Healthcare Cybersecurity

71% of Ransomware Attack Victims Refuse to Pay the Ransom

The latest data from the ransomware remediation firm, Coveware, shows the number of victims of ransomware attacks choosing to pay the ransom has fallen to a record low. At the start of 2019, 85% of victims of ransomware attacks paid a ransom following an attack, by the middle of 2021 the percentage had fallen to 46%, and in Q4, 2023, only 29% of victims paid the ransom. In 2019, ransomware groups started engaging in double extortion tactics, where access is gained to victims’ networks and data is exfiltrated before file encryption. Ransom payments are required to obtain the keys to decrypt files and to prevent stolen data from being leaked or sold. For many victims, the main reason for paying the ransom was to prevent a data leak rather than to obtain the keys to decrypt files. Coveware reports that in ransomware attacks involving data theft, in Q3, 2023, only 26% of victims paid the ransom.

There are many reasons behind the steady decline in ransom payments. One of the main factors is better preparedness, such as ensuring that a backup is made of all sensitive data and the backup is stored securely in an air-gapped system where it cannot be encrypted in an attack. In attacks where there is data theft, paying the ransom could prevent a data leak or the sale of the data; however, ransomware groups are not trusted to delete the stolen data. There have been attacks where payment of the ransom has not prevented a data leak, and paying up has led to further extortion attempts and attacks. There has also been a law enforcement crackdown and in some regions, paying a ransom is now illegal.

Prohibiting ransomware payments is one of the measures being considered by governments to curb attacks. If paying a ransom to a ransomware group is prohibited, ransomware groups would, in theory, stop conducting attacks in that country. Coveware suggests the reality would be different. The attacks would likely continue and companies would stop reporting attacks and seeking assistance from law enforcement. It would become much harder to track ransomware attacks and law enforcement investigations of ransomware groups would be severely hampered. All the good work by law enforcement to encourage victims to report attacks would be undone and as soon as a ban is implemented, a large illegal market would be created.

In the United States, several states have imposed partial bans on ransom payments, such as prohibiting state agencies and organizations from paying ransoms yet these bans do not appear to be having the desired effect, as ransomware attacks in those states have not reduced. Coveware believes that banning ransom payments amounts to capitulation. “A ban would signal that as a country, we are admitting that we are incapable of defending ourselves. That we are helpless against the threat of cyber extortion.”

Coveware’s data shows the efforts made by companies to prepare for ransomware attacks have paid off. Enterprises are no longer being crippled by file encryption and can recover their data without paying the ransom, and the efforts of law enforcement to disrupt and dismantle ransomware groups have produced meaningful results. “This fight will not be won overnight. It will take years, but the fight IS winnable,” said Coveware.

With revenues from ransomware attacks falling, ransomware groups need to conduct more attacks or increase their ransom demands, but Coveware’s data shows that ransom payments have reduced. In Q4, 2023, the average ransom payment was $568,705, down 33% from Q3, 2023. The median payment in Q4, 2023 was unchanged from the previous quarter and remained at $200,000.

In Q3, 2023 there was little change in the most active ransomware groups, with Akira retaining the top spot with 17% of attacks, followed by Blackcat with 10%, LockBit with 8%, and Play Ransomware with 6%; however, there has been an increase in activity by smaller ransomware groups and non-affiliated lone wolf actors. In around one-third of attacks, the method used to gain initial access to victims’ networks was unknown. Out of the other attacks, RDP compromise was the most common and has been increasing since Q3, 2022. Email phishing was the second most common initial access vector, although the popularity of this method declined over the same period. The exploitation of software vulnerabilities was the third most common initial access vector, with the Cisco ASA vulnerability (CVE-2023-20269) one of the most commonly exploited vulnerabilities.

Between Q2, 2022, and Q2, 2023, ransomware gangs favored attacks on large companies but the average size of victim companies has been falling with medium-sized companies seen as the sweet spot. Attacks are easier to conduct as investment in cybersecurity is lower than at large firms and mid-sized companies have sufficiently large revenues to allow large ransom demands to be issued. In Q4, 2023, the average size of a victim company was 231 employees, down 32% from Q3, 2023. In Q4, 2023, 22.2% of attacks were on companies in the professional services sector, with healthcare the second most attacked industry with 16% of attacks, followed by the public sector with 11.1% of attacks.

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HHS Unveils Voluntary HPH Cybersecurity Performance Goals

The Department of Health and Human Services (HHS) has unveiled the Cybersecurity Performance Goals (CPGs) that were outlined in its December 2023 Healthcare Sector Cybersecurity Strategy. These voluntary goals will help healthcare organizations take the necessary steps to improve cybersecurity and guide them through implementing high-impact measures to quickly improve resilience to cyber threats and recover quickly should their defenses be breached.

Cyberattacks on healthcare organizations have increased significantly in recent years with 2023 breaking records for the number of data breaches (725) and the number of breached records (133M). The HHS Cybersecurity Strategy aims to help the healthcare and public health (HPH) sector prepare for and respond to cyber threats, adapt to a rapidly changing threat landscape, and improve cyber resilience across the sector, with the establishment of voluntary cybersecurity goals the first step in that process.

The voluntary CPGs will help HPH sector organizations prioritize the implementation of high-impact cybersecurity practices – cybersecurity practices that will have the greatest impact on improving resilience to the most common attack vectors. As outlined in the HHS cybersecurity strategy, two tiers of CPGs have been developed: Essential CPGs and Enhanced CPGs. The essential CPGs are relatively low-cost minimum foundational cybersecurity practices that will greatly improve cybersecurity, and the enhanced CPGs are intended to encourage the adoption of more advanced cybersecurity practices. The aim is to get all healthcare delivery organizations to adopt the essential CPGs to make it harder for cyber actors to gain access to their networks and incentivize them to mature their cybersecurity programs by adopting the Enhanced CPGs.

The CPGs were developed based on the Cross-Sector CPGs released by the Department of Homeland Security’s Cybersecurity and Infrastructure Security Agency (CISA) in March 2023, which were intended to serve as a cybersecurity baseline for all critical infrastructure entities. The HHS collaborated with CISA and the industry to develop the healthcare-specific CPGs, which were also informed by common industry cybersecurity frameworks, guidelines, best practices, and strategies such as the National Cybersecurity Strategy, Healthcare Industry Cybersecurity Practices (HICP) and the National Institute of Standards and Technology (NIST) Cybersecurity Framework.

Layered Protection at Each Stage of the Attack Chain

The HPH CPGs are concerned with improving resiliency at all points in digital systems that can be exploited by cyber actors. The Essential CPGs will help HPH sector organizations address common vulnerabilities to improve their security posture, improve incident response, and minimize residual risk. The Enhanced CPGs are intended to help HPH sector organizations mature their cybersecurity capabilities and improve their defense against additional attack vectors.

Essential HPH CPGs

  • Mitigate Known Vulnerabilities
  • Email Security
  • Multifactor Authentication
  • Basic Cybersecurity Training for the Workforce
  • Strong Encryption for Sensitive Data in Transit
  • Revoke Credentials for Departing Workforce Members, Including Employees, Contractors, Affiliates, and Volunteers
  • Basic Incident Planning and Preparedness
  • Unique Credentials for all members of the Workforce
  • Separate User and Privileged Accounts
  • Vendor/Supplier Cybersecurity Requirements

Enhanced CPGs

  • Asset Inventory
  • Third-Party Vulnerability Disclosure
  • Third-Party Incident Reporting
  • Cybersecurity Testing
  • Cybersecurity Mitigation
  • Detect and Respond to Relevant Threats and Tactics, Techniques, and Procedures (TTP)
  • Network Segmentation
  • Centralized Log Collection
  • Centralized Incident Planning and Preparedness
  • Configuration Management

Initially, the CPHs will be voluntary; however, the HHS will use these CPGs to inform future rulemaking, including new cybersecurity requirements for healthcare organizations that participate in Medicare and Medicaid programs, the planned updates to the HIPAA Security Rule, and HHS efforts to incentivize the adoption of cybersecurity practices. Any new regulatory updates that include new cybersecurity requirements will be subject to standard notice and comment periods.

“We have a responsibility to help our health care system weather cyber threats, adapt to the evolving threat landscape, and build a more resilient sector,” said HHS Deputy Secretary Andrea Palm. “The release of these cybersecurity performance goals is a step forward for the sector as we look to propose new enforceable cybersecurity standards across HHS policies and programs that are informed by these CPGs.”

The HHS outlined in its cybersecurity strategy its plans to make funds available to help under-resourced healthcare delivery organizations make the necessary investments in cybersecurity by helping to cover the initial costs of implementing the essential CPGs. The HHS also plans to create an incentive program to encourage the adoption of the Enhanced CPGs. The establishment of these programs to help financially challenged hospitals is essential, as while the creation of the CPGs is a great first step, many healthcare delivery organizations simply do not have the funding available to make the necessary investments to improve cybersecurity.

The HPH CPGs are detailed in an 11-page PDF document that can be accessed on the HHS HPH Cyber website.

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Patch Fortra GoAnywhere Now: Exploit Code Released for Critical Flaw

Fortra has disclosed and patched a critical vulnerability in its GoAnywhere Managed File Transfer (MFT) solution. The vulnerability – CVE-2024-0204 – is an authentication bypass bug due to a path traversal weakness. If exploited, an unauthenticated user can create a new admin user via the administration portal and remotely take control of the customer’s environment and gain access to their network. The vulnerability has a CVSS severity score of 9.8 out of 10.

Fortra explained in its security advisory that the vulnerability affects all versions of GoANywhere MFT prior to 7.4.1. All users of the file transfer solution should ensure they update to version 7.4.1 as soon as possible. If it is not possible to immediately upgrade, Fortra has suggested temporary workarounds.

For non-container deployments, users should delete the InitialAccountSetup.xhtml file in the install directory and restart the services. For container deployments, the InitialAccountSetup.xhtml file should be deleted and replaced with an empty file, followed by a restart.

Managed file transfer solutions are attractive targets for hackers. Last year, the Clop ransomware group exploited a vulnerability in Fortra’s GoAnywhere MFT – CVE-2023-0669 – and attacked 129 of the company’s clients, including several healthcare organizations. Exploitation of the flaw is likely and according to Searchlight Cyber threat intelligence engineer, John Honey, a proof-of-concept exploit for the vulnerability is being circulated on at least one Telegram channel.

After upgrading to version 7.4.1 or implementing the workaround, an audit should be conducted to see if any new admin users have been added to the admin users group in the GoAnywhere administrator portal Users -> Admin Users section. The cybersecurity firm Horizon3 also recommends checking the logs for the database -\GoAnywhere\userdata\database\goanywhere\log\*.log. – as they include the transactional history of the database and will contain entries if new admin users have been added.

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HC3 Warns of Threat of Unauthorized Remote Access via ScreenConnect Tool

The ScreenConnect remote access tool has been abused by a threat actor to gain access to the networks of organizations in the healthcare and public health (HPH) sector. According to a sector alert from the Health Sector Cybersecurity Coordination Center (HC3), between October 28 and November 8, 2023, an unknown threat actor abused a locally hosted ScreenConnect instance to gain remote access to victims’ networks.

Once access was gained, the threat actor installed further remote access tools including SecureConnect and AnyDesk instances to allow persistent access to victims’ networks. Researchers at the cybersecurity company Huntress identified two attacks on distinct healthcare organizations and the threat actor’s activity suggests network reconnaissance was being conducted in preparation for attack escalation.

On November 14, the vendor of ScreenConnect said the threat actor gained access to an unmanaged on-premises instance of ScreenConnect that had not been updated since 2019. The ScreenConnect vendor said the organizations affected had gone against recommended best practices. In the attack, the threat actor leveraged local ScreenConnect instances used by the pharmacy supply chain and management systems solution provider Transaction Data Systems (now Outcomes). The company makes Rx30 and ComputerRx software that is used by pharmacies in all 50 states. The Huntress researchers have not been able to determine the impact of the attack, but say it could be substantial.

HC3 has provided Indicators of Compromise (IoCs) associated with the attack and advises all clients of the pharmacy supply chain and management systems solution provider to take immediate action and examine their systems and networks for the IoCs. If any of the IoCs are identified they should be taken seriously and warrant a prompt and thorough investigation and comprehensive breach response.

According to HC3, the compromised endpoints used an unmanaged instance of a Windows Server 2019 system and organizations should take concerted steps to safeguard their infrastructure. HC3 recommends implementing enhanced endpoint monitoring solutions, robust cybersecurity frameworks, and engaging n proactive threat hunting to mitigate potential threat actors’ intrusions.

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Hospital IT Help Desks Targeted in Sophisticated Payment Fraud Scam

U.S. hospitals are being targeted by cybercriminals in a sophisticated payment fraud scam, according to the American Hospital Association (AHA). The AHA has received multiple reports of scammers contacting hospital IT departments to perform password resets and enroll new devices to obtain multifactor authentication (MFA) codes. Once access has been gained to employee email accounts, they send instructions to payment processors to divert legitimate payments to attacker-controlled U.S. bank accounts. The funds are then transferred to overseas accounts.

According to the AHA, scammers contact IT departments and pose as revenue cycle employees or other employees in sensitive financial roles. They provide stolen personal information to verify their identity to pass the security checks that are necessary to perform a password reset to enroll a new device to receive MFA codes. The devices used to receive the codes often have a local area code. With a new device enrolled, the scammer will receive MFA codes, allowing them to access employee email accounts. This technique also allows the scammers to defeat phishing-resistant MFA.

The AHA has received dozens of reports from U.S. hospitals that have been targeted and had payments diverted to attacker-controlled accounts. Anyone who falls victim to such a scam should immediately report it to the Federal Bureau of Investigation (FBI) and their financial institution to try to get the transfer blocked and recover the fraudulently transferred funds. The FBI has been able to successfully block fraudulent transfers of funds if notified within 72 hours of the transfer being made.

Hospitals should consider implementing stricter IT help desk security protocols to ensure they do not fall victim to these scams. John Riggi, AHA’s national advisor for cybersecurity and risk, suggests that as a minimum, any requests for password resets should require a call back to the number on record for the employee requesting a password reset and enrollment of a new device. Some hospitals have implemented procedures that require any such request to be made in person at the IT help desk. Riggi also suggests implementing policies that require the supervisor of the employee to be contacted to verify any such request. “This scheme once again demonstrates how our cyber adversaries are quickly evolving their tactics to defeat technological cyber defenses through social engineering schemes,” said Riggi.

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Citrix Patches 2 Actively Exploited NetScaler ADC and Gateway Zero Days

Two zero-day vulnerabilities have been identified in customer-managed Citrix NetScaler Application Delivery Controller and NetScaler Gateway devices that are being exploited in the wild. The vulnerabilities are present in the NetScaler management interface can be exploited in unpatched devices that are exposed to the Internet.

The Cybersecurity and Infrastructure Security Agency (CISA) has added the vulnerabilities to its Known Exploited Vulnerabilities Catalog, and while attacks have been limited, CISA warns that the vulnerabilities are frequent attack vectors for malicious cyber actors and exploitation is likely to increase in the coming days. In December, Citrix released an advisory about a vulnerability dubbed CitrixBleed (CVS-2023-4966) which has been extensively exploited by ransomware groups. As such, CISA has advised all federal agencies to ensure the patches are applied as soon as possible and at most within a week.

The two recently disclosed zero-day bugs are unrelated to CitrixBleed.  CVE-2023-6549 is a high-severity buffer overflow vulnerability with a CVSS base score of 8.2. The flaw can be exploited in a denial-of-service attack. CVE-2023-6548 is a medium-severity code injection vulnerability with a CVSS base score of 5.5, which can be exploited to achieve remote code execution. In order to exploit the latter, an attacker would need to be authenticated but only requires low-level privileges.

The vulnerabilities are far less severe than CitrixBleed, nonetheless, customers have been advised to promptly apply the patches as the vulnerabilities are under active exploitation. Proof-of-concept exploit code is not believed to have been publicly released but that is likely to happen soon and exploitation will increase considerably.

The vulnerabilities are present in the following NetScaler ADC and NetScaler Gateway versions:

  • NetScaler ADC and NetScaler Gateway 14.1 before 14.1-12.35
  • NetScaler ADC and NetScaler Gateway 13.1 before 13.1-51.15
  • NetScaler ADC and NetScaler Gateway 13.0 before 13.0-92.21
  • NetScaler ADC 13.1-FIPS before 13.1-37.176
  • NetScaler ADC 12.1-FIPS before 12.1-55.302
  • NetScaler ADC 12.1-NDcPP before 12.1-55.302

Citrix has released patches to fix both vulnerabilities and has suggested a workaround if that is not possible.

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December 2023 Healthcare Data Breach Report

There was no letup in healthcare data breaches as the year drew to a close, with December seeing the second-highest number of data breaches of the year. The Department of Health and Human Services (HHS) Office for Civil Rights received 74 reports of healthcare data breaches of 500 or more records in December, which helped make 2023 a record-breaking year for healthcare data breaches. While there may still be some late additions to the list, as of January 18, 2023, 725 data breaches of 500 or more healthcare records have been reported to OCR in 2023 – The highest number since OCR started publishing records of data breaches on its “Wall of Shame.” To add some perspective, that is more than twice the number of data breaches that were reported in 2017.

It is not just the number of data breaches that is concerning. Healthcare data breaches have been increasing in severity and there have been ransomware attacks that have seen patients contacted and threatened directly with the exposure of their sensitive health data. Many of the data breaches reported in 2023 have been on a colossal scale, with December no exception with two multi-million-record data breaches reported.

Since 2009, when OCR created its Wall of Shame, the number of breached records has been trending upwards, but even the most pessimistic of security professionals would not have predicted at the start of 2023 that there would be such a massive rise in breached records. 2021 was a bad year with 45.9 million records breached, and 2022 was worse with 51.9 million breached records, but in 2023, an astonishing 133 million records were exposed or stolen. On January 18, 2023, the OCR breach portal showed 133,068,542 individuals had their protected health information exposed or stolen in 2023.

We will explore the year’s data breaches in greater detail and make predictions for the coming year in posts over the next few days but first, let’s take a dive into December’s data breaches to see where and how 11,306,411 healthcare records were breached.

The Biggest Healthcare Data Breaches in December 2023

Two of the largest data breaches of 2023 were reported in December, the largest of which occurred at the New Jersey-based analytics software vendor, HealthEC. Hackers gained access to a system used by more than 1 million healthcare professionals to improve patient outcomes. The platform contained the protected health information of 4,452,782 individuals. The data breach was the second in as many months to result in the exposure of the health data of more than 1 million Michigan residents, prompting the Michigan Attorney General to call for new legislation to hold companies accountable for breaches of healthcare data.

A 2.7 million-record data breach was reported by another business associate, ESO Solutions. ESO Solutions is a provider of software solutions for hospitals, health systems, EMS agencies, and fire departments, and had its network breached and files encrypted with ransomware. At least 12 health systems and hospitals are known to have been affected.

More than 900,000 records were obtained by hackers who gained access to an archive of data from the now defunct Fallon Ambulance Services, which was being stored to meet data retention requirements by Transformative Healthcare, and a cyberattack on Electrostim Medical Services exposed the data of almost 543,000 patients.

It has now been 7 months since the Clop hacking group exploited a zero-day vulnerability in Progress Software’s MOVEit Transfer solution and data breach reports continue to be issued. More than 2,600 organizations worldwide had data stolen in the attacks, with the healthcare industry among the worst affected.

Name of Covered Entity State Covered Entity Type Individuals Affected Cause of Data Breach
HealthEC LLC NJ Business Associate 4,452,782 Hacking incident (Data theft confirmed)
ESO Solutions, Inc. TX Business Associate 2,700,000 Ransomware attack
Transformative Healthcare (Fallon Ambulance Services) MA Healthcare Provider 911,757 Hacking incident (Data theft confirmed)
Electrostim Medical Services, Inc. dba EMSI FL Healthcare Provider 542,990 Hacking incident
Cardiovascular Consultants Ltd. AZ Healthcare Provider 484,000 Ransomware attack (Data theft confirmed)
Retina Group of Washington, PLLC MD Healthcare Provider 455,935 Ransomware attack
CompleteCare Health Network NJ Healthcare Provider 313,973 Ransomware attack (Data theft confirmed)
Health Alliance Hospital Mary’s Avenue Campus NY Healthcare Provider 264,197 Hacking incident (Data theft confirmed)
Independent Living Systems, LLC FL Business Associate 123,651 Hacking incident (MOVEit)
Pan-American Life Insurance Group, Inc. LA Health Plan 105,387 Hacking incident (MOVEit)
Meridian Behavioral Healthcare, Inc. FL Healthcare Provider 98,808 Hacking incident
Mercy Medical Center IA Healthcare Provider 97,132 Hacking incident at business associate (PJ&A)
Pan-American Life Insurance Group, Inc. LA Business Associate 94,807 Hacking incident (MOVEit)
Regional Family Medicine AR Healthcare Provider 80,166 Hacking incident
HMG Healthcare, LLC TX Healthcare Provider 80,000 Hacking Incident (Data theft confirmed)
Heart of Texas Behavioral Health Network TX Healthcare Provider 63,776 Hacking incident
Kent County Community Mental Health Authority d/b/a Network180 MI Healthcare Provider 59,334 Unauthorized email account access
Highlands Oncology Group PA AR Healthcare Provider 55,297 Ransomware attack
Southeastern Orthopaedic Specialists, PA NC Healthcare Provider 35,533 Ransomware attack (Data theft confirmed)
Eye Physicians of Central Florida, PLLC, a division of Florida Pediatric Associates, LLC FL Healthcare Provider 31,189 Hacking incident (Data theft confirmed)
Clay County Social Services MN Business Associate 22,005 Ransomware attack (Data theft confirmed)
Bellin Health WI Healthcare Provider 20,790 Hacking incident
Neuromusculoskeletal Center of the Cascades, PC OR Healthcare Provider 19,373 Unauthorized email account access
Independent Living Systems, LLC FL Healthcare Provider 19,303 Hacking incident (MOVEit)
Community Memorial Healthcare, Inc. KS Healthcare Provider 14,798 Hacking incident
VNS Choice dba VNS Health Health Plans NY Health Plan 13,584 Unauthorized email account access
Hi-School Pharmacy WA Healthcare Provider 12,779 Ransomware attack

Many HIPAA-regulated entities keep information to the bare minimum in their breach reports, which allows them to meet legal requirements for breach reporting while minimizing the risk of disclosing information that could be used against them in class action lawsuits. The problem with this minimalistic breach reporting is the victims of the breach are not given enough information to accurately assess the risk they face, and the lack of transparency in data breach reporting makes it difficult to accurately assess how hackers are gaining access to healthcare networks and the nature of the attacks.

This is especially true for ransomware attacks and data theft/extortion attacks. Several breaches have been reported as hacking incidents where a possibility of unauthorized access to or theft of patient data, when the threat actors behind the attacks have claimed responsibility and have added the breached entity to their data leak sites. This trend has grown throughout the year.

December 2023 Data Breach Causes and Data Locations

All of December’s data breaches of 10,000 or more records were hacking incidents, which accounted for 83.78% of the month’s 74 data breaches (62 incidents) and 99.79% of the month’s breached healthcare records (11,283,128 records). The average breach size was 181,986 records and the median breach size was 6,728 records. In 2009, hacking incidents accounted for 49% of all data breaches of 500 or more records. In 2023, hacking incidents accounted for 79.72% of all large data breaches. Something clearly needs to be done to improve resiliency to hacking and there are signs of action being taken at the state and federal level.

In December 2023, OCR published its Healthcare Sector Cybersecurity Strategy which details several steps that OCR plans to take to improve cyber resiliency in the healthcare sector and patient safety. The extent to which these plans will be made a reality will depend on Congress making the necessary funding available. OCR is planning a much-needed update to the HIPAA Security Rule in 2024 and has stated that it will establish voluntary cybersecurity goals for the healthcare sector. OCR will be working with Congress to provide financial assistance for domestic investments in cybersecurity to help cover the initial cost. The New York Attorney General has also announced that there will be new cybersecurity requirements for hospitals in the state after a significant increase in cyberattacks, and that funds have been made available to help low-resource hospitals make the necessary improvements.

There were 8 data breaches classified as unauthorized access/disclosure incidents, involving 14,998 healthcare records. The average breach size was 1,875 records and the median breach size was 1,427 records. There were four loss/theft incidents reported in December, two of which involved stolen paperwork and two involved the loss of electronic devices, with the latter preventable if encryption had been used. 8,285 records were lost across these incidents.

The most common location of breached healthcare data was network services, which is unsurprising given the large number of hacking incidents. 14 data breaches involved protected health information stored in email accounts, three of which resulted in the exposure of more than 10,000 records.

Where did the Data Breaches Occur?

The raw data from the OCR data breach portal shows healthcare providers were the worst affected entity in December with 49 reported breaches of 500 or more records, followed by business associates with 13 breaches, health pans with 11, and a single breach at a healthcare clearinghouse. While healthcare providers suffered the most breaches, it was data breaches at business associates that exposed the most records. Across the 13 business associate-reported breaches, 7,416,567 records were breached, compared to 3,730,791 records in the 49 breaches at healthcare providers. The health plan breaches exposed 156,479 records and 2,574 records were exposed in the healthcare clearinghouse data breach.

These figures do not tell the full story, as the reporting entity may not be the entity that suffered the data breach. Many data breaches occur at business associates of HIPAA-covered entities but are reported to OCR by the covered entity rather than the business associate. A deeper dive into the data to determine where the breach actually occurred reveals there were 24 data breaches at business associates (7,544,504 records), 43 data breaches at healthcare providers (3,616,078 records), 6 data breaches at health plans (143,255 records), and one breach at a healthcare clearinghouse (2,574 records).

The average size of a business associate data breach was 314,354 records (median: 2,749 records), the average size of a healthcare provider data breach was 84,095 records (median: 5,809 records), and the average health plan data breach was 23,876 records (median: 7,695 records). The chart below shows where the data breaches occurred rather than the reporting entity.

Geographical Distribution of Healthcare Data Breaches

HIPAA-regulated entities in 32 states reported data breaches of 500 or more records in December. California was the worst affected state with 85 large data breaches followed by New York and Texas with 7 reported breaches.

State Number of Breaches
California 8
New York & Texas 7
Florida 6
Massachusetts 4
New Jersey, Tennessee & Wisconsin 3
Arkansas, Connecticut, Illinois, Kansas, Kentucky, Louisiana, Maryland, North Carolina & Washington 2
Alaska, Arizona, Colorado, Iowa, Michigan, Minnesota, Mississippi, Missouri, Montana, New Mexico, North Dakota, Oregon, South Carolina, Virginia & West Virginia 1

HIPAA Enforcement in December 2023

OCR announced two enforcement actions against healthcare providers in December to resolve alleged violations of the HIPAA Rules. OCR continued its enforcement initiative targeting noncompliance with the HIPAA Right of Access with its 46th enforcement action over the failure to provide individuals with timely access to their medical records. Optum Medical Care of New Jersey settled its investigation and agreed to pay a financial penalty of $160,000 to resolve allegations that patients had to wait between 84 days and 231 days to receive their requested records when they should have been provided within 30 days.

OCR also announced its first-ever settlement resulting from an investigation of a phishing attack. Lafourche Medical Group in Louisiana suffered a phishing attack that resulted in the exposure of the protected health information of almost 35,000 individuals. While phishing attacks are not HIPAA violations, OCR’s investigation uncovered multiple violations of the HIPAA Security Rule, including no risk analyses prior to the 2021 phishing attack, and no procedures to regularly review logs of system activity before the attack. Lafourche Medical Group chose to settle the investigation and paid a $480,000 penalty.

These two enforcement actions bring the total number of OCR enforcement actions involving financial penalties up to 13, the lowest annual total since 2019, although there was a slight increase in funds raised from these enforcement actions with $4,176,500 collected in fines. OCR is pushing Congress to increase the penalties for HIPAA violations to make penalties more of a deterrent and also to provide much-needed funding to allow OCR to clear the backlog of HIPAA compliance investigations, in particular investigations of hacking incidents. Currently, OCR’s hands are tied, as the department’s budget has remained the same for years, aside from annual increases for inflation, yet its caseload of breach investigations has soared.

HIPAA Enforcement by State Attorneys General

State attorneys general have the authority to enforce HIPAA compliance and 2023 saw an increase in enforcement actions. The HIPAA Journal has tracked 16 enforcement actions by state attorneys general in 2023 that resolved violations of HIPAA or equivalent state consumer protection and data breach notification laws. In December, three enforcement actions were announced, two by New York Attorney General Letitia James and one by Indiana Attorney General Todd Rokita. New York has been particularly active this year having announced 4 settlements to resolve HIPAA violations in 2023 and the state also participated in two multi-state actions.

In December, AG James announced a settlement had been reached with Healthplex to resolve alleged violations of New York’s data security and consumer protection laws with respect to data retention, logging, MFA, and data security assessments which contributed to a cyberattack and data breach that affected 89,955 individuals. The case was settled for $400,000. AG James also investigated New York Presbyterian Hospital over a reported breach of the health information of 54,396 individuals related to its use of tracking technologies on its website, which sent patient data to third parties such as Meta and Google in violation of the HIPAA Privacy Rule and New York Executive Law. The case was settled for $300,000.

The Indiana Attorney General investigated CarePointe ENT over a breach of the health information of 48,742 individuals. AG Rokita alleged that CarePointe ENT was aware of security issues several months before they were exploited by cybercriminals but did not address them in a timely manner. There was also no business associate agreement with its IT services provider. The investigation was settled for $125,000.

The data for this report was obtained from the U.S. Department of Health and Human Services’ Office for Civil Rights on January 18, 2023.

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Multiple Threat Groups Exploiting Ivanti VPN/NAS Zero-Days

Urgent action is required to fix two zero day flaws in Ivanti Connect Secure VPN and Policy Secure NAS appliances. The vulnerabilities were discovered by researchers at Volexity and were disclosed by Avanti last week. While they have been exploited in the wild since December 2023 by an Advanced Persistent Threat group, the attacks have been highly targeted and at the time of the disclosure, fewer than 20 customers had been attacked but the situation has now changed. On January 11, 2023, multiple threat actors started mass exploiting the flaws in indiscriminate attacks on businesses of all sizes across multiple sectors.

Ivanti will be releasing patches to fix the flaws starting in the week of January 22, 2024, and final patches will be released in the week of February 19, 2024; however, there is a workaround that can prevent exploitation of the flaws until the patches are released Any HIPAA-regulated entity that uses one of the vulnerable products should ensure that the workaround is implemented immediately given the extent to which the flaws are being exploited.

The vulnerabilities are CVE-2023-46805, an authentication bypass flaw (CVSS 8.2) that is present in of Ivanti ICS 9.x, 22.x and Ivanti Policy Secure, and CVE-2024-21887, a command injection vulnerability (CVSS 9.1) in Ivanti Connect Secure 9.x, 22.x and Ivanti Policy Secure. The authentication bypass flaw allows an unauthenticated remote attacker to bypass security controls and access restricted resources, and the command injection flaw allows an authenticated administrator to send specially crafted requests and execute arbitrary commands on the appliance.

The initial attacks were conducted by an unknown APT group that downloaded malware tool kits for espionage purposes. The latter attacks have been conducted by multiple threat actors. One actor has already attacked hundreds of appliances and backdoored targets’ systems using a GIFTEDVISITOR webshell variant. According to Volexity, as of January 14, 2023, more than 1,700 ICS VPN appliances had been compromised with the webshell.

In addition to applying the mitigation measures, customers have been advised to run the Ivanti Integrity Checker Tool to identify signs of compromise.

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At Least 141 Were Hospitals Directly Affected by Ransomware Attacks in 2023

Last year was a particularly bad year for ransomware attacks. According to an analysis by the cybersecurity firm Emsisoft, 46 hospital systems suffered ransomware attacks in 2023, up from 25 in 2022 and 27 in 2021. Across those 46 attacks, at least 141 hospitals were directly affected and experienced disruption due to the lack of access to IT systems and patient data.

It is difficult to accurately report on ransomware attacks in the healthcare sector, as many victims fail to disclose whether ransomware was used. Breach notification letters to the affected individuals and state Attorneys General often describe ransomware attacks as cyberattacks, unauthorized access, hacking incidents, security incidents, or encryption events, and as such, the number of attacks experienced in the sector is likely to be significantly understated. Emsisoft’s State of Ransomware in the U.S.: Report and Statistics 2023 reveals 2,207 U.S. hospitals, schools, and governments were directly impacted by ransomware in 2023 and many others were indirectly impacted via attacks on their supply chains.

Without access to patient records and essential IT systems, hospitals are often forced to put their emergency departments on redirect, with ambulances sent to neighboring healthcare facilities. Other hospitals in the region are placed under an increased strain due to the sharp increase in the number of patients, and the resource constraints caused by the increase in patients has a negative impact on time-sensitive conditions such as acute stroke.

The outages caused by these attacks mean scheduled appointments often need to be canceled and rescheduled and bottlenecks occur with lab testing and radiology, resulting in delays to diagnosis and treatment, longer patient stays, a slowing of patient throughput, and the disruption inevitably results in poorer patient outcomes. While there have been no reported deaths in the United States as a direct result of ransomware attacks, studies have shown that following a ransomware attack, there is an increase in medical complications and mortality rates. One study, conducted by McGlave, Neprash, and Nikpay of the University of Minnesota School of Public Health, found that in-hospital mortality for patients already admitted at the time of a ransomware attack increased. The attacks also caused a 17%-25% reduction in hospital volume during the initial attack week, and they estimated that between 2016 and 2021, ransomware attacks killed between 42 and 67 Medicare patients.

These attacks naturally have a significant financial impact. According to the Verizon Cost of a Data Breach Report, the average cost of a healthcare data breach increased to its highest ever level in 2023, costing an average of $11 million, a 53% increase since 2020. Emsisoft said 32 of the 46 attacks on health systems resulted in sensitive data, including protected health information, being stolen.

The average ransom payment in 2028 was $5,000, but by 2023 the average payment increased by 29,900% to around $1.5 million. The increased profits from ransomware attacks allow ransomware groups to scale their operations, pay initial access brokers, and purchase zero-days, which means even more attacks can be conducted. Fewer victims are now paying ransoms which means ransom demands need to increase to make up for the shortfall. Some ransomware groups have also started engaging in more aggressive tactics, such as contacting patients and demanding payment. Some attacks on plastic surgery centers have resulted in intimate images being publicly posted and patients being told they needed to pay to have those images removed from the Internet. One group contacted individual patients and threatened them with the release of their sensitive data and demanded $50 per patient to delete their data.

Many ransomware groups operate out of countries that turn a blind eye to the attacks, and some nation states are thought to use ransomware groups as proxies. While international law enforcement operations have successfully disrupted some ransomware groups, the individuals involved are rarely brought to justice. With so much money involved and a low risk of being caught, attacks are unlikely to reduce and may even continue to increase. The solution suggested by Emsisoft and many other experts is simple. Since ransomware attacks are conducted by financially motivated threat actors, making attacks unprofitable is the easiest way of tackling the problem. Governments should therefore ban ransom payments and cut off this very lucrative income stream.

“Current counter-ransomware strategies amount to little more than building speed bumps and whacking moles. The reality is that we’re not going to defend our way out of this situation, and we’re not going to police our way out of it either. For as long as ransomware payments remain lawful, cybercriminals will do whatever it takes to collect them,” said Emsisoft Threat Analyst, Brett Callow. “The only solution is to financially disincentivize attacks by completely prohibiting the payment of demands. At this point, a ban is the only approach that is likely to work.”

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