Question 1

What is the HIPAA Security Rule?

Accepted Answer

The HIPAA Security Rule establishes national standards to protect the confidentiality, integrity, and availability of electronic protected health information (ePHI) through administrative, physical, and technical safeguards.

Question 2

What is considered a HIPAA violation in cybersecurity?

Accepted Answer

A HIPAA violation occurs when PHI or ePHI is impermissibly used or disclosed or insufficiently safeguarded. Common causes include weak access controls, missing risk analyses, unencrypted devices, improper workforce training, and delayed breach reporting.

Question 3

What are administrative, physical, and technical safeguards?

Accepted Answer

Administrative safeguards are policies, procedures, and training. Physical safeguards protect facilities and devices. Technical safeguards include access controls, audit logging, transmission security, and encryption.

Question 4

Is a HIPAA risk assessment required annually?

Accepted Answer

HIPAA requires a regular and thorough risk analysis but does not mandate a specific frequency. Many organizations perform it annually and whenever significant changes occur, such as new systems, vendors, or workflows.

Question 5

What should a HIPAA risk assessment include?

Accepted Answer

It should identify where ePHI resides, evaluate threats and vulnerabilities, assess likelihood and impact, review current controls, document risk levels, and define prioritized remediation steps and timelines.

Question 6

What is the role of encryption in HIPAA compliance?

Accepted Answer

Encryption is an addressable implementation specification. If reasonable and appropriate, it should be implemented for data at rest and in transit. If not implemented, the decision must be documented and an equivalent alternative safeguard applied.

Question 7

What is a Business Associate under HIPAA?

Accepted Answer

A Business Associate is any person or organization, other than a workforce member of a covered entity, that creates, receives, maintains, or transmits PHI on behalf of a covered entity. Examples include cloud providers, IT support, billing services, and certain consultants. A Business Associate Agreement (BAA) is required before PHI access.

Question 8

Do business associates need to be HIPAA compliant?

Accepted Answer

Yes. Business associates must implement appropriate safeguards for PHI, comply with applicable HIPAA requirements, enter into a BAA, report incidents and breaches, and ensure their subcontractors that handle PHI also comply.

Question 9

What happens if a business associate causes a breach?

Accepted Answer

Both the covered entity and the business associate have obligations. The business associate must investigate, mitigate, and notify the covered entity. Breach notifications to individuals, HHS, and in some cases the media may be required based on the incident size and circumstances.

Question 10

How do I secure remote access to ePHI?

Accepted Answer

Use VPN or zero-trust access, require multi-factor authentication, enforce least-privilege access, encrypt devices, manage endpoints and patches, disable local data storage when possible, and monitor logs for suspicious activity.

Question 11

Can employees use personal devices under HIPAA?

Accepted Answer

Yes, if governed by a BYOD policy that enforces device encryption, screen locks, remote wipe, mobile device management, separation of work data, and prohibits storing ePHI in unsecured apps or locations.

Question 12

What is considered a HIPAA data breach?

Accepted Answer

A breach is an impermissible use or disclosure of unsecured PHI that compromises its security or privacy, such as ransomware, lost or stolen devices, misdirected emails, or unauthorized access, unless a documented risk assessment shows a low probability of compromise.

Question 13

How soon must a HIPAA breach be reported?

Accepted Answer

Affected individuals must be notified without unreasonable delay and no later than 60 days after discovery. Reporting to HHS depends on the number of affected individuals; large breaches (500 or more) require more immediate reporting and, in some cases, media notice.

Question 14

What are the penalties for HIPAA violations?

Accepted Answer

HIPAA penalties vary by tier based on level of culpability, with per-violation amounts and annual caps per violation type. Enforcement may include corrective action plans, settlement amounts, and monitoring. Actual amounts depend on the facts and current HHS guidance.

Question 15

Can my practice be audited for HIPAA compliance?

Accepted Answer

Yes. HHS’s Office for Civil Rights conducts audits and investigations, particularly after breaches or complaints. Maintaining documentation, training records, and current risk analyses helps demonstrate compliance readiness.

Question 16

What documentation is required to prove HIPAA compliance?

Accepted Answer

Keep current risk analyses, remediation plans, security and privacy policies, workforce training logs, incident response procedures, business associate agreements, access audit logs, and evidence of ongoing monitoring and evaluations.

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