HIPAA Compliance News

The HIPAA Risk Analysis: Guidance and Tools for HIPAA Covered Entities and Business Associates

The HIPAA Risk analysis is a foundational element of HIPAA compliance, yet it is something that many healthcare organizations and business associates get wrong. That places them at risk of experiencing a costly data breach and a receiving a substantial financial penalty for noncompliance.

The HIPAA Risk Analysis

The administrative safeguards of the HIPAA Security Rule require all HIPAA-covered entities to “conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information.” See 45 C.F.R. § 164.308(u)(1)(ii)(A).

The risk analysis is a foundational element of HIPAA compliance and is the first step that must be taken when implementing safeguards that comply with and meet the standards and implementation specifications of the HIPAA Security Rule.

If a risk analysis is not conducted or is only partially completed, risks are likely to remain and will therefore not be addresses through an organization’s risk management process – See § 164.308(u)(1)(ii)(B) – and will not be reduced to a reasonable and appropriate level to comply with the § 164.306 (a) Security standards: General Rules.

A HIPAA risk analysis is also necessary to determine whether it is reasonable and appropriate to use encryption or whether alternative safeguards will suffice – See 45 C.F.R. §§ 164.312(a)(2)(iv) and (e)(2)(ii).

A risk analysis should also be used to guide organizations on authentication requirements – See 45 C.F.R. § 164.312(c)(2) – and the methods that should be used to protect ePHI in transit – See 45 C.F.R. § 164.312(c)(2).

If risks are allowed to persist, they can potentially be exploited by hackers and other malicious actors resulting in impermissible disclosures of ePHI.

During investigations of data breaches, the Department of Health and Human Services’ Office for Civil Rights looks for HIPAA compliance failures that contributed to the cause of the breach. One of the most common violations discovered is a failure to conduct a comprehensive, organization-wide risk analysis. A high percentage of OCR resolution agreements cite a risk analysis failure as one of the primary reasons for a financial penalty.

Requirements of a HIPAA Risk Analysis

The HIPAA Security Rule states that a risk analysis is a required element of HIPAA compliance, but does not explain what the risk analysis should entail nor the method that should be used to conduct a risk analysis. That is because there is no single method of conducting a risk analysis that will be suitable for all organizations, nor are there any specific best practices that will ensure compliance with this element of the HIPAA Security Rule.

OCR has explained the requirements of a HIPAA risk analysis on the HHS website. HHS guidance on risk analysis requirements of the HIPAA Security Rule is also available as a downloadable PDF (36.1 KB), with further information available in the NIST Risk Management Guide for Information Technology Systems – Special Publication 800-30 (PDF – 480 KB).

A Security Risk Assessment Tool to Guide HIPAA-Covered Entities Through a HIPAA Risk Analysis

The risk analysis process can be a challenge. To make the process easier, the HHS’ Office of the National Coordinator for Health Information Technology (ONC), in collaboration with the Office for Civil Rights, has developed a downloadable security risk assessment tool that guides HIPAA-covered entities through the process of conducting a security risk assessment.

After downloading and installing the tool, healthcare organizations can enter information and a report will be generated that helps them determine risks in policies, processes and systems and details some of the methods that can be used to mitigate weaknesses when the user is performing a risk assessment.

On October 15, 2018, ONC updated the tool (version 3.0). The aim of the update was “to make it easier to use and apply more broadly to the risks of the confidentiality, integrity, and availability of health information. The tool diagrams HIPAA Security Rule safeguards and provides enhanced functionality to document how your organization implements safeguards to mitigate, or plans to mitigate, identified risks,” wrote ONC.

The new features include an updated and enhanced user interface, a modular workflow, custom assessment logic, a progress tracker, threat and vulnerability ratings, more detailed reports, assess tracking, business associate track, and several enhancements to improve the user experience.

Use of the tool will not guarantee compliance with HIPAA or other federal, state, or local laws, but it is incredibly useful tool for guiding HIPAA-covered entities and business associates through the process of conducting a HIPAA-compliant risk analysis.

The updated Security Risk Assessment Tool can be downloaded from the HealthIT.gov website on this link.

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$16 Million Anthem HIPAA Breach Settlement Takes OCR HIPAA Penalties Past $100 Million Mark

OCR has announced that an Anthem HIPAA breach settlement has been reached to resolve potential HIPAA violations discovered during the investigation of its colossal 2015 data breach that saw the records of 78.8 million of its members stolen by cybercriminals.

Anthem has agreed to pay OCR $16 million and will undertake a robust corrective action plan to address the compliance issues discovered by OCR during the investigation.

The previous largest ever HIPAA breach settlement was $5.55 million, which was agreed with Advocate Health Care in 2016. “The largest health data breach in U.S. history fully merits the largest HIPAA settlement in history,” said OCR Director Roger Severino.

Anthem Inc., an independent licensee of the Blue Cross and Blue Shield Association, is America’s second largest health insurer. In January 2015, Anthem discovered cybercriminals had breached its defenses and had gained access to its systems and members’ sensitive data. With assistance from cybersecurity firm Mandiant, Anthem determined this was an advanced persistent threat attack – a continuous and targeted cyberattack conducted with the sole purpose of silently stealing sensitive data.

The attackers first gained access to its IT systems on December 2, 2014, with access continuing until January 27, 2015. During that time the attackers stole the data of 78.8 million plan members, including names, addresses, dates of birth, medical identification numbers, employment information, email addresses, and Social Security numbers.

The attackers gained a foothold in its network through spear phishing emails sent to one of its subsidiaries. They were then able to move laterally through its network to gain access to plan members’ data.

Anthem reported the data breach to OCR on March 13, 2015; however, by that time OCR was already a month into a compliance review of Anthem Inc. OCR took prompt action after Anthem uploaded a breach notice to its website and media reports started to appear indicating the colossal scale of the breach.

The OCR investigation uncovered multiple potential violations of HIPAA Rules. Anthem chose to settle the HIPAA violation case with no admission of liability.

OCR’s alleged HIPAA violations were:

  • 45 C.F.R. § 164.308(u)(1)(ii)(A) – A failure to conduct a comprehensive, organization-wide risk analysis to identify potential risks to the confidentiality, integrity, and availability of ePHI.
  • 45 C.F.R. § 164.308(a)(1)(ii)(D) – The failure to implement regularly review records of information system activity.
  • 45 C.F.R. § 164.308 (a)(6)(ii) – Failures relating to the requirement to identify and respond to detections of a security incident leading to a breach.
  • 45 C.F.R. § 164.312(a) – The failure to implement sufficient technical policies and procedures for electronic information systems that maintain ePHI and to only allow authorized persons/software programs to access that ePHI.
  • 45 C.F.R. § 164.502(a) – The failure to prevent the unauthorized accessing of the ePHI of 78.8 million individuals that was maintained in its data warehouse.

“Unfortunately, Anthem failed to implement appropriate measures for detecting hackers who had gained access to their system to harvest passwords and steal people’s private information,” said Roger Severino. “We know that large health care entities are attractive targets for hackers, which is why they are expected to have strong password policies and to monitor and respond to security incidents in a timely fashion or risk enforcement by OCR.”

In addition to the OCR HIPAA settlement, Anthem has also paid damages to victims of the breach. Anthem chose to settle a class action lawsuit filed on behalf of 19.1 million customers whose sensitive information was stolen. Anthem agreed to settle the lawsuit of $115 million.

2018 OCR HIPAA Settlements and Civil Monetary Penalties

Given the size of the Anthem HIPAA settlement it is no surprise that 2018 has seen OCR smash its previous record for financial penalties for HIPAA violations. The latest settlement takes OCR HIPAA penalties past the $100 million mark.

There have not been as many HIPAA penalties in 2018 than 2016(13), although this year has seen $1.4 million more raised in penalties than the previous record year and there are still 10 weeks left of 2018. The total is likely to rise further still.

OCR Financial Penalties for HIPAA Violations (2008-2018)

Year Settlements and CMPs Total Fines
2018 1 $24,947,000
2017 1 $19,393,000
2016 2 $23,505,300
2015 3 $6,193,400
2014 5 $7,940,220
2013 5 $3,740,780
2012 6 $4,850,000
2011 6 $6,165,500
2010 13 $1,035,000
2009 10 $2,250,000
2008 7 $100,000
Total 59 $100,120,200


HIPAA Fines and CMPs

Largest Ever Penalties for HIPAA Violations

Year Covered Entity Amount Settlement/CMP
2018 Anthem Inc $16,000,000 Settlement
2016 Advocate Health Care Network $5,550,000 Settlement
2017 Memorial Healthcare System $5,500,000 Settlement
2014 New York and Presbyterian Hospital and Columbia University $4,800,000 Settlement
2018 University of Texas MD Anderson Cancer Center $4,34,8000 Civil Monetary Penalty
2011 Cignet Health of Prince George’s County $4,300,000 Civil Monetary Penalty
2016 Feinstein Institute for Medical Research $3,900,000 Settlement
2018 Fresenius Medical Care North America $3,500,000 Settlement
2015 Triple S Management Corporation $3,500,000 Settlement
2017 Children’s Medical Center of Dallas $3,200,000 Civil Monetary Penalty

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Aetna Settles HIPAA Violation Case with State AGs

In 2017, errors occurred with two Aetna mailings that resulted in the impermissible disclosure of the protected health information of plan members, including HIV statuses and AFib diagnoses.

A class action lawsuit was filed on behalf of the victims of the HIV status breach which was settled for $17 million in January. Now Aetna has reached settlements with the attorneys general for New Jersey, Connecticut, and the District of Columbia to resolve the alleged HIPAA violations discovered during an investigation into the privacy breaches.

The first mailing was sent on July 28, 2017 by an Aetna business associate. Over-sized windowed envelopes were used for the mailing, through which it was possible to see the names and addresses of plan members along with the words “HIV Medications.” Approximately 12,000 individuals received the mailing.

In September, a second mailing was sent on behalf of Aetna to 1,600 individuals. This similarly resulted in an impermissible disclosure of PHI. In addition to names and addresses, the logo of an IMPACT AFib study was visible, which suggested the individual had been diagnosed with atrial fibrillation.

A multi-state investigation was launched to investigate potential violations of the Health Insurance Portability and Accountability Act (HIPAA) and state laws pertaining to the protected health information of state residents, including the Consumer Protection Procedures Act in DC and the New Jersey AIDS Assistance Act.

The investigation confirmed that in both cases there had been an impermissible disclosure of protected health information, that Aetna failed to protect consumers’ confidential health information, and that Aetna had deceived consumers about its ability to safeguard their health information.

Aetna has agreed to settlements with the State of Connecticut ($99,959), the District of Columbia ($175,000) and a civil monetary penalty of $365,211.59 will be paid to the State of New Jersey. Washington also participated in the investigation but has yet to decide on an appropriate settlement amount.

“Companies entrusted with individuals’ protected health information have a duty to avoid improper disclosures,” said New Jersey attorney general Gurbir Grewal. “Aetna fell short here, potentially subjecting thousands of individuals to the stigma and discrimination that, unfortunately, still may accompany disclosure of their HIV/AIDS status. I am pleased that our investigation has led Aetna to adopt measures to prevent this from happening again.”

“Every patient should feel confident that their insurance company or health provider will safeguard their confidential medical information. Today’s action will prevent further disclosures and warns other insurance companies that they are responsible for protecting consumers’ private information,” said, District of Columbia attorney general Karl A. Racine.

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HSS Secretary Issues Limited Waiver of HIPAA Penalties Following Declaration of Public Health Emergency in Florida and Georgia

Following the presidential declaration of public health emergencies in the states of Florida and Georgia in the wake of hurricane Michael, secretary of the Department of Health and Human Services (HHS) Alex Azar has followed suit in both states and has exercised his authority to waive HIPAA sanctions and penalties for certain provisions of the HIPAA Privacy Rule in the disaster areas.

The HHS announced the public health emergency in Florida on October 9, and Georgia on October 11.

The HIPAA Privacy Rule does permit healthcare providers to share protected health information during disasters to assist patients and ensure they receive the care they need, including sharing information with friends, family members and other individuals directly involved in a patient’s care. The HIPAA Privacy Rule allows the sharing of PHI for public health activities and to prevent or reduce a serious and imminent threat to health or safety. HIPAA-covered entities are also permitted to share information with disaster relief organizations that have been authorized by law to assist with disaster relief efforts without first obtaining permission from patients.

During natural disasters the HIPAA Privacy and Security Rules remain in effect, although following the secretarial declaration, sanctions and penalties against HIPAA covered entities have been waived for the following provisions of the HIPAA Privacy Rule:

  • The requirements to obtain a patient’s agreement to speak with family members or friends involved in the patient’s care. See 45 CFR 164.510(b).
  • The requirement to honor a request to opt out of the facility directory. See 45 CFR164.510(a).
  • The requirement to distribute a notice of privacy practices. See 45 CFR 164.520.
  • The patient’s right to request privacy restrictions. See 45 CFR 164.522(a).
  • The patient’s right to request confidential communications. See 45 CFR 164.522(b).

The waiver only applies to qualifying hospitals in the emergency area for the period identified in the public health emergency declaration. Qualifying hospitals are permitted to take advantage of the waiver for up to 72 hours, provided their disaster protocol has been implemented.

The waiver is only in place for the 72-hour period or the duration of the public health emergency declaration, whichever terminates sooner. Once the 72-hour time period is over or the presidential or secretarial declaration terminates, the waiver ends, even for patients still under a hospital’s care.

“We are working closely with state health authorities and private sector partners from hospitals and other healthcare facilities to save lives and protect public health after Hurricane Michael,” said secretary Azar. The declarations will help to ensure that residents in both states have continuous access to the care they need.”

The HHS has said more than 400 medical and public health personnel have been moved into the disaster areas along with caches of medical equipment and a further 300 personnel from the National Disaster Medical Systems and the U.S. Public Health Service Commissioned Corps have been placed on alert. HHS teams will be providing medical services in shelters, assisting with disease surveillance, offering behavioral support to residents and responders, and will be helping to assess whether further federal medical and health support is required in the disaster areas.

HHS guidance on hurricane preparedness, response and recovery can be found here.

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Hospitals Failing to Fully Comply with HIPAA Requirement for Providing Patients with Copies of Medical Records

The HIPAA Privacy Rule gave patients the right to obtain a copy of their medical records from their healthcare providers. Under HIPAA, copies of medical records should be provided to patients as soon as possible, but no later than 30 days from when the request is made.

Even though compliance with the HIPAA Privacy Rule has been mandatory since April 14, 2003, there have been several cases of hospitals failing to provide patients with copies of their medical records. In 2011, the Department of Health and Human Services’ Office for Civil Rights (OCR) sent a message to healthcare providers about this aspect of HIPAA compliance when it issued a $4,300,000 civil monetary penalty to Cignet Health of Prince George’s County.

Even though it has now been 15 years since compliance with the HIPAA Privacy Rule became mandatory, there is still widespread noncompliance when it comes to providing patients with copies of their medical records.

According to a new study published in JAMA Network Open, healthcare providers are not providing patients with copies of their full medical records, many are charging excessive amounts, and some hospitals are making it hard for patients to find out about and exercise their right to have a copy of their health data.

The study was conducted by Yale University School of Medicine researchers who evaluated processes for releasing medical records to patients at 83 of the leading hospitals in the United States. According to the study, only 53% of hospitals provided patients with the option of obtaining their entire medical record.

HIPAA requires patients to be provided with copies of their medical records in the format of their choice, yet many hospitals were failing to comply with this requirement and there were discrepancies between information provided over the phone and what was detailed on release forms.

For example, over the telephone, 83% of hospitals said copies of medical records could be picked up in person, yet only 48% stated this on the release forms. 66% said electronic medical records could be provided on a CD over the telephone, but this was only an option on 25% of forms.

In 2016, OCR clarified patients’ right to access their medical records and the amounts that healthcare providers can charge for providing patients with copies of their health information. A flat fee of no more than $6.50 was recommended to release electronically maintained medical records to a patient. However, the study revealed that 48 of the 83 hospitals charged patients more than this amount. One hospital charged $541.50 for a 200-page medical record.

43% of hospitals did not state on the request forms how much patients would be charged for exercising their right to obtain a copy of their medical records and only 35% of hospitals disclosed exact costs on the release form or the web page where the form could be downloaded.

At least 7 hospitals (8%) were non-compliant with the maximum processing time of 30 days, with each of those hospitals providing a time range with the upper limit outside the 30-day maximum.

Information on forms was found to be incomplete or incorrect and patients were required to call the medical records department to find out the full parameters for releasing medical records. Some hospitals were unwilling to provide paper and electronic copies of medical records and there was no consistency in processes for releasing medical records to patients across the 83 hospitals that were studied.

“The lack of a uniform procedure for requesting medical records across US hospitals highlights a systemic problem in complying with the right of access under HIPAA,” wrote the researchers. “Because every institution creates its own process and implements its own regulations, variability in what and how records can be received occurs.”

Co-author of the report, Harlan Krumholz, MD, said, “If we really want to move to a healthcare system where patients are at the center, then we need to find ways to ensure that they have agency over their own data. We’re far from that right now.”

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California HIV Patient PHI Breach Lawsuit Allowed to Move Forward

A lawsuit filed by Lambda Legal on behalf of a victim of a data breach that saw the highly sensitive protected health information of 93 lower-income HIV positive individuals stolen by unauthorized individuals has survived a motion to dismiss.

The former administrator of the California AIDS Drug Assistance Program (ADAP), A.J. Boggs & Company, submitted a motion to dismiss but it was recently rejected by the Superior Court of California in San Francisco.

In the lawsuit, Lambda Legal alleges A.J. Boggs & Company violated the California AIDS Public Health Records Confidentiality Act, the California Confidentiality of Medical Information Act, and other state medical privacy laws by failing to ensure an online system was secure prior to implementing that system and allowing patients to enter sensitive information.

A.J. Boggs & Company made its new online enrollment system live on July 1, 2016, even though it had previously received several warnings from nonprofits and the LA County Department of Health that the system had not been tested for vulnerabilities.

It was alleged that the failure to ensure its system was secure meant that any information entered in the portal by patients was at risk of exposure and could potentially be obtained by unauthorized individuals. In November 2016, four months after the system went live, A.J. Boggs & Company took the system offline to correct the flaws.

However, in February 2017, the California Department of Health discovered that the flaws in its portal had been exploited and unauthorized individuals had gained access to the system and had downloaded the private and highly sensitive information of 93 patients with HIV or AIDS. Following the discovery, the contract with the firm was cancelled and a new state-run system was adopted.

The ADAP program provides states with federal funding to provide financial assistance to low-income individuals with HIV or AIDS to make HIV medications more affordable, extending access to Medicaid when patients earned too much. Any medical data breach is serious, although the disclosure of an individual’s HIV status is especially so.

“HIV is still a highly stigmatized medical condition,” said Scott Schoettes, HIV Project Director at Lambda Legal. “When members of already vulnerable communities — transgender people, women, people of color, undocumented people, individuals with low incomes — already face challenges in accessing health care, undermining the trust they have in the ADAP is not just a breach of security; it creates a barrier to care.”

Lambda Legal is seeking statutory and compensatory damages for the patient and is seeking class action status to allow the other 92 breach victims to be included in the lawsuit.

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Claxton-Hepburn Medical Center Fires Several Employees for Inappropriate PHI Access

Claxton-Hepburn Medical Center, a not-for-profit 115-bed community hospital in Ogdensburg, NY, has fired several employees for accessing patient health records without authorization.

The PHI breaches were discovered during an internal investigation. It is unclear whether that investigation was launched following a complaint that had been received or if the patient privacy violations were uncovered during a routine audit of PHI access logs – A requirement of HIPAA.

Claxton-Hepburn Medical Center has not publicly disclosed how many employees were terminated over the violations, only reporting that all employees who purposely committed the acts were terminated. It is also currently unclear exactly how many patients’ PHI was breached.

Claxton-Hepburn Medical Center has confirmed that training is given to all employees on the first day of employment detailing the requirements of HIPAA and the importance of protecting the privacy of patients. All employees are made aware that accessing patient health information is only permitted when PHI needs to be viewed to complete work duties or when patient records need to be updated, as per the requirements of the HIPAA Privacy Rule. Employees are also made aware that any unauthorized accessing of PHI will result in disciplinary action. It would have been clear to the employees concerned that their actions were in violation of HIPAA Rules.

The discovery of the privacy breaches has prompted the hospital to implement further safeguards to reduce the likelihood of future HIPAA violations of this nature occurring. Claxton-Hepburn Medical Center has also notified all patients by mail whose records were inappropriately accessed.

While it is possible for criminal charges to be filed against healthcare employees for HIPAA Privacy Rule violations, in this instance Claxton-Hepburn Medical Center has not involved the police.

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HIPAA Quiz Launched by Compliancy Group

A new HIPAA Quiz has been launched by the Compliancy Group, which serves as a quick and easy free tool to assess the current state of HIPAA compliance in an organization.  

Healthcare organizations that have implemented policies and procedures to comply with the Health Insurance Portability and Accountability Act (HIPAA) Rules may think that they are fully compliant with all provisions of the HIPAA Privacy, Security, and Breach Notification Rules. However, HHS’ Office for Civil Rights (OCR) compliance audits and investigations into data breaches and complaints often reveal certain requirements of HIPAA have been missed or misinterpreted.

OCR investigates all breaches of more than 500 records and so far in 2018, six financial penalties have been issued to HIPAA covered entities to resolve HIPAA violations. The average settlement/civil monetary penalty in 2018 is $1,491,166.

State attorneys general also investigate data breaches and complaints and can also issue fines for noncompliance with HIPAA Rules. There have been five fines issued by state attorneys general in 2018 to resolve HIPAA violations. The average settlement amount is $514,563 in 2018 and was $718,800 in 2017.

To help healthcare organizations comply with HIPAA Rules and avoid financial penalties, the Compliancy Group, a team of HIPAA compliance experts that help healthcare organizations meet HIPAA requirements, has released a free HIPAA Quiz that allows healthcare organizations to conduct a quick assessment to determine whether they are meeting the basic requirements of HIPAA. The quiz consists of yes/no questions that have been designed to get a baseline reading of HIPAA compliance against the fundamental elements of HIPAA.

“We designed the Compliancy Group HIPAA Quiz to empower health care professionals,” said Joe Bilello, Vice President of Compliancy Group. “Too often we see misconceptions around HIPAA compliance in the health care market. We hope the HIPAA Quiz will give users the chance to find out what’s really required for HIPAA compliance, rather than relying on hearsay and outdated information. Compliancy Group is always here to help address HIPAA concerns for anyone from single-doctor practices, to large-scale technology providers.”

The HIPAA compliance assessment tool can be accessed on this link.

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Massachusetts Gynecologist Spared Jail Time for Criminal HIPAA Violation

In April 2018, the former Massachusetts-based gynecologist Rita Luthra, 65, of Longmeadow, was convicted of criminally violating the HIPAA Privacy Rule and obstructing a federal investigation into a nationwide kickback scheme. At her sentencing on September 19, 2018, Luthra was spared jail time and a fine and was given one year of probation.

Luthra was accused of being paid $23,500 to prescribe Warner Chilcott’s osteoporosis drugs, although Luthra maintained she had been paid the money as ‘speaker fees’ for speaking at medical educational events, which took place in her office, and for writing a research paper, although that paper was never finished. The jury found that Luthra lied to federal agents about money she had received from the pharmaceutical firm.

Luthra also denied providing a pharmaceutical sales representative with access to patient health information in order to complete pre-authorization forms for insurance companies that were refusing to approve prescriptions for two osteoporosis drugs that Warner Chilcott was pushing. She also allegedly instructed her assistant to lie to federal investigators and back up her story. The jury also found that Luthra had violated the HIPAA Privacy Rule.

After Luthra was arrested she lost her license to practice and also faced up to six years in jail with one year of supervised release and a maximum fine of $300,000 – $50,000 for the HIPAA violation and $250,000 for obstruction. However, U.S. District Judge Mark G. Mastroianni opted for leniency and sentenced Luthra to just one year of probation. Prosecutors were pushing for Luthra to receive a jail term of two and a half years and pay a financial penalty of $40,000. Judge Mastroianni also rejected the defense’s argument that she should be given community service.

Luthra’s lawyer, Stephen Spelman, said “Dr. Rita Luthra dedicates herself to serving others, and spends her professional lifetime treating women and girls from the disadvantaged communities in Western Massachusetts, never caring whether her patients could pay.”

Spelman also explained in a presentencing memo that Luthra “Suffered repeated beatings by her husband, who on multiple occasions tried to amputate her fingers with knives – because she was a surgeon. After one particularly vicious assault, she left the marriage, fleeing her marital home on a snowy night with literally nothing but the clothes on her back.”

It was Luthra’s work with disadvantaged women and girls in the impoverished areas of Springfield that prompted Judge Mastroianni to reject the prosecutors’ recommendation of a fine and to spare Luthra jail time. Prosecutors were pushing for jail time and a fine to serve as a deterrent, although Judge Mastroianni explained in his ruling, “Her loss of license and ability to practice is a substantial deterrent.”

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