We will examine the updated 2018 HIPAA Audit Protocol as well as other questionnaires that have been used in the past and may be used to help prepare an organization for a future review. We will present methods for using the contents of the HIPAA Audit Protocol to build your own compliance plan by extracting the contents and relating your compliance activities and documentation directly to the questions that might be asked, thereby creating a compliance management tool to ensure continued compliance improvement.
We will review the contents of the 2018 HIPAA Audit Protocol to show what documentation needs to be on hand should your organization be selected for an audit or enforcement action. We will explain the enforcement regulations and the recent changes that increase fines and create new penalty levels, including new penalties for willful neglect of compliance that begin at over $10,000. Documentation requirements for compliance will be explored and a framework of security policies necessary for compliance will be presented.
The results of prior HHS audits (and their penalties) will be discussed, including recent actions involving multi-million dollar fines and settlements.A plan for attaining compliance will be presented.The steps to follow to prepare for an audit and respond to an audit request will be outlined.In addition, upcoming trends in information security risks will be discussed so you can start to plan for the work you'll need to do to stay in compliance and keep patient information private and secure.
The random HIPAA Compliance Audit program had a year of trial audits in 2012.The US Department of Health and Human Services reviewed the results of that work and performed a second round of audits, this time including HIPAA Business Associates,beginning in 2016 and concluding in 2017.The law calls for a permanent Audit program, but HHS has indicated that the HIPAA audit program will be on hold for at least the time being, and that the next product will be a report on best practices learned in the audits conducted so far.But that doesn’t mean there will be no enforcement of the HIPAA rules.In fact, preparing for a HIPAA Audit is one of the best ways to be ready to respond to any enforcement action, and going through an internal HIPAA Audit will help you find issues before they become problems that can lead to penalties.
In this session we will discuss the HIPAA audit program and how it works, and discuss the areas that caused the most issues in the 2012 audits and the areas that were targeted in the 2016 audits.We will explore what kind of issues were most prevalent and what kind of entities had the most problems, and show where entities need to improve their compliance the most.We will also explore the typical risk issues that lead to breaches of health information and see how those issues may be targets for auditors and enforcement action in the future.
Knowing what questions are likely to be asked and have been asked at prior HIPAA compliance audits can make preparing for and surviving a HIPAA audit or enforcement review much easier. USDHHS has published an updated, July 2018 protocol for the HIPAA audits, so it is possible to know how to prepare for an audit or enforcement review. Nearly any health care covered entity may be subject to an audit or enforcement investigation; all entities need to know what kinds of questions they’ll be asked, what information they'll need to provide and how to prevent issues that could lead to violations and fines.
Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities. He is a frequent speaker regarding HIPAA, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference. Sheldon-Dean has more than 16 years of experience specializing in HIPAA compliance, more than 34 years of experience in policy analysis and implementation, business process analysis, information systems and software development, and 8 years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician. Sheldon-Dean received his B.S. degree, summa cum laude, from the University of Vermont and his master’s degree from the Massachusetts Institute of Technology.