The US Department of Health and Human Services Office for Civil Rights (OCR) will soon begin a second phase of audits for compliance with HIPAA privacy, security and breach notification standards as required by the HITECH Act. In this second phase, OCR will audit both covered entities and their business associates, unlike the pilot audits of 2011 and 2012, which focused on covered entities alone. This On the Subject details practical steps that covered entities, including employer-sponsored group health plans, and their business associates can take to prepare for a potential audit.
HIPAA covered entities have reported that the HHS Office for Civil Rights recently sent pre-audit screening surveys to a pool of covered entities that may be selected for the previously delayed second phase of HIPAA compliance audits. This On the Subject describes the phase two audit program and identifies steps that covered entities and business associates should take to prepare for these audits.
The U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) will soon begin a second phase of audits (Phase 2 Audits) of compliance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy, security and breach notification standards (HIPAA Standards) as required by the Health Information Technology for Economic and Clinical Health (HITECH) Act. Unlike the pilot audits during 2011 and 2012 (Phase 1 Audits), which focused on covered entities, OCR will conduct Phase 2 Audits of both covered entities and business associates. The Phase 2 Audit Program will focus on areas of greater risk to the security of protected health information (PHI) and pervasive noncompliance based on OCR’s Phase I Audit findings and observations, rather than a comprehensive review of all of the HIPAA Standards. The Phase 2 Audits are also intended to identify best practices and uncover risks and vulnerabilities that OCR has not identified through other enforcement activities. OCR will use the Phase 2 Audit findings to identify technical assistance that it should develop for covered entities and business associates. In circumstances where an audit reveals a serious compliance concern, OCR may initiate a compliance review of the audited organization that could lead to civil money penalties.
The following sections summarize OCR’s Phase 1 Audit findings, describe the Phase 2 Audit program and identify steps that covered entities and business associates should take to prepare for the Phase 2 Audits.
Final HIPAA privacy and security regulations issued by the U.S. Department of Health and Human services will require action by group health plan sponsors by September 2013.
The Office for Civil Rights of the U.S. Department of Health and Human Services published final modifications to the privacy, security and breach notification standards under HIPAA and the HITECH Act, which require covered entities and business associates to update their policies, procedures, agreements, security measures and operations to comply with new restrictions and requirements, and to benefit from new flexibility.
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