Compliance Advisory Services

HIPAA Incident Privacy and Breach Identification refers to the processes and
regulations under the Health Insurance Portability and Accountability Act (HIPAA) that govern the identification, reporting, and management of breaches involving protected health information (PHI).
Why It is Critical for Healthcare Organizations:

1. Legal Compliance – Healthcare providers and their business associates must follow HIPAA’s Breach Notification Rule, which mandates reporting breaches of unsecured PHI.
2. Patient Trust & Confidentiality – Protecting patient data ensures privacy and security, reinforcing trust between healthcare providers and patients.
3. Risk Assessment & Mitigation – Organizations must assess the nature and extent of compromised PHI, including identifiers and the likelihood of re-identification.
4. Financial & Reputational Impact – Failure to comply can result in hefty fines and damage to an organization’s reputation.
5. Preventative Measures – Identifying breaches early allows organizations to mitigate risks and prevent further unauthorized disclosures.

Healthcare organizations, including Business Associates, should respond to a potential electronic protected health information (ePHI) data breach immediately to mitigate risks and comply with HIPAA regulations. Under HIPAA’s Breach Notification Rule, affected individuals must be notified without unreasonable delay and no later than 60 days after discovery. If the breach affects 500 or more individuals, it must be reported to the Department of Health and Human Services (HHS) within 60 days. Smaller breaches can be reported annually.

ITS Alliances services play a crucial role in supporting a covered entity or business associate after a breach involving protected health information (PHI) has been identified. The responsibilities are outlined under HIPAA regulations, specifically the Breach Notification Rule.
Typical Support Provided:

1. Immediate Notification – Depending upon whom was breached we must notify HHS without unreasonable delay, and no later than 60 days after discovering the breach.
2. Detailed Breach Information – Reports to provide details such as:
   • The nature and extent of the breach.
   • The individuals affected.
   • Any mitigation efforts taken.
3. Risk Assessment & Investigation – We would assist in evaluating the impact of the breach and determining whether ePHI was compromised.
4. Media Notification – If the breach affects 500 or more residents in a single state, the entity must notify prominent media outlets to ensure public awareness. We would create the public press release and work with each media outlet as needed.
5. Mitigation & Corrective Actions – Depending upon the impact of the breach, implement security improvements, conduct employee training, and revise policies and/or procedures to prevent future breaches.

After a privacy and security data breach, following the proper steps helps ensure a smooth compliance audit by demonstrating accountability, risk mitigation, and adherence to regulatory requirements. Here’s how each step contributes:

1. Incident Identification & Containment
   • Shows auditors that the organization acted swiftly to limit damage.
   • Demonstrates proactive security measures to prevent further exposure.
   
2. Risk Assessment & Investigation
   • Provides a detailed analysis of the breach, including affected data and individuals.
   • Helps auditors evaluate whether proper risk management was in place.
   
3. Notification & Reporting
   • Compliance audits check whether the organization met legal deadlines for notifying affected individuals and authorities.
   • Ensures transparency and adherence to HIPAA’s Breach Notification Rule.
   
4. Corrective Actions & Security Enhancements
   • Auditors review whether the organization implemented stronger security controls post-breach.
   • Demonstrates a commitment to preventing future incidents.
   
5. Documentation & Compliance Review
   • A well-documented breach response helps auditors verify policy adherence.
   • Ensures the organization has updated protocols to align with regulatory standards.

By following these steps, healthcare organizations can strengthen their compliance posture, reduce penalties, and build trust with patients and regulators.