learn more about Abyde’s innovative software solutions, schedule an educational consultation.  

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August 5, 2026 The latest HIPAA fine is another clear reminder that ransomware attacks are, unfortunately, here to stay in the healthcare industry. A settlement involving the OSF Healthcare System was recently announced by the Office for Civil Rights (OCR). As an enterprise healthcare provider in the midwest, the organization serves 174 locations, including 16 hospitals – a prime target for a ransomware attack.    So, what happened?  In April 2021, OSF discovered that they joined the unlucky club of ransomware victims when a malicious actor deployed Nephilim, a ransomware strain made to target larger organizations. Once the ransomware infected OSF systems, the hacker demanded payment or patient Protected Health Information (PHI) would be leaked online. In this attack, sensitive information like financial account information, driver’s license numbers, medical record numbers, and more, were all exposed. Over 53,000 patient records were exposed in this attack.  When ransomware attacks in healthcare have soared 278% in recent years, it’s more of a when then an if your organization doesn’t have the right safeguards in place.  While the breach was discovered in April, OSF healthcare reported the breach to the OCR in October. The OCR took it from there, digging into what precautions (or lack thereof) let this happen.  What did the OCR discover? If you’ve read any of our other fine breakdowns, you already know where this is going: another missing Security Risk Analysis (SRA).  The SRA is a required document every HIPAA-regulated entity (ie: every practice and their Business Associates that handle patient information) needs to complete. The SRA is a thorough review of the physical, technical, and administrative safeguards in place to prevent PHI ending up in the wrong hands. While the OCR didn’t specify exactly how the ransomware got into OSF’s system, a technical safeguard vulnerability was very likely the entry point. A proactive SRA could have flagged that gap before it turned into a major breach. In addition to missing this required documentation, OSF also took too long to report the breach to the OCR and notify affected patients. This is a direct violation of the Breach Notification Rule, which requires organizations to notify patients within 60 days of a discovered breach. Moreover, since the breach impacted more than 500 patients, OSF was also required to report this breach to the OCR within 2 months as well. Time is of the essence in every component of a breach, from securing systems to ensuring affected parties are aware to protect themselves and an over five month delay was unacceptable in the eyes of the OCR.    What was the result?  OSF’s settlement tops the list as the largest fine of the year, coming in at $552,250, plus government monitoring for the next two years.  It’s very important to note that this breach occurred in 2021, meaning that over five years were spent from the initial breach, to investigations, to the public press releases. Also, the average cost of a healthcare breach is over 7 million dollars –  from implementing secure systems, notifying patients, legal fees, and more. The Takeaway While the settlement payment and Corrective Action Plan (CAP) are just the cherries on top, this experience was a tremendous cost of time, money, and resources, highlighting the importance of making sure everything is secure before a situation occurs.  So, when was the last time you looked at your SRA? It’s time to seriously analyze your current compliance posture. Ransomware groups don’t check whether you’re a small dental office or a 16-hospital health system before they attack, they check whether the door was left open. Time and again, OCR’s findings come back to the same root cause: organizations can’t secure what they haven’t even identified as a problem. Looking to review your current compliance standings? Meet with our team of experts for a complimentary educational consultation. 

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Spencer Gifts HIPAA Settlement: Ransomware, Risk Analysis, and What Comes Next

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