Every Check Has a Balance—Even with Healthcare IT

electronic health record EHR auditBarry Mathis, PYA Principal-Information Technology, authored the below article, “Every Check Has a Balance—Even with Healthcare IT,” which recently was published by the Tennessee Society of Certified Public Accountants.

This article first appeared in the November/December 2016 issue of the Tennessee CPA Journal. It is reprinted with permission.

Every check has a balance—even with healthcare IT.  In this case, for every check there is an audit.  Providers receive federal and state funds based on their ability to provide access to electronic health records (EHR).  In order to qualify under the Centers for Medicare & Medicaid Services EHR incentive program, providers must demonstrate that they are meaningfully using their EHR by meeting thresholds for numerous objectives.  Among the core objectives is the responsibility to protect electronic health information created or maintained by certified electronic health record technology (CEHRT).  The completion of a HIPAA Security Risk Analysis (HSRA), implementation of necessary security updates, and the correction of identified security deficiencies represent measures providers should take when protecting electronic health information created or maintained by the CEHRT.

Outlined by the Department of Health and Human Services (HHS), the minimum necessary steps to complete an HSRA include:

  • Identifying the scope of the analysis
  • Gathering the data
  • Identifying and documenting potential threats and vulnerabilities
  • Assessing current security measures
  • Determining the likelihood of threat occurrence
  • Determining the potential impact of threat occurrence
  • Determining the level of risk
  • Identifying security measures
  • Finalizing the documentation

Despite this detailed guidance, some providers may have hastily completed the HSRA or completely misunderstood the requirement.  Providers now are being audited and discovering a gap between what they understood and what was expected.  During these audits, providers who fail to furnish adequate evidence that they have met a core measurement could find their Meaningful Use (MU) payments recalled.

Ongoing MU audits are not the only audits providers face when it comes to HIPAA.  The Office of Civil Rights (OCR) has begun Phase 2 of the federal HIPAA audits.  These audits are comprised of desk audits and a smaller number of on-site audits.  Since the inception of the Phase 2 audits, approximately 200 providers have received notification to submit documentation for a desk audit.  Approximately 50 providers, both from within and outside of the desk audit pool, have been notified of an on-site HIPAA audit.  Although the scope of a desk audit is limited to a total of seven controls drawn from the Security Rule, Privacy Rule, and the Breach Notification Rule, the HSRA is a required component of all audits.

tncpa-journal-table

Desk audits are underway, and the OCR will base the audits only on the documents submitted in its specified electronic process within ten business days.  Business Associates (BAs) desk audits commenced this fall, and the selection pool is largely comprised of BAs identified by the Covered Entities (CEs) in their document responses.  Comprehensive on-site audits of both CEs and BAs will begin in early 2017.

So, what should you be doing now to prepare for future HIPAA audits?

  1. If you have not yet completed an HSRA, complete one as soon as possible.  To comply with HIPAA, you must review, correct, modify, and update security protections.  If no HSRA has been completed, you are in violation of the HIPAA Rule, and delaying the HSRA could result in additional fines and ultimately lead to a breach.
  2. Review your HSRA for alignment with HHS guidance.  Have you identified all ePHI, threats, vulnerabilities, and likelihood of exposure?  Have you completed the analysis and prioritized your risks?  Do you have an updated mitigation plan?
  3. Gather your documentation to include the HSRA results, your mitigation plan, and your HIPAA policies and procedures.  Organize and standardize formats to make uploading and reviewing documentation an easier process.  Refrain from submitting superfluous documentation, as there is a 10MB file size limitation.
  4. Using the OCR 2016 HIPAA Desk Audit Guidance on Selected Protocol Elements, conduct internal reviews to identify gaps that might delay your response to an OCR audit request.
  5. If gaps are identified, begin mitigation efforts now.  Be prepared to include additional commentary and detailed mitigation plans, as needed.

Do not assume that just because you were not included in the first round of audits that you will not be audited in the future.  OCR plans to identify additional on-site audits beginning in 2017.  It is likely that the documentation required for these audits will be similar to the documentation required for the desk audits.  On-site audits will not be limited to specific control areas; rather, they will be comprehensive HIPAA compliance audits.

 

[1] https://www.hhs.gov/sites/default/files/2016HIPAADeskAuditAuditeeGuidance.pdf

[2] Retain the documentation required…for 6 years from the date of its creation or the date when it last was in effect, whichever is later (emphasis added) (45 CFR 164.316)


Barry Mathis

Barry Mathis

Principal

Related Posts
An article by PYA Principal W. Lyle Oelrich was recently published by Becker’s Hospital Review. “10 Physician Compensation Statistics: How Does Your Organization Measure Up?” provides a list of statistics...
Read More

“10 Physician Compensation Statistics: How Does Your Organization Measure Up?”

Are you feeling unease about the impending Tuesday, April 17 tax filing deadline? Fear not –the Internal Revenue Service (IRS) permits a taxpayer to file an extension to allow time...
Read More

The Tax Deadline Looms: Need More Time?

Businesses are increasingly reliant on technology to achieve organizational objectives. However, with the convenience and efficiency of technology come intensifying risks of data loss and theft. High-profile data breaches top...
Read More

Cybersecurity Framework “SOCs” It to Cyber Threats

Engage. Share. Encourage. The American Healthcare Lawyers Association (AHLA) is hosting AHLA Day April 19, 2018, and these impactful words are setting the tone. AHLA receptions will be held across...
Read More

Join PYA in Celebrating Our Health Lawyer Colleagues During AHLA Day

PYA has released a white paper that discusses the importance of the AICPA’s cybersecurity risk management framework and System and Organization Controls for Cybersecurity in assessing the strength and effectiveness...
Read More

New PYA White Paper: Framework Offers Companies Solution for Cybersecurity Risk

PYA has added 2018 reimbursement updates to a white paper that provides valuation guidance to hospitals considering telemedicine arrangements for providing much-needed healthcare services at lower costs. As patient demand...
Read More

PYA White Paper “An Introduction to Valuing Telemedicine” Gets 2018 Updates

Compliance Today magazine recently published an article, “Regulatory Compliance: Physician Needs Assessments Are an Integral Step,” authored by PYA Principal Tynan O. Kugler. It highlights the critical role physician needs...
Read More

Regulatory Compliance: Physician Needs Assessments Are an Integral Step

Medicare cards are getting a much-needed facelift.  The Centers for Medicare & Medicaid Services has announced its intention to remove Social Security numbers from the cards in an effort to...
Read More
Medicare card scam

New Medicare Cards in the Mail—Don’t Fall Prey to Scammers

PYA has released an updated white paper offering a succinct list of changes and updated instructions for providing and billing Medicare for chronic care management. PYA, a national professional services...
Read More

Updated White Paper Addresses Changes in Providing and Billing Medicare for Chronic Care Management Services

Share This Insight

If you received value from this article, please share it with your network (e.g., Facebook, Twitter, LinkedIn). Icons below for your convenience.

Stay Current

* indicates required
Monthly eNewsletters
See more newsletter and alert options.

PYA Population Health Ascend

PYA Healthcare Blog

PYA Thought Leadership Services

The Healthcare Loop