Is your organization keeping up with the challenges of HIPAA compliance and the HIPAA Privacy Rule?  Are you concerned over weaknesses in your HIPAA compliance programHave you considered a HIPAA Gap Analysis or HIPAA Audit to assess your program for risk areas?  In short, now may be the time to take this important step.

Key Features of a HIPAA Gap Anaylsis

The Basic Steps of an Audit

  1. Determine the current procedures. Do you have policies and procedures? Do you have a privacy officer? Have you completed a risk analysis?
  2. Compare the current procedures with the expectations of the Privacy Rule. Do the procedures comply with the HIPAA Privacy Rule?
  3. Define the gaps. Compare the current to the expected procedures to determine the gaps in your program.
  4. Develop a corrective. This plan must clearly spell out the actions you will take to correct the gaps.

A HIPAA Gap Analysis and/or Audit is a focused review and analysis of a covered entity or business associates. It will assist in identifying risks and vulnerabilities of the covered entity. By completing this important step we will help your organization understand the risks. Our HIPAA compliance audit will give you the information you need to protect your program. You will avoid costly HIPAA violations.

The U.S. Department of Health and Human Services (HHS) states that a HIPAA Gap Analysis is typically a narrowed examination of a compliance program. It is meant to assess whether certain controls or safeguards required by the HIPAA Rule have been implemented.

How a Gap Analysis Works

A HIPAA compliance audit will review the overall flow of protected health information (PHI) created, accessed, used and disclosed within the organization. The gap analysis reviews any existing policies, procedures and the safeguards that are in place to protect the information, and the policies that give individuals’ rights over their PHI. It will also assess the level of training that has taken place within your organization to satisfy the requirements of the Privacy Rule. Finally it will address all identified risks to the organization

HIPAA Gap Analysis & Security Risk Analysis

A HIPAA Gap Analysis is a good starting point for beginning a HIPAA compliance program or improving an existing compliance program. It is a useful tool for creating a valid snapshot of your HIPAA program. However, the HIPAA Gap Analysis works in conjunction with a Security Risk Analysis (SRA).

The HIPAA Security Risk Analysis is an in-depth examination of the administrative, physical and technical safeguards for electronic PHI (ePHI) required by the Security Rule. It will examine the program in a different way than the gap analysis.

A HIPAA Security Risk Analysis usually requires the expertise of an IT professional who is familiar with HIPAA and the HIPAA Privacy & Security Rule. Information collected in a HIPAA Gap Analysis will assist the organization in the completion of the Security Risk Analysis.

HIPAA Gap Analysis

Administrative Safeguard Analysis

Initially, the HIPAA Gap Analysis begins with a review of items required by the HIPAA Rules as identified in the HIPAA Privacy Rule.

Data reviewed in a HIPAA Gap Analysis includes the policies the covered entity or business associates must have in place.

Some examples include right to access PHI, to request an amendment to PHI or an accounting of disclosures, to request a restriction, and make a privacy complaint, and others. These include administrative requirements such as policies, business associate agreements, named privacy and security officials, training on the policies that affect employees’ job duties, a complaint process, and breach reporting.

Physical Safeguard Analysis

In addition a HIPAA Gap Analysis includes a review of physical safeguards which protect information systems and related equipment and facilities from hazards and intrusions. The analysis also examines physical safeguards that protect paper PHI maintained in the regular course of business. In addition it also addresses verbal PHI used and disclosed within the organization.

Technical Safeguard Analysis

Finally, the HIPAA Gap Analysis reviews technical safeguards that protect ePHI. It does so by reviewing the mechanisms that protect the confidentiality, integrity and availability of the data.

Technical safeguards control access to PHI and assure the information is true and accurate. They ensure PHI is available for those authorized to use the information to perform their job functions. The optimal way to assure adequacy of safeguards is through a HIPAA Security Risk Analysis.

How a HIPAA Gap Analysis Helps You

A HIPAA Gap Analysis will identify deficiencies, threats and vulnerabilities that exist between the policies currently in place & HIPAA Rule requirements. This type of HIPAA compliance audit will examine the existing compliance program and the HIPAA Rules requirements. The analysis describes the gaps identified and highlights necessary remediation. As a result we can assist you to resolve deficiencies, reduce risk, and bring the program into compliance.

Most importantly, the Audit will give covered entities and business associates an overall snapshot of their compliance efforts. It will help them discover areas where they are non-compliant with HIPAA Rules, or which put them at risk.

Additionally, it will give the organization a roadmap to compliance. This type of HIPAA Risk Analysis can be a good jumping point to a HIPAA Security Risk Analysis. Finally, this will give the privacy officer the information needed to move forward with any necessary revisions to the program.

Learn About HIPAA Audits

There is no better way to learn more about HIPAA Audits and how they work than through our HIPAA Compliance course material or through our HIPAA Resources. Take the opportunity now to learn more about this important subject.

Compliance Training

Who should get a HIPAA Audit or HIPAA Gap Analysis?

All organizations who handle PHI and bill electronically, may benefit from a HIPAA gap analysis.

This instrument will assist an organization to determine how it stands in relation to the HIPAA Privacy Rule requirements.