What is HIPAA & How Do You Avoid Violations in Your Aesthetic Practice?
As you operate your aesthetic practice and it becomes increasingly digital, you face challenges in keeping your patients’ personal information safe and secure. The Health Insurance Portability and Accountability Act of 1996, (“HIPAA”) provides a crucial framework for ensuring the privacy and security of an individual’s medical information in the United States. In this blog post, we will explore HIPAA, what it is and how to avoid violations in your aesthetic practice by applying key steps to maintain compliance.
What is HIPAA?
According to the Centers of Disease Control and Prevention (CDC), the Health Insurance Portability and Accountability Act of 1996, (“HIPAA”) is a United States federal law “that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.” The “Privacy Rule”, established by the act, sets these national standards and requirements for the protection of specific patient health information, and it is controlled by the U.S. Department of Health and Human Services (“HHS”). The HHS published a final regulation in the form of the Privacy Rule in December 2000, and it became effective on April 14, 2001.
The Privacy Rule governs the use and disclosure of individual health information, known as Protected Health Information (PHI). It provides standards for individual privacy rights, allowing patients to understand and control how their health information is used.
To ensure compliance with the Privacy Rule, patients are asked a series of questions regarding their health information when they visit a healthcare provider’s office. Patients have the right to determine how their health information is disclosed and who has access to it. The Office for Civil Rights within the HHS office is responsible for enforcing the privacy rule. They can implement compliance penalties, including monetary fines and imprisonment.
Who Is Covered by the Privacy Rule?
Certain organizations are subject to the Privacy Rule and are considered “Covered Entities”. These covered entities include healthcare providers, who electronically transmits health information in connection with certain transactions (e.g., claims, benefit eligibility inquiries, referral authorization requests and other transactions under the HIPAA Transactions Rule), health plans, healthcare clearinghouses and business associates. Health plans include dental, vision and heath insurers such as Blue Cross Blue Shield, Medicare, United, Aetna, and Cigna. Healthcare clearinghouses are entities that process nonstandard information into a standard format and often receive identifiable health information when providing or processing services for health plans. Lastly, a business associate is a person or organization “that performs certain functions or activities on behalf of, or provides certain services to, a covered entity that involve the use or disclosure of individually identifiable health information”. (2022. Summary of the HIPAA Privacy Rule. U.S. Department of Health & Human Services)
As a covered entity, it is crucial to take the necessary measures to ensure that your patient’s information is protected and that you comply with the Privacy Rule.
Healthcare Provider Responsibilities under Privacy Rule: Notice and Patient Rights
As a healthcare provider with a direct treatment relationship with patients, you need to keep some things in mind. You must provide your patients with notice of your privacy practices no later than the first date of service under the Privacy Rule. To comply with this regulation, provide your patients with the necessary paperwork as soon as they enter office. This counts as the first service and delivery date. Patients have the option to decline a copy of the notice if they choose. You must post the notice in a clear, prominent location and display it on your website with a HIPAA notice or link. Additionally, you must revise and distribute the notice when there’s a material change.
Under the Privacy Rule, your patients have specific rights. Among which is the right to access their medical records, request amendments and obtain copies. As a provider, you must keep a history of the six most recent Treatment, Payment, and Operations (TPO) disclosures, which your patients can access. It’s important to protect printed information containing identifiable health information to prevent theft or loss. Therefore, you must take appropriate measures to ensure the security of printed information. Clearinghouses must obtain authorization from individuals to sell patient mailing lists and disclose information for life insurance purposes. By complying with these regulations, you can safeguard your patients’ privacy, and avoid HIPAA violations in your practice.
Protecting Printed Information
You must follow specific protocols in your aesthetic practice to ensure the privacy and security of your patients’ protected health information. This involves directing incoming correspondence through a direct channel and avoiding copying documents indiscriminately.
To prevent patients from viewing other patients’ information, you must also adhere to a clean desk protocol. Any papers containing sensitive information should be shredded once they are no longer needed instead of being recycled or discarded.
It is critical to keep in mind that printers and copiers have hard drives that may store sensitive information. Therefore, when disposing of or returning these devices, ensure that all protected health information is destroyed to avoid potential breaches.
Storage of Paper-Based Data
To secure sensitive patient information, protect paper charts in your warehouse. It is important to lock the files routinely, even after hours. Ensure that authorized personnel have access to the keys. A well-defined policy should outline who is allowed access to these areas and their job description.
Unauthorized access can result in the theft of protected health information, leading to serious consequences. To prevent this, you must have a well-defined policy in place to safeguard patient data. Protect your patients’ information by securing paper charts in your warehouse with the necessary protocols in place.
Protecting Telephone Calls
It’s essential to protect patient privacy when it comes to telephone calls in your aesthetic practice. The first step is to train all staff members on HIPAA regulations and best practices for handling calls. Verify the identity of callers and do not assume their identity based on relationships or listings. Additionally, be aware of any visitors or patients nearby when taking calls. Consider using physical barriers such as walls or soundproofing to prevent unauthorized access.
When leaving messages, do not provide lab test results unless the patient has given permission to do so in their HIPAA notice. If a family member answers the phone, leave a message requesting the patient to return the call without providing any further information. This is crucial because disclosing patient information to unauthorized individuals can lead to legal issues. Ultimately, controlling HIPAA in your office is the responsibility of all staff members. It’s crucial to have policies and training in place to ensure patient privacy is protected at all times.
The Importance of a Designated Privacy Officer and Ongoing Training
To ensure that HIPAA is properly controlled in your office, it’s important to have a designated privacy officer. This person can be the office manager, a HIPAA compliance officer, or anyone else in the office. They need to be knowledgeable and responsible enough to take on the role. Additionally, adopt written privacy policies, develop a notice of privacy practices, establish a grievance process, and provide ongoing employee training. Doing this ensures that everyone in the office is aware of HIPAA policies and procedures.
Train new staff members on HIPAA policies, procedures, and protocols, so they understand their responsibilities and obligations under the law. HIPAA can be complicated, so it’s important to provide clear and concise training that is consistent for all staff members. By taking these steps, you can help ensure that your office is in compliance with HIPAA regulations and that patient data is properly protected.
HIPAA Business Associate Agreements
A business associate is a person or organization that performs certain functions or activities on behalf of a covered entity involving the use of protected health information. This can include legal, actuarial, accounting, consulting, data management, and administrative services.
In fact, anyone with access to protected health information about your clients, including service providers, subcontractors, direct vendors, and insurance companies, should be considered a business associate. To ensure compliance with HIPAA regulations, have a business associate agreement with each and every vendor you do business with. This includes even those with limited access to protected health information.
Purpose of HIPAA Business Associate Agreements
The purpose of a HIPAA Business Associate Agreement is to legally define what will happen in the event of a breach of protected health information. This document outlines the responsibilities and confidentiality requirements of the business associate and holds them accountable for any breaches.
Have a business associate agreement with any entity that may come into contact with protected health information. Such entities include biomedical transport waste providers, cleaning crews, and pharmaceutical reps. Failure to have such an agreement can result in fines and other consequences, as HIPAA is a federal law. Likewise, ensure that any email or software used to transmit protected health information is HIPAA-compliant to avoid any violations.
Administrative Safeguards for Protected Health Information
The administrative safeguards for protected health information certainly include eight standards, which are essential to protecting individuals and their private information. These standards consist of the following:
- Security management processes
- Assigned security responsibility
- Workforce security
- Information access management
- Security awareness training
- A contingency plan
- An evaluation
- Business associate contracts and other arrangements.
Following these standards provides healthcare providers with the necessary authority to safeguard private information and protect patients. It is vital to implement these safeguards to ensure that individuals’ rights are protected and healthcare providers maintain compliance with HIPAA regulations.
Online Security: The Significance of Using Strong and Unique Passwords
When it comes to online security, using strong and unique passwords is essential. However, creating and remembering passwords that meet the requirements of various websites and applications can be a frustrating experience. Most websites require passwords to have a mix of upper and lower-case letters, numbers, and special characters. Additionally, they may prohibit the use of previously used passwords or suggest using a randomly generated strong password that is nearly impossible to remember.
Writing down passwords in a secure location can help, but it is important to make sure that the written passwords are protected as well. Despite the challenges, it is crucial to prioritize strong passwords to protect sensitive information from potential cyber attacks.
HIPAA Fines and Cybersecurity Insurance for Protected Health Information
As aesthetic practice providers, owners and administrators, it is undoubtedly crucial to understand the potential fines associated with HIPAA violations. If caught, fines can range anywhere from five to $25,000 per violation, which can add up quickly. Since the chances of getting caught are relatively low, it is up to you as healthcare professionals to take the necessary steps to prevent any breaches from happening in the first place.
Make sure to provide your patients with the necessary HIPAA paperwork that outlines who is eligible to receive their protected health information and in what format. Patients should sign this paperwork, which becomes a part of their permanent file, and any refusals or requests for a copy should be appropriately documented. It is also recommended that you have a business associate agreement filed to protect yourself from liability should a breach occur.
Despite the extra fees, it is strongly advised that aesthetic practices invest in cybersecurity insurance. If a breach does occur, it can be challenging and expensive to recover lost data and defend against potential lawsuits. Cybersecurity insurance can provide a layer of protection, with at least one or two million dollars of coverage suggested. While it may be tempting to avoid these additional expenses, the potential consequences of a breach can be far more severe. Protect yourself and your patients by taking the necessary precautions and investing in cybersecurity insurance.
HIPAA compliance is a must for you in your aesthetic practice. If you would like to have professional guidance in how to achieve this, as well as how to maximize profit, reduce costs and ultimately thrive in your aesthetic practice, don’t hesitate to reach out to our team of experts for coaching! Schedule a free consult with our award-winning expert, Jay Shorr, to make sure that you’re on the right path to success!
To learn more about HIPAA, what it is and how to prevent violations in your aesthetic practice, be sure to listen to episode 81 of Shorr Solutions: The Podcast!
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About Shorr Solutions:
Shorr Solutions is an award-winning practice management consulting company with offices in South and Central Florida. We work with aesthetic medical practices in all 50 states of the U.S. to help them strengthen the operational, financial, and administrative health of their business. With decades of industry experience, our father-daughter partners, Jay Shorr and Mara Shorr, lead our knowledgeable team of experts to assist practices in the aesthetic medical fields increase efficiency, increase revenue, and decrease their costs.
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