6/2/2025 Did you know Business Associates (BAs) are at risk for ransomware attacks just as much as Covered Entities? Ransomware attacks disproportionately affect healthcare organizations, with malicious actors looking to exploit Protected Health Information (PHI). When PHI includes sensitive information such as Social Security Numbers, addresses, phone numbers, and more, it provides someone with a lot of information to use for the wrong reasons. A medical billing BA in Massachusetts, Comstar, LLC, recently experienced the fallout of a ransomware attack. Trusted with the PHI of over 70 practices, the organization did not have the proper safeguards to mitigate risk after a cybercrime. Part of this was a missing Security Risk Analysis (SRA), or a thorough assessment of an organization’s potential vulnerabilities. This latest enforcement represents the responsibility of BAs to uphold their commitments and for all HIPAA-regulated entities to complete and maintain an SRA. What Happened? In May 2022, a malicious actor intruded Comstar’s network servers. Comstar was unaware of this intrusion for several days. In the meantime, the hacker encrypted nearly 600,000 patient records with ransomware. Even though these patients weren’t directly Comstar’s, they assumed the responsibility of protecting their data. While it is not public what steps Comstar took to mitigate risks after the initial ransomware breach, it was discovered that the organization did not complete an SRA. This assessment is at the foundation of a compliant practice and is a requirement of HIPAA. After this discovery, the organization was fined $75,000 and put under a Corrective Action Plan (CAP), or government monitoring, for two years. This assessment is at the foundation of a compliant practice and is a requirement of HIPAA. Recently, the Office for Civil Rights (OCR) has sharpened its focus on this commonly missed requirement with the latest Risk Analysis Initiative. This fine is the 9th enforcement of this initiative. Streamlining the SRA with Software When less than 20% of BAs could showcase a compliant SRA when being audited, completing the SRA is unfortunately a common oversight by regulated entities. Additionally, this is a responsibility of both Covered Entities and BAs, and both parties must carefully handle PHI. With smart software, BAs can easily streamline the SRA and complete the assessment that pinpoints common vulnerabilities organizations face. By simplifying the SRA, intelligent solutions can empower an organization to cultivate a culture of compliance for its staff, securely meet requirements, and handle PHI. To learn more about how your organization can easily complete the SRA, meet with a compliance expert today.
OCR Continues to Take Non-Compliance By Storm – Announcing 17th Right Of Access Settlement
March 25, 2021 We are definitely no meteorologists over here but if there’s one pattern that we’ve gotten pretty good at predicting, it’s the government’s focus on HIPAA non-compliance. And with another right of access settlement hitting our inboxes just yesterday – it’s looking like HIPAA enforcement season is in full effect. Arbour, Inc., d.b.a Arbour Hospital (“Arbour”), was the latest to get caught in the Office for Civil Rights (OCR) storm – but instead of heavy rainfall and thunder, the Massachusetts-based behavioral health provider was hit with a whooping $65,000 fine and corrective action plan. The announcement marks the 17th right of access settlement since the OCR declared their enforcement initiative back in the fall of 2019, proving that whoever said that lightning never strikes the same place twice clearly didn’t know HIPAA. Arbour first showed up on the OCR’s radar back in July of 2019, after they received a complaint alleging that the practice had failed to respond to a patient’s record request in a timely manner. Despite the OCR providing technical assistance, the practice took a rain check on providing record access and a second patient complaint came rolling in later that month. As a result of the OCR’s investigation, Arbour finally provided the patient with their records more than 5 months after the patient’s initial request – making the perfect storm for a HIPAA violation. With 17 cases settled and $1,068,500 collected in fines since the right of access initiative began, it’s looking like when it rains, it pours as far as OCR enforcement is concerned. And if the numbers aren’t telling enough, Acting OCR Director Robinsue Frohboese made their storm-warning loud and clear in her latest statement: “Health care providers have a duty to provide their patients with timely access to their own health records, and OCR will hold providers accountable to this obligation so that patients can exercise their rights and get needed health information to be active participants in their health care.” A key takeaway from the 17 practices’ caught in the government’s flood zone? In more than half of the published settlements, the organization was notified twice by the OCR and provided with technical assistance. And if they had listened to the first warning siren, they could’ve potentially avoided the settlement entirely. Since taking timely action in response to a patient’s records request has shown to be an ongoing issue for covered entities of all specialties and size – with the proposed HIPAA Privacy Rule changes shortening the record response time from 30 days to 15 days, we can foresee dark skies ahead if practices don’t start complying. So, how do you avoid the hailstorm that comes with an OCR audit? Simply put, ensuring your practice adheres to state and federal Patient Right of Access laws while also having the necessary policies and procedures to back it up is a great place to start. But in order to fully weather the elements of government enforcement, you must meet ALL of the requirements that fall under the HIPAA umbrella and keep your compliance program a priority come rain or shine.