Overview: In this session we will discuss the HIPAA audit program and how it works, and discuss the areas that caused the most issues in the 2012 audits. We will explore what kind of issues and what kind of entities had the most problems, and show where entities need to improve their compliance the most.
We will also explore the typical risk issues that lead to breaches of health information and see how those issues may be a target for auditors in 2014
We will review the contents of the HIPAA Audit Protocol used in 2012 to show what documentation needs to be on hand should your organization be selected for an audit in 2014
The HIPAA Audit Protocol is not easy to use in its incarnation as a Web-based tool, and it does have several deficiencies because of the changes in the rules that became enforceable September 23, 2013. We will present methods for using the contents of the HIPAA Audit Protocol to build your own compliance plan by extracting and updating the contents and relating your compliance activities directly to the questions that might be asked
In this session we will discuss the HIPAA audit and enforcement regulations and processes, and how they apply to HIPAA covered entities and business associates. We will explain the enforcement regulations and the recent changes that increase fines and create new penalty levels, including new penalties for willful neglect of compliance that begin at $10,000
We will discuss what information and documentation must be prepared in advance so that you can be ready for an audit at any time, including sample information request forms and questions asked at prior audits
The session will also cover how to know if you may become the subject of an audit or enforcement action, and what you can do to help limit your exposure. We will discuss how most enforcement actions come about and what can be done to prevent incidents that lead to enforcement activity
The HIPAA Privacy, Security, and Breach Notification regulations (and the recent changes to them) and how they will be audited will be explained. Documentation requirements for compliance will be explored and a framework of security policies necessary for compliance will be presented
The HIPAA Audit Protocol questions will be explored and ways of using the content to develop a compliance plan will be discussed. The process of exporting the questions will be shown, and a sample spreadsheet showing the results will be presented
The results of prior HHS audits (and their penalties) will be discussed, including recent actions involving multi-million dollar fines and settlements. A plan for attaining compliance will be presented. The steps to follow to prepare for an audit and respond to an audit request will be outlined
Why should you attend:
While in the past, audits had been performed only at entities that reported a breach or had a compliant filed against them, the new rule calls for audits whether or not there is a complaint or breach. This means that the HHS Office for Civil Rights (OCR) can show up and ask to perform an audit on short notice, and your organization will need to provide a response in less than ten business days. Knowing what questions are likely to be asked and have been asked at prior HIPAA compliance audits can make preparing for and surviving a HIPAA audit much easier.
USDHHS has published the protocol used for the 2012 HIPAA audits by the HHS contractors, so it is possible to know much better now how to prepare for an audit. Nearly any health care covered entity may be subject to an audit; all entities need to know what kinds of questions they'll be asked, what information they'll need to provide and how to prevent issues that could lead to violations and fines.
Areas of weakness as shown in the 2012 audits and as shown by breach reports are likely targets for the next round of audit questions, and HHS is sending out requests for information to 1200 covered entities and business associates to determine their suitability to be audited.
If your organization is not ready, the HIPAA rules have new, significantly higher fines, including mandatory minimum fines of $10,000 for willful neglect of compliance. In addition, HIPAA enforcement has taken on a new importance at HHS; officials have publicly stated that enforcement is now a priority, and that means being ready for an audit is more important than ever. The "slap-on-the-wrist" days are over and fines and settlements are being levied, with more on the way -- don't let your organization be hit for an audit unprepared.
Areas Covered in the Session:
Find out what the audit process is, what HHS OCR is likely to ask you if you are selected for an audit, and what you'll have to have prepared already when they do
Learn how to make the HIPAA Audit Protocol useful to you as a way to organize and track your compliance work, and collect your documentation references
Find out what you'll need to have documented to survive an audit and avoid fines
Learn how to use an information security management process to evaluate risks and make decisions about how best to protect PHI and meet patient needs and desires
Find out what policies and procedures you should have in place
Learn about the training and education that must take place and be documented to ensure your staff uses health information properly and does not risk exposure of PHI
Find out the steps that must be followed in the event of a breach of PHI
Learn about how the HIPAA audit and enforcement activities are now being increased and how you must be prepared or risk significant penalties
Who Will Benefit:
Information Systems Manager
Chief Information Officer
Health Information Manager
The random HIPAA Compliance Audit program had a year of trial audits in 2012. The US Department of Health and Human Services has reviewed the results of that work and the HIPAA audit program is being restarted in 2014 based on what was learned from the 2012 audits.
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.
Overview: The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and its regulations (the "Privacy Rule" and the "Security Rule") protect the privacy of an individual's health information and govern the way that covered entities and now business associates collect, maintain, use, and disclose protected health information ("PHI"). Creation and implementation of policies and procedures are a requirement for HIPAA compliance.
For HIPAA, if it is not in writing, it is not. This maxim holds true for all covered entities and business associates when creating and implementing HIPAA compliance policies and procedures. To ensure compliance with HIPAA regulations, an organization must have written documentation as set forth by HIPAA's administrative requirements. Now that DHHS is considering breaches involving lack of a policy (even if HIPAA does not say that you must have a policy concerning that activity) as willful neglect, which carries the stiffest civil money penalties, you must consider what policies you need.
In this webinar, we will discuss what the required policies are, policies that you must have if they are reasonable and appropriate, and other policies that are not mentioned in HIPAA but that DHHS may nonetheless consider as being necessary. Learn what a policy should contain and how to draft a policy.
Areas Covered in the Session:
The HIPAA requirement to have policies and procedures
Other policies that may be necessary
Contents of HIPAA policies
How to write a policy
Training on policies
Retention of policies
Who Will Benefit:
HIPAA Compliance Officers
HIPAA Security Officers
HIPAA Privacy Officers, CFOs
Medical Records Personnel
Health Information Management Professionals
Health Care Attorneys
Jonathan P. Tomes , J.D., is a health care attorney and partner in the law firm of TOMES & DVORAK, CHARTERED. He has written more than 50 books, including The Compliance Guide to HIPAA and the DHHS Regulations, and dozens of articles in the area of HIPAA compliance.
Phone No: 800-385-1607
Event Link: http://bit.ly/1ptrhGu