Webinar Duration: 90 minutes
RECORDED: Access recorded version only for one participant; unlimited viewing for 6 months (Access information will be emailed 24 hours after the completion of payment)
SPEAKER: Jim Sheldon-Dean
In this session we will discuss the HIPAA audit program and how it works, and discuss the areas that caused the most issues in prior audits. We will explore what kind of issues and what kind of entities had the most problems, and show where entities need to improve their compliance the most. We will also explore the typical risk issues that lead to breaches of health information and see how those issues may be a target for auditors in the 2014-2015 round.
– We will review the contents of the HIPAA Audit Protocol used in 2012 to show what documentation needs to be on hand should your organization be selected for an audit in the 2014-2015 round. The HIPAA Audit Protocol is not easy to use in its incarnation as a Web-based tool, and it does have several deficiencies because of the changes in the rules that became enforceable September 23, 2013, but we will present methods for using the contents of the HIPAA Audit Protocol to build your own compliance plan by extracting and updating the contents and relating your compliance activities directly to the questions that might be asked.
– In this session we will discuss the HIPAA audit and enforcement regulations and processes, and how they apply to HIPAA covered entities and business associates. We will explain the enforcement regulations and the recent changes that increase fines and create new penalty levels, including new penalties for willful neglect of compliance that begin at $10,000.
– We will discuss what information and documentation must be prepared in advance so that you can be ready for an audit at any time, including sample information request forms and questions asked at prior audits. The session will also cover how to know if you may become the subject of an audit or enforcement action, and what you can do to help limit your exposure. We will discuss how most enforcement actions come about and what can be done to prevent incidents that lead to enforcement activity.
– The HIPAA Privacy, Security, and Breach Notification regulations (and the recent changes to them) and how they will be audited will be explained. Documentation requirements for compliance will be explored and a framework of security policies necessary for compliance will be presented. The HIPAA Audit Protocol questions will be explored and ways of using the content to develop a compliance plan will be discussed. The process of exporting the questions will be shown, and a sample spreadsheet showing the results will be presented.
– The results of prior HHS audits (and their penalties) will be discussed, including recent actions involving multi-million dollar fines and settlements. A plan for attaining compliance will be presented. The steps to follow to prepare for an audit and respond to an audit request will be outlined.
Why should you attend:
– While in the past, audits had been performed only at entities that reported a breach or had a compliant filed against them, the new rule calls for audits whether or not there is a complaint or breach. This means that the HHS Office for Civil Rights (OCR) can show up and ask to perform an audit on short notice, and your organization will need to provide a response in less than ten business days. Knowing what questions are likely to be asked and have been asked at prior HIPAA compliance audits can make preparing for and surviving a HIPAA audit much easier
– USDHHS has published the protocol used for the 2012 HIPAA audits by the HHS contractors, and sets of questions asked in audots have become available, so it is possible to know much better now how to prepare for an audit. Nearly any health care covered entity or business associate may be subject to an audit; all entities need to know what kinds of questions they’ll be asked, what information they’ll need to provide and how to prevent issues that could lead to violations and fines
– Areas of weakness as shown in the 2012 audits and as shown by breach reports are likely targets for the next round of audit questions. If your organization is not ready, the HIPAA rules have new, significantly higher fines, including mandatory minimum fines of $10,000 for willful neglect of compliance
– In addition, HIPAA enforcement has taken on a new importance at HHS; officials have publicly stated that enforcement is now a priority, and that means being ready for an audit is more important than ever. The “slap-on-the-wrist” days are over and fines and settlements are being levied, with more on the way — don’t let your organization be hit for an audit unprepared
Areas Covered in the Session:
– Find out what the audit process is, what HHS OCR is likely to ask you if you are selected for an audit, and what you’ll have to have prepared already when they do
– Learn how to make the HIPAA Audit Protocol useful to you as a way to organize and track your compliance work, and collect your documentation references
– Find out what you’ll need to have documented to survive an audit and avoid fines
– Learn how to use an information security management process to evaluate risks and make decisions about how best to protect PHI and meet patient needs and desires
– Find out what policies and procedures you should have in place
– Learn about the training and education that must take place and be documented to ensure your staff uses health information properly and does not risk exposure of PHI
– Find out the steps that must be followed in the event of a breach of PHI
– Learn about how the HIPAA audit and enforcement activities are now being increased and how you must be prepared or risk significant penalties
Who Will Benefit:
– Compliance Director
– Privacy Officer
– Security Officer
– Information Systems Manager
– HIPAA Officer
– Chief Information Officer
– Health Information Manager
– Healthcare Counsel/lawyer
– Office Manager
– Contracts Manager
Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities.
Sheldon-Dean serves on the HIMSS Information Systems Security Workgroup, has co-chaired the Workgroup for Electronic Data Interchange Privacy and Security Workgroup, and is a recipient of the WEDI 2011 Award of Merit. He is a frequent speaker regarding HIPAA and information privacy and security compliance issues at seminars and conferences, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference in Washington, D.C.
Sheldon-Dean has more than 30 years of experience in policy analysis and implementation, business process analysis, information systems and software development. His experience includes leading the development of health care related Web sites; award-winning, best-selling commercial utility software; and mission-critical, fault-tolerant communications satellite control systems. In addition, he has eight years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician. Sheldon-Dean received his B.S. degree, summa cum laude, from the University of Vermont and his master’s degree from the Massachusetts Institute of Technology.