Cyberattacks on business associates of healthcare organizations have increased to the point where attacks on business associates now outnumber attacks on healthcare providers. In addition to an increase in cyberattacks on third-party suppliers, the impact and destruction caused by those attacks have also increased, according to a recent report from the vendor risk management company, Black Kite.

Each year, Black Kite analyzes the impact of third-party cyberattacks and data breaches and publishes the findings in its Third-Party Breach Reports. For the 2023 report, Black Kite analyzed 63 third-party breaches which affected at least 298 companies, and reports a doubling of the impact and destruction caused by those breaches. In 2021, an average of 2.46 companies were affected by each third-party breach with the number of affected companies increasing to an average of 4.73 per breach in 2022.

The most common root cause of third-party data breaches in 2022 was unauthorized network access, which accounted for 40% of cyberattacks on third parties. Black Kite attributes the increase in these types of intrusions to the continued high numbers of employees working remotely, which introduces vulnerabilities that cybercriminals can exploit.  Ransomware continues to be extensively used in cyberattacks on third parties and was involved in 27% of third-party breaches in 2022; however, there was a slight year-over-year decrease in ransomware attacks. Black Kite attributes the decrease to Russian sanctions, which have hampered the ability of Russian cybercriminals to conduct ransomware attacks. 9.5% of breaches were due to unsecured servers, 6.3% of breaches were due to human error, 3.2% were caused by phishing, and 3.2% involved malware.

Other notable findings include an increase in the time taken to notify the companies affected by these breaches, which increased by around 50% year-over-year to an average of 108 days from the date of the attack to the disclosure date. The delay in notifications means cybercriminals are given more time to misuse stolen data, resulting in even greater damage. Technical service vendors were the most targeted third parties, accounting for 30% of all data breaches, followed by vendors of software services and healthcare services. Healthcare organizations were the most common victims of third-party breaches, accounting for 34.9% of third-party incidents in 2022 – up 1% from 2021 – followed by finance (14%), and government (14%).

“Global business ecosystems continue to get more complex, with every organization increasingly impacted by the cybersecurity posture of their partners, and their partners’ partners, and so on,” said Jeffrey Wheatman, Senior Vice President, and Cyber Risk Evangelist at Black Kite. “The reality is your attack surface is much bigger than the stuff you can control. But the good news is, you can assess and monitor your extended ecosystem to spot vulnerabilities, take action and avoid catastrophe.”

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A joint cybersecurity advisory has been issued by the U.S. Cybersecurity and Infrastructure Security Agency (CISA), National Security Agency (NSA), Federal Bureau of Investigation (FBI), Department of Health and Human Services (HHS), and the Republic of Korea’s Defense Security Agency and National Intelligence Service warning of state-sponsored North Korean (DPRK) ransomware attacks on U.S. critical infrastructure organizations. The agencies have gathered increasing evidence that DPRK threat actors are conducting the attacks to obtain ransom payments to support DPRK national-level priorities and objectives, and the U.S. healthcare and public health (HPH) sector is one of the primary targets.

“The North Korean actor behind these incidents, best known as Andariel, has been carrying out a targeted global ransomware campaign against hospitals and healthcare providers. Hospitals that are already under enormous pressure have experienced major disruptions, most of which have gone unnoticed to the public,” John Hultquist, Head of Mandiant Intelligence Analysis – Google Cloud, told the HIPAA Journal. “In many cases, hospitals have quietly recovered their systems or paid out the ransom without ever reporting the incident or even knowing they were dealing with North Korean spies. This suits the North Koreans who can’t be legally paid due to sanctions. They often hide their identity by claiming to be known ransomware operators.”

Andariel has used multiple ransomware variants in their attacks, especially strains such as Maui and H0lyGh0st, although the authoring agencies have identified DPRK involvement with attacks using BitLocker, Deadbolt, ech0raix, GonnaCry, Hidden Tear, Jigsaw, LockBit 2.0, My Little Ransomware, NxRansomware, Ryuk, and YourRansom. Exploits for a range of common vulnerabilities and exposures (CVEs) are used to gain initial access to networks and escalate privileges, with recent exploits including the Log4Shell vulnerability in Apache Log4j software library (CVE 2021-44228), and unpatched vulnerabilities in SonicWall appliances (CVE-2021-20038) and TerraMaster NAS devices (CVE-2022-24990).

There are sanctions risks for organizations paying ransom demands to North Korean threat groups. The U.S. Department of the Treasury’s Office of Foreign Assets Control (OFAC) has designated numerous malicious actors under its cyber-related sanctions program, including Andariel. To get around these restrictions, the DPRK threat actors obfuscate their involvement by operating with or under third-party foreign affiliate identities and use third-party foreign intermediaries to receive ransom payments. Virtual private networks (VPNs), virtual private servers (VPSs), and third-country IP addresses are used to make it appear that the attacks did not originate in the DPRK.

“Andariel’s core mission is to gather intelligence for the North Korean state, targeting the government, the defense sector, journalists, among others. In contrast to some of their peers who are solely focused on filling state coffers, Andariel appears to use crime as a means to self-fund their operations,” explained Hultquist. “Cybercrime is a lifeline for the North Korean regime and necessary to keep their cyber capabilities afloat. They are unlikely to be deterred anytime soon, so the impetus is on us to step up and defend our hospitals, before someone gets hurt.”

The cybersecurity advisory includes details of the tactics, techniques, and procedures used by the DPRK threat actors, along with Indicators of compromise (IoCs) and recommended mitigations.

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Malicious actors used a variety of methods to gain initial access to victims’ networks but in 2022, cybercriminal groups appeared to focus on Remote Desktop Protocol and attacking cloud databases, according to cyber insurer Coalition. RDP is one of the most common ways that initial access brokers (IABs) and ransomware gangs gain access to victims’ networks and RDP is by far the most common remote-scanning by malicious actors. RDP scanning traffic was very high in 2022, with data collected from Coalition’s honeypots indicating RDP scans accounted for 37.67% of all detected scans. Whenever a new vulnerability is identified in RDP, scans soar as cybercriminals rush to identify targets that can be attacked.

Ransomware continues to be an enormous problem. In 2022, the gangs increasingly targeted cloud databases, especially Elasticsearch and MongoDB databases, a large number of which have been captured by ransomware gangs. The team identified 68,423 hacked MongoDB databases in 2022, and 22,846 Elasticsearch databases that had been ransomed.

The number of new software vulnerabilities has been growing steadily over the past 6 years. In 2022, more than 23,000 new common IT vulnerabilities and exposures (CVEs) were discovered, the highest number of any year to date. Coalition predicts this trend will continue in 2023 and expects more than 1,900 new CVEs to appear each month – a predicted increase of 13% from 2022. Each month Coalition expects an average of 270 high-severity vulnerabilities and 155 critical vulnerabilities to be disclosed and stressed that organizations need to remain vigilant and keep on top of patching and quickly close these security gaps.

With so many vulnerabilities now being reported, keeping on top of patching can be a major challenge. Given the huge number of vulnerabilities security teams need to address, patching is often slow, and that gives hackers a significant window of opportunity to exploit the flaws. Prompt patching is essential, as a majority of newly disclosed CVEs are exploited by cybercriminals within 30 days of the vulnerabilities being made public, with most exploited within 90 days. Exploitation can occur incredibly quickly. For instance, the Fortinet vulnerability, CVE-2022-40684, was exploited within 2 days of the announcement.

Malicious actors typically focus on exploiting a limited set of vulnerabilities. When they discover new vulnerabilities that can be exploited, they tend to stick with their tried and tested exploits and attack as many businesses as possible. While the goal of security teams should be to ensure all vulnerabilities are patched promptly, the huge number of reported vulnerabilities can make that an almost impossible task. The greatest gains can be made by prioritizing patching and ensuring the most commonly exploited vulnerabilities are patched first. The Cybersecurity and Infrastructure Security Agency (CISA) maintains a catalog of known exploited vulnerabilities, and each year publishes a list of the most commonly exploited flaws. All vulnerabilities on these lists should be prioritized and patched first.

Effective prioritization of patching can be a challenge as it is not always clear which vulnerabilities are most likely to be exploited. IT teams often assess vulnerabilities using the Exploit Prediction Scoring System (EPSS) and CVSS severity score, yet this information is not always available when vulnerabilities are first disclosed. Coalition has gotten around this problem by developing the Coalition Exploit Scoring System (CESS), which acts as a scoring system for vulnerabilities. The system uses deep learning models that can predict the CVSS score for a vulnerability based on its description, the likelihood of an exploit being developed quickly based on past exploit availability for CVEs, and the likelihood of exploit usage against Coalition policyholders by modeling past attacks.

“With so many vulnerabilities to address, systems often go unpatched for years, leaving huge swaths of the internet unprotected,” said Coalition in the report.  “Leaders responsible for protecting network security need the most accurate and insightful information to act upon — and they need an effective way to prioritize which CVEs to respond to. We have attempted to provide that necessary context and the CVSS/CESS framework to help cybersecurity leaders and practitioners make informed decisions about their digital risk and react quickly to harmful vulnerabilities.”

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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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