The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that establishes national standards for the protection of individuals’ health information. One of the key requirements of HIPAA is the breach notification rule, which mandates covered entities and business associates to report breaches of unsecured protected health information (PHI) to affected individuals, the Department of Health and Human Services (HHS), and, in some cases, the media. In this blog post, we will explore the HIPAA breach reporting requirements, including when to report a breach, who to report it to, and what information should be included in the breach notification.
What Is HIPAA Breach?
A HIPAA breach is the acquisition, access, use, or disclosure of protected health information (PHI) in a manner not permitted by the Health Insurance Portability and Accountability Act (HIPAA) regulations, which compromises the security or privacy of the PHI. HIPAA breaches can occur in a variety of ways, such as stolen electronic devices, hacking, employee error, paper records, insider theft, or vendor breaches.
PHI includes any information that can be used to identify an individual and relates to the individual’s past, present, or future physical or mental health condition, healthcare services received, or payment for healthcare services. Examples of PHI include medical records, test results, billing information, and insurance information.
When And To Whom Should You Report For HIPAA Breaching?
Here are the key points on when and to whom to report a HIPAA breach:
- Covered entities and business associates must report breaches of unsecured protected health information (PHI).
- You must report the breach without unreasonable delay, but no later than 60 days following the discovery of the breach.
- The reporting timeline begins when the breach gets notice.
- Breaches affecting 500 or more individuals must report it to HHS and, in some cases, to the media.
- The notification to HHS must submit through the HHS website.
- The breach notification must be in writing and must include a description of the breach, the types of unsafe PHI, steps that affected individuals can take to protect themselves, and contact information for the covered entity or business associate.
- If the breach involves a business associate, they must notify the entity without unreasonable delay, but no later than 60 days following the discovery of the breach.
- Healthcare organizations must have policies and procedures in place to promptly identify and report breaches.
- Failure to report a HIPAA breach can result in significant financial penalties, reputational damage, and legal action.
These are all the basic information that you need to look at before HIPAA Breach reporting.
How Do I Report A HIPAA Breach?
To report a HIPAA breach, you should follow these steps:
- Determine that a breach has occurred: Review the situation and determine whether there has been a breach of unsecured PHI, as defined by HIPAA regulations.
- Contain the breach: If possible, take steps to contain the breach and prevent further unauthorized access or disclosure of PHI.
- Notify your HIPAA Privacy Officer: Notify your organization’s HIPAA Privacy Officer or other designated HIPAA compliance official as soon as possible.
- Investigate the breach: Conduct a thorough investigation of the breach to determine the scope of the breach, the PHI involved, and the cause of the breach.
- Report the breach to affected individuals: Notify the affected individuals in writing, providing them with a description of the breach, the types of PHI that were compromised, steps that affected individuals can take to protect themselves, and contact information for the covered entity or business associate.
- Report the breach to HHS: If the breach affects 500 or more individuals, you must report the breach to the Department of Health and Human Services (HHS) within 60 days of discovery.
- Report the breach to the media: If the breach affects 500 or more individuals, you need to report the breach to the media.
- Document the breach: Keep detailed records of the breach, including the steps taken to contain the breach, investigate the breach, and notify affected individuals, HHS, and the media.
Remember that timely reporting of a HIPAA breach is critical. Failure to report a breach in a timely manner can result in significant financial penalties, reputational damage, and legal action. It’s important to have policies and procedures in place to promptly identify and report breaches and to provide timely and accurate information to affected individuals, HHS, and the media if required.
What Are The Common HIPAA Breach Violations?
There are many different types of HIPAA violations that can result in a breach of protected health information (PHI). Here are some of the most common HIPAA breach violations:
- Lost or stolen devices: A common HIPAA violation is the loss or theft of electronic devices that contain PHI, such as laptops, smartphones, or tablets. If these devices are not properly secured or encrypted, it can lead to a breach of PHI.
- Employee mistakes: Employee mistakes such as sending PHI to the wrong person or leaving PHI in an insecure location can also result in a breach.
- Hacking: Cyberattacks such as hacking or ransomware can also result in a breach of PHI. These attacks can compromise the security of electronic PHI and result in unauthorized access or disclosure.
- Business associate breaches: Business associates that handle PHI on behalf of covered entities must also comply with HIPAA regulations. A breach by a business associate can result in a breach of PHI.
- Improper disposal of PHI: Improper disposal of PHI, such as throwing away paper records without shredding them, can also result in a breach.
- Lack of employee training: HIPAA requires covered entities and business associates to train their employees on HIPAA regulations. A lack of training can result in inadvertent violations and breaches.
- Insufficient risk analysis: HIPAA requires covered entities and business associates to conduct risk analyses to identify and address potential security threats. An insufficient risk analysis can result in a breach.
- Failure to encrypt data: HIPAA requires covered entities and business associates to encrypt electronic PHI. Failure to do so can result in a breach.
Overall, it’s important for covered entities and business associates to understand HIPAA regulations and implement policies and procedures to prevent breaches and respond promptly if a breach occurs.
In conclusion, HIPAA breaches can have serious consequences for covered entities. The business associates, and individuals with leakage health information (PHI). Common HIPAA breach violations include lost or stolen devices, employee mistakes, hacking, improper disposal of PHI, lack of employee training, insufficient risk analysis, failure to encrypt data, unauthorized access, and delayed breach reporting. By following HIPAA regulations and taking steps to protect PHI, covered entities and business associates can help prevent breaches and protect the privacy and security of individuals’ health information. If you are looking to implement any of the Infosec compliance frameworks such as SOC 2 compliance, HIPAA, ISO 27001, and GDPR compliance, Impanix can help. Book a Free consultation call with our experts or email us at [email protected] for inquiries.