Healthcare organizations have been investing in cybersecurity to improve their defenses against increasingly numerous and sophisticated cyberattacks; however, while an organization’s security posture can be improved, it can only be as good as the weakest link.

Cybercriminals are increasingly targeting the supply chain in their attacks, as these are usually the weakest links in the security chain. Healthcare organizations typically contract with many different vendors which are often provided with sensitive data or privileged access to healthcare networks. In 2022, data breaches at business associates increased to the point where reported data breaches with business associate involvement outnumbered the data breaches at healthcare providers. Many of the data breaches at business associates affected dozens of healthcare clients. Assessing and managing supply chain risk is now one of the biggest cybersecurity challenges in healthcare.

A recent study conducted by SecurityScorecard and the Cyentia Institute explored the reasons why data breaches at third parties and fourth parties are now so common. The report –Close Encounters of the Third (and Fourth) Party Kind – was based on data from more than 230,000 primary organizations and 73,000 vendors and products used by those organizations.

Third parties and fourth parties introduce risk but managing and reducing those risks to an acceptable level can be a monumental challenge due to the complex interconnected web of third- and fourth-party relationships. For example, SecurityScorecard looked at one small company – a website code developer that provides code that determines how website visitors interact with websites. Approximately 12,500 organizations use that company’s code on their websites, and there are 232,000 fourth parties with relationships with those organizations. While those 232,000 organizations do not have a direct relationship with the company, 98.7% have an indirect, once-removed relationship with the website code developer. If the company’s code were to be compromised, almost 229,000 companies would experience some level of exposure.

Third and Fourth Parties Much More Likely to Have Poor Security Ratings

SecurityScorecard investigated the extent to which third-party vendors are used. The analysis showed that, on average, organizations use around 10 third-party vendors. In healthcare, the average was 15.5.  That calculation is based on third-party vendors that are visible from outside-in scanning of an organization’s Internet-facing infrastructure using SecurityScorecard’s Automatic Vendor Detection. While these numbers are relatively low, there are expansive fourth-party relationships. Each organization typically has indirect relationships with between 60 and 90 times the number of fourth parties as third parties.

Third and fourth-party data breaches are incredibly common. More than 98% of primary organizations said they had a business relationship with a vendor that experienced a data breach in the past 2 years, and almost half of the organizations had indirect links to at least 200 fourth-party vendors that had experienced a data breach in the past 2 years. Security Scorecard also assessed the relative security of first parties and third parties. Twice the number of primary organizations (38.4%) had the highest security rating of A compared to third parties (17.7%), but more concerning is third parties were almost five times as likely to receive a security rating of F as primary organizations. An examination of fourth parties found that they were 10x more likely to have a failing security grade than an A. Poor security ratings do not necessarily mean an organization will experience a data breach, but SecurityScorecard’s analysts determined that firms with poor security ratings were 7.7% more likely to experience a data breach.

“Many organizations are still unaware of the dependencies and exposures inherent to third-party relationships, and simply focus on managing their own security posture. Others are aware of those issues, but don’t make vendor decisions based on security and/or require vendors to meet certain standards. Even firms that do establish third-party security requirements can struggle to continually monitor compliance and progress,” explained SecurityScorecard in the report. The good news is that organizations are now paying much greater attention to vendor risk, with Gartner reporting that 60% of companies now use cyber risk as a significant determinant when conducting third-party transactions.

As cyber actors focus their efforts on the supply chain, managing third and fourth-party risk has never been more important. While this can be a challenge, the first step is to gain visibility into your entire vendor ecosystem, as without that visibility it is not possible to accurately assess risk and make informed decisions. Once those third and fourth parties have been identified, the security posture of those organizations needs to be assessed. SecurityScorecard also recommends collaborating with those vendors and helping them to improve their security, and using automation to continuously monitor vendors’ cyber risk and generate alerts when there are notable changes to their security posture. That then allows organizations to be more proactive and help their vendors address vulnerabilities before they are exploited.

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The French Computer Emergency Response Team (CERT-FR) has warned about an ongoing ransomware campaign targeting VMware ESXi hypervisors that have not been patched against the critical heap-overflow vulnerability tracked as CVE-2021-21974.

VMware issued a patch on February 3, 2021, to fix the vulnerability; however, hundreds of VMware ESXi virtual machines are still vulnerable to the exploit and are now being attacked. The vulnerability affects the Open Service Location Protocol (OpenSLP) service and can be exploited by an unauthenticated attacker in a low-complexity attack to remotely execute code.

According to CERT-FR, the campaign targets ESXi hypervisors in version 6.x and prior to 6.7 through OpenSLP port 427, and warns that the following versions are vulnerable to the exploit:

• ESXi 7.x versions earlier than ESXi70U1c-17325551
• ESXi versions 6.7.x earlier than ESXi670-202102401-SG
• ESXi versions 6.5.x earlier than ESXi650-202102101-SG

A workaround has been provided by CERT-FR in the alert for any organizations unable to immediately apply the patch, but CERT-FR strongly recommends patching to address the issue. CERT-FR has warned that patching the vulnerability or applying the workaround is not sufficient to protect against attacks, as the vulnerability may already have been exploited to deliver malicious code. After applying the mitigations, system scans should be performed to detect signs of compromise. VMware said the attacks involve a new ransomware variant dubbed ESXiArgs, which appends encrypted files with the .args extension. While it has yet to be confirmed, these attacks do not appear to involve data exfiltration, only file encryption.

Over the weekend, security researchers have been reporting hundreds of machines have been attacked, which likely involves the automated or semi-automated exploitation of the vulnerability. Over 500 machines are believed to have been targeted, with The Stack reporting that attacks are being conducted at a rate of around 20 per hour. OVHcloud customers are the worst affected, although attacks are now more widespread and are hitting customers of other hosting companies. OVH issued a security advisory on Friday warning customers about the campaign, urging them to patch immediately. While the attacks appeared to initially target vulnerable VMware ESXi hypervisors in Europe, the attacks are now more widespread and SingCERT in Singapore has now issued an advisory warning about the ransomware campaign.

There have been reports that earlier versions of VMware ESXi hypervisors are also being targeted by ransomware gangs, although VMware says the vulnerability is restricted to the above 6.x and 7.x versions. That could indicate CVE-2021-21974 is not the only vulnerability being exploited. What is clear is multiple ransomware gangs have released Linux versions of their ransomware specifically to target ESXi hypervisors, with the Royal ransomware group one of the latest to release a new Linux version for attacks on ESXi.

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The pro-Russian hacking group, Killnet, is conducting a campaign of Distributed Denial of Service (DDoS) attacks on U.S. hospitals in apparent retaliation for U.S. support of Ukraine. The attacks started a few days after the United States and other countries agreed to provide tanks to Ukraine to help with the fight against the Russian invasion.

Killnet is a hacktivist group that has been active since at least January 2022 and its activities are connected to the Russian invasion of Ukraine. While the group’s views align with Russia, connections to the Russian Federal Security Service (FSB) and Russian Foreign Intelligence Service (SVR) have not been confirmed. The group is known for conducting denial of service (DoS) and DDoS attacks on government institutions and private organizations in countries providing support to Ukraine.

The attacks involve flooding hospital servers and websites with thousands of connection requests and packets per minute, causing the systems to slow down. In some cases, the attacks have rendered servers and websites temporarily unavailable. DDoS attacks are generally short-lived, but disruption can continue for several hours or days. While these attacks cause disruption, it has been suggested that Killnet is attempting to create fear, uncertainty, and doubt in the ability of governments to protect against cyberattacks.

In 2022, the group conducted DDoS attacks on government websites and private companies in Romania, Germany, Georgia, Italy, the Czech Republic, and Japan. In the United States, the group attacked the American defense firm Lockheed in retaliation for the provision of the HIMARS systems to Ukraine, and several attacks were conducted on U.S. airports in October. A senior member of the group, known as Killmilk, issued a threat to the U.S. government claiming attacks would be conducted on healthcare providers to obtain the sensitive personal data of Americans in retaliation for the policy of the U.S. Congress with respect to Ukraine.

While those threats do not appear to have materialized, the group’s latest DDoS campaign has seen at least 15 hospitals and health systems targeted, including University of Michigan Health, Stanford Healthcare, Banner Health, Anaheim Regional Medical Center, Atrium Health, Hollywood Presbyterian Medical Center, University of Pittsburg Medical Center, Jefferson Health, Abrazo Health, Duke University Hospital, Buena Vista Regional Medical Center, Heart of the Rockies Regional Medical Center, and Cedars-Sinai Hospital.

University of Michigan Health said the websites of U-M hospital and Mott Children’s Hospital were attacked on Monday but are now back up and running. The affected websites were hosted by a third-party vendor and did not contain any patient information. A third-party vendor has been providing assistance to mitigate the attack. The wave of attacks prompted the Health Sector Cybersecurity Coordination Center (HC3) to issue an analyst note about the group and provide mitigations that can help to reduce the severity of DDoS attacks, but warned that it is not possible to fully mitigate against the risk of DDoS attacks.

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Multiple vulnerabilities have been identified in the popular open source electronic health record and medical practice management software, OpenEMR. OpenEMR is used by healthcare organizations around the world for recording and managing sensitive patient data, and patients used the software for scheduling appointments online, communicating with their healthcare providers, and paying medical bills. OpenEMR is used by more than 100,000 healthcare providers worldwide that serve more than 200 million patients.

Three vulnerabilities were discovered last year by security researcher Dennis Brinkrolf. Brinkrolf analyzed the open source code using Sonar’s static application security testing (SAST) engine. Three vulnerabilities were identified that could be chained together to achieve remote code execution, take control of vulnerable OpenEMR instances, and steal sensitive patient data.

The first vulnerability – an unauthenticated file read vulnerability – could be exploited by a malicious actor using a rogue MySQL server to read arbitrary files in OpenEMR systems. Those files contain certificates, passwords, tokens, and backups. The other two vulnerabilities – an authenticated local file inclusion flaw and authenticated reflected XSS vulnerability – can be exploited in combination with the first vulnerability to execute arbitrary code on any vulnerable OpenEMR server and steal sensitive data. In the worst-case scenario, the attacker would be able to compromise the entire critical infrastructure of an organization.

For instance, the reflected XSS vulnerability could be exploited to upload a malicious PHP file to the server. The attacker could then use path traversal via the Local File Inclusion bug to execute the PHP file. While it may take several attempts to determine the appropriate Unix timestamp, the attacker would eventually be able to achieve remote code execution and could configure the system in a way to allow data exfiltration.

Brinkrolf reported the vulnerabilities to OpenEMR on October 24, 2022, and patches were released to fix all three vulnerabilities within a week. Medical practices that use OpenEMR should check to make sure they are running the latest version of the software, and if they are running any version prior to 7.0.0 they should update the software immediately.

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While the Hive ransomware operation was infiltrating servers, exfiltrating data, and demanding ransom payments from their victims, their activities were being observed from within. The FBI has had access to Hive’s ransomware servers since July 2022 and was learning about the group’s methods and has been helping victims recover without paying the ransom. The FBI was biding time until the ideal moment to strike and strike it did. The Department of Justice (DOJ) has announced that the Hive ransomware gang’s digital infrastructure has been seized, including the group’s Tor payment site, data leak site, and the infrastructure used by the group’s leadership and affiliates for communications.

The Hive ransomware gang was one of the most active and aggressive ransomware-as-a-service (RaaS) operations, having conducted more than 1,500 attacks on entities in over 80 countries in less than two years. While some ransomware actors have terms and conditions preventing their affiliates from conducting attacks on the healthcare sector, that was not the case with Hive, which has conducted many attacks on hospitals and health systems, along with schools, financial firms, and critical infrastructure entities.  Healthcare victims include Consulate Health, Lake Charles Memorial Health, Tift Regional Medical Center, Greenway Health, Johnson Memorial Health, Partnership HealthPlan, First Choice Community Healthcare, and Missouri Delta Medical Center.

The Hive gang has been active since at least June 2021 and is believed to have generated in excess of $100 million in ransom payments. The group is known to gain initial access to networks through a range of techniques, including phishing, stolen credentials, remote desktop protocol, VPNs, and by exploiting vulnerabilities in Internet-exposed devices. After gaining access to networks, the group moves laterally, identifies data of interest, exfiltrates files, and then demands payment for the decryption keys and to prevent the publication of stolen data. If victims refuse to pay, the stolen data are publicly released on its data leak site.

The takedown of the group’s infrastructure came at the end of a months-long infiltration of its infrastructure, with assistance provided by Europol, the U.S. Secret Service, the U.S. Attorney’s Office for the Eastern District of Virginia, the U.S. Attorney’s Office for the Central District of California, and law enforcement agencies in Germany, the Netherlands. The FBI gained access to two dedicated servers and one virtual server hosted by a Californian hosting provider, which were being leased by the gang, and law enforcement in the Netherlands assisted with the seizure of two backup servers hosted in the country. The servers were being used to host the main data leak site, negotiation site, and the Internet interfaces used by the members and affiliates.

The FBI obtained information on planned attacks and contacted victims to warn them, and during the past 6 months has prevented approximately $130 million in ransom payments. The FBI has obtained the decryption keys for approximately 300 victims that were currently under attack and has distributed approximately 1,000 decryption keys to previous victims. The FBI also obtained records of communications, malware file hash values, and information on 250 affiliates that were conducting attacks for the gang, along with a list of past victims. The websites used by the gang now display a notice rotating in English and Russian warning that the sites have been seized.

“The Department of Justice’s disruption of the Hive ransomware group should speak as clearly to victims of cybercrime as it does to perpetrators,” said Deputy Attorney General Lisa O. Monaco. “In a 21st century cyber stakeout, our investigative team turned the tables on Hive, swiping their decryption keys, passing them to victims, and ultimately averting more than $130 million dollars in ransomware payments. We will continue to strike back against cybercrime using any means possible and place victims at the center of our efforts to mitigate the cyber threat.”

The Hive group communicates in Russian and is believed to operate out of the country. There is no extradition treaty between Russia and the United States, and Russia has previously been reluctant to take action against ransomware gangs operating within its borders. The information obtained on members and the gang and affiliates is likely to lead to indictments, although it may prove difficult to bring those individuals to justice. While the operation has caused considerable disruption to the Hive operation, the group is well-resourced and has obtained significant sums in ransom payments so it is probable that the infrastructure will be rebuilt and operations will recommence under a different name. Even so, this is a major achievement and has prevented many damaging attacks on the healthcare sector.

“The disruption of the Hive service won’t cause a serious drop in overall ransomware activity but it is a blow to a dangerous group that has endangered lives by attacking the healthcare system. Unfortunately, the criminal marketplace at the heart of the ransomware problem ensures a Hive competitor will be standing by to offer a similar service in their absence, but they may think twice before allowing their ransomware to be used to target hospitals.” John Hultquist, Head of Mandiant Threat Intelligence, Google Cloud explained to HIPAA Journal. “Actions like this add friction to ransomware operations. Hive may have to regroup, retool, and even rebrand. When arrests aren’t possible, we’ll have to focus on tactical solutions and better defense. Until we can address the Russian safehaven and the resilient cybercrime marketplace, this will have to be our focus.”

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Blackberry has recently published its Global Threat Intelligence Report, which provides actionable and contextualized intelligence that can be used to improve cyber resilience. The report is based on data collected by Blackberry and threat intelligence provided by third parties, gathered over 90 days between September and November 2022.

Throughout the reporting period, downloaders were among the most commonly observed threats. Downloaders are malicious software that often masquerade as legitimate digital documents and executables and are used to download a range of other malicious software. Once installed, these downloaders often remain undetected for long periods and form large botnets of infected devices. The operators of these botnets partner with other threat groups to deliver third-party payloads. One of the most commonly used downloaders is Emotet, which first emerged in 2014 as a banking Trojan. An international law enforcement operation successfully shut down the Emotet botnet in April 2021 but it was eventually rebuilt and started to be used again at the end of 2021. After a 4-month hiatus in 2022, activity resumed, with the botnet grown via phishing emails with malicious Office attachments. Emotet commonly drops the IcedID banking Trojan, which in turn often delivers ransomware payloads.

Qakbot is another common downloader that is similarly distributed in phishing emails. The emails typically have a LNK hyperlink that directs the user to a malicious domain where a ZIP file is downloaded. The ZIP files contain an executable file that delivers QakBot. QakBot is able to hijack existing message threads for propagation, targeting individuals in the victims’ contact list, making it appear that the emails have been sent in response to a previous conversation. The QakBot operators provide initial access to networks for several ransomware operations. The Blackberry researchers also detected an increase in GuLoader, which is often used to deliver information stealers such as Redline and Racoon, with the malicious payloads often hosted on cloud services such as Google Cloud and OneDrive, as well as malicious Telegram bots. Throughout 2022, LockBit was the most commonly used ransomware variant and remained so throughout the 90-day analysis period. RedLine and Racoon were the most commonly observed information stealers, and njRAT and FlawedAmmyy were the most commonly identified remote access Trojans.

For its latest report, Blackberry analyzed attacks on the healthcare sector, which the researchers say is particularly vulnerable to attacks due to the widespread use of medical technology with a long service life, the complex and often interconnected nature of healthcare systems, and the vast amounts of sensitive data that are routinely collected and stored. Ransomware still poses the biggest threat to the healthcare sector, and all of the threat groups that rely on ransomware are actively targeting the healthcare industry. While some ransomware-as-a-service operations claim to have operating rules prohibiting attacks on the healthcare sector, those promises cannot be guaranteed and there have been many cases where healthcare organizations have been attacked despite these rules being in place.

Qakbot was the most commonly observed Trojan in attacks on the healthcare sector, most commonly to provide access to healthcare networks for ransomware affiliates and initial access brokers. Emotet was not very active over the analysis period, although attacks are expected to increase. Meterpreter, a payload delivered via Metasploit, and BloodHound were active during the analysis period and had been used in attacks on the healthcare sector. One attack used Meterpreter along with SharpHound, a collector for BloodHound often used for lateral movement. The researchers echoed the advice of CISA and recommend network and system administrators intentionally execute BloodHound to understand possible attack paths.

Several attacks on the sector involved TinyNuke, which was used to deliver the Netwire RAT, and some attacks involved the PlugX RAT, which is commonly used by nation-state actors such as Mustang Panda, which suggests nation-state actors and cybercriminals are actively targeting the sector. Information stealers such as RedLine and Racoon have been extensively used in attacks in 2022; however, these malware variants do not appear to have been used specifically to attack the sector.

The financially motivated threat group, TA505, remains highly active and has targeted the healthcare sector. The group is known to use Clop ransomware, the FlawedAmmyy RAT, and banking Trojans. ALPHV is a relatively new cybercriminal group that has been conducting attacks on the healthcare sector. The group often deploys BlackCat ransomware and is known for using innovative extortion tactics and unconventional attack methods. ALPHV claimed responsibility for the recent attack on NextGen Healthcare. The Vietnam-based threat actor, APT32, the Chinese APT group, Mustang Panda, the Russian threat actor, APT29, and the cybercriminal group, TA542, have also been highly active and have a history of attacking healthcare organizations.

The researchers believe the healthcare industry will continue to be targeted throughout 2023 and ransomware will remain one of the biggest threats. They also predict more targeted attacks on cloud infrastructure as threat actors seek to gain additional visibility into the organizations that they seek to undermine or extract profit.

“The growth of targeted attacks in the automotive, healthcare, and financial industries cast a harsh light on the critical need to protect these sectors’ expansive and vulnerable threat surfaces,” said the researchers. “Defending your organization against malware and cyberattacks requires in-depth knowledge of how threat actors are targeting your industry, the tools that they use, and their possible motivations. This detailed knowledge provides contextual, anticipative, and actionable cyberthreat intelligence that can reduce the impact of threats on your organization.”

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Ransomware gangs are finding it much harder to profit from their attacks as fewer victims are ransoms to obtain the decryption keys and prevent the exposure of stolen data, according to two recently released reports from the ransomware remediation firm, Coveware, and blockchain analysis firm, Chainalysis.

Coveware reports that in Q1, 2019, 85% of ransomware victims paid the ransom following an attack. Since then, the percentage making payments has been steadily declining, with just 37% of ransomware victims paying up in the last two quarters of 2022. Coveware said around 50% of organizations paid ransoms in 2021, compared to 41% in 2022. Chainalysis said total ransomware revenue fell by 40.3% year-over-year, dropping from $765.6 million in 2021 to $456.8 million in 2022. While ransomware victims do not always publicly disclose attacks or if a ransom has been paid, the figures strongly suggest there is an increasing unwillingness of victims to pay up.

There are several reasons for the decline in profits. Organizations have improved their defenses, are monitoring their networks more closely for signs of compromise, and have developed incident response plans for ransomware attacks that allow quicker recovery, so fewer organizations find themselves in a position where they have little alternative other than paying the ransom. Insurance companies have played a key role in improving defenses against ransomware. Bill Siegel, CEO, and co-founder of Coveware, said following large losses in 2019 from ransomware attacks, insurance companies updated their terms and conditions for their cyber insurance policies, requiring their customers to ensure that cybersecurity standards were maintained, including following best practices for backups, implementing multi-factor authentication, and developing and testing an incident response plan.

Chainalysis suggests that the legal risk from paying ransoms has increased and that this could also be a factor. Payment of a ransom to any ransomware group that has been sanctioned by the Department of the Treasury’s Office of Foreign Assets Control (OFAC) risks a significant financial penalty. If there is any potential connection between an attack and an entity on the OFAC sanctions list, paying a ransom is incredibly risky.

Faced with dwindling profits, ransomware groups have changed their tactics, with some opting to target larger organizations in the hope of getting sizeable ransom payments, while others have started targeting smaller organizations due to the difficulty of getting larger organizations to pay up. According to Coveware, in the last quarter of 2022, the average ransom payment increased by 58% to $408,644 and the median payment increased by 342% to $185,972, which Coveware attributes to the decline in revenues forcing gangs to increase their ransom demands.

While it is becoming harder for cybercriminals to profit from ransomware attacks, that does not mean fewer attacks are being conducted. The data vary but suggest that the number of attacks has remained fairly constant or declined only slightly. There also appears to have been an increase in re-extortion, whether ransomware gangs demand further payments from victims after the ransom is paid. While this tactic was more common in attacks on smaller organizations, it is increasingly being used by ransomware groups that target medium- and large-size companies. Of course, one of the problems with this approach is victims will be even less likely to pay up.

The Federal Bureau of Investigation (FBI) discourages organizations from paying ransoms, but payment is not prohibited. The FBI encourages victims to report attacks even when the ransom is paid and provides assistance to victims. This approach appears to be working. By increasing the support provided to victims, organizations get the help they need to quickly mitigate attacks and the FBI gains valuable insights into how the groups are operating, allowing the agency to predict who the groups may target next. Threat intelligence can then be shared with those organizations to help them better defend against attacks.

With ransomware attacks becoming less profitable, this could prompt cybercriminals to abandon ransomware; however, with profits dwindling, ransomware gangs may get even more aggressive and could pile even more pressure on victims or conduct more destructive attacks. The advice from the FBI is to invest in defenses, implement an incident response plan, and call the FBI immediately in the event of an attack. Bryan A. Vorndran, assistant director of the FBI’s Cyber Division, said the FBI can put a cyber-trained agent on the doorstep of virtually any organization in the country within an hour of the incident being reported. That agent will then be able to provide timely assistance and help organizations recover quickly.

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