What Does It Mean To Be HIPAA Compliant?

January 17, 2023

One of the significant drivers of quality healthcare is adequate patient information. But you will agree that people generally defect from sharing their deep personal data when there is no trust in place. 

In healthcare, adhering to Acts and laws by governing bodies to protect patient data is a must as patient confidentiality is psychologically related to patient safety. 

As more healthcare organizations began to adopt electronic records and other digital solutions for processing and to store patient information, the need for a more intentional approach to safeguard patient information became obvious. 

Therefore, the Federal Government passed the Health Insurance Portability and Accountability Act (HIPAA)

As a healthcare provider, it is crucial to understand HIPAA compliance in your practice at any level. 

Apart from safeguarding patient information, maintaining HIPAA compliance saves your organization from huge penalties and even a potential license withdrawal,  

What Is HIPAA? 

Enacted in 1996 and signed by President Bill Clinton, the Health Insurance and Portability Act (HIPAA) Is an Act that sets standard rules and policies for healthcare organizations and other companies dealing with Protected Health Information (PHI) to protect patients privacy. 

Around the time of signing, situations involving corporations invading the privacy of American citizens for personal gains were rampant. Also, about a third of fortune 500 companies factored in medical history as part of the criteria to hire an employee without the employee's explicit consent.

If any of the issues mentioned above were to occur today, the organizations involved would face a heavy penalty. 

Today, HIPAA compliance has become even more critical, with cybersecurity being a thing. Hackers profit from selling patient information on the black market after breaching through a hospital's health record database. 

To fully understand what it means to be HIPAA compliant, we need to consider who is subject to HIPAA and the nature of the data HIPAA covers. 

Parties and Data Involved in HIPAA 

HIPAA applies to three parties; The patients, covered entities, and business associations. 

  • Patients: Patients are at the center of HIPAA as a rule set up to protect them in the first place.
  • Covered Entities: HIPAA regulation identifies a covered entity as an organization that creates, stores, or transmits PHI electronically. Examples of covered entities include; healthcare providers, clearinghouses, and health insurance panels.
  • Business Associates: They are defined as any organization that deals with or encounters PHI in any way while working on contracted projects on behalf of covered entities. 

Many organizations may qualify as business associates because healthcare organizations depend on many third-party services to aid their operations. 

Some business associates include practice management firms, IT providers, shredding companies, EHR platforms, billing companies, physical storage providers, email hosting services, etc. 

Examples of data that are protected under HIPAA include; Names, addresses, images, Social Security Numbers (SSN), medical records, account numbers, health plan numbers, phone numbers, biometric data, IP addresses, etc. 

Understanding HIPAA Laws

HIPAA laws fall into four sections: The Privacy Rule and Security Rule, established with HIPAA inception in 1996; the Breach Notification Rule; and Omnibus Rule, added in 2009. 

As outlined by the US Department of Health and Human Services (HHS), the Privacy Rule establishes national policies to protect Individually Identifiable Health Information. 

The Security Rule establishes security standards to protect health information stored or transferred in electronic form. The security implements safeguard policies that covered entities must adhere to secure patient electronic PHI. 

The Office of Civil Rights (OCR) is responsible for enforcing both Privacy and Security Rules within the HHS. 

The HIPAA Breach Notification Rule outlines a set of policies guiding business associates and covered entities in the event of a data breach involving PHI or e-PHI. 

The Rule outlines the different requirements for breach reporting depending on the nature and extent of the breach. Regardless of the severity, your practice is required to report all violations to the HHS OCR. 

Lastly, the HIPAA Omnibus Rule mandates that business associates be HIPAA compliant; it also rules surrounding Business Associate Agreements (BAAs). 

BAAs are agreements that must exist between covered entities and business associates before any transfer of PHI or e-PHI between them.  

What Is Required For HIPAA Compliance? 

At this point, you need to understand that HIPAA compliance is an ongoing process, - the rules evolve. Being HIPAA compliant today doesn't mean that you will be compliant tomorrow. However, the general requirements for HIPAA compliance include the following; 

Self Audits

To be HIPAA compliant, you need to conduct annual audits and reviews to assess Technical, Administrative, and Physical gaps in compliance with HIPAA Privacy and Security Rules. 

Remediation Plans 

After conducting your internal audits and identifying the gaps in your compliance, you must implement remediation plans to reverse compliance violations. You are required to document your remediation plans with well-detailed calendar dates on when you intend to implement them.

Policies, Procedures, Employee Training 

This requirement entails developing policies and procedures corresponding to the HIPAA Privacy and Security Standards. This means that HIPAA compliance standards should integrate into the mode of operation of your organization. 

You should regularly update your internal policies and operational procedures to account for changes in the compliance standards.

You should also conduct annual staff training in line with these policies and procedures. Along with these, HIPAA requires a documented employee attestation stating your staff has read and understood your organizational policies and procedures. 


Your healthcare organization must document all efforts taken to become HIPAA compliant. It is an essential requirement as It has a considerable role during a HIPAA investigation and passing external HIPAA audits. 

Business Associates Management

You are also required to have a detailed record of all vendor's business associates you share PHI or e-PHI with in any way. It would help execute Business Associate Agreements (BAAs) to mitigate liabilities and ensure PHI is handled securely. 

HIPAA standards mandate you to review BAAs annually to account for changes to the nature of organizational relationships with vendors. 

Incidence Management

In a data breach, you should have a laid down measure to document the violation and notify your patients that your data has been accessed inappropriately. This requirement is under the HIPAA Breach Notification Rule. 

In a nutshell, it means to be HIPAA compliant to first make patient privacy a priority and culture within your organization and have dependable; employees, training, policies, and Business Associate Agreements. 

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