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The Security Risk Analysis: Setting the Pace for MIPS and HIPAA Compliance

December 4, 2024

As a healthcare provider, tackling your daily to-do list probably feels like running a marathon without a finish line at times. You’re tasked with managing a successful business, keeping up with ever-changing legislation and new technology while ensuring that your top priority of patient care never falls behind.

Despite the challenging course, there’s a benefit to keeping pace with both quantity and quality. Providers are rewarded for going the extra mile thanks to Value-Based payment programs like MIPS and other government incentives like the HIPAA Safe Harbor Law. 


What is MIPS?

 You’ve most likely heard of the Merit-based Incentive Payment System (MIPS) and might already be a participant in it.

Whether it’s a Quality Payment Program or new legislation passed into law, the government continually emphasizes the importance of being proactive rather than reactive and providing incentives for doing so.

This is why it’s valuable to know whether your organization is eligible to participate in government programs (you can check here).

Many of these different program requirements align with the standards your practice already has to meet under HIPAA law—protecting your patients, checking off compliance requirements, and receiving incentives can often be done all in one stride.

 To take a quick step back, MIPS is one of two payment tracks under the Medicare Quality Payment Program. The Centers for Medicare and Medicaid Services (CMS) uses this system to measure eligible clinician performance and reward high-value, low-cost care.

MIPS participants can receive a payment adjustment to their Medicare reimbursements based on their performance scores across four different categories:

  • Quality: The type of care you deliver based on specific measures of performance.
  • Promoting Interoperability: Focuses on patient engagement and electronic exchange of information using Electronic Health Record (EHR) technology to improve patient access to their health information and exchange of information between providers.
  • Improvement Activities: Your participation in clinical activities that work towards improving care coordination and patient engagement and safety.
  • Cost: Assesses the cost of care you provide in relation to your Medicare claims.


The Importance of the Security Risk Analysis (SRA)

Before you can engage with the various performance measures, you must first meet a prerequisite for participating in the MIPS Promoting Interoperability performance category. This requirement is crucial not only for achieving HIPAA compliance but also for benefiting from other government incentives: the Security Risk Analysis (SRA).

Conducting an SRA involves evaluating any potential risks to your organization’s electronic Protected Health Information (ePHI) and implementing necessary security updates and safeguards to address any identified vulnerabilities.

Your organization must complete an SRA at least once a year to comply with MIPS and HIPAA standards. Additionally, it’s important to review and update the assessment regularly throughout the year to reflect any changes in your processes.


Getting Compliant for MIPS

Beginning your compliance journey can be overwhelming, but it is essential to take advantage of government initiatives such as MIPS. Intelligent software solutions can help keep your practice on track by outlining the requirements for HIPAA compliance and offering a streamlined SRA that meets MIPS standards.

To learn more about how to become compliant for MIPS, schedule a meeting with a compliance expert today.

 

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October 9, 2026 Penelope Schweitzer No comments yet

October 9, 2026 The latest HIPAA penalty doesn’t involve a hospital system or a massive ransomware attack. It involves a practice that probably looks a lot like yours. Dr. Linda Shen is the owner of Shen Smiles, a solo dental practice with one location in Drums, Pennsylvania. It all started with one patient asking for their health records. It ended with a $140,000 penalty and a much closer look at how the practice handled HIPAA. The lesson? Every HIPAA-regulated practice, big or small, can face enforcement. What happened? It’s unclear when the patient first asked for their records, but patient records need to be provided within 30 days from the initial request. In April 2020, the patient’s attorney filed a complaint with the Office for Civil Rights (OCR). The patient had asked for their health records multiple times and never got it. Once OCR started digging, the missed request turned out to be just the beginning. Patient records weren’t properly maintained, staff had never received formal HIPAA Privacy Rule training, and there were no policies for handling patient requests. Dr. Shen admitted that the records were never provided because a former employee had taken them. That’s another violation, this theft is a breach, which means it needed to be reported to the OCR, patients needed to be notified, and given options to protect themselves (such as credit monitoring). These are baseline requirements every Covered Entity is expected to have in place. No compliance framework, like policies and training, means no HIPAA playbook, so when a patient asks for records (or records go missing), staff is unprepared and unaware how to handle the situation. In July 2024, OCR proposed a $140,000 Civil Money Penalty. Dr. Shen appealed, but ultimately settled on the full amount. The Takeaway for Practices Patient access has been an OCR priority for years through its HIPAA Right of Access Initiative. And as this case shows, one complaint is all it takes to open the door to a review of your entire compliance program. Now is the time to ask: Do we have written HIPAA policies our team can find? Do we have a process to answer every record request within 30 days? Can we prove every team member has completed HIPAA training? If any of those gave you pause, now’s the time to fix it, before OCR comes asking. Looking for the first step? Meet with one of our compliance experts to see where you currently stand.

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September 21, 2026   The HHS Office for Civil Rights (OCR) has announced its biggest HIPAA settlement of the year, reaching nearly a million dollars.  Ambry, a genetic testing and clinical genomics provider based in Aliso Viejo, California is at the center of this enforcement. A settlement was reached over a 2020 phishing attack that exposed the Protected Health Information (PHI) of more than 225,000 individuals. This settlement is a clear reminder that even large organizations trip up on HIPAA requirements.    What happened In January 2020, an employee email account at Ambry was compromised through a phishing attack.  The breach potentially exposed a wide range of PHI, including names, addresses, dates of birth, Social Security Numbers, financial details, and more. Ambry reported the breach to OCR in March 2020, which kicked off the investigation.    Where OCR found gaps OCR’s investigation identified several HIPAA Security Rule gaps, including: No accurate, thorough risk analysis of risks and vulnerabilities to ePHI No process for cutting off access to ePHI when an employee left or no longer needed access No unique user IDs for tracking who was accessing ePHI systems These are baseline HIPAA requirements that every Covered Entity and Business Associate is expected to have in place.   The settlement terms Ambry paid $700,000 and agreed to a two-year corrective action plan, under which it must: Complete a thorough risk analysis of ePHI confidentiality, integrity, and availability Build and execute a risk management plan addressing what that analysis turns up Review and update Security Rule policies and procedures as needed Implement unique user identification across all ePHI systems Train the whole workforce on those updated policies The takeaway for practices When 90% of healthcare hacks start with a successful phishing attempt, it’s key your team is aware of the role they play to keep data safe. Every practice should ask; Do we know exactly where our ePHI lives and how it moves through our systems? Do we have a current, documented risk analysis? Would we catch it fast if a former employee’s access wasn’t revoked? Looking for the first step of addressing these gaps? Meet with one of our compliance experts to see where you currently stand. 

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September 1, 2026   The Office for Civil Rights (OCR) announced its 55th settlement under the HIPAA Right of Access Initiative, and this one is a good reminder that “we’ll get to it” is an easy shortcut to a massive financial penalty.   What happened Azul Vision, Inc., a California optometry enterprise healthcare provider, took nearly two years to provide a patient her healthcare records failed to give a patient timely access to her health records. She requested her records in January 2023. She didn’t actually receive them until January 2025, or two years later, and only after OCR opened an investigation following her complaint in April 2023.   The importance of Right of Access The HIPAA Privacy Rule’s Right of Access is straightforward: patients are entitled to their healthcare records within 30 days of a request, with one possible 30-day extension if needed.    The cost Azul Vision agreed to a two-year, OCR-monitored corrective action plan and paid $50,000. The corrective action plan requires the practice to: Review and revise its written policies and procedures for Privacy Rule compliance.  Regularly report to HHS a log of every PHI access request it receives, including when it came in and when it was resolved, Train all workforce members on right of access requirements and the practice’s own procedures.   Practical takeaways Have a documented, assigned process for access requests: not an informal “someone will handle it” arrangement. Track every request against the 30-day (or extended 60-day) clock: If nothing is timestamping requests, nothing is catching the ones that slip. Train staff specifically on right of access: this is a distinct Privacy Rule obligation from general HIPAA awareness, and it’s clearly one OCR is actively enforcing.   The bottom line A single records request that went unanswered turned into a $50,000 penalty, two years of federal monitoring, and a detrimental hit to the organization’s reputation. That’s a steep price for what really comes down to a missing process. If your team can’t answer “what happens the moment a patient asks for their records?” right now, that’s the gap to close before your practice ends up as OCR’s next enforcement case. Want a streamlined way to close your compliance gaps? Meet with an Abyde expert today!

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