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A Real World Breach – Why HIPAA Compliance Matters

Developing and implementing a HIPAA compliance plan can often seem like preparing for a tornado on a sunny day. You’ve never had a real-world breach before and you don’t foresee an OCR audit anytime in the near future. However, as one of our clients recently discovered, it pays to be prepared because tornadoes hit unexpectedly.

What Happened

One of our client’s employees recently reported a breach to the company’s Privacy Officer. The breach report stated that the company’s insurance agency (their Business Associate) accidentally sent the employee’s and his current wife’s Explanation of Benefits (EOB) to the employee’s ex-wife. Understandably, this employee wants to file a complaint. He is well within his rights to do so. The employee can file his complaint with any or all of the following:

  1. The Insurance Company – To file with them he must request a complaint form from the employer’s Privacy Officer
  2. Health & Human Services – Forms found here
  3. State Attorney General – Forms found online
  4. Insurance Commission – Forms found online

The breach was the insurance agent’s fault, however, our client hired the insurance company. So they called us with the big question:

What is their liability?

Because of the Common Law of Agency Provision, an employee reporting a matter to HHS could open the employer up to an investigation—meaning OCR could come in and do a full audit of the insurance agent (the Business Associate), and the Employer (the Covered Entity).

What is the Common Law of Agency Provision?

HIPAA’s Common Law of Agency Provision in the 2013 Omnibus ruling states that a Covered Entity is responsible for the HIPAA compliance of their Business Associates (BAs). Now, this doesn’t mean you have to follow your BAs around. After all, we contract with them to make our lives easier. What it means is that you need to do your due diligence and audit your BAs BEFORE you work with them. At a minimum, the review should include a summary of the BA’s compliance plan and employee training records.

What to do after a Real-World Breach?

If you have a breach, everyone needs to review:

  1. What happened?
  2. How did you handle the breach?
  3. Is this a systemic problem or just a onetime issue?
  4. Where was the breakdown, and how can it be mitigated going forward?

If you discover a systemic issue, the Covered Entity is responsible for terminating the relationship with the Business Associate. At that point, the Covered Entity must recover any PHI the BA is maintains, or require the information to be destroyed according to the terms of the Business Associate Agreement.

What is next?

Fortunately for our client, prior to this real-world breach, they prepared a compliance plan using our Turn-Key Compliance Solution, trained their staff using our online training, and are in the process of completing the implementation of this plan. As part of that process, they put a BA Agreement in place with the insurance agent that caused the breach. The employer is prepared for an investigation led by OCR or a State Attorney General.

Need help creating your HIPAA Compliance Plan? Contact us today!

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Related Posts

Essential Guide to Email Authentication and Deliverability: How to Configure DMARC, SPF, and DKIM Records

Essential Guide to Email Authentication and Deliverability: How to Configure DMARC, SPF, and DKIM Records

Essential Guide to Email Authentication and Deliverability: How to Configure DMARC, SPF, and DKIM Records
*This process is technical and requires access to your Domain Name Server (DNS). It’s recommended to have an IT professional handle these configurations to avoid potential issues. If you proceed yourself, back up your current settings with screenshots or copies before making any changes.
Organizations rely heavily on email for marketing and communication, making it a prime target for malicious actors. Phishing, spoofing, and other email attacks can inflict significant financial and reputational damage. In response to this growing threat, email providers are tightening their security measures, and businesses that aren’t paying attention risk having their emails blocked.
A recent announcement from Microsoft, highlighted in their Tech Community blog, highlights that Outlook is implementing stricter requirements for high-volume senders to protect users from unwanted and potentially harmful messages. This move serves as a clear signal: email authentication is no longer optional – it’s required for all organizations, regardless of their sending volume.
The key to making sure your emails reach their intended recipients is all in the configuration and alignment of your Domain-based Message Authentication, Reporting and Conformance (DMARC), Sender Policy Framework (SPF), and DomainKeys Identified Mail (DKIM) records. These protocols verify an organization actually sent the emails and tells receiving servers your messages are legitimate and shouldn’t be sent to spam folders or blocked.
What makes SPF, DKIM, and DMARC so crucial?
SPF (Sender Policy Framework): This record lists the authorized mail servers permitted to send emails on your behalf. When your email server receives an email, it checks it and verifies if the sending server’s IP address matches the list in your SPF record. This helps prevent attackers from spoofing your domain using unauthorized servers.
DKIM (DomainKeys Identified Mail): DKIM adds a digital signature to your outgoing emails. This signature is cryptographically linked to your domain and verified by the receiving server using a public key published in your DNS records. DKIM ensures the integrity of the email content and confirms that it hasn’t been tampered with in transit.
DMARC (Domain-based Message Authentication, Reporting & Conformance): DMARC builds upon SPF and DKIM. It tells receiving servers what to do with emails that fail SPF and/or DKIM checks. You can set policies to “none” (monitor), “quarantine” (send to spam), or “reject” (block). DMARC also enables reporting, allowing you to gain valuable insights into who sends emails using your domain and identify potential spoofing attempts.
Microsoft’s Stance: A Wake-Up Call
The stricter requirements being implemented by Outlook for high-volume senders emphasize the need for organizations to set up and review their authentication protocols. While the current focus is on high-volume senders, it is clear: email providers are looking for authenticated mail. Failing to correctly set up your DMARC, SPF, and DKIM records will lead to deliverability issues of emails.
What Your Company Needs to Do Now:
Regardless of size or email volume, every company should take the following steps to make sure its email authentication is configured correctly. Here’s a checklist:
Audit Your Existing Records: Check for existing SPF, DKIM, and DMARC configurations. Are they accurate and up-to-date?
Implement Missing Records: If you are missing any of these records, add them immediately. *Consult with your IT team or email service provider for guidance.
Check Alignment: It’s crucial to make sure there is alignment between your SPF, DKIM, and DMARC records. This means that the domain used for SPF and the signing domain in DKIM should match the “From” address domain in your emails. DMARC relies on this alignment to function effectively.
Start with a Monitoring Policy: For DMARC, it’s often best to start with a “none” policy to monitor how your emails are being handled and identify any legitimate sending sources that might not be properly authenticated.
Gradually Enforce Stronger Policies: Once you clearly understand your email flows and have addressed any authentication issues, move gradually towards stronger DMARC policies like “quarantine” or “reject” to protect your domain from spoofing actively.
Regularly Review and Update: The email landscape is constantly changing. Regularly review and update your authentication records as needed, especially when changing your emails or third-party sending services.
The Benefits of Proper Email Authentication:
Properly configuring and aligning your DMARC, SPF, and DKIM records offers significant benefits:
Improved Email Deliverability: Your legitimate emails are more likely to reach the inbox, avoiding spam folders and blocks.
Enhanced Brand Reputation: Protecting your domain from spoofing builds trust with your recipients and safeguards your brand’s reputation.
Increased Security: You significantly reduce the risk of using your domain for phishing and other malicious activities.
Compliance with Evolving Standards: By staying ahead of the curve, you ensure your email practices align with the increasingly stringent requirements of email providers.
The message is clear: email authentication is no longer optional. The recent emphasis from major providers like Microsoft underscores its critical importance in maintaining reliable and secure email communication. By taking the steps to audit and align your DMARC, SPF, and DKIM records, your organization can protect itself, customers, and reputation. Don’t wait until your emails are blocked – act now to secure your email.
Have questions or need help with your HIPAA compliance? Schedule a call with our experts today. https://www.totalhipaa.com/get-started/
To check your DMARC Records go here
https://www.totalhipaa.com/dmarc-lookup-free/
All records, a free and easy tool to use
https://easydmarc.com/

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