5 HIPAA Violations and How to Avoid Them

The Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, is a federal law that safeguards patient health information. For aesthetic practitioners, the significance of HIPAA compliance cannot be overstated.

Non-compliance can result in civil and criminal penalties, leading to a potential loss of license, hefty fines, or even imprisonment. Beyond the legal requirement to comply with HIPAA regulations, it is the ethical and professional responsibility to protect patient privacy.

What Is HIPAA?

HIPAA is a US law with two core standards: the Privacy Rule and the Security Rule. The Privacy Rule addresses the use and disclosure of protected health information (PHI) by covered entities. The Security Rule applies to the use and disclosure of all electronic forms of PHI by covered entities.

What Is PHI?

PHI refers to any piece of individually identifiable information, such as a patient’s address, credit card information, or photos.

Who Are Considered Covered Entities?

Covered entities include health plans, healthcare providers, and healthcare clearinghouses.

What Is a HIPAA Violation?

A HIPAA violation occurs when a practice or healthcare organization fails to meet the standards defined by HIPAA, even if no harm has resulted. It is a breach in the management, storage, or transmission of PHI, typically without the patient’s knowledge or consent.

Adhering to HIPAA regulations is a legal requirement, and failure to comply can lead to severe penalties. HIPAA compliance is also essential in gaining and maintaining patient trust, which is a cornerstone of any medical practice.

Patients need to know that their sensitive health information is secure and will only be used as necessary for their treatment and billing.

COMMON HIPAA Violations and How to Avoid Them

Here are common HIPAA violation examples and how to avoid them:

1. Sharing and Snooping on Healthcare Records

Unauthorized access or disclosure of PHI is a grave HIPAA violation. Some of the most common examples are employees gossiping about patients’ PHI to unauthorized individuals, posting PHI on social media, and snooping on the medical records of friends, family members, co-workers, celebrities, and neighbors.

These HIPAA violations are severe and, when discovered, are grounds for termination of employment. In some cases, it may result in criminal charges. To prevent this, restrict PHI access to only those staff members who require it for their role, and emphasize the importance of patient confidentiality in all staff training and communications.

2. Failure to Perform an Organization-Wide Risk Analysis

HIPAA requires all healthcare providers to conduct comprehensive risk assessments to identify potential vulnerabilities in safeguarding PHI. An organization-wide risk analysis may include the following:

• Auditing security vulnerabilities and flaws
• Implementing or improving authentication protocols
• Reviewing employee HIPAA training
• Identifying potential cyber threats
• Reviewing incident response plans

This helps you identify any flaws in your internal systems and security measures, such as if it is susceptible to ransomware attacks. Avoid this HIPAA violation by conducting regular risk assessments and having appropriate action plans in place.

3. Failure to Enter a HIPAA-Compliant Business Associate Agreement (BAA)

Most healthcare practices collaborate with third parties (business associates) in their operations, which involves sharing PHI. HIPAA requires covered entities and business associates to enter a business associate agreement (BAA).

The purpose of a BAA is to ensure that the business associate will appropriately safeguard PHI per HIPAA requirements. They are an essential component in maintaining HIPAA compliance and protecting patient data. Always sign a BAA with all third parties you outsource services from before disclosing PHI.

This HIPAA violation occurs more often than you think, especially as not all BAAs comply with HIPAA standards. Two commonly overlooked scenarios of when to sign a BAA are the use of medical appointment booking software, and the use of email platforms such as Gmail.

Medical appointment booking software, like Demandforce, is a popular tool used by healthcare practices. Providing an online booking functionality to clients makes scheduling appointments with cosmetic providers easier. However, this requires clients to enter PHI into the platform, which is then stored on Demandforce servers. As PHI is involved, providers must sign a BAA with the business associates supplying the software.

Email Platforms: Gmail is one of the most used email platforms for communicating, sending, and sharing data internally. It is familiar, popular, easy to use, and can be integrated into any of Google’s apps. But is Gmail HIPAA compliant? While standard Gmail does not come with a BAA, there are steps you can take to enter one with Google and make Gmail HIPAA compliant. It involves obtaining a Google Workspace account, signing a BAA provided by Google, buying third-party encryption software, and following Google’s HIPAA guide.

4. Lack of Employee Training

HIPAA requires that all employees must receive thorough HIPAA training. This includes not just surgeons and nurses but administrative and custodial staff and business associates as well.

To avoid this, conduct regular training programs explaining HIPAA regulations, how to protect and handle PHI, and your practice’s specific procedures and protocols. These are key to protecting patient health information and preventing inadvertent violations.

5. Failure to Encrypt PHI

Unencrypted PHI is a prime target for cybercriminals and one of the leading causes of data breaches in the healthcare industry. As a cosmetic surgeon, you must ensure that all PHI in your practice is encrypted, whether at rest or in transit. This includes data on servers, laptops, flash drives, and emails.

Prevent this violation by following cybersecurity best practices, such as:

• Using only HIPAA-compliant software
• Encrypting all devices used for accessing or storing PHI
• Implementing two-factor authentication (2FA) on all devices
• Regularly updating software

HIPAA Compliance Is a Priority

HIPAA compliance is not just a legal requirement but a crucial part of maintaining trust with your patients. By understanding the potential pitfalls and implementing effective strategies and procedures, you can create a safe and compliant cosmetic surgery practice.

Begin by conducting a comprehensive HIPAA compliance audit, educating your team about the importance of these regulations, and establishing stringent data protection measures. Reach out to experts if needed.

Remember, your patients’ safety, privacy, and trust are paramount. Make HIPAA compliance a priority today for the secure, ethical, and prosperous practice of tomorrow.

Joanne Van Der Veen is an experienced freelance healthcare writer covering the latest in clinical research and medicinal chemistry.