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HIPAA Privacy Complaints

HIPPA Complaint

HIPAA Journal published an article online this week addressing client HIPAA violation complaints and whether or not health care providers are equipped to properly address these complaints. According to the article, in order for an efficient response to be conducted, policies should be developed covering the complaints procedure and staff must be trained to handle HIPAA privacy complaints correctly. Also, patients must also be clearly informed how they can make a HIPAA privacy complaint if they feel that their privacy has been violated or HIPAA Rules have been breached. This should be clearly stated in your Notice of Privacy Practices.

For more information and to view the full article visit HIPAA Journal’s website here.

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October 2017 Healthcare Data Breaches

In October 2017, there were 27 healthcare data breaches reported to the Department of Health and Human Services’ Office for Civil Rights. Those data breaches resulted in the theft/exposure of 71,377 patient and plan member records. October saw a significant fall in the number of reported breaches compared to September, and a major fall in the number of records exposed.

Healthcare data breaches by month (July-October 2017)

October saw a major reduction in the number of breached records, with the monthly total almost 85% lower than September and almost 88% lower than the average number of records breached over the preceding three months.

healthcare records breached July-October 2017

Healthcare providers were the worst hit in October with 19 reported data breaches. There were six data breaches reported by health plans and at least two incidents involved business associates of HIPAA-covered entities.

October 2017 Healthcare Data Breaches by Covered Entity Type

October 2017 healthcare data breaches by covered entity type

Main Causes of October 2017 Healthcare Data Breaches

Unauthorized access/disclosures were the biggest causes of healthcare data breaches in October. There were 14 breaches reported involving unauthorized access/disclosures, 8 hacking incidents, four cases of theft, and one unencrypted laptop computer was lost.

cause of october 2017 healthcare data breaches

Unauthorized access/disclosures were the leading causes of October 2017 healthcare data breaches, although hacking/IT incidents exposed more records – Over twice the number of records exposed by unauthorized access/disclosures and hacking/IT incidents exposed more records than all other breach types combined.

october 2017 healthcare data breaches - records exposed

Location of Exposed and Stolen Protected Health Information

Email was the most common location of breached PHI in October. Five of the nine incidents involving email were the result of hacking/IT incidents such as phishing. The remaining four incidents were unauthorized access/disclosures such as healthcare employees sending emails containing PHI to incorrect recipients. Five incidents involved paper records, highlighting the importance of securing physical records as well as electronic protected health information.

october 2017 healthcare data breaches - location of breached PHI

October 2017 Healthcare Data Breaches by State

In October, healthcare organizations based in 22 states reported data breaches. The state that experienced the most data breaches was Florida, with 3 reported breaches. Maryland, Massachusetts, and New York each had two breaches.

Alabama, Arizona, California, Connecticut, Georgia, Iowa, Illinois, Kansas, Kentucky, Louisiana, Missouri, North Carolina, Ohio, Rhode Island, Tennessee, Texas, Virginia, and Washington each had one reported breach.

Largest Healthcare Data Breaches in October 2017

 

Breached Entity Entity Type Breach Type Individuals Affected
Chase Brexton Health Care Healthcare Provider Hacking/IT Incident 16,562
East Central Kansas Area Agency on Aging Business Associate Hacking/IT Incident 8,750
Brevard Physician Associates Healthcare Provider Theft 7,976
MHC Coalition for Health and Wellness Healthcare Provider Theft 5,806
Catholic Charities of the Diocese of Albany Healthcare Provider Hacking/IT Incident 4,624
MGA Home Healthcare Colorado, Inc. Healthcare Provider Hacking/IT Incident 2,898
Orthopedics NY, LLP Healthcare Provider Unauthorized Access/Disclosure 2,493
Mann-Grandstaff VA Medical Center Healthcare Provider Theft 1,915
Arch City Dental, LLC Healthcare Provider Unauthorized Access/Disclosure 1,716
John Hancock Life Insurance Company (U.S.A.) Health Plan Unauthorized Access/Disclosure 1,715

The post October 2017 Healthcare Data Breaches appeared first on HIPAA Journal.

HHS Privacy Chief Deven McGraw Departs OCR: Iliana Peters Now Acting Deputy

Deven McGraw, the Deputy Director for Health Information Privacy at the Department of Health and Human Services’ Office for Civil Rights (OCR) has stepped down and left OCR. McGraw vacated the position on October 19, 2017.

McGraw has served as Deputy Director for Health Information Privacy since July 2015, replacing Susan McAndrew. McGraw joined OCR from Manatt, Phelps & Phillips, LLP where she co-chaired the company’s privacy and data security practice. McGraw also served as Acting Chief Privacy Officer at the Office of the National Coordinator for Health IT (ONC) since the departure of Lucia Savage earlier this year.

In July, ONC National Coordinator Donald Rucker announced that following cuts to the ONC budget, the Office of the Chief Privacy Officer would be closed out, with the Chief Privacy Officer receiving only limited support. It therefore seems an opportune moment for Deven McGraw to move onto pastures new.

OCR’s Iliana Peters has stepped in to replace McGraw in the interim and will serve as Acting Deputy Director until a suitable replacement for McGraw can be found. Peters has vacated her position as senior advisor for HIPAA Compliance and Enforcement at OCR. There are no plans to bring in a replacement for McGraw at the ONC.

One of the first tasks for Peters will be to ensure the statutory obligations of the 21st Century Cures Act are met, and to issue guidance for healthcare organizations and patients on health data access and guidance on the allowable uses and disclosures of protected health information for patients receiving treatment for mental health or substance use disorder.

McGraw is an expert in HIPAA and privacy laws and will be sorely missed at OCR. McGraw said on Twitter, “The HIPAA team at OCR is in good hands with Iliana Peters as Acting Deputy.”

Politico reports that McGraw will be heading to Silicon Valley and will be joining a health tech startup that will be focused on “empowering consumers.” At present, no announcement has been made about which company she is joining. Politico reports that McGraw will be “part of a very small team doing the thinking about what the product will look like, the data we’re collecting and how we’ll manage and secure it.”

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Q3, 2017 Healthcare Data Breach Report

In Q3, 2017, there were 99 breaches of more than 500 records reported to the Department of Health and Human Services’ Office for Civil Rights (OCR), bringing the total number of data breaches reported in 2017 up to 272 incidents. The 99 data breaches in Q3, 2017 resulted in the theft/exposure of 1,767,717 individuals’s PHI. Up until the end of September, the records of 4,601,097 Americans have been exposed or stolen as a result of healthcare data breaches.

Q3 Data Breaches by Covered Entity

Healthcare providers were the worst hit in Q3, reporting a total of 76 PHI breaches. Health plans reported 17 breaches and there were 6 data breaches experienced by business associates of covered entities.

There were 31 data breaches reported in July, 29 in August, and 39 in September. While September was the worst month for data breaches, August saw the most records exposed – 695,228.

The Ten Largest Healthcare Data Breaches in Q3, 2017

The ten largest healthcare data breaches reported to OCR in Q3, 2017 were all the result of hacking/IT incidents. In fact, 36 out of the 50 largest healthcare data breaches in Q3 were attributed to hacking/IT incidents.

Covered Entity Entity Type Number of Records Breached

Type of Breach

Women’s Health Care Group of PA, LLC Healthcare Provider 300,000 Hacking/IT Incident
Pacific Alliance Medical Center Healthcare Provider 266,123 Hacking/IT Incident
Peachtree Neurological Clinic, P.C. Healthcare Provider 176,295 Hacking/IT Incident
Arkansas Oral & Facial Surgery Center Healthcare Provider 128,000 Hacking/IT Incident
McLaren Medical Group, Mid-Michigan Physicians Imaging Center Healthcare Provider 106,008 Hacking/IT Incident
Salina Family Healthcare Center Healthcare Provider 77,337 Hacking/IT Incident
Morehead Memorial Hospital Healthcare Provider 66,000 Hacking/IT Incident
Network Health Health Plan 51,232 Hacking/IT Incident
St. Mark’s Surgical Center, LLC Healthcare Provider 33,877 Hacking/IT Incident
Sport and Spine Rehab Healthcare Provider 31,120 Hacking/IT Incident

Main Cause of Healthcare Data Breaches in Q3, 2017

For much of 2017, the main cause of healthcare data breaches was unauthorized disclosures by insiders, although in Q3, 2017, hacking was the biggest cause of healthcare data breaches. These incidents involve phishing attacks, malware and ransomware incidents, and the hacking of network servers and endpoints. These hacking incidents involved the exposure/theft of considerably more data than all of the other breach types combined. In Q3, 1,767,717 healthcare records were exposed/stolen, of which 1,578,666 – 89.3% – were exposed/stolen in hacking/IT incidents.

Location of Breached PHI

If vulnerabilities exist, it is only a matter of time before they will be discovered by hackers. It is therefore essential for HIPAA covered entities and their business associates conduct regular risk assessments to determine whether any vulnerabilities exist. Weekly checks should also be conducted to make sure the latest versions of operating systems and software are installed and no patches have been missed. Misconfigured servers, unsecured databases, and the failure to apply patches promptly resulted in 31 data breaches in Q3, 2017.

In Q3, 34 incidents were reported that involved email. While some of those incidents involved misdirected emails and the deliberate emailing of ePHI to personal email accounts, the majority of those breaches saw login details disclosed or ransomware/malware installed as a result of employees responding to phishing emails.  The high number of phishing attacks reported in Q3 shows just how important it is to train employees how to recognize phishing emails and how to report suspicious messages. Training should be an ongoing process, involving classroom-based training, CBT sessions, and phishing simulations, with email updates sent to alert employees to specific threats.

The post Q3, 2017 Healthcare Data Breach Report appeared first on HIPAA Journal.

Proposed Rule for Certification of Compliance for Health Plans Withdrawn by HHS

In January 2014, the HHS proposed a new rule for certification of compliance for health plans. The rule would have required all controlling health plans (CHPs) to submit a range of documentation to HHS to demonstrate compliance with electronic transaction standards set by the HHS under HIPAA Rules. The main aim of the proposed rule – Administrative Simplification:
Certification of Compliance for Health Plans – was to promote more consistent testing processes for CHPs. The HHS has now announced that the proposed rule has now been withdrawn.

Had the proposed rule made it to the final rule stage, CHPs would have been required to demonstrate compliance with HIPAA administration simplification standards for three electronic transactions: Eligibility for a health plan, health care claim status, and health care electronic funds transfers (EFT) and remittance advice. The failure to comply with the new rule would have resulted in financial penalties for CHPs.

Most employers’ health plans were handled by their insurance carriers, so the proposed rule would not have affected them directly, although a significant burden would have been placed on self-funded employers by the rule change. Following publication of the proposed rule in the federal register in January 2014, HHS received more than 72 public comments. After examining those comments, the HHS made the decision to withdraw the proposed rule.

HHS will be re-examining the issues raised in the comments and will be exploring options and alternatives to comply with statutory requirements.

The Secretary of the HHS explained that regulations have already been established for compliance with HIPAA administration simplification standards, and enforcement of compliance with those standards. While the proposed rule has been withdrawn, the HHS has confirmed that covered entities are still required to comply with 45 CFR parts 160 and 162.

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HHS Secretary Tom Price Resigns

It has been a short stint as Secretary of the U.S. Department of Health and Human Services for Tom Price, who resigned from the post on September 29, 2017, two days shy of 8 months in the position. At just 231 days, Price is the shortest serving HHS Secretary in U.S. History.

Price was nominated for the position of HHS Secretary by President Trump on November 29, 2016. The nomination was approved by the Senate Health, Education, Labor, and Pensions Committee on February 1, 2017.

However, Price resigned under pressure following revelations about his extensive use of charter jets and military aircraft to travel across the United States for government work. Rather than use commercial airlines for travel, Price had spent more than $400,000 on private jets, even though commercial airline flights were available.

Price had vowed not refrain from using private charter flights for travel in the future and offered to pay back part of the costs incurred, reportedly $51,887, to cover the cost of seats. President Trump said that would be “unacceptable,” leaving him little choice but to tender his resignation.

Price said in his resignation letter, “I have spent 40 years both as a doctor and public servant putting people first. I regret that the recent events have created a distraction from these important objectives. Success on these issues is more important than any one person. In order for you to move forward without further disruption, I am officially tendering my resignation.”

The response from the White House was short on detail, simply confirming “Thomas Price offered his resignation earlier today and the President accepted.”

Price will be replaced by the current Deputy Assistant Secretary for Health, Don J. Wright of Virginia. Wright was appointed Acting Secretary of the HHS from 11:59 p.m. on September 29. He will serve in the position until a replacement is found.

There are several potential candidates for the position, including Scott Gottlieb, the current commissioner of the Food and Drug Administration, Seema Verma, administrator of the Centers for Medicare and Medicaid Services, and Former Louisiana Gov. and HHS assistant secretary, Bobby Jindal.

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2017 is Raising the Bar for Annual HIPAA Breaches

HIPAA News

This week MSPmentor published an article online regarding the current pace of HIPAA breaches potentially doubling that of 2016. According to the article, the 66 percent increase – thus far – is driven by a sharp rise in the number of incidents designated as “Hacking/IT Incident,” which were up 82 percent, to 104 in 2017. The second most common cause for a HIPAA breach this year was unauthorized access or disclosure, which totaled 69 cases. An MSPmentor review of records maintained by the U.S. Department of Health and Human Services Office of Civil Rights (OCR) suggests hackers are stepping up attacks against healthcare targets, which hold the holy grail of data: Detailed medical information.

For the full article visit MSPmentor’s website here.

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Ensuring Availability of HIPAA During Natural Disasters

This week Mondaq published an article online regarding the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) reminded health care providers of the importance of ensuring the availability and security of health information during and after natural disasters.

According to the article, OCR recently published a bulletin during Hurricane Harvey discussing how the HIPAA Privacy Rule applies to sharing protected health information (PHI) during natural disasters. Recirculated while Irma was looming, the guidance document reminds health care providers that HHS may waive sanctions and penalties against a covered hospital for certain activities (e.g., obtaining a patient’s agreement before speaking with family or friends involved in the patient’s care) during an emergency. However, the waiver is limited to certain hospitals located within an emergency area and for a specific period of time. More importantly, OCR noted in the bulletin that the Privacy Rule still applies to covered entities and their business associates during such emergencies, but the Privacy Rule does allow the disclosure of PHI without the patient’s consent for the patient’s treatment or public health activities. Covered entities may also share PHI with a patient’s family or friends identified by the patient as being involved in their care, but OCR recommends that the covered entities obtain verbal permission or otherwise confirm that the patient does not object to sharing the information with these individuals.

For the full article visit Mondaq’s website here.

For daily HIPPA News visit our HIPAA News sidebar at https://hipaanews.net

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The Compliancy Group Helps Imperial Valley Family Care Medical Group Pass HIPAA Audit

The Department of Health and Human Services’ Office for Civil Rights commenced the second round of HIPAA compliance audits late last year. The audit program consists of desk-based audits of HIPAA-covered entities and business associates, followed by a round of in-depth audits involving site visits. The desk audits have been completed, with the site audits put on hold and expected to commence in early 2018.

Only a small number of covered entities have been selected to be audited as part of the second phase of compliance audits; however, covered entities that have escaped an audit may still be required to demonstrate they are in compliance with HIPAA Rules.

In addition to the audit program, any HIPAA-covered entities that experiences a breach of more than 500 records will be investigated by OCR to determine whether the breach was the result of violations of HIPAA Rules. OCR also investigates complaints submitted through the HHS website.

The first round of HIPAA compliance audits in 2011/2012 did not result in any financial penalties being issued, but that may not be the case for the second round of audits. Also, the past two years as seen an increase in financial penalties for noncompliance with HIPAA Rules that was discovered during investigations of complaints and data breaches.

There is now an elevated risk of an audit or investigation and OCR is issuing more fines for noncompliance. Consequently, covered entities cannot afford to take chances. Many healthcare organizations are turning to HIPAA compliance software and are seeking assistance from compliance experts to ensure their compliance programs are comprehensive and financial penalties are avoided.

Imperial Valley Family Care Medical Group Calls in HIPAA Compliance Experts

Imperial Valley Family Care Medical Group is a multi-specialty physician’s group with 16 facilities spread throughout California. IVFCMG was not selected for a desk audit, although following the theft of a laptop computer, OCR investigated the breach. IVFCMG was required to demonstrate compliance with HIPAA Rules and provide documentation to show the breach was not caused by the failure to follow HIPAA Rules.

Covered entities may fear a comprehensive HIPAA audit, but investigations into data breaches are also comprehensive. OCR often requires considerable documentation to be provided to assess compliance following any breach of protected health information. In the case of IVFCMG, OCR’s investigation was comprehensive.

Responding to OCR’s comprehensive questions in a timely manner was essential. IVFCMG, like many covered entities that are investigated or selected for an audit must be careful how they respond and all questions must be answered promptly and backed up with appropriate documentation.

As we have already seen this year, if HIPAA Rules are not followed to the letter after a data breach is experienced, fines can follow. Presense Health was fined $475,000 by OCR for potential violations of the HIPAA Breach Notification Rule following a breach of PHI.

Following the breach, IVFCMG turned to a third-party firm for assistance and contacted the Compliancy Group. By using the firm’s Breach Response Program, IVFCMG was able to ensure all of the required actions were completed, in the right time frame, and all of those processes were accurately documented.

The Breach Response Program is part of the Compliancy Group’s “The Guard” HIPAA compliance software platform. Compliancy Group simplifies HIPAA compliance, allowing healthcare professionals to confidently run their practice while meeting all the requirements of the HIPAA Privacy, Security and Breach Notification Rules. The Guard uses the “Achieve, Illustrate, and Maintain” methodology to ensure continued compliance, with covered entities guided by HIPAA compliance experts all the way.

IVFCMG’s Chief Strategic Officer, Don Caudill, said “Their experts provided us with a full report and documentation proving that our HIPAA compliance program satisfied the law – which ultimately helped us avoid hundreds of thousands of dollars in fines.” When OCR responded to the initial breach report asking questions about another aspect of HIPAA Rules, IVFCMG was able to respond in a timely fashion and provide the evidence to prove it was in compliance.

HIPAA compliance software helps covered entities pass a HIPAA audit, respond appropriately when OCR investigates data breaches and complaints, and avoid fines for non-compliance. OCR has increased its enforcement activity over the past two years and healthcare data breaches are on the rise. Non-compliance with HIPAA Rules is therefore much more likely to be discovered and result in financial penalties.

Small to medium sized HIPAA-covered entities with limited resources to dedicate to HIPAA compliance can benefit the most from using HIPAA compliance software and receiving external assistance from HIPAA compliance experts.

“Responding to a HIPAA audit requires sensitivity and expertise,” Bob Grant, Chief Compliance Officer of Compliancy Group, told HIPAA Journal. “As a former auditor, I’ve developed The Guard and our Audit Response Program to satisfy the full extent of the HIPAA regulatory requirements. Giving federal auditors everything they need to assess the compliance of your organization is our number one goal. Our Audit Response Program is the only program in the industry to give health care professionals the power to illustrate their compliance so they can get back to running their business in the aftermath of a HIPAA audit.”

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