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Thursday, January 16, 2020
HIPAA Privacy and Security Compliance Webinar
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Please note: • All phone lines will automatically be muted on entry, and will remain muted for the length
of the presentation.• You may submit written questions via the “chat” icon shown here .
Karen WakeAVP Commercial InsuranceJohnson Financial Group
Opening Remarks
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Agenda
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» 11:00am• Opening remarks and introductions
» 11:00am to 11:25am• “HIPAA Refresher for Employers/Health Plan Sponsors”
• Jason Gutzman, VP Employee Benefits Consultant
» 11:25am to 11:50am• “2020 HIPAA Risk Preview”
• Steve Frew, VP Risk Consultant
» 11:50am to 12:00pm• Q&A and closing remarks
Featured Presenters
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Jason GutzmanRHU, MHP, REBC, ChHC, CSFS,
GBA, CEBSVP Employee Benefits Consultant
Johnson Financial Group
Steve FrewJD, CIPP/US
VP Risk ConsultantJohnson Financial Group
Presented by: Jason Gutzman
HIPAA Refresher for Employers/Health Plan
Sponsors
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» What is HIPAA» Who is subject to the HIPAA Rules» What information is Protected» Key requirements of HIPAA Rules» Enforcement» Compliance Steps
Outline
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What is HIPAA?
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The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is federal legislation in which addresses issues ranging from health insurance coverage to national standard identifiers for healthcare providers.
The portions that are important for our purposes are those that deal with protecting the privacy (confidentiality) and security (safeguarding) of health data, which HIPAA calls Protected Health Information or PHI, and breach notification rules. These important Rules were issued in 2013 and diligently enforced by the Office for Civil Rights (OCR) – a division of Health and Human Services (HHS).
HIPAA Rules
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Health Plans are Covered Entities
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Employers
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Protected Health Information
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Information Definitions
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Privacy Rule Overview
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Special Exception for Fully Insured Health Plans
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Use and Disclosure Rules
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Disclosures to Employers
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Disclosures to Business Associates
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Privacy Notice
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Other Individual Rights
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Administrative Requirements
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Security Rule Overview
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Risk Analysis
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Security Safeguards
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Examples of Safeguards
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Breach Notification Rule Overview
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What Is a Breach?
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• A breach could result from many activities. » Accessing more than the minimum necessary» Failing to log off when leaving a workstation» Unauthorized access to PHI» Sharing confidential information, including passwords» Having patient-related conversations in public settings» Improper disposal of confidential materials in any form» Copying or removing PHI from the appropriate area
• Why?» Curiosity…about a co-worker or friend» Laziness…so shared sign-on to information systems» Compassion…the desire to help someone» Greed or malicious intent…for personal gain
What Constitutes a Breach?
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Covered Entity Breach Notification Requirements
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Common Employer Mistakes
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Most Common HIPAA Complaints
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HIPAA Penalties
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What Employers Need to Do
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When in doubt, consult with legal counsel!
Presented by: Steve Frew
2020 HIPAA Risk Preview
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» HIPAA threats – 2020 starting line-up» OCR HIPAA enforcement» HIPAA reporting» Risk management tips
Outline
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Threat Sources
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Breakdown
Laptops Documents Disk drives Flash drives Desktops
Theft or Loss of Device
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Method
Email Brute force Backdoor
Outside Attack – Hackers
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0 10 20 30 40 50 60 70 80
Stolen Creds
Malware
Ransomware
Type of attack
Hackers
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Error Misuse
Employees – Errors and Intent
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• Data or hardcopy posted to wrong patient record
• Data or hardcopy not securely disposed of» Hard drives » Hardcopy in trash» Copies or printouts left in insecure setting» Multi-part forms
Improper Filing and Disposal
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• Release after expiration of authorization• Failure to provide copies in timely manner upon
request» New OIG hot button
Late Release of Information
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OCR HIPAA Enforcement
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COVERED ENTITY AMOUNT CAUSE
Elite Dental Services –Dallas
$10,000 • Disclosed PHI in response to unfavorable YELP review
• Failure to implement P&P on social media posts
• Inadequate notice of privacyJackson Health $2,154,000 Employee selling PHI of VIPS for 5
years. Accessed more than 24,000 patient records.
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COVERED ENTITY AMOUNT CAUSE
Korunda $85,000 Complaint of failing to provide access to medical records in format requested. OCR provided technical assistance to CE but they failed to promptly provide access
Medical Informatics Engineering
$100,000 Hacker accessed 3.5 million medical records.• Failure to conduct risk
assessment
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COVERED ENTITY AMOUNT CAUSE
Texas HHS $1.6 million
• Failure to conduct risk assessment
• Failure to respond to known security incident
• 187 day failure to notify affected individuals
• Failure to notify media 147 daysSentara $2,175,000 Owner entity of 10 hospitals mixed
up billing and disclosed PHI of 577 patients but only reported 8 to OCR• No business associate
agreement with owner entity for billing services
• Failure to notify OCR in timely manner
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COVERED ENTITY AMOUNT CAUSE
University of Rochester Medical Center
$3 million • Theft of unencrypted laptop disclosed PHI of 43 patients
• Failed to conduct risk assessment
• Failed to implement security measures
• Inadequate policies and procedures
• Failure to adopt encryption or document why encryption was not reasonable and adopt equivalent alternative protection
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COVERED ENTITY AMOUNT CAUSE
Bayfront Health $85,000 Failure to provide medical records in timely manner and form -- 10 months
Cottage Health $3 million 2 breaches in two years total of 60,000+ records• Failure to conduct risk
assessment• Inadequate security measures• Failure to conduct tech
evaluation following new OS install
• Failure to have business associate agreement with contractor
HIPAA Reporting
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Reporting <500
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Reporting >500
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• Breach Portal» Notice to the Secretary of HHS Breach of Unsecured
Protected Health Information» https://ocrportal.hhs.gov/ocr/breach/wizard_breach.jsf
Where to Report
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Reporting Page
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Risk Management Tips
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Mobile Security and HIPAA
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Secure access authentication
Encrypt
Remote wipe
Block file share
Update regularly
Approved apps only
VPN on public Wi-Fi
HIPAA Security on the Cloud
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Business Associate Agreement:
Written agreement Privacy and security terms Duties Subcontractors:
• Audit rights• Insurance & Limits
Formulate a Defensive Strategy
Assume you will be hit
Secure your email system Data loss protection
systems Role based privileging
Multifactor access
Monitor-audit-test
Build human firewalls
Encrypt everything
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Download at: https://www.johnsonbank.com/Resources/Articles/2018-10-05-HIPAA-Toolkit
Questions?
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Thank you for attending!
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