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Everything You Need to Know About HIPAA and HIPAA Compliance

As a healthcare organization, you need to understand and comply with HIPAA regulations. HIPAA regulation is concerned with safeguarding health information to secure it from cyberattacks.

You may need to upgrade your technology or hire an IT consultant to help you store your data on cloud solutions and secure it. In this article, we will help you understand what HIPAA compliance is and why it matters.

What is HIPAA Compliance?

HIPAA refers to the Health Insurance Portability and Accountability Act of 1996. It consists of regulatory standards that clarify how one should lawfully use and disclose protected health information (PHI).

The department of Health and Human Services (HHS) regulates HIPAA compliance while the Office of the Civil Rights (OCR) enforces it. The OCR’s mandate includes offering routine guidance on emerging issues that affect health care and investigating the violation of HIPAA regulations.

HIPAA compliance refers to the process followed by business entities and covered entities to secure and protect PHI as outlined in the Health Insurance Portability and Protection Act of 1996. Health care organizations need to implement HIPAA regulations to help them protect the security, privacy, and integrity of PHI.

What is Protected Health Information?

Protected Health Information refers to any demographic data that can identify a client or patient of a HIPAA-beholden entity. It includes social security number, name, and phone number. Financial information, full facial photos, medical records, and addresses also form part of PHI.

This information may be stored and transmitted physically or electronically. Whether you are storing and sharing PHI physically or electronically, you must comply with HIPAA.

Who Needs to Comply with HIPAA?

HIPAA targets 2 types of entities. Let us discuss them briefly here:

Covered Entities

HIPAA defines a covered entity as any organization that creates, collects, or transmits protected health information electronically. Healthcare providers, health insurance providers, and healthcare clearinghouses are among the healthcare entities that HIPAA lists as covered entities.

Business Associates

According to HIPAA, a business associate is an organization that may come across PHI while working for a covered entity. They are the businesses that assist a covered entity process, transmit, interpret, or store PH data.

Covered entities work with many forms of businesses. They may include consultants, attorneys, accountants, and IT providers. Your IT provider, like Acom Networks, plays a significant role in ensuring you are continuously complying with HIPAA regulations. This helps you develop systems for the safe transfer and storage of data.

An Outline of HIPAA Regulations

Some of the HIPAA rules you should be aware of include:

HIPAA Privacy Rule

This rule applies to covered entities but not business associates. It consists of a set of national standards that govern the rights of a patient to PHI. Under this rule, a patient has a right to access PHI, while healthcare providers have a right to deny access to PHI.

Healthcare providers also have a right to use or disclose PHI. The PHI contents may be found in Notices of Private Practice or HIPAA release forms.

HIPAA Security Rule

The HIPAA security rule forms the foundation for the national standards that govern the secure handling, maintenance, and transmission of electronic PHI. It applies to both business associates and covered entities that can potentially share PHI electronically.

The rule outlines technical, administrative, and physical safeguards you should put in place in your organization. Each organization listed under HIPAA should document its specifics of the regulation in its HIPAA Policies and Procedures.

HIPAA Breach Notification Rule

This rule outlines the process that business associates and covered entities must follow when after a data breach involving PHI. The rule categorizes these breaches into minor and meaningful breaches, depending on the size and scope.

You should report all forms of breaches to HHS OCR. However, the protocols of reporting depend on the type of breach.

HIPAA Omnibus Rule

This is a set of rules outlining compliance requirements for business associates. It states that business associates must comply with HIPAA. It also outlines guidelines surrounding Business Associate Agreements (BAAs), which are the contracts between covered entities and business associates.

BAAs may also involve two business associates listed under HIPAA. Sign your BAAs before allowing business associates to access, process, or transmit PHI.

What Do You Require to Comply with HIPAA?


As a HIPAA requirement, you should conduct an annual self-audit of your organization to assess the technical, physical, and administrative gaps in HIPAA Privacy and Security Standards compliance. This procedure on its own does not indicate compliance but helps your organization identify areas where you should improve to ensure you are complying.

Remedial Plans

After identifying gaps in compliance during your self-audit, you need to come up with remediation plans. You must document your remediation plans, including the calendar dates when you intend to remedy the compliance gaps.

Policies, Procedures, and Employee Training

Business associates and covered entities should develop policies and procedures in line with HIPAA regulatory standards. You should document, review, and update your HIPAA policies and procedures regularly. Train your employees on these policies and procedures.


Covered entities and business associates listed under HIPAA should document their compliance efforts. The documents help when HHS OCR is investigating an organization for non-compliance.

Business Associate Management

Record all the vendors that you share PHI to using any means. Also, have and execute your BAAs to ensure PHI is handled securely to mitigate any liability that may arise from the wrongful handling.

Incident Management

Whenever you have a data breach, inform patients whose data has been compromised.  Also, document the incident and report to HHS OCR.

What is the Importance of HIPAA Compliance?

For Proactive Data Protection

A reliable IT consultant like Acom Networks can help you manage your PHI big data proactively. This will keep your data and systems safe from cyberattacks through ransomware, malware, or phishing that may affect your processes and business continuity.

Enhances Profitability

Compliance ensures you do not experience data breaches that may result in downtime. Ensure you are using the right technology to secure your data to help you remain productive and profitable.

Besides, compliance also safeguards your reputation. This enhances your client’s trust and loyalty, enhancing your profitability and business growth.

Improved Customer Trust

Your clients will trust you more when they know you have sealed all loopholes of data breaches.  Patients are likely to choose a healthcare provider that keeps their data securely to avoid unauthorized exposure and misuse.

To ensure continued compliance, consider outsourcing your IT services to experienced and reliable companies