HIPAA policies and procedures are vital features of any plan that addresses HIPAA compliance. All covered entity organizations that handle protected health information (PHI) must follow the HIPAA Privacy Rule. It is the responsibility of these organizations to safeguard all protected health information and demonstrate this through carefully crafted HIPAA privacy policy. HIPAA Associates will guide you through the steps needed to create the necessary hipaa policy to satisfy HIPAA.
HIPAA Compliance
- Covered entities must create plans that include HIPAA Policies & Procedures that help safeguard Protected Health Information (PHI) which the organization handles. This includes all forms of PHI such as written, verbal and electronic.
- To be fully prepared an entity must also perform a full Security Risk Analysis to assess the health and security of their HIPAA program.
- An organization must also name a Privacy-Security Officer to oversee the function of the Compliance Plan.
- A training program must be in place to address every member of the organization based on their function in the organization.
HIPAA Policies and Procedures
HIPAA Policies and Procedures must be in place to ensure compliance with the HIPAA Rules. These protect PHI and give individuals rights over their PHI and responsibilities to covered entities. The HIPAA Policies implement appropriate administrative, technical, and physical safeguards to protect the privacy and security of PHI. In addition, one must consider that privacy laws vary from state by state and must be considered every time HIPAA Polices are created or modified. It is important you obtain expert help when creating your HIPAA Policies & Procedures to include the appropriate state regulations
- Business Associate Agreements
A covered entity must enter into a Business Associate Agreement with each organization or vendor that accesses, uses or discloses PHI to on behalf of the organization . This will ensure the Business Associate uses appropriate safeguards to protect the PHI in the same manner that the covered entity must. It is essential that every covered entity create Business Associate Agreements with any entity that handles PHI on their behalf.
Prime examples of Business Associates would include accounting, billing, legal, risk management and IT services. We will help you identify business associates and provide business associate agreements.
Designate a Compliance Officer
Privacy and Security Officers must be appointed through the HIPAA Policies to oversee the HIPAA program. They are responsible for oversight of the program and for tracking, investigating, resolving and documenting all privacy and security complaints and investigative steps taken. They ensure there is no retaliation against any workforce member or other individual for reporting a PHI breach or filing a HIPAA complaint.
HIPAA Associates can help you prepare a Privacy & Security officer
Conduct Effective Training and Education
The program must implement a training plan that trains workforce members on the requirements and HIPAA Policies that apply to them in their individual roles. The training program must train all workforce members upon employment on HIPAA and Policies and Procedures and on a regular basis thereafter.
HIPAA Associates has available training programs
Develop Effective Lines of Communication
Employees must have avenues available to them for reporting concerns internally. An organization should have multiple reporting methods such as the compliance officer and an anonymous hotline. All organizations must take reports seriously and conduct a thorough follow-up of each report. This is a very important function within all organizations.
HIPAA Associates can help you create reporting mechanisms
Conduct Internal Monitoring and Auditing
A well-functioning program will have an ongoing process that evaluates and assess the organization to detect inappropriate behavior. This will also help to ensure effectiveness of education and corrective action. The compliance program should in addition monitor compliance with privacy and provide a risk assessment of potential privacy issues. A formal risk assessment is a critical part of monitoring and auditing a privacy compliance program. The Health Insurance Portability and Accountability Act (HIPAA) Security Rule requires that covered entities and its business associates conduct a risk assessment of their healthcare organization. A risk assessment helps your organization ensure it is compliant with HIPAA’s administrative, physical, and technical safeguards. A risk assessment also helps reveal areas where your organization’s protected health information (PHI) could be at risk.
Internal staff or an external contractor should conduct an audit of the overall programs at least annually. The findings should be made available to the Chief Compliance Officer and/or the Chief Operating Officer.
HIPAA Associates can help you with a risk assessment
Enforce Standards of Conduct Through Guidelines
It is important that an organization have well published standards of conduct. These must outline an organization’s rules, responsibilities, proper practices, and/or expectations of its employees. A compliance plan should clearly state the implications and penalties of violating the standards of conduct. The organization should review the disciplinary guidelines at least annually with all employees. These guidelines should be available to all employees so that they may be aware of expectations.
HIPAA Associates will help you with disciplinary guidelines
Respond Promptly to Detected Offenses and Undertake Corrective Action
It is imperative for an organization to ensure timely and effective remedial action for offenses. Lack of a response may create additional exposure for the organization. As mentioned earlier it is important to have reasonable disciplinary guidelines that are followed. The types of disciplinary actions might be staff education, termination of the employee or fines. In addition, every time there is a breach or an incident it is mandatory the compliance officer investigate and offer a corrective plan to prevent future issues.
HIPAA Associates can help create a corrective action plan
HIPAA Associates Can Help Your Practice
Our professionals are prepared to assist you with all of these important policies and procedures. HIPAA Associates offers HIPAA Policies that include HIPAA privacy and HIPAA security. This includes all security policies and procedures and breach reporting requirements in compliance with the HIPAA Rules.
Of great importance, HIPAA Associates is always available to assist you when questions arise regarding the HIPAA Rule. HIPAA Consulting is the main focus of our organization. We would be happy to discuss with you how we can help with your program.
HIPAA Policies and Procedures
Our HIPAA Policies and Procedures consist of Privacy & Security Policies for your staff. We will help you be fully prepared for the HIPAA Privacy Rule.
Download our HIPAA Compliance Checklist
HIPAA Associates presents their HIPAA Compliance Checklist for 2021. We believe this will give you a good start on creating your HIPAA Polices & Procedures.
HIPAA Privacy Policy Templates
Our Privacy Policy Template is ready for purchase by the organization. This is easily modifiable for immediate use. It covers all the HIPAA Privacy Policies & Procedures to be compliant with the Privacy Rule & HITECH Regulations.
HIPAA Security Policy Template
We offer Security Policies that will help you prepare for Security Rule compliance. These are ready for you to implement with your organization.
Customized HIPAA Policies and Procedures
We specialize in fully customized HIPAA Policies created specifically for your organization. We consider all the key features of your covered entity and its specific requirements and create your HIPAA Polices & Procedures in close consultation with your Privacy and Security Officer.
HIPAA Consulting and Breach Reporting
We provide HIPAA consulting and advise on individual issues related to HIPAA privacy, security and breach notification. HIPAA Associates has the knowledge and breadth of experience to assess your unique situation and needs to craft the plan that you need for ultimate protection for PHI and the organization. Consequently, we can help protect your organization from issues that may otherwise bring involvement by the Office for Civil Rights.
Privacy Complaint Response
We will assist with response to HIPAA complaints and investigate any privacy or security matter on your behalf whether from a patient, another individual or the Office for Civil Rights. We have extensive experience in responding to Office for Civil Rights investigative letters and working with them to resolve complaints.
HIPAA Breach Reporting
HIPAA Associates works with clients on the breach analysis to determine if they are dealing with a breach of unsecured PHI. For incidents that are reportable breaches there are steps and deadlines that one must follow for compliant reporting to the individual and to the Office for Civil Rights. It is important to follow all necessary steps to report a breach successfully to the OCR. Breaches vary depending on the facts and circumstances. We have the experience to know what information to include in a breach notification letter and in the report to the OCR. Additionally, we will guide you through the additional steps that must take place for large breaches that affect 500 or more individuals. We have the experience to help you with your HIPAA Breach Reporting.
Frequently Asked Questions:
Do we need a HIPAA Compliance Plan?
Any covered entity that handles protected health information (PHI) must be prepared to protect that information. This is done by creating and implementing a HIPAA compliance plan with policies and procedures to safeguard PHI. The must outline the steps you will have to take in the event of a breach.
The plan will ensure that all workforce members are properly trained on how to handle PHI in all its forms.
HIPAA Associates is prepared to create the perfect compliance plan for your organization that has all the necessary policies, procedures and training you will need to keep your PHI safe.
HIPAA Associates is prepared to create the perfect compliance plan for your organization that has all the necessary policies, procedures and training you will need to keep your PHI safe.
How do I handle a breach?
It is important to follow all the steps to report a breach to the OCR. Every breach is different and must be handled on a case by case basis. A full breach analysis must be performed to determine if there was an impermissible use or disclosure that compromises the security of protected health information. Factors to be resolved are:
1. The nature and extent of the breach including identifiers
2. The unauthorized person to whom disclosure is made
3. Whether the PHI was acquired or viewed
4. The extent to which the risk to PHI has been mitigated.
HIPAA Associates can help your organization through this process to ensure you follow all the important steps.
How to create a Compliance Plan
- Implement Policies & Standards
Policies and procedures help establish the rules your organization will need to carry out the requirements of federal health care program guidelines.
- Designate a Compliance Officer
The compliance officer will be responsible for operating and monitoring the compliance program.
- Conduct an effective training program
All personnel should receive training on fraud & abuse laws as well as the compliance program.
- Develop effective lines of communication
Employees must have avenues available for reporting concerns internally. Anonymous reporting must be available.
- Conduct internal monitoring and auditing
A good program will have an ongoing process to evaluate and assess the organization for inappropriate behavior.
- Enforce standards of conduct with guidelines
An organization must have well published standards of conduct. The plan should clearly state the implications and penalties of violating the standards.
- Respond promptly to violations and take corrective action
An organization must ensure timely and effective remedial action for offenses.
