Disclaimer: This blog article was written by an AdvancedMD partner. The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of AdvancedMD.
Amidst all of the other events in Washington DC in January, a law was passed that amended the HIPAA Regulations. The amendment requires the department of Health and Human Services to take certain items into account during a HIPAA investigation. The text of the bill reads as follows:
when making determinations relating to fines under such section 1176 (as amended by section 13410) or such section 1177, decreasing the length and extent of an audit under section 13411, or remedies otherwise agreed to by the Secretary, the Secretary shall consider whether the covered entity or business associate has adequately demonstrated that it had, for not less than the previous 12 months, recognized security practices in place that may—
‘‘(1) mitigate fines under section 1176 of the Social Security Act (as amended by section 13410);
‘‘(2) result in the early, favorable termination of an audit under section 13411; and
‘‘(3) mitigate the remedies that would otherwise be agreed to in any agreement with respect to resolving potential violations of the HIPAA Security rule (part 160 of title 45 Code of Federal Regulations and subparts A and C of part 164 of such title) between the covered entity or business associate and the Department of Health and Human Services.
‘‘(b) DEFINITION AND MISCELLANEOUS PROVISIONS. —
‘‘(1) RECOGNIZED SECURITY PRACTICES.—The term ‘recognized security practices’ means the standards, guidelines, best practices, methodologies, procedures, and processes developed under section 2(c)(15) of the National Institute of Standards and Technology Act, the approaches promulgated under section 405(d) of the Cybersecurity Act of 2015, and other programs and processes that address cybersecurity and that are developed, recognized, or promulgated through regulations under other statutory authorities. Such practices shall be determined by the covered entity or business associate, consistent with the HIPAA Security rule (part 160 of title 45 Code of Federal Regulations and subparts A and C of part 164 of such title).
So, what does this mean?
Go to section 2(c)(15) of the National Institute of Standards and Technology Act
(15) on an ongoing basis, facilitate and support the development of a voluntary, consensus-based, industry-led set of standards, guidelines, best practices, methodologies, procedures, and processes to cost-effectively reduce cyber risks to critical infrastructure (as defined under subsection (e));
Putting all of this legalese into English. If you do a HIPAA security risk analysis, implement reasonable policies, procedures and an action plan to ensure you are doing everything you can to reduce the chance of a cyber security breach, then the government needs to take that into account and must mitigate any potential fines you may be facing.
Clients of TLD Systems have a HIPAA Security Manual which includes all of the factors listed in item (15) above. They also have access to training for their staff on the HIPAA rules and regulations and have an action plan to take steps to reduce the possibility of a cyber incident.
TLD Systems has a proven track record and to date not a single active client of TLD Systems has been fined for a HIPAA violation.
For more information, please visit TLD Systems at https://www.tldsystems.com.
