Do You Know How to Handle a HIPAA Breach?
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The document provides guidance on handling HIPAA breaches, outlining obligations such as breach notification to affected individuals, the media, and the Secretary of Health and Human Services. It highlights the importance of conducting a risk assessment to determine whether a breach has occurred and discusses training and policies that organizations should implement to ensure compliance. The document emphasizes the necessity of credit monitoring services and cyber insurance to mitigate risks associated with breaches.
Do You Know How to Handle a HIPAA Breach?
- 1. Do You Know How To Handle A HIPAA Breach? Claudia A. Hinrichsen, Esq. The Greenberg, Dresevic, Hinrichsen, Iwrey, Kalmowitz, Lebow & Pendleton Law Group (516) 492-‐3390 chinrichsen@thehlp.com
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- 3. Agenda I. DefiniSon of Breach and Risk Assessment II. NoSficaSon obligaSons in event of HIPAA breach III. GeYng you own “house in order” IV. What to do when social security numbers are disclosed V. Credit monitoring for impacted paSents VI. Insurance for HIPAA breaches VII. QuesSons?
- 4. I HIPAA Omnibus Rule • New HIPAA regulaSons became effecSve on September 23, 2013 • Significant modificaSons made to HIPAA rules, including breach noSficaSon, among other things • Harm standard removed • Four factors must be considered in risk assessment
- 5. Determine Whether a Breach Occurred • Impermissible use or disclosure of protected health informaSon (PHI) is presumed to be a breach unless the Covered EnSty is able to demonstrate that there is “low probability that PHI has been compromised.” • Applies to “unsecured PHI” which is not rendered unusable, unreadable, or indecipherable I
- 6. Determine Whether a Breach Occurred At least the four following factors must be assessed: 1) The nature and extent of the PHI involved, including the types of idenSfiers and the likelihood of re-‐ idenSficaSon; 2) The unauthorized person who used the PHI or to whom the disclosure was made; 3) whether the PHI was actually acquired or viewed; and 4) The extent to which the risk to the PHI has been mi;gated. I
- 7. I Results of Risk Assessment • If evaluaSon of the factors fails to demonstrate that low probability that the PHI has been compromised, breach no;fica;on is required.
- 8. I Example 1 • If informaSon containing dates of health care service and diagnosis of certain employees was impermissibly disclosed to their employer, the employer may be able to determine that the informaSon pertains to specific employees based on the informaSon available to the employer, such as dates of absence from work. • In this case, there may be more than a low probability that the protected health informaSon has been compromised.
- 9. I Example 2 • If a laptop computer was stolen and later recovered and a forensic analysis shows that the protected health informaSon on the computer was never accessed, viewed, acquired, transferred, or otherwise compromised, the Covered EnSty could determine that the informaSon was not actually an unauthorized individual even though the opportunity existed.
- 10. I Example 3 • If financial informaSon, such as credit card numbers or social security numbers was disclosed, the Covered EnSty may determine that a breach has occurred as unauthorized use or disclosure of such informaSon could increase the risk of idenSty thef or financial fraud.
- 11. NotiIication Obligations in the Event of a HIPAA Breach • NoSficaSon to affected individuals • NoSficaSon to the media • NoSficaSon to the Secretary of the Department of Health and Human Services (the Secretary) • Other noSficaSons II
- 12. NotiIication to Affected Individuals • All noSces to affected individuals must be wrihen in plain language and include: • A brief descripSon of what happened, including the date of the breach and the date of the discovery of the breach, if known; • A descripSon of the types of PHI (not the specific PHI) that were involved in the breach (such as whether full name, social security number, date of birth, home address, account number, diagnosis, disability code or other types of informaSon were involved); II
- 13. NotiIication to Affected Individuals • Any recommended steps individuals should take to protect themselves from potenSal harm resulSng from the breach; • A brief descripSon of what the Covered EnSty is doing to invesSgate the breach, to miSgate harm to individuals and to protect against any further breaches; and • Contact informaSon for the Privacy Officer of the Covered EnSty. II
- 14. II Method of NotiIication • The covered enSty must noSfy affected individuals by: 1. Wrihen noSficaSon by first-‐class mail to the individual at the last known address of the individual 2. If the individual agrees to electronic noSce and such agreement has not been withdrawn, by electronic mail
- 15. II Method of NotiIication • In the case of minors or individuals who lack legal capacity due to a mental or physical condiSon, the parent or personal representaSve should be noSfied. • If the covered enSty knows that an individual is deceased, the noSficaSon should be sent to the individual's next of kin or personal representaSve if the address is known.
- 16. II Method of NotiIication • In urgent situaSons where there is a possibility for imminent misuse of the unsecured PHI, addiSonal noSce by telephone or other means may be made. However, direct wrihen noSce must sSll be provided.
- 17. II NotiIication to the Media • If the breach of unsecured PHI involves more than 500 residents of a state or jurisdicSon, prominent media outlet must be noSfied (most likely via a press release) without unreasonable delay and no later than 60 days afer discovery. PLEASE NOTE: The noSficaSon to the media is not a subsStute for the noSficaSon to the individual.
- 18. II NotiIication to the Secretary • For breach of unsecured PHI that involves more than 500 individuals, the Secretary of the Department of Health and Human Services should be noSfied via ocrnoSficaSons.hhs.gov without unreasonable delay and no later than 60 days aBer discovery.
- 19. II NotiIication to the Secretary • If the breach of unsecured PHI involve less than 500 individuals, the Covered EnSty’s Privacy Officer should maintain an internal log or other documentaSon of the breach. This informaSon should then be submihed annually (before March 1st) to the Secretary of HHS for the preceding calendar year via the website. • The health care provider should maintain its internal log or other documentaSon of breaches for six years.
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- 23. III Getting Your “House in Order” • Review/update the pracSce’s policies and procedures • Provide training to all employees in: • Updated policies • Prompt reporSng • EvaluaSon and documentaSon of breaches • Create an ac;on plan to respond to security incidents and breaches • Conduct regular internal audits • Consider geYng insurance for HIPAA breaches
- 24. Most Common Forms of Breach • Impermissible uses and disclosures of protected health informaSon • Lack of safeguards of protected health informaSon • Lack of pa5ent access to their protected health informaSon • Uses or disclosures of more than the Minimum Necessary protected health informaSon • Complaints to the covered enSty
- 25. OfIice of Civil Rights (OCR) Audits • OCR has completed audits for 115 enSSes with a total of 979 audit findings and observaSons: • 293 regarding Privacy • 592 regarding Security • 94 regarding Breach No;fica;on • An evaluaSon is currently underway to make audits a permanent part of enforcement efforts. • Security Rule assessment will be highly scruSnized. III
- 26. IV Social Security Numbers • Most states have addiSonal laws regulaSng noSficaSon of unauthorized disclosure of social security numbers. • These regulaSons require that noSficaSon be provided in the most expediSous Sme possible and without unreasonable delay. • The person that owns or licenses the computerized data must provide noSce to the individual.
- 27. IV Social Security Number Breach • Typically the following must be done immediately afer discovery of the breach: • Detailed noSce to affected residents within state • NoSficaSon to other governmental agencies, including, but not limited to: • State Ahorney General • Department of State • Consumer ReporSng Agencies PLEASE NOTE: The Ahorney General may bring a civil acSon and the court may also award injuncSve relief.
- 28. V Credit-‐Monitoring • According to the U.S. Federal Trade Commission, it takes an average of 12 months for a vicSm of idenSty thef to noSce the crime. • Credit-‐monitoring services will regularly alert the individual of any changes to their credit, helping stop thef before it gets out of control.
- 29. V Credit-‐Monitoring • Covered enSSes and others who maintain PHI may need to offer such services to affected individuals to miSgate risk. • Companies such as IdenSty Guard, Equifax, and Experian offer credit-‐monitoring, providing credit alerts to individuals every business day. • The average cost of credit monitoring per person is $15 a month with credit alerts which will report new accounts, credit inquiries, address changes, changes to current accounts/account informaSon, etc.
- 30. Business Associate Agreements • Covered EnSSes should include indemnificaSon language in their Business Associate Agreement for any costs related to a breach including free credit-‐monitoring for affected individuals. • A Covered EnSty may also consider requiring business associates to have data breach insurance. V
- 31. VI Cyber/Breach Insurance • A recent study by the Ponemon InsStute reported that 76% of parScipaSng organizaSons in the study who had experienced a security exploit ranked cyber security risks as high or higher than other insurable risks, such as natural disasters, business interrupSons, and fire. • Many general liability insurance polices are excluding data breaches ad security compromises.
- 32. VI Cyber/Breach Insurance • Data breach insurance may be necessary to cover the costs of responding to a breach and may include: • Defense costs and indemnity for a statutory violaSon, regulatory invesSgaSon, negligence or breach of contract • Credit or idenSty costs as part of a covered liability judgment, award or sehlement • Forensic costs incurred in the defense of covered claim
- 33. VII Conclusion • “Thus far in 2013, 48 percent of reported data breaches in the United States have been in the medical/healthcare industry. In 2012, there were 154 breaches in the medical and healthcare sector, accounSng for 34.5 percent of all breaches in 2012, and 2,237,873 total records lost.” • ITRC Breach Report, IdenSty Thef Resource Center, May 2013 • A plan of acSon is crucial in order to appropriately handle a breach. • Proper and Smely noSficaSon is necessary
- 34. HIPAA Compliance HITECH Attestation Risk Assessment Omnibus Rule Ready Meaningful Use core measure 15 Policy & Procedure Templates Free Demo and 60 Day Evaluation www.compliancy-‐group.com HIPAA Hotline 855.85HIPAA 855.854.4722
- 35. VII Questions?