Unraveling the HIPAA Privacy Rule: Your guide to protecting personal health information

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The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule is designed to protect personal health information (PHI) while allowing necessary data flow in the healthcare industry. 

The HIPAA Privacy Rule applies to covered entities like healthcare providers and health plans, as well as their business associates. Adhering to HIPAA not only builds patient trust but also safeguards sensitive health information, enhancing the quality of healthcare by protecting health records from unauthorized release or misuse.

In this blog post, we’ll demystify the HIPAA Privacy Rule to help you understand how it safeguards PHI and ensures healthcare providers and their business associates maintain confidentiality.

Key takeaways

• The HIPAA Privacy Rule protects PHI and provides patients with the right to access and control their health information
• Covered entities must adhere to obligations such as protecting PHI, reporting breaches, and ensuring compliance for successful HIPAA Privacy Rule compliance
• Non-compliance can incur hefty fines or criminal charges

Understanding the HIPAA Privacy Rule

The HIPAA Privacy Rule aims to safeguard your PHI by regulating its use and disclosure. It sets guidelines for disclosure, with penalties for non-compliance, affecting healthcare providers and health plans. 

So, what constitutes PHI? Essentially, any health info about an individual that is created, received, stored, or transmitted by a covered entity and can be linked to identify the person. 

Specifically, PHI includes:

• Name, address, birth date, and Social Security Number
• Individual’s physical or mental health condition
• Any care provided to the individual
• Information concerning the individual that is provided by a healthcare provider or health plan
• Any information related to the individual’s past, present, or future physical or mental health
• Billing information from your doctor
• Any other identifying information used in the course of providing healthcare to the individual

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Specifically, it’s important to note that these items alone do not qualify as PHI—it’s specifically when they can be tied to past, present, or future healthcare services that they become PHI.

HIPAA secures PHI by enforcing the implementation of appropriate protections by covered entities, as detailed in the HIPAA Security Rule. This limits how your PHI can be used and shared, giving you control over your health data. And if the rules aren’t followed, there can be serious consequences: civil monetary penalties ranging from $100 to $50,000 per violation.

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Electronic Protected Health Information (ePHI)

Electronic Protected Health Information, or ePHI, is any Protected Health Information (PHI) that is created, stored, transmitted, or received electronically. ePHI includes a wide range of information such as patient names, addresses, social security numbers, medical records, and any other personally identifiable health information. Under the HIPAA Security Rule, healthcare providers and their business associates are required to implement administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and security of ePHI.

The “minimum necessary” requirement

Consider this scenario: A patient visits a healthcare facility for an ailment, and suddenly, their entire medical history becomes accessible to multiple healthcare providers within that organization and beyond. This is where the “minimum necessary” requirement comes into play to prevent unnecessary PHI disclosure. It ensures that your business and its associates only access or share the necessary amount of PHI to perform a specific task.

This requirement applies to all entities managing PHI, including healthcare providers, health plans, health maintenance organizations, and all entities covered under HIPAA regulations. As a business, you are responsible for maintaining the confidentiality and security of patients’ PHI by assessing your practices, implementing suitable safeguards, and limiting information sharing to a need-to-know basis.

Rights and protections for patients: A business perspective

As a business handling Personal Health Information (PHI), it’s crucial to understand and uphold the rights of the patients whose data you manage. The HIPAA Privacy Rule emphasizes the importance of patients’ control over their health data, and as a business, it’s your responsibility to ensure these rights are respected.

Consider the potential damage if patients were left in the dark about how their health information is being used or shared. The HIPAA Privacy Rule mandates transparency, requiring you to provide patients with the right to:

• Access their medical records
• Request changes to their medical records
• Receive notifications about how their health information may be used and shared by your business.

Ensuring access to personal health information

Patients have the right to access their PHI, request copies, and even direct your business to transmit a copy to a designated person or entity. As a business, you’re required to facilitate this access to help patients stay informed and maintain control of their health information.

You are given up to 30 calendar days from when you receive a request to provide access, with an additional 30 calendar days if needed. The designated record set, which includes the patient’s medical record and other health information, should be readily available upon request. This ensures transparency and gives patients control over their PHI.

Facilitating control over PHI disclosure

As a business, you are obligated to ensure that patients can control the release of their sensitive health information. This means obtaining written consent or authorization before sharing any health records and preventing unauthorized access or exploitation of sensitive health information.

HIPAA empowers businesses to facilitate control over PHI disclosure by providing access, allowing requests for restrictions on its disclosure, and educating patients about their rights under the Privacy Rule. In this way, businesses can help keep PHI private and maintain patients’ control over how it’s used and shared.

6 permitted uses and disclosures of PHI

Although the prime objective of the HIPAA Privacy Rule is to safeguard your PHI, there exist six specific scenarios where PHI can be disclosed without needing your authorization. These exceptions are designed to ensure necessary data flow in the healthcare industry while still maintaining your privacy.

The six allowed uses and disclosures involve PHI sharing for treatment, payment, healthcare operations, public health activities, research, and when mandated by law through public health authorities. Let’s explore each of these situations in more detail.

1. To the individual whose PHI it is

This may seem obvious, but it is worth capturing: First and foremost, personal health information, also known as PHI, can be disclosed to the individual it pertains to. 

However, steps must be taken to validate the identity of the person before such a disclosure is made (especially pertinent if it is requested electronically.) Sharing PHI with the patient ensures that they have access to their health information and can make informed decisions.

2. For payment and healthcare operations

PHI can be used for payment and healthcare operations without authorization. This allows healthcare providers to disclose PHI for their own payment purposes and for the payment activities of other covered entities involved in patient care.

HIPAA doesn’t enforce particular limitations on utilizing PHI for payment and healthcare operations. However, covered entities need to establish policies and procedures that limit the information they disclose and request, ensuring PHI remains protected.

3. Disclosures made with patient agreement

In certain situations, PHI can be used or disclosed with the opportunity for you to agree or object. This allows you to maintain control over your health information and decide whether you’re comfortable with its use or disclosure.

HIPAA mandates that you should be given an opportunity to consent or refuse before certain uses and disclosures, like ones involving people in your care, facility directories, and fundraising. Failing to provide this opportunity can result in penalties and potential violations of HIPAA regulations.

What happens if an individual is incapacitated?

“Where the individual is incapacitated, in an emergency situation, or not available, covered entities generally may make such uses and disclosures if, in the exercise of their professional judgment, the use or disclosure is determined to be in the best interests of the individual.” – HHS

4. Incidental uses and disclosures

Incidental uses and disclosures of PHI are permitted under HIPAA. These are secondary uses or disclosures that can’t be prevented, are limited, and occur as a result of an allowed or necessary use or disclosure of PHI.

Incidental uses and disclosures in healthcare settings might include a hospital visitor inadvertently hearing a provider’s private conversation or an accidental PHI disclosure during a front desk conversation. The key is that these incidents can’t be prevented and occur during compliant activities.

5. Public interest and benefit activities

HIPAA also allows PHI to be used or disclosed for public interest and benefit activities. These activities involve the use or disclosure of PHI for public health and safety purposes, ensuring the overall well-being of society.

Examples of public interest and benefit activities under the HIPAA Privacy Rule include:

• Disclosing PHI to public health authorities for disease surveillance or prevention
• Sharing information with law enforcement agencies to prevent or investigate crimes
• Providing information to government agencies for national security purposes

6. Research, public health purposes (provided a data use agreement)

Lastly, PHI can be used for research, public health purposes, or healthcare operations if the patient enters into a data use agreement. This ensures that PHI is only used for legitimate purposes and with consent.

In order to obtain a data use agreement, the patient needs to sign a contract that outlines how their personal health info can be used and shared. By doing so, they maintain control over your PHI while allowing it to be used for essential healthcare activities.

HIPAA privacy rule enforcement

The Office for Civil Rights (OCR) plays a critical role in enforcing the HIPAA Privacy Rule. The OCR takes responsibility for assuring that covered entities and business associates adhere to the Privacy Rule’s provisions, thereby safeguarding your personal health information.

By investigating complaints, conducting reviews, and taking action when necessary, the OCR promotes compliance with the HIPAA Privacy Rule and helps safeguard your PHI.

Role of the OCR

The OCR’s primary responsibility is to enforce the HIPAA Privacy Rule and ensure that covered entities and business associates comply with its provisions. This role entails scrutinizing complaints, carrying out compliance reviews, and initiating corrective measures when required.

To report a HIPAA violation, you can file a complaint electronically through the OCR’s portal or with the Health Information Privacy Complaint Package. The OCR plays a crucial role in maintaining the integrity of the healthcare system and protecting your privacy.

Penalties for non-compliance

Non-compliance with the HIPAA Privacy Rule can lead to serious consequences, including fines, corrective action plans, and even criminal charges in severe cases. Non-compliance penalties can vary, starting from $100 to $50,000 per violation, and can escalate to a maximum fine of $1.5 million annually.

In the most severe cases, criminal charges may be filed against those who knowingly obtain or use protected health information without authorization. This can result in fines, corrective action plans, or even jail time for up to 10 years.

Navigating state laws and HIPAA regulations

State laws and HIPAA regulations can interact, sometimes creating confusion for both healthcare providers and patients. However, the general rule is that HIPAA preempts state laws that conflict with its provisions unless the state law provides greater privacy protections.

Comprehending the interplay between state laws and HIPAA regulations assures that your PHI is protected under the strictest privacy standards, regardless of whether they emanate from federal or state sources.

Preemption of state laws

Preemption implies that federal HIPAA regulations take precedence over any state laws that contradict its provisions. This ensures that your PHI is protected under the most stringent privacy standards, regardless of the specific state laws in place.

However, there are exceptions to the preemption rule in HIPAA. Federal requirements override state laws that contradict the HIPAA Privacy Rule unless an exception applies, such as state laws that are stricter than HIPAA or state laws related to public health.

Greater protections under state laws

There are situations in which state laws provide greater privacy protections than HIPAA. In these cases, state laws are not preempted and must be followed by covered entities and business associates.

Examples of state laws that offer more privacy than HIPAA include the California Consumer Privacy Act (CCPA), Illinois Biometric Information Privacy Act (BIPA), and Massachusetts Data Privacy Law. By understanding and adhering to both federal and state privacy regulations, you can trust that your PHI is protected to the highest standard.

Confused? Thoropass can help

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• STEP 1: Onboarding. Get up and running in minutes with native integrations, policy templates, and clear action items.
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• STEP 4: And beyond… Leverage our end-to-end platform to add frameworks, renew attestation, and ensure continuous compliance.

Learn more about what your HIPAA compliance journey with Thoropass will look like here!

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