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OCR’s Phase 2 of HIPAA Audit Program Focuses on Business Associates

The Department of Health and Human Services’ (HHS) announcement that they will begin auditing Business Associates in October motivated a Covered Entity’s compliance officer to call Total HIPAA last week. He had done a Google search on what a Covered Entity should do to monitor their Business Associates and the Business Associate Subcontractors. The only guidance he could find was a Total HIPAA blog from December 15, 2015.

In that blog, Total HIPAA suggested the following questions be sent to Business Associates:

  1. What is your security program?
  2. How are you educating your workforce?
  3. How do you manage access to and handling of patient/client information?
  4. Do you have policies and procedures for both Privacy and Security?
  5. Have you vetted your Business Associate Subcontractors?

There are many other questions that a Covered Entity can ask a Business Associate. These five questions open the conversation and will help a Covered Entity qualify the HIPAA compliance of their Business Associates.

The phone call continued with this question: How does a Covered Entity determine if the Business Associate is requiring their Subcontractors to be compliant?  Our answer: Request the BA submit the same five questions to the Subcontractors.

Will HHS be satisfied in the case of an audit that the Covered Entity is making a good faith effort to secure their clients’/patients’ PHI? HHS has indicated that they are not sure what they will find during the process of the desk audits. The HHS Office for Civil Rights’ (OCR) will issue preliminary reports to each of the Covered Entities and Business Associates selected.1 We should have more guidance after the audits are completed. Submitting these questions will certainly show HHS that all three categories, Covered Entities, Business Associates and Business Associate Subcontractors, recognize that they all must meet the same set of compliance requirements.

It is important to be sure your Business Associate Agreements are up-to-date and include revisions required under the Omnibus Final Rule in order to stay HIPAA compliant. For the upcoming BA audits in October, OCR will notify 40-50 Business Associates and, unlike Covered Entities, Business Associates aren’t getting any warning. “The time to prepare for the audits is now” says David Holtzman, VP of Compliance at Security Consultancy. He goes on to say “Business Associates should be prepared to produce their policies and procedures for notifying their Covered Entities when there has been a breach incident, as well as samples of when and how they have done so.”1

The best advice to give is Be Prepared! Make sure your BAAs are renewed or modified to include regulations in the HIPAA Omnibus Final Rule of 2013. Ask your Business Associates the 5 questions listed above and suggest they send those same 5 questions to their Subcontractors. Take note that after the desk audits, OCR has plans to conduct on-site audits as well for both Covered Entities and Business Associates.

Now is not the time to worry, rather it is the time to take action. Privacy attorney Kirk Nahra states, “The time to worry will be when there is an actual [breach] investigation, so they should use this opportunity to get their documents and policies lined up.”1 Audits are a great chance to get organized and make sure your documents, policies, and procedures are all in compliance with HIPAA.

For more information on how to quickly and cost-effectively meet compliance requirements, check out this video: HIPAA Prime™

  1. HealthInfoSecurity – OCR Business Associate HIPAA Audits Coming Soon

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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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