...Accountability Act of 1996 (HIPAA). As such, the HHS rolled out a new audit initiative to assess compliance across the nation with the privacy and security standards for protected health information This paper focus on how the audit program of HIPPA works, what the covered entity can do to prepare for the audit, and what happens once the audit is complete. Introduction Ever since implementation of the HIPAA privacy and security standards, entities have been required to establish and maintain a variety of compliance mechanisms, including written policies and procedures, training of responsible workforce members, business associate agreements, relevant notices to patients or plan participants, and health plan document amendments. Until now, most compliance actions have been complaint-driven investigations arising from alleged violations of the HIPAA privacy or security standards (Arant, 2011). Pursuant to the HITECH Act, a more robust enforcement program was created to make a more ???? The U.S. Department of Health & Human Services' Office for Civil Rights (OCR) administers HIPAA (including the HITECH amendments) by investigating complaints, enforcing rights, promulgating regulations, developing policy and providing technical assistance and public education. Since the enactment of HITECH in 2009, OCR has assumed another function: compliance audits. HITECH requires periodic audits to ensure that covered entities and business associates are complying with the HIPAA privacy and security...
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...and Accountability Act Compliance Guide US Department of Health and Human Services Information Security Program Health Insurance Portability and Accountability Act (HIPAA) Compliance Guide September 14, 2005 Page i Health Insurance Portability and Accountability Act Compliance Guide US Department of Health and Human Services Table of Contents Table of Contents .......................................................................................... i Preface.........................................................................................................iii Document Change History ............................................................................iv 1. Introduction ....................................................................................... 1 1.1 1.2 1.3 1.4 2. 2.1 Purpose ........................................................................................... 1 Background...................................................................................... 1 Scope.............................................................................................. 2 Document Organization ..................................................................... 4 HIPAA Administrative Simplification Requirements ........................... 5 General Overview ............................................................................. 5 2.1.1 HIPAA Administrative Simplification Goals and Objectives ............. 5 2.1.2 HIPAA Definitions ..........
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...HIPAA Security Standards: Guidance on Risk Analysis Introduction The Office for Civil Rights (OCR) is responsible for issuing annual guidance on the provisions in the HIPAA Security Rule.1 (45 C.F.R. §§ 164.302 – 318.) This series of guidances will assist organizations2 in identifying and implementing the most effective and appropriate administrative, physical, and technical safeguards to secure electronic protected health information (e-PHI). The guidance materials will be developed with input from stakeholders and the public, and will be updated as appropriate. We begin the series with the risk analysis requirement in § 164.308(a)(1)(ii)(A). Conducting a risk analysis is the first step in identifying and implementing safeguards that comply with and carry out the standards and implementation specifications in the Security Rule. Therefore, a risk analysis is foundational, and must be understood in detail before OCR can issue meaningful guidance that specifically addresses safeguards and technologies that will best protect electronic health information. The guidance is not intended to provide a one-size-fits-all blueprint for compliance with the risk analysis requirement. Rather, it clarifies the expectations of the Department for organizations working to meet these requirements.3 An organization should determine the most appropriate way to achieve compliance, taking into account the characteristics of the organization and its environment. We note that some of...
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...Introduction There are multiple benefits of electronic health records (EHR), which include improved care, quicker access to patient files, and increased physician oversight of care. However, with the benefit of convenience of using EHRs, comes the responsibility of protecting electronic protected health information (ePHI) and safeguarding sensitive patient data. The Health Insurance Portability and Accountability Act (HIPAA) focuses on protecting ePHI with guidelines to ensure organizations have implemented “reasonable and appropriate” security measures to adhere to HIPAA rules and maintain patient confidentiality. HIPAA requires covered entities to conduct risk assessments to verify compliance and attempt to uncover areas where ePHI is at risk of compromise. This analysis of the iTrust database, as related to the new requirements that iTrust wishes to implement, will discuss the threats and vulnerabilities and the potential impact on the iTrust web application and database. Section I: iTrust Threats & Vulnerabilities and Countermeasures A detailed analysis of the iTrust database detected several high-risk vulnerabilities that...
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...HIPAA COW Risk Analysis & Risk Management Toolkit Networking Group Guide for the HIPAA COW Risk Analysis & Risk Management Toolkit Disclaimers This Guide and the HIPAA COW Risk Analysis & Risk Management Toolkit (Toolkit) documents are Copyright by the HIPAA Collaborative of Wisconsin (“HIPAA COW”). They may be freely redistributed in their entirety provided that this copyright notice is not removed. When information from this document is used, HIPAA COW shall be referenced as a resource. They may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This Guide and the Toolkit documents are provided “as is” without any express or implied warranty. This Guide and the Toolkit documents are for educational purposes only and do not constitute legal advice. If you require legal advice, you should consult with an attorney. Unless otherwise noted, HIPAA COW has not addressed all state pre-emption issues related to this Guide and the Toolkit documents. Therefore, these documents may need to be modified in order to comply with Wisconsin/State law. The Toolkit provides an example HIPAA Security Risk Assessment and documents to support completing a Risk Analysis and Risk Mitigation Implementation Plan. While it covers a broad spectrum of the requirements under the HIPAA Security Rule and HITECH, it may not cover all measures needed to secure your patients’ electronic protected health information (ePHI). It...
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...experience in Software Development Lifecycle (SDLC) and business reengineering process, offering extensive experience in healthcare domain. Areas of expertise include HIPAA compliance ANSI X12 4010 to 5010 and ICD 9 to ICD 10, EDI transactions and Claims Adjudication process. Experience with FACETS and NASCO configuration, coordination of benefits (COB), Medicare and Medicaid programs; strong interpersonal communication, writing, presentation and collaboration skills. QUALIFICATIONS SUMMARY | | * Proven track record of delivering cost-effective, high performance technology solutions to meet the constantly changing business needs. * Demonstrated experience in gathering requirements and developing detailed functional specifications through JAD sessions, interviews, observation, and on site meetings with SME, business users & development teams. * Adept at writing business requirement documents (BRD), functional requirement documents (FRD), system requirement specifications (SRS), system design specifications (SDS) and other project related documents. * Expertise in conducting gap analysis, SWOT analysis, risk analysis, root-cause analysis and change management assessment. * Proficient in business process reengineering and Software Development Life Cycle (SDLC), including analysis, design, development, testing, and implement of software applications, employing Rational Unified Process (RUP), Waterfall, and Agile methodologies. * Well versed...
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...society as a whole (Austin & Boxerman, 2008). Discuss the impacts of breach to Healthcare Information systems, especially the financial and privacy impacts. Some of the most devastating security breaches can occur during employee termination when steps are not taken to remove access to resources in a timely manner. HIPAA guidelines specify that when employees are terminated, that certain steps, at a minimum, must be followed. These include changing locks, removal from access lists, removal of user account, and confiscation of keys, tokens and other access cards. Though these steps may seem to be common sense, some organizations may not have documented procedures to follow when an employee is terminated. Additionally, the responsibility for carrying out the termination procedures must be clearly assigned and documented (SANS Institute, 2001). Security Training In order for a security program to work well, the employees must be educated insecurity practices such as password protection, monitoring login failures and other basic practices. A well-educated workforce can become an extension of the security group of any organization through simple awareness. The HIPAA regulations require a Security Awareness training program that includes: awareness training for all personnel, security reminders to the workforce, virus...
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...The HIPAA-compliant Voalte Platform enables seamless, secure interfacing between disparate systems. Voalte Platform provides capabilities that enable: Collaboration Solutions “Streamline secure communication between caregivers. Management Solutions " Access and manage smart phones and applications easily from any location. Analytics Solutions “Comprehensive reporting and analytics that can drive improvements and results. Integration Solutions " Build on a flexible foundation that integrates all aspects of existing infrastructure, providing interoperability between disparate systems and data. HIPAA‐compliant texting The Joint Commission did not ban all text messaging solutions, however. Instead, it established Administrative Simplification Provisions (AS) that serve as guidelines for developing secure communication systems. Under the AS guidelines, the following four major areas are critical to compliance: • Secure data centers—Healthcare organizations typically store patient information in either onsite or offsite (cloud) data centers. HIPAA requires these centers to have a high level of physical security as well as policies for reviewing controls and conducting risk assessment on an ongoing basis. • Encryption—AS stipulates that ePHI must be encrypted both in transit and at rest. • Recipient authentication—Any communication containing ePHI must also be delivered only to its intended recipient. A texting solution should allow the sender to know if, when, and to...
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...an organization with many operational benefits is continuous log management policies. In addition to helping solve network security related issues, logs can be extremely beneficial in identifying unauthorized access and behaviors. Security logs assist in identifying policy violators, fraudulent behavior, real time operational problems, and provide necessary data to perform auditing, transaction back tracking and forensic analysis. In addition to the many benefits of having policies in place for continuous log analysis, standards and regulations have increased business awareness of the requirements for archiving and reviewing system logs as part of daily continuity. Some of the influential regulations that reference log management and other information security task include the following. • Federal Information Security Management Act of 2002 (FISMA) requires entities to ensure the development and execution of organizational processes and internal controls designed to secure information systems. Health Insurance Portability and Accountability Act of 1996 (HIPAA) encompasses information security benchmarks for protecting consumer health information. Violation Penalties can range from $100-$1.5 million per violation and 1year-10year criminal sentences. ISO 17799 is an audit checklist...
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...HIPAA instituted the national standards for the privacy and security of guarding patient health information and the HITECH created breach notification requirements to provide more transparency for the patient whose information may be at threaten. HITECH insist on the HHS Office for Civil Rights to conduct administer and manage recurring audits for covered entity and business associate compliance with the HIPAA Privacy, Security, and Breach Notification Rules. HHS phase 2 of the program will audit both covered entities and business associates. The definition of covered entity for HIPAA is health plans, healthcare clearinghouses, and providers who transmit health information electronically in connection with HHS adopted standards. Once providers,...
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...SUMMARY Over 6 years of Business Analysis experience with in-depth knowledge of business processes in health care, banking and financial industries ▪ Experienced in interacting with business users to identify their needs, gathering requirements and authoring Business Requirement Documents (BRD), Functional Requirement Document (FRD) and Software Requirement Specification (SRS) across the deliverables of a project. ▪ In-Depth Knowledge in facilitating Joint Application Development (JAD), Rapid Application Development (RAD) and Joint Requirement Planning (JRP) sessions, interviews, workshops and requirement elicitation sessions with end-users, clients, stakeholders and development team. ▪ Strong Knowledge with Iterative approach for Software Development as per Rational Unified Process (RUP). Involved in inception, elaboration, construction & transition phases using rational tools like Requisite Pro, Clear Case and Clear Quest during various phases of RUP. ▪ Experienced in Business Analysis, SWOT Analysis, Gap Analysis, Risk Analysis, Disaster Recovery Planning, Testing and Project Planning. ▪ Extensive knowledge of Medicaid, Medicare, Procedural and Diagnostic codes and Claims Process. ▪ Expertise in EDI and HIPAA Testing Privacy with multiple transactions exposure such as Inbound Claims 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response...
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...Regards to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Paul T. MacDonald University of Maryland University College DBST670 Fall 2013 Professor Jon McKeeby Abstract With the expansion of healthcare administration now further into more levels of federal and state governments, the amount of sensitive patient data has increased incrementally This data is moved from within and without of all stages of the healthcare process. From an office visit to the doctor, to the medications filled at the local pharmacy, to the bills handled by multiple insurance agencies, delicate patient information is being viewed, handled and passed along. The list of individuals who access the confidential information can include office staff, laboratory personnel, nurses, doctors, insurance agents, case managers and many more. The Health/Insurance Portability and Accountability Act of 1996 (HIPAA) was created to safeguard patients’ medical data security and privacy. HIPAA incorporates requirements that allow for a comprehensive review that will show anyone who has looked at confidential medical patient information. HIPAA is structured to provide a complete security access and auditing for Oracle database information. This framework designates data access points such as User Access Control, System Administration, Object Access and Data Changes that should be monitored and controlled. An accurate HIPAA compliant security execution assures all such access areas are plainly...
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...the HIPAA Omnibus Rule, healthcare organizations face key compliance challenges, including dealing with their business associates and ensuring that patient information is adequately protected to avoid breaches. The healthcare sector, as well as government sector systems handling health-related data, are increasingly targets of cybercriminals because of the information those systems contain, which ranges from Social Security numbers to health insurance identification numbers. What are healthcare entities' key struggles? What are they doing to step up compliance while also improving overall protection of patient data? We conducted our third annual Healthcare Information Security Today survey to find out. The 2014 survey sheds light on seven hot topics: * HIPAA Omnibus: Compliance is Challenging * Breach Prevention: Trend Analysis * Risk Assessments: Getting Better or Cutting Corners? * Encryption and Authentication: Room for Improvement * Mobile Tech: Inadequate Protection * Web Portals: Work in Progress * Priorities, Investments and Staffing Keeping records secure is a challenge that doctors, public health officials and federal regulators are just beginning to grasp. And, as two recent incidents at Howard University Hospital show, inadequate data security can affect huge numbers of people. On May 14, federal prosecutors one of the hospital’s medical technicians with violating the Health Insurance Portability and Accountability Act, or HIPAA. The...
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...medical savings accounts, to improve access to long-term care services and coverage, to simplify the administration of health insurance, and for other purposes. HIPAA Colloquial acronym(s) Enacted by the 104th United States Congress Citations Public Law Stat. Pub.L. 104–191 110 Stat. 1936 [1] [2] Legislative history [3] • • • • • • • • • Introduced in the House as H.R. 3103 [4] by Bill Archer (D-TX) on March 18, 1996 [5] Committee consideration by: House Ways and Means Passed the House on March 28, 1996 (267–151 Passed the Senate on April 23, 1996 (100-0 [6] ) [7] ) [8] ) and by the Senate on , in lieu of S. 1028 Reported by the joint conference committee on July 31, 1996; agreed to by the House on August 1, 1996 (421–2 [9] August 2, 1996 (98–0 ) Signed into law by President Bill Clinton on August 21, 1996 e v t [10] The Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub.L. 104–191 [1], 110 Stat. 1936 [2] , enacted August 21, 1996) was enacted by the United States Congress and signed by President Bill Clinton in 1996. It has been known as the Kennedy–Kassebaum Act or Kassebaum-Kennedy Act after two of its leading sponsors.[11] Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative...
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...Topic Paper #1: HIPAA - How the Security Rule Supports the Privacy Rule INTRODUCTION: HIPAA privacy rule: The HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections. (HHS, 2003) HIPAA security rule: The HIPAA Security Rule establishes national standards to protect individuals’ electronic personal health information that is created, received, used, or maintained by a covered entity. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information. (HHS, 2003) Typically ePHI is stored in: • Computer hard drives • Magnetic tapes, disks, memory cards • Any kind of removable/transportable digital memory media • All transmission media used to exchange information such as the Internet, leased lines, dial-up, intranets, and private...
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