1. 1 HIPAA Privacy & Security Overview Know HIPAA Presents

2. Agenda 2 HIPAA Overview Privacy Practices Security definitions Security standards Security safeguards Security incidents Sanctions Breach notification Enforcement update

3. 3 Overview of HIPAA We Focus on This Portion of HIPAA only. HIPAA Title I — Health Care Access, Portability and Renewability Title II — Preventing Health Care Fraud and Abuse Title III — Tax- Related Health Provisions Title IV — Group Health Plan Requirements Title V — Revenue Offsets Subtitle F — Administrative Simplification Privacy Electronic Transactions Unique Identifiers Information Security Employer Identifier Code Sets

4. Covered Entities - Must Comply #1 – Health care providers #2 - Group health plans (fully or self-insured employer sponsored plans & health insurance issuers) #3 - Clearinghouses Business Associate - Should Comply #4 – Firms working with covered entities. Examples include Billing Services, Transcription Services, TPA’s, brokers Who Does HIPAA Impact? 4

5. Protected Health Information (PHI) is information relating to past present or future physical or mental health of an individual (employee) whether they are active or terminated. Individually Identifiable PHI is that which identifies an individual. This could include: name, address, date of birth, Social Security number, telephone numbers, e-mail address, account numbers, Group Health Plan beneficiary number, or any other unique identifying number, characteristic or code. Protected Health Information (PHI) Individually Identifiable Health Information 5

6. Applies to paper/oral/electronic records Sets boundaries on the Use and Disclosure of health information Gives “individuals” more control over their own health information Establishes safeguards for protecting the privacy of health information. Holds covered entities accountable for violations of privacy requirements. Privacy Rule 6

7. Some requirements that a covered entity must comply with include, but is not limited to the following: Designating a Privacy Official. Designating a Contact for handling Complaints. Developing policies and procedures on the use and disclosure of individually identifiable health information. Providing training to all workforce members on the policies and procedures that affect their job duties. Providing a Notice of Privacy Practices to individuals Privacy Regulation 7

8. They share this information with other healthcare providers. They are permitted to use and/or disclose information for treatment, payment or health care operations without getting permission from an individual. To use information for any other reason or to disclose it to any one other than the patient or Covered Entity may require a signed and verified authorization. How Does Covered Entity Use Protected Health Information? 8

9. What is an authorization When is it used Authorizations 9

10. Individual has the right to access their protected health information, receive an accounting, amendment their protected health information, file a complaint, request confidential communications or restrict access to their protected health information. Other Aspects of HIPAA Administration 10

11. All Covered Entity employees that have access to protected health information agree that at no time, during or after their employment with Covered Entity, will they use, access or disclose protected health information to anyone except as required or permitted in the course and scope of their duties. Unauthorized use/disclosure may result in disciplinary action up to and including termination. Civil or criminal penalties may also apply. Confidentiality 11

12. Covered entities must implement appropriate safeguards to protect an individual’s protected health information. –Remember to do the following: Records that contain protected health information should be maintained in a secure location or locked away. Records that contain protected health information should be shredded before discarding the information. Passwords should not be shared with anyone. Electronic protected health information needs to be safeguarded as well. Safeguards 12

13. HIPAA Security 13 May 21, Purdue University May 21, Jackson Community College (Michigan) May 19, Westborough Bank (Florida) May, Business Week On-line forum May 14, MTSU May 5, Wharton school (MSU) May 2, Time Warner April 28, Bank of America, Commerce Bankorp, PNC Bank April 21, Carnegie Mellon University April 20, AmeriTrade April 8, San Jose Medical Group March 28, University of California, Berkley March 20, Kellogg MBA program March 17, Boston College March 17, Chico State University March 16, Kaiser Permanente March 8, DSW March, LexisNexis (Seisint) February 15, Bell v. Michigan Council 25 February, Bank of America February, Choice Point February, PayMaxx November, Wells Fargo November, Gibson Sentencing US District Court November, Minneapolis School District

14. Individually identifiable health information: –Transmitted by electronic media –Maintained in electronic media –Transmitted or maintained in any other form or medium What is Electronic PHI? 14

15. Only those that need access Physical access Technical access The covered entity is responsible for the confidentiality, integrity and availability of EPHI The covered entities safeguards are the first line of defense Security Standards 15

16. Must have Policies & Procedures Security measures are appropriate and reasonable Considerations: Size Complexity Mission Purposes of the EPHI created, maintained and transmitted Security Standards - General rules 16

17. Risk Analysis Risk Management Sanction Policy Information System Activity Review Security Management Process 17

18. Workforce security Information access Facility Security plan Workstation use Device & Media controls Access controls (technical) Administrative requirements Safeguards 18

19. Training Security reminders Protection against malicious software Password management Security Awareness 19

20. Data backups Disaster recovery Emergency operation plan May have –Critical applications and data –Testing and revisions Contingency Plans ( Availability) 20

21. Who When New employees or contractors Due to changes Workforce Security Training 21

22. Security Incidents Sanctions Breach Notification Events requiring action 22

23. What are they? What should you do? –Actions depend on the incident –Who was responsible, third party? –Are Sanctions required? Security Incidents 23

24. Workforce members who violate health plans Privacy or Security Policies may be subject to disciplinary actions, up to and including termination. The amount and type of corrective action used in any particular situation will depend on the facts and circumstances. The company maintains the discretion to determine whether corrective action is appropriate. Sanctions/Violations 24

25. Notification to individuals Notification to the media Notification to the Secretary Notification by a business associate Law enforcement delay Burden of proof Specifics 25

26. Annual guidance regards technology Random audits Reports to congress Increased fines 2013 changes Guidance & Enforcement 26

27. ProblemGeneral Penalty Civil Violation$100/offense; up to 1.5mil/ year Wrongful Action$50,000/offense; 1 year in prison False Pretense$100,000/offense; 5 years in prison Intent to Sell$250,000/offense; 10 years in prison Why Comply? 27 The price for non-compliance:

28. Questions 28 ?