HIPAA Breach Evaluation and Reporting - What Qualifies as a Reportable Breach and how to Report It

Why Should You Attend:

The HIPAA Breach Notification Rule has been in effect since 2010 and was significantly modified in 2013. We will discuss the origins of the rule and how it works, including interactions with other HIPAA rules and penalties for violations.

Whenever there may be a privacy issue involving Protected Health Information, there may be a reportable breach under the HIPAA regulations. Not all privacy violations are reportable breaches, though, so it is essential to have a good process for evaluating incidents to see if they have resulted in a reportable breach.

Any privacy rule violation that results in an acquisition, access, use, or disclosure of PHI in violation of the HIPAA Privacy Rule may be a breach, unless the incident is one of the defined exceptions from the definition. A breach is reportable unless the information was secured or destroyed in the incident, or unless a risk analysis shows that there is a low probability of compromise of the information, based on at least four factors defined in the rules.

We will examine how to determine if a privacy violation is potentially a breach according to the definition, and then describe the subsequent steps in the evaluation, if it is determined that the definition has been met. We will discuss the exceptions to the breach definition for inadvertent internal uses, or when it can be determined that the information could not be retained in any way by the receiving party.

Entities can avoid notification if the information has been encrypted according to Federal standards. We will cover the guidance from the US Department of Health and Human Services that shows how to encrypt so as to prevent the need for notification in the event of lost data. Failing that, a risk analysis can be conducted to determine the probability of compromise of the information, considering four factors: what the data is and how well-identified it is, to whom was it released and do they have obligations to protect the information, whether or not the information actually exposed, and whether or not the incident has been mitigated properly. However, it must be noted that any compromise of the information by Ransomware that denies access or control of your information should be treated as a reportable breach.

In addition, any reporting must be made within the required time frames, or penalties can result, as shown in recent enforcement actions by HHS for late reporting of breaches.

We will help you understand what isn’t a breach and under what circumstances you don’t have to consider breach notification. You’ll find out how to report the smaller breaches (less than 500 individuals), and you’ll know why you want to avoid a breach involving more than 500 individuals – media notices, Web site notices, and immediate notification of HHS, including posting on the HHS breach notification “wall of shame” on the Web.

We will explain, based on historical analysis of reported breaches, what measures must be taken today to protect information from the most common threats, as well as discuss information security trends and explain what kinds of efforts will need to be undertaken in the future to protect the security of PHI.

Areas Covered in the Webinar:

• The definition of a Breach under HIPAA
• Evaluating the Privacy violation
• Reviewing the exceptions to the definition of a breach
• What is good enough encryption according to the rules
• Performing the Risk Analysis to determine the necessity to report
• Ransomware and Breaches – When to Report
• Avoiding Breaches
• The most common causes of breaches
• Reporting breaches to HHS and the individuals
• Reporting breaches to the press and other agencies
• Documenting your analysis and decisions

Who Will Benefit:

This webinar will provide valuable assistance to all personnel in medical offices, practice groups, hospitals, academic medical centers, insurers, business associates (shredding, data storage, systems vendors, billing services, etc). Employees who will benefit include:

• Compliance director
• CEO
• CFO
• Privacy Officer
• Security Officer
• Information Systems Manager
• HIPAA Officer
• Chief Information Officer
• Health Information Manager
• Healthcare Counsel/Lawyer
• Office Manager
• Contracts Manager

Jim Sheldon-Dean
Principal and Director of Compliance Services, Lewis Creek Systems, LLC

Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities. He is a frequent speaker regarding HIPAA, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference. Sheldon-Dean has more than 16 years of experience specializing in HIPAA compliance, more than 34 years of experience in policy analysis and implementation, business process analysis, information systems and software development, and eight years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician.

Sheldon-Dean received his B.S. degree, summa cum laude, from the University of Vermont and his master’s degree from the Massachusetts Institute of Technology.

Topic Background:

Breaches of Protected Health Information are becoming more and more common and can be a result of a variety of circumstances, from words spoken too loudly in a public setting, to a lost thumb drive full of medical records, to files being held for ransom by hackers.

Any violation of the HIPAA Privacy Rule may be a reportable breach under the HIPAA Breach Notification rules, requiring notification of individuals and HHS when information security is breached. Any incident involving a HIPAA issue must be evaluated to see if it is reportable, and any decisions or actions must be fully documented.

Determining whether to report or not is not necessarily straightforward, but there are guidelines to follow to help at every step of the way. Even Ransomware attacks by hackers may be reportable, if you lose control of your data and don’t know exactly what happened.

Breach investigations, even for small breaches, are a new priority at HHS, and the HHS regional offices are taking on the job of looking into small breaches (affecting under 500 individuals), especially when there have been multiple breaches or repeated similar breaches.

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