HIPAA Audit and Enforcement Update - Using Lessons Learned to Prepare for Reviews

We will review the HIPAA enforcement actions taken to date and the issues that led to penalties and corrective action plans, and discuss the recent direction in HIPAA enforcement actions.  Enforcement of HIPAA rules for Business Associates has been clarified, new actions have targeted patient rights of access and HIPAA Business Associates, and information security management remains a favorite topic for HHS enforcement teams, following up on the endless stream of breach reports.

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 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 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 more than $11,700.  Documentation requirements for compliance will be explored.

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 or enforcement action and respond to an audit request or enforcement review 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.

Areas Covered in the Session:-

• The new focus of HIPAA enforcement actions will be explained, and prior enforcement actions will be detailed to explain the issues that led to violations.
• The HIPAA Random Audit program will be explained.
• Learn how fines and penalties for violations of the HIPAA regulations have been significantly increased and now include mandatory fines for willful neglect of the rules that begin at more than $11,700 minimum and can reach more than $50,000 per day.
• Find out what HHS OCR is likely to ask you if you are selected for an audit or enforcement review, and what you'll have to have prepared already when they do.
• The HIPAA Audit Protocol will be examined along with the sets of questions asked at other HIPAA audits previously.
• Learn how having a good compliance process can help you stay compliant more easily.
• Find out what you'll need to have documented to survive an audit or enforcement review and avoid fines. 
• Learn how to use the contents of the HIPAA Audit Protocol as the foundation of your compliance activities and documentation.

Background:-

HIPAA Enforcement has seen a big increase in settlements and fines, with an expanding focus that now emphasizes the protection of individual rights and providing the security necessary to protect information from breaches.  The random HIPAA Compliance Audit program has been put on hold, but we are still learning lessons from even the initial audits way back in 2012.  But, as the recent actions indicate, 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.

Why Should You Attend?

In order to avoid getting into trouble with the HIPAA rules, it is essential to understand what has happened at other organizations that have had enforcement actions taken against them. Understanding what has gone wrong for others is essential to avoid those same problems in your organization, and reviewing enforcement actions is key to developing the understanding you need.

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.

In this session, we will discuss HIPAA enforcement actions as well as the HIPAA audit program and how it works, and discuss the areas that caused the most issues in prior audits and enforcement actions. 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.

Not recognizing and avoiding the issues others have had is a sure recipe for non-compliance and penalties in the millions of dollars.

Who Will Benefit?

• Compliance Manager
• HIPAA Privacy Officer
• HIPAA Security Officer
• CEO
• Office Manager
• HR Director
• Privacy Officer
• CIO
• Records Release Manager
• HIM Manager
• Counsel