Health Insurance Portability and Accountability Act (HIPAA)

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The Health Insurance Portability and Accountability Act (HIPAA) is United States legislation that provides data privacy and security requirements for safeguarding medical information. The law was originally passed almost 30 years (in 1996) ago due to health data breaches caused by cyberattacks tied back to sloppy protective measures at health insurers and providers. In 2013, the HITECH Act added some much-needed updates to the act to reflect the migration to Online and Internet service models.

Since 1996, HIPAA has been modified to include processes for safely storing and sharing patient medical information electronically. It also includes administrative simplification provisions, which are aimed at increasing efficiency and reducing administrative costs by establishing national standards.

In healthcare circles, adhering to HIPAA Title II is what most people mean when they refer to ‘HIPAA Compliance’. Also known as the Administrative Simplification provisions, Title II includes the following HIPAA compliance requirements:

  • National Provider Identifier Standard. Each healthcare entity, including individuals, employers, health plans, and healthcare providers, must have a unique 10-digit National Provider Identifier number, or NPI.
  • Transactions and Code Sets Standard. Healthcare organizations must follow a standardized mechanism for electronic data interchange (EDI) in order to submit and process insurance claims.
  • HIPAA Privacy RuleOfficially known as the Standards for Privacy of Individually Identifiable Health Information, this rule establishes national standards to protect patient health information.
  • HIPAA Security RuleThe Security Standards for the Protection of Electronic Protected Health Information (ePHI) sets standards for patient data security.
  • HIPAA Enforcement RuleThis rule establishes guidelines for investigations into HIPAA compliance violations.
  • HIPAA Privacy Officer: Covered entities (entities that must comply with HIPAA requirements) must adopt a written set of privacy procedures and designate a privacy officer to be responsible for developing and implementing all required policies and procedures.

What does this mean for an SMB?

HIPAA applies to organizations that are considered HIPAA-covered entities. It also names 3rd parties working with covered entities as Business Associates (BA). HIPAA requires covered entities working with 3rd parties who access HIPAA data to secure a Business Associate Agreement (BAA) with them. A BAA is a contract that imposes specific safeguards on the PHI that a BAA uses, processes, or otherwise manipulates as a 3rd party to the covered entity. 

A HIPAA-covered entity is any organization or corporation that directly handles PHI or personal health records (PHRs). Covered entities are required to comply with HIPAA and the Health Information Technology for Economic and Clinical Health (HITECH) Act mandates for the protection of PHI and PHRs.

Covered entities fall into three categories:

  1. Healthcare provider. Healthcare providers include doctors, clinics, psychologists, dentists, chiropractors, nursing homes, and pharmacies.
  2. Health plan. Health plans include health insurance companies, health maintenance organizations (HMOs), company health plans, and government healthcare programs, such as Medicare, Medicaid, and military healthcare programs.
  3. Healthcare clearinghouse. Healthcare clearinghouses are entities that process nonstandard health information they receive from another entity into a standard format or vice versa. Examples include billing services and community healthcare systems for managing health data.

Entities can use the HHS online tool to determine if they qualify as a HIPAA-covered entity or BA and, consequently, if they must comply with HIPAA or not.

Additional Cybersecurity Recommendations

Additionally, these recommendations below will help you and your business stay secure with the various threats you may face on a day-to-day basis. All of the suggestions listed below can be gained by hiring CyberHoot’s vCISO Program development services.

  1. Govern employees with policies and procedures. You need a password policy, an acceptable use policy, an information handling policy, and a written information security program (WISP) at a minimum.
  2. Train employees on how to spot and avoid phishing attacks. Adopt a Learning Management system like CyberHoot to teach employees the skills they need to be more confident, productive, and secure.
  3. Test employees with Phishing attacks to practice. CyberHoot’s Phish testing allows businesses to test employees with believable phishing attacks and put those that fail into remedial phish training.
  4. Deploy critical cybersecurity technology including two-factor authentication on all critical accounts. Enable email SPAM filtering, validate backups, deploy DNS protection, antivirus, and anti-malware on all your endpoints.
  5. In the modern Work-from-Home era, make sure you’re managing personal devices connecting to your network by validating their security (patching, antivirus, DNS protections, etc) or prohibiting their use entirely.
  6. If you haven’t had a risk assessment by a 3rd party in the last 2 years, you should have one now. Establishing a risk management framework in your organization is critical to addressing your most egregious risks with your finite time and money.
  7. Buy Cyber-Insurance to protect you in a catastrophic failure situation. Cyber-Insurance is no different than Car, Fire, Flood, or Life insurance. It’s there when you need it most.

All of these recommendations are built into CyberHoot the product or CyberHoot’s vCISO Services. With CyberHoot you can govern, train, assess, and test your employees. Visit and sign up for our services today. At the very least continue to learn by enrolling in our monthly Cybersecurity newsletters to stay on top of current cybersecurity updates.

To learn more about HIPAA, watch this short 2-minute video:

CyberHoot does have some other resources available for your use. Below are links to all of our resources, feel free to check them out whenever you like: 

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