The document summarizes key points from a presentation on anticipated changes to HIPAA privacy and security regulations for 2024 and beyond. It discusses proposed 2023 rule changes enhancing protections for reproductive health information. These changes are being extended into 2024 through ongoing rulemaking. The presentation covers differences between privacy and security, employee training requirements, best practices for cybersecurity and incident response, and conclusions on avoiding liability when new regulations take effect.
2023 Proposed HIPAA Amendments: What You Need to KnowConference Panel
In 2022, the Supreme Court issued a decision in the Dobbs v. Jackson Women's Health Organization case, prompting the federal Health and Human Services (HHS) to take action.
The proposed changes aim to protect the privacy of reproductive health care information and align with federal law, preempting contrary state laws in certain situations. Covered entities and business associates in the healthcare industry need to anticipate and prepare for these changes, ensuring they comply with the updated regulations when they become law in 2023.
This topic is crucial for healthcare professionals and organizations to understand how the evolving HIPAA regulations will affect the handling of reproductive health care information and overall privacy practices. Adhering to these changes will help avoid risks and liabilities associated with non-compliance and ensure the proper protection of sensitive health information.
Register,
https://conferencepanel.com/conference/hipaa-and-proposed-changes-for-2023
HIPAA Boot Camp: A Step-by-Step Guide to Achieving ComplianceConference Panel
Join our HIPAA Boot Camp Webinar for healthcare practitioners and employees to learn the essentials of HIPAA laws and requirements upon initial employment and practice in the healthcare industry. Discover how to navigate the implementation of HIPAA mandates for medical records privacy, ensuring compliance with federal regulations protecting Protected Health Information. Stay up-to-date with new HIPAA rules through regular training and updates, as mandated by HIPAA itself. Don't miss this opportunity to enhance your understanding of HIPAA and safeguard patient privacy. Register for our HIPAA Boot Camp Webinar today!
Register,
https://conferencepanel.com/conference/hipaa-boot-camp-the-basics-of-exactly-what-you-need-to-know
Use of E-mailing, Texting, and Personal Devices by Health Care Professionals ...Conference Panel
In this internet-savvy world where everything is shared clicks, it gets difficult to safeguard protected health information. You must be well-versed with the concept and the term ‘Protected Health Information. You must know that as per the latest HIPAA rules not anything or everything related to PHI can be shared on the internet.
Although emailing and texting proves a lot more convenient for health care practitioner as well as patients these communication methods have security risks and inherent pitfalls. Implementing e-mail and text solutions in the health care setting is a complex issue and several factors must be addressed.
Basics of HIPAA privacy as to electronic communication devices
Examples of state licensure laws governing protected health information and solving how to apply them to the health care practitioner
This informative webinar begins with the most basic of questions: Does the HIPAA Privacy Rule permit health care providers to use e-mail to discuss health issues and treatment with their patients?
Find out the answer and examine how the privacy rules of HIPAA allow covered entities and health care providers to communicate electronically, such as through e-mail or texting, with their patients and with other health care practitioners, but only provided those health care practitioners apply reasonable safeguards when doing so. This is mandated by federal administrative regulation.
This webinar is thus an advanced overview of the many rules, both by HIPAA at the federal level and in state licensure laws, that govern e-mailing and texting with patients and with other health care practitioners.
Who Should Attend
Health care attorneys
corporate compliance officers in health care
medical records staff of medical offices and health care entities
hospital attorneys
health care practitioners who are covered entities
law enforcement officers in health care compliance
state boards and agencies with jurisdiction over state licenses to practice a health care profession
While healthcare practitioners faced cyber-attacks, questions and discussions on what HIPAA changed for privacy and security in 2022 came up. Are healthcare departments unable to develop safety for these concerns? Seeking this scenario, the webinar on HIPAA Rulings and Guidance for 2022 adorns how HIPAA gave a new structure. The expert Mark R Brengelman throws light on how the pandemic was beneficial for telehealth and telemedicine practice. The HIPAA Ruling Update 2022 is dedicated to the preservation of healthcare away from cybercriminals and instilling cybersecurity at the upper side. The webinar helps update on HIPAA landscape for 2022 in the areas to identify anticipated changes, and the need for interoperability, as well as helps in comparing the access of patient data by the state laws being defined under HIPAA.
To cater to the unwanted challenges that were coming up in the path of HIPAA, HIPAA Rulings and Guidance for 2022 proceeded with new regulations with both eyes on the advantages as well disadvantages of electronic health records. To prepare yourself well and safeguard the information of your patients, and follow the digitalized transformation to secure the data, capture what HIPAA Ruling Update 2022 has for you in this webinar!
The actions on securing Protected Health Information (PHI) of patients were an alarming step to sensitize the data and health records of the hospitals. How cybercriminals target healthcare was a big question to be spotlighted and given utmost importance in 2022. The webinar helps update on HIPAA landscape for 2022 in the areas to identify anticipated changes, and the need for interoperability, as well as helps in comparing the access of patient data by the state laws being defined under HIPAA. To cater to the unwanted challenges that were coming up in the path of HIPAA, HIPAA Rulings and Guidance for 2022 proceeded with new regulations with both eyes on the advantages as well disadvantages of electronic health records. To prepare yourself well and safeguard the information of your patients, and follow the digitalized transformation to secure the data, capture what HIPAA Ruling Update 2022 has for you in this webinar!
HIPAA Guidelines and Electronic Communication: What Healthcare Professionals ...Conference Panel
Learn how HIPAA privacy rules permit healthcare providers to communicate electronically with patients and colleagues while maintaining confidentiality. Discover the precautions needed, such as verifying email addresses and limiting information in unencrypted emails. Patients have rights to request alternative communication methods, and healthcare providers must accommodate reasonable requests. Find out how to navigate state licensure laws for additional confidentiality measures. Gain clarity on patient consent and communication practices for electronic communication in healthcare.
Register,
https://conferencepanel.com/conference/emailing-texting-use-of-personal-devices-by-healthcare-professionals
The current healthcare system in the United States is heavily influenced by HIPAA Security. This translates into a need to understand technology and cybersecurity beyond the use of anti-malware applications. This presentation presents some of the basics Covered Entities and Business Associates must be aware of as it relates to HIPAA Security.
2023 Proposed HIPAA Amendments: What You Need to KnowConference Panel
In 2022, the Supreme Court issued a decision in the Dobbs v. Jackson Women's Health Organization case, prompting the federal Health and Human Services (HHS) to take action.
The proposed changes aim to protect the privacy of reproductive health care information and align with federal law, preempting contrary state laws in certain situations. Covered entities and business associates in the healthcare industry need to anticipate and prepare for these changes, ensuring they comply with the updated regulations when they become law in 2023.
This topic is crucial for healthcare professionals and organizations to understand how the evolving HIPAA regulations will affect the handling of reproductive health care information and overall privacy practices. Adhering to these changes will help avoid risks and liabilities associated with non-compliance and ensure the proper protection of sensitive health information.
Register,
https://conferencepanel.com/conference/hipaa-and-proposed-changes-for-2023
HIPAA Boot Camp: A Step-by-Step Guide to Achieving ComplianceConference Panel
Join our HIPAA Boot Camp Webinar for healthcare practitioners and employees to learn the essentials of HIPAA laws and requirements upon initial employment and practice in the healthcare industry. Discover how to navigate the implementation of HIPAA mandates for medical records privacy, ensuring compliance with federal regulations protecting Protected Health Information. Stay up-to-date with new HIPAA rules through regular training and updates, as mandated by HIPAA itself. Don't miss this opportunity to enhance your understanding of HIPAA and safeguard patient privacy. Register for our HIPAA Boot Camp Webinar today!
Register,
https://conferencepanel.com/conference/hipaa-boot-camp-the-basics-of-exactly-what-you-need-to-know
Use of E-mailing, Texting, and Personal Devices by Health Care Professionals ...Conference Panel
In this internet-savvy world where everything is shared clicks, it gets difficult to safeguard protected health information. You must be well-versed with the concept and the term ‘Protected Health Information. You must know that as per the latest HIPAA rules not anything or everything related to PHI can be shared on the internet.
Although emailing and texting proves a lot more convenient for health care practitioner as well as patients these communication methods have security risks and inherent pitfalls. Implementing e-mail and text solutions in the health care setting is a complex issue and several factors must be addressed.
Basics of HIPAA privacy as to electronic communication devices
Examples of state licensure laws governing protected health information and solving how to apply them to the health care practitioner
This informative webinar begins with the most basic of questions: Does the HIPAA Privacy Rule permit health care providers to use e-mail to discuss health issues and treatment with their patients?
Find out the answer and examine how the privacy rules of HIPAA allow covered entities and health care providers to communicate electronically, such as through e-mail or texting, with their patients and with other health care practitioners, but only provided those health care practitioners apply reasonable safeguards when doing so. This is mandated by federal administrative regulation.
This webinar is thus an advanced overview of the many rules, both by HIPAA at the federal level and in state licensure laws, that govern e-mailing and texting with patients and with other health care practitioners.
Who Should Attend
Health care attorneys
corporate compliance officers in health care
medical records staff of medical offices and health care entities
hospital attorneys
health care practitioners who are covered entities
law enforcement officers in health care compliance
state boards and agencies with jurisdiction over state licenses to practice a health care profession
While healthcare practitioners faced cyber-attacks, questions and discussions on what HIPAA changed for privacy and security in 2022 came up. Are healthcare departments unable to develop safety for these concerns? Seeking this scenario, the webinar on HIPAA Rulings and Guidance for 2022 adorns how HIPAA gave a new structure. The expert Mark R Brengelman throws light on how the pandemic was beneficial for telehealth and telemedicine practice. The HIPAA Ruling Update 2022 is dedicated to the preservation of healthcare away from cybercriminals and instilling cybersecurity at the upper side. The webinar helps update on HIPAA landscape for 2022 in the areas to identify anticipated changes, and the need for interoperability, as well as helps in comparing the access of patient data by the state laws being defined under HIPAA.
To cater to the unwanted challenges that were coming up in the path of HIPAA, HIPAA Rulings and Guidance for 2022 proceeded with new regulations with both eyes on the advantages as well disadvantages of electronic health records. To prepare yourself well and safeguard the information of your patients, and follow the digitalized transformation to secure the data, capture what HIPAA Ruling Update 2022 has for you in this webinar!
The actions on securing Protected Health Information (PHI) of patients were an alarming step to sensitize the data and health records of the hospitals. How cybercriminals target healthcare was a big question to be spotlighted and given utmost importance in 2022. The webinar helps update on HIPAA landscape for 2022 in the areas to identify anticipated changes, and the need for interoperability, as well as helps in comparing the access of patient data by the state laws being defined under HIPAA. To cater to the unwanted challenges that were coming up in the path of HIPAA, HIPAA Rulings and Guidance for 2022 proceeded with new regulations with both eyes on the advantages as well disadvantages of electronic health records. To prepare yourself well and safeguard the information of your patients, and follow the digitalized transformation to secure the data, capture what HIPAA Ruling Update 2022 has for you in this webinar!
HIPAA Guidelines and Electronic Communication: What Healthcare Professionals ...Conference Panel
Learn how HIPAA privacy rules permit healthcare providers to communicate electronically with patients and colleagues while maintaining confidentiality. Discover the precautions needed, such as verifying email addresses and limiting information in unencrypted emails. Patients have rights to request alternative communication methods, and healthcare providers must accommodate reasonable requests. Find out how to navigate state licensure laws for additional confidentiality measures. Gain clarity on patient consent and communication practices for electronic communication in healthcare.
Register,
https://conferencepanel.com/conference/emailing-texting-use-of-personal-devices-by-healthcare-professionals
The current healthcare system in the United States is heavily influenced by HIPAA Security. This translates into a need to understand technology and cybersecurity beyond the use of anti-malware applications. This presentation presents some of the basics Covered Entities and Business Associates must be aware of as it relates to HIPAA Security.
Health IT Data Security – An Overview of Privacy, Compliance, and Technology ...M2SYS Technology
Radical advancements in health IT development and implementation have pushed the issue of health data security to the forefront of the collective healthcare provider mindset as they attempt to strike a balance between patient access to electronic health record protected health information (PHI) and data protection. The fact that so many health IT vendors now have access to and possess protected health information necessitated shift changes in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 which was enacted to establish ground rules for the privacy protection of individually identifiable health information.
We invited Mac McMillan, Chair of the HIMSS Privacy and Security Task Force to discuss what these new changes are, define their parameters, the mission of the HIMSS PRivacy & Security Task Force, his definition of what “privacy” actually is, comments on new technology that are viable options for healthcare providers to implement as a way to protect access to sensitive patient data, and his thoughts on the increased adoption of PHI management applications such as Microsoft HealthVault.
Listen in to this podcast for more information on the latest health IT industry developments and regulations that govern PHI and for insight from Mac on why healthcare providers and third party vendors should pay close attention to compliance with recent HIPAA changes.
While researchers are technically not covered by HIPAA, it still is important to protect patient's Protected Health Information(PHI). This is a presentation I did for the Society of Clinical Research Associates (SOCRA)
MPCA HIPAA Compliance/Meaningful Use Requirements and Security Risk Assessment Series: HIPAA/HITECH Requirements for FQHCs and the New Omnibus Rule (Part 1)
HIPAA Compliance: What Medical Practices and Their Business Associates Need t...Skoda Minotti
Most medical practices are aware of the HIPAA HITECH requirements that affect their organizations, and the fines that they face if they are not compliant in the ways they handle patient health information (PHI).
What a lot of professionals don’t know is that HIPAA HITECH regulations also hold business associates, (i.e. other professionals from other companies who could also have access to PHI) just as responsible for protecting the data as the medical practices who own that information.
CHAPTER3 Maintaining ComplianceMANY LAWS AND REGULATIONS.docxchristinemaritza
CHAPTER
3 Maintaining Compliance
MANY LAWS AND REGULATIONS ARE IN PLACE regarding the protection of
information technology (IT) systems. Companies have a requirement to comply with the laws that
apply to them. The first step is to understand the laws. You’re not expected to be a lawyer, but you
should understand the basics of relevant laws.
Once you have an idea of which laws and regulations apply, you can then dig in deeper to
ensure your organization is in compliance. The cost of not complying can sometimes be
expensive. Fines can be in the hundreds of thousands of dollars. Some offenses can result in jail
time.
Chapter 3 Topics
This chapter covers the following topics and concepts:
• What U.S. compliance laws exist
• What some relevant regulations related to compliance are
• What organizational policies for compliance should be considered
• What standards and guidelines for compliance exist
Chapter 3 Goals
When you complete this chapter, you will be able to:
• Define compliance
• Describe the purpose of FISMA
• Identify the purpose and scope of HIPAA
• Describe GLBA and SOX, and the impact for IT
• Describe the purpose of FERPA
• Identify the purpose and scope of CIPA
• List some federal entities that control regulations related to IT
• Describe the purpose of PCI DSS
• Describe the contents of SP 800-30
• Describe the purpose of COBIT
• Describe the purpose of ISO and identify some relevant security standards
• Identify the purpose of ITIL
• Identify the purpose of CMMI
U.S. Compliance Laws
Many laws exist in the United States related to information technology (IT). Companies affected
by the laws are expected to comply with the laws. This is commonly referred to as compliance.
Many organizations have internal programs in place to ensure they remain in compliance with
relevant laws and regulations. These programs commonly use internal audits. They can also use
certification and accreditation programs. When compliance is mandated by law, external audits are
often done. These external audits provide third-party verification that the requirements are being
met.
An old legal saying is “ignorance is no excuse.” In other words, you can’t break the law and
then say “I didn’t know.” The same goes for laws that apply to any organization. It’s important for
any organization to know what the relevant laws and regulations are.
You aren’t expected to be an expert on any of these laws. However, as a manager or executive,
you should be aware of them. You can roll any of the relevant laws and regulations into a
compliance program for more detailed checks.
This section covers the following U.S. laws:
• Federal Information Security Management Act (FISMA) 2002
• Health Insurance Portability and Accountability Act (HIPAA) 1996
• Gramm-Leach-Bliley Act (GLBA) 1999
• Sarbanes-Oxley Act (SOX) 2002
• Family Educational Rights and Privacy Act (FERPA) 1974
• Children’s Internet Protection Act (CIPA) 2000
Federal Information ...
Presentation designed to explain Business Associates the basics of HIPAA and real-life examples of cases that failed to implement and follow HIPAA requirements on a timely basis.
HIPAA Compliance Made Easy: Conducting a Risk AssessmentConference Panel
Conducting a HIPAA risk assessment is a legal requirement, and this webinar will equip healthcare organizations with the knowledge and tools necessary to fulfill this obligation. By understanding the risks that threaten the confidentiality, integrity, and availability of protected health information, organizations can take proactive measures to mitigate these risks and establish a robust compliance framework.
Attending the "How to Conduct a HIPAA Risk Assessment Webinar" will empower healthcare organizations to embark on a continuous risk assessment process, enabling them to stay informed about evolving threats and ensure ongoing compliance with HIPAA standards and implementation specifications. By embracing the insights and best practices shared in the webinar, organizations can strengthen their security posture and safeguard patient information effectively.
Register,
https://conferencepanel.com/conference/how-to-conduct-a-hipaa-risk-assessment-and-the-surprising-danger-of-not-doing-one
PACT Cybersecurity Series Event, speaker Gregory M. Fliszar, Esq. of Cozen O'...eringold
Gregory Fliszar, J.D., Ph.D., of Cozen O'Connor will make this presentation on Friday, February 26, 2015, at a PhilaPACT (Greater Philadelphia Alliance for Capital Technologies) cybersecurity series event at Philadelphia Marriott West in West Conshohocken.
Greg Fliszar, a member of the Business Law Department and the Health Law Practice Group and the Privacy, Data & Cyber Security Industry Team, will present on the legal issues of cybersecurity and healthcare at this timely discussion. In the wake of the Anthem cyber breach, protecting the security of medical records, and compliance with HIPAA and HITECH, are relevant to a variety of businesses that provide services to the health-care industry. Greg will share his insights on how to protect your organization's data.
Learn more about Greg's expertise and experience at http://www.cozen.com/people/bios/fliszar-gregory.
To register for the event, go to http://www.cozen.com/events/2015/pact-cybersecurity-series-event.
This presentation discusses how to comply with HIPAA and HITECH privacy laws. Learn key terms such as Protected Health Information, the Privacy Rule and the Security Rule as well as major changes brought by HIPAA and HITECH.
Chapter 10 Privacy and Security of Health RecordsLearnin.docxcravennichole326
Chapter 10 Privacy and Security of Health Records
Learning Outcomes
After completing this chapter, you should be able to:
♦ List HIPAA transactions and uniform identifiers
♦ Understand HIPAA privacy and security concepts
♦ Apply HIPAA privacy policy in a medical facility
♦ Discuss HIPAA security requirements and safeguards
♦ Follow security policy guidelines in a medical facility
♦ Explain electronic signatures
Understanding HIPAA
In Chapter 11 we will discuss various ways the Internet is being used for healthcare, including various implementations of EHR on the Internet, Internet-based personal health records (PHR), and remote access. In Chapter 12 we will explore the relationship of the EHR data to the determination of codes required for medical billing. Before moving to those topics it is prudent to understand HIPAA. HIPAA is an acronym for the Health Insurance Portability and Accountability Act, passed by Congress in 1996.
The HIPAA law was intended to:
♦ Improve portability and continuity of health insurance coverage.
♦ Combat waste, fraud, and abuse in health insurance and healthcare delivery.
♦ Promote use of medical savings accounts
♦ Improve access to long-term care
♦ Simplify administration of health insurance
HIPAA law regulates many things. However, a portion known as the Administrative Simplification Subsection1 of HIPAA covers entities such as health plans, clearinghouses, and healthcare providers. HIPAA refers to these as covered entities or a covered entity. This means a healthcare facility or health plan and all of its employees. If you work in the healthcare field, these regulations likely govern your job and behavior. Therefore, it is not uncommon for healthcare workers to use the acronym HIPAA when they actually mean only the Administrative Simplification Subsection of HIPAA.
Note Covered Entity
HIPAA documents refer to healthcare providers, plans, and clearing-houses as covered entities. In the context of this chapter, think of a covered entity as a healthcare organization and all of its employees.
As someone who will work with patients’ health records, it is especially important for you to understand the regulations regarding privacy and security. However, let us begin with a quick review of HIPAA, then study the privacy and security portions in more depth.
HIPAA implementation and enforcement is under the jurisdiction of several entities within the U.S. Department of Health and Human Services (HHS). This chapter will make extensive use of documents prepared by HHS.
Administrative Simplification Subsection
The Administrative Simplification Subsection has four distinct components:
1. Transactions and code sets
2. Uniform identifiers
3. Privacy
4. Security
HIPAA Transactions and Code Sets
The first section of the regulations to be implemented governed the electronic transfer of medical information for business purposes such as insurance claims, payme ...
Medicare and Medicaid Managed Care Enrollments in 2024Conference Panel
The process of enrolling with Medicare and Medicaid Managed Care as a provider/organization can be incredibly tedious and time-consuming. The number of new Medicare and Medicaid enrollment applications continues to decline due to the enormous complexities surrounding enrollment application requirements. The cost of getting these enrollment application submissions wrong can have systemic consequences on an organization, including cash flow delays, credentialing issues, coding issues, claims backlogs, denial management issues, patient satisfaction, and even impact quality scores.
In 2024, Medicare opened the enrollment gates for new mental health providers (MFTs and MHCs) that had previously been excluded from providing services to Medicare beneficiaries. In today's webinar, we discuss the submission options, which providers are eligible for Medicare and Medicaid enrollment, each enrollment type, how to navigate the enrollment process, key terminology, what ancillary documentation is needed with enrollment submission, applicable fees, linkage issues with PTAN numbers, most common errors, and best practice tips for successfully completing the Medicare and Medicaid enrollments in 2024.
Learning Objectives
Understand the CMS 855 enrollment submission process for 2024.
Recall CMS 855A, 855B, and 855I Application requirements for 2024.
Recall the most complicated sections on the 855 applications for 2024.
Recall strategies to complete 855 forms accurately for 2024.
Recall ancillary documentation required with 855 enrollment submissions for 2024.
Avoid common rejections and errors with 855 form submissions.
Recall best practice tips for 855 form submissions for 2024.
Areas Covered
Dissect the various Medicare and Medicaid enrollment types in 2024.
Outline a sample workflow for completing Medicare enrollment.
Outline a sample workflow for completing Medicaid Managed Care enrollment.
Review enrollment forms for Medicare and Medicaid.
Discuss the most challenging Medicare and Medicaid enrollment sections for 2024.
Discuss strategies to complete the Medicare and Medicaid enrollment forms accurately for 2024.
Review the process of reassigning Medicare benefits to organizations for 2024.
Review the ancillary documentation required with Medicare and Medicaid enrollment submission for 2024.
Discuss the most common rejections and errors with Medicare and Medicaid enrollment form submissions for 2024
Register Now,
https://conferencepanel.com/conference/medicare-and-medicaid-managed-care-enrollments
Dispelling HIPAA Myths: Texting, Emailing, and BYOD Best PracticesConference Panel
This 90-minute webinar will detail your practice (or business) information technology and how it relates to the HIPAA/HITECH Security Rule and securing PHI in transmission – what is required and what is myth… I will review multiple examples and specific scenarios and offer simple, common-sense solutions. I will also discuss the do's and don'ts relating to encryption and updated bulletins provided by the Office for Civil Rights.
Areas covered will be texting, email, encryption, medical messaging, voice data, personal devices, and risk factors.
I will uncover myths versus reality as they relate to this enigmatic law based on over 1000 risk assessments performed and years of experience in dealing directly with the Office for Civil Rights HIPAA auditors.
I will speak on specific experiences from over 18 years of experience working as an outsourced compliance auditor and expert witness on multiple HIPAA cases in state law and thoroughly explain how patients can now get cash remedies for wrongful disclosures of private health information.
More importantly, I will show you how to limit those risks by taking proactive steps and utilizing best practices.
Don't always believe what you read online about HIPAA, especially regarding encryption and IT; many groups sell more than necessary.
Register Now,
https://conferencepanel.com/conference/2024-hipaa-texting-and-emailing-dos-and-donts
More Related Content
Similar to Breaking Down the Latest HIPAA Modifications: What's New in 2024 and Beyond
Health IT Data Security – An Overview of Privacy, Compliance, and Technology ...M2SYS Technology
Radical advancements in health IT development and implementation have pushed the issue of health data security to the forefront of the collective healthcare provider mindset as they attempt to strike a balance between patient access to electronic health record protected health information (PHI) and data protection. The fact that so many health IT vendors now have access to and possess protected health information necessitated shift changes in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 which was enacted to establish ground rules for the privacy protection of individually identifiable health information.
We invited Mac McMillan, Chair of the HIMSS Privacy and Security Task Force to discuss what these new changes are, define their parameters, the mission of the HIMSS PRivacy & Security Task Force, his definition of what “privacy” actually is, comments on new technology that are viable options for healthcare providers to implement as a way to protect access to sensitive patient data, and his thoughts on the increased adoption of PHI management applications such as Microsoft HealthVault.
Listen in to this podcast for more information on the latest health IT industry developments and regulations that govern PHI and for insight from Mac on why healthcare providers and third party vendors should pay close attention to compliance with recent HIPAA changes.
While researchers are technically not covered by HIPAA, it still is important to protect patient's Protected Health Information(PHI). This is a presentation I did for the Society of Clinical Research Associates (SOCRA)
MPCA HIPAA Compliance/Meaningful Use Requirements and Security Risk Assessment Series: HIPAA/HITECH Requirements for FQHCs and the New Omnibus Rule (Part 1)
HIPAA Compliance: What Medical Practices and Their Business Associates Need t...Skoda Minotti
Most medical practices are aware of the HIPAA HITECH requirements that affect their organizations, and the fines that they face if they are not compliant in the ways they handle patient health information (PHI).
What a lot of professionals don’t know is that HIPAA HITECH regulations also hold business associates, (i.e. other professionals from other companies who could also have access to PHI) just as responsible for protecting the data as the medical practices who own that information.
CHAPTER3 Maintaining ComplianceMANY LAWS AND REGULATIONS.docxchristinemaritza
CHAPTER
3 Maintaining Compliance
MANY LAWS AND REGULATIONS ARE IN PLACE regarding the protection of
information technology (IT) systems. Companies have a requirement to comply with the laws that
apply to them. The first step is to understand the laws. You’re not expected to be a lawyer, but you
should understand the basics of relevant laws.
Once you have an idea of which laws and regulations apply, you can then dig in deeper to
ensure your organization is in compliance. The cost of not complying can sometimes be
expensive. Fines can be in the hundreds of thousands of dollars. Some offenses can result in jail
time.
Chapter 3 Topics
This chapter covers the following topics and concepts:
• What U.S. compliance laws exist
• What some relevant regulations related to compliance are
• What organizational policies for compliance should be considered
• What standards and guidelines for compliance exist
Chapter 3 Goals
When you complete this chapter, you will be able to:
• Define compliance
• Describe the purpose of FISMA
• Identify the purpose and scope of HIPAA
• Describe GLBA and SOX, and the impact for IT
• Describe the purpose of FERPA
• Identify the purpose and scope of CIPA
• List some federal entities that control regulations related to IT
• Describe the purpose of PCI DSS
• Describe the contents of SP 800-30
• Describe the purpose of COBIT
• Describe the purpose of ISO and identify some relevant security standards
• Identify the purpose of ITIL
• Identify the purpose of CMMI
U.S. Compliance Laws
Many laws exist in the United States related to information technology (IT). Companies affected
by the laws are expected to comply with the laws. This is commonly referred to as compliance.
Many organizations have internal programs in place to ensure they remain in compliance with
relevant laws and regulations. These programs commonly use internal audits. They can also use
certification and accreditation programs. When compliance is mandated by law, external audits are
often done. These external audits provide third-party verification that the requirements are being
met.
An old legal saying is “ignorance is no excuse.” In other words, you can’t break the law and
then say “I didn’t know.” The same goes for laws that apply to any organization. It’s important for
any organization to know what the relevant laws and regulations are.
You aren’t expected to be an expert on any of these laws. However, as a manager or executive,
you should be aware of them. You can roll any of the relevant laws and regulations into a
compliance program for more detailed checks.
This section covers the following U.S. laws:
• Federal Information Security Management Act (FISMA) 2002
• Health Insurance Portability and Accountability Act (HIPAA) 1996
• Gramm-Leach-Bliley Act (GLBA) 1999
• Sarbanes-Oxley Act (SOX) 2002
• Family Educational Rights and Privacy Act (FERPA) 1974
• Children’s Internet Protection Act (CIPA) 2000
Federal Information ...
Presentation designed to explain Business Associates the basics of HIPAA and real-life examples of cases that failed to implement and follow HIPAA requirements on a timely basis.
HIPAA Compliance Made Easy: Conducting a Risk AssessmentConference Panel
Conducting a HIPAA risk assessment is a legal requirement, and this webinar will equip healthcare organizations with the knowledge and tools necessary to fulfill this obligation. By understanding the risks that threaten the confidentiality, integrity, and availability of protected health information, organizations can take proactive measures to mitigate these risks and establish a robust compliance framework.
Attending the "How to Conduct a HIPAA Risk Assessment Webinar" will empower healthcare organizations to embark on a continuous risk assessment process, enabling them to stay informed about evolving threats and ensure ongoing compliance with HIPAA standards and implementation specifications. By embracing the insights and best practices shared in the webinar, organizations can strengthen their security posture and safeguard patient information effectively.
Register,
https://conferencepanel.com/conference/how-to-conduct-a-hipaa-risk-assessment-and-the-surprising-danger-of-not-doing-one
PACT Cybersecurity Series Event, speaker Gregory M. Fliszar, Esq. of Cozen O'...eringold
Gregory Fliszar, J.D., Ph.D., of Cozen O'Connor will make this presentation on Friday, February 26, 2015, at a PhilaPACT (Greater Philadelphia Alliance for Capital Technologies) cybersecurity series event at Philadelphia Marriott West in West Conshohocken.
Greg Fliszar, a member of the Business Law Department and the Health Law Practice Group and the Privacy, Data & Cyber Security Industry Team, will present on the legal issues of cybersecurity and healthcare at this timely discussion. In the wake of the Anthem cyber breach, protecting the security of medical records, and compliance with HIPAA and HITECH, are relevant to a variety of businesses that provide services to the health-care industry. Greg will share his insights on how to protect your organization's data.
Learn more about Greg's expertise and experience at http://www.cozen.com/people/bios/fliszar-gregory.
To register for the event, go to http://www.cozen.com/events/2015/pact-cybersecurity-series-event.
This presentation discusses how to comply with HIPAA and HITECH privacy laws. Learn key terms such as Protected Health Information, the Privacy Rule and the Security Rule as well as major changes brought by HIPAA and HITECH.
Chapter 10 Privacy and Security of Health RecordsLearnin.docxcravennichole326
Chapter 10 Privacy and Security of Health Records
Learning Outcomes
After completing this chapter, you should be able to:
♦ List HIPAA transactions and uniform identifiers
♦ Understand HIPAA privacy and security concepts
♦ Apply HIPAA privacy policy in a medical facility
♦ Discuss HIPAA security requirements and safeguards
♦ Follow security policy guidelines in a medical facility
♦ Explain electronic signatures
Understanding HIPAA
In Chapter 11 we will discuss various ways the Internet is being used for healthcare, including various implementations of EHR on the Internet, Internet-based personal health records (PHR), and remote access. In Chapter 12 we will explore the relationship of the EHR data to the determination of codes required for medical billing. Before moving to those topics it is prudent to understand HIPAA. HIPAA is an acronym for the Health Insurance Portability and Accountability Act, passed by Congress in 1996.
The HIPAA law was intended to:
♦ Improve portability and continuity of health insurance coverage.
♦ Combat waste, fraud, and abuse in health insurance and healthcare delivery.
♦ Promote use of medical savings accounts
♦ Improve access to long-term care
♦ Simplify administration of health insurance
HIPAA law regulates many things. However, a portion known as the Administrative Simplification Subsection1 of HIPAA covers entities such as health plans, clearinghouses, and healthcare providers. HIPAA refers to these as covered entities or a covered entity. This means a healthcare facility or health plan and all of its employees. If you work in the healthcare field, these regulations likely govern your job and behavior. Therefore, it is not uncommon for healthcare workers to use the acronym HIPAA when they actually mean only the Administrative Simplification Subsection of HIPAA.
Note Covered Entity
HIPAA documents refer to healthcare providers, plans, and clearing-houses as covered entities. In the context of this chapter, think of a covered entity as a healthcare organization and all of its employees.
As someone who will work with patients’ health records, it is especially important for you to understand the regulations regarding privacy and security. However, let us begin with a quick review of HIPAA, then study the privacy and security portions in more depth.
HIPAA implementation and enforcement is under the jurisdiction of several entities within the U.S. Department of Health and Human Services (HHS). This chapter will make extensive use of documents prepared by HHS.
Administrative Simplification Subsection
The Administrative Simplification Subsection has four distinct components:
1. Transactions and code sets
2. Uniform identifiers
3. Privacy
4. Security
HIPAA Transactions and Code Sets
The first section of the regulations to be implemented governed the electronic transfer of medical information for business purposes such as insurance claims, payme ...
Medicare and Medicaid Managed Care Enrollments in 2024Conference Panel
The process of enrolling with Medicare and Medicaid Managed Care as a provider/organization can be incredibly tedious and time-consuming. The number of new Medicare and Medicaid enrollment applications continues to decline due to the enormous complexities surrounding enrollment application requirements. The cost of getting these enrollment application submissions wrong can have systemic consequences on an organization, including cash flow delays, credentialing issues, coding issues, claims backlogs, denial management issues, patient satisfaction, and even impact quality scores.
In 2024, Medicare opened the enrollment gates for new mental health providers (MFTs and MHCs) that had previously been excluded from providing services to Medicare beneficiaries. In today's webinar, we discuss the submission options, which providers are eligible for Medicare and Medicaid enrollment, each enrollment type, how to navigate the enrollment process, key terminology, what ancillary documentation is needed with enrollment submission, applicable fees, linkage issues with PTAN numbers, most common errors, and best practice tips for successfully completing the Medicare and Medicaid enrollments in 2024.
Learning Objectives
Understand the CMS 855 enrollment submission process for 2024.
Recall CMS 855A, 855B, and 855I Application requirements for 2024.
Recall the most complicated sections on the 855 applications for 2024.
Recall strategies to complete 855 forms accurately for 2024.
Recall ancillary documentation required with 855 enrollment submissions for 2024.
Avoid common rejections and errors with 855 form submissions.
Recall best practice tips for 855 form submissions for 2024.
Areas Covered
Dissect the various Medicare and Medicaid enrollment types in 2024.
Outline a sample workflow for completing Medicare enrollment.
Outline a sample workflow for completing Medicaid Managed Care enrollment.
Review enrollment forms for Medicare and Medicaid.
Discuss the most challenging Medicare and Medicaid enrollment sections for 2024.
Discuss strategies to complete the Medicare and Medicaid enrollment forms accurately for 2024.
Review the process of reassigning Medicare benefits to organizations for 2024.
Review the ancillary documentation required with Medicare and Medicaid enrollment submission for 2024.
Discuss the most common rejections and errors with Medicare and Medicaid enrollment form submissions for 2024
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https://conferencepanel.com/conference/medicare-and-medicaid-managed-care-enrollments
Dispelling HIPAA Myths: Texting, Emailing, and BYOD Best PracticesConference Panel
This 90-minute webinar will detail your practice (or business) information technology and how it relates to the HIPAA/HITECH Security Rule and securing PHI in transmission – what is required and what is myth… I will review multiple examples and specific scenarios and offer simple, common-sense solutions. I will also discuss the do's and don'ts relating to encryption and updated bulletins provided by the Office for Civil Rights.
Areas covered will be texting, email, encryption, medical messaging, voice data, personal devices, and risk factors.
I will uncover myths versus reality as they relate to this enigmatic law based on over 1000 risk assessments performed and years of experience in dealing directly with the Office for Civil Rights HIPAA auditors.
I will speak on specific experiences from over 18 years of experience working as an outsourced compliance auditor and expert witness on multiple HIPAA cases in state law and thoroughly explain how patients can now get cash remedies for wrongful disclosures of private health information.
More importantly, I will show you how to limit those risks by taking proactive steps and utilizing best practices.
Don't always believe what you read online about HIPAA, especially regarding encryption and IT; many groups sell more than necessary.
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https://conferencepanel.com/conference/2024-hipaa-texting-and-emailing-dos-and-donts
Medical Record Chapter: Meeting the CMS Hospital CoPs and Access RequirementsConference Panel
This program will cover the CMS regulations and interpretive guidelines for medical records for acute and critical access hospitals in detail. There will also be a brief discussion of the Interoperability and Patient Access Rules. The law affects healthcare providers and effectively grants patients immediate access to health information in their electronic medical records – without charge. Certain records are excluded, and the rule establishes exceptions to “information blocking’. This rule and its implications for healthcare providers will be discussed.
This program will revisit information on HIPAA from the Office of Civil Rights, including the difference between patient access versus when authorization is needed. There will also be a discussion on The Joint Commission, which changed many of its standards to comply with the CMS CoP requirements.
Other topics to be discussed include the security of health information and OCR Security Risk Assessment.
Learning Objectives
Recall that CMS has specific informed consent requirements.
Describe when a history and physical must be done and what is required by CMS.
Explain both CMS and The Joint Commission standards on verbal orders.
Recall that CMS has standards for preprinted orders, standing orders, and protocols.
Describe when and circumstances by which healthcare providers can “block” patients/others' access to health information.
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https://conferencepanel.com/conference/medical-record-chapter-meeting-the-cms-hospital-cops-and-access-requirements
Grievances and Complaints 2024 Compliance with the CMS CoPs, Joint Commission...Conference Panel
Hospitals receiving Medicare or Medicaid reimbursements must adhere to CMS Conditions of Participation, with grievance requirements often cited for deficiencies. While acute hospitals have specific grievance standards outlined in the patient rights section, Critical Access Hospitals (CAHs) must also establish policies to address patient grievances.
Exploring Section 1557 of the Affordable Care Act, enforced by the Office of Civil Rights, hospitals are mandated to have grievance procedures to investigate alleged noncompliance, including discrimination.
This program delves into Joint Commission standards on complaints and DNV Healthcare's grievance standards, intersecting with CMS guidelines. Staff education and adherence to hospital grievance policies, board approval, and comprehensive documentation in medical records are essential.
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https://conferencepanel.com/conference/grievances-and-complaints-2024
The 2024 Prior Authorization Process For Medical ProvidersConference Panel
Prior Authorizations are a cost containment strategy that third-party payers leverage to control costs, restrict patient access to services, testing, and medications, and ultimately discourage medical providers from ordering unnecessary medical treatment. Prior authorizations are a major source of headaches for healthcare providers nationwide. Despite the intention to control costs and ensure appropriate care, the prior authorization process has been criticized for its enormous administrative burden, potential delays in necessary medical treatment, and added complexity for healthcare providers.
Striking a balance between cost control and efficient patient care remains a major challenge in the healthcare industry. Join us for an insightful 60-minute webinar as we take a deep dive into the complexities of the Prior Authorization process, discuss the pearls and pitfalls, define medical necessity requirements, and demystify the intricacies of obtaining prior authorizations, ensuring a smoother workflow and higher approval outcomes in 2024.
Learning Objectives
Understand the major Prior Authorization Updates for 2024.
Recall medical necessity and its critical role in the Prior Authorization approval process.
Identify which insurance payers require Prior Authorizations in 2024.
Recall methods for obtaining Prior Authorizations in 2024.
Recognize common challenges experienced when obtaining Prior Authorizations.
Understand how to escalate and appeal Prior Authorization denials in 2024.
Areas Covered
Discuss the major Prior Authorization Updates for 2024.
Explore the 2024 Prior Authorization requirements for Medicare Advantage Plans.
Define medical necessity and its critical role in the Prior Authorization approval process.
Explore the regulatory landscape for Prior Authorizations in 2024.
Identify which insurance payers require Prior Authorizations in 2024.
Discuss methods for obtaining Prior Authorizations in 2024.
Review common challenges experienced when obtaining Prior Authorizations.
Outline successful strategies to overcome challenges with obtaining Prior Authorizations in 2024.
Discuss how to escalate and appeal Prior Authorization denials in 2024.
Share best practice compliance tips for Prior Authorizations in 2024.
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https://conferencepanel.com/conference/mastering-the-2024-prior-authorization-process-for-medical-providers
Protecting Patient Privacy: Navigating HIPAA in Digital LandscapesConference Panel
Learn how to safeguard your healthcare practice from unintentional HIPAA violations in online marketing. Discover simple steps to ensure compliance with HIPAA Privacy Rule while effectively engaging patients online. Join our webinar to understand the risks of using visible and invisible tracking technologies and how to mitigate them. Stay competitive in the digital marketplace without compromising patient privacy. Don't miss out on essential administrative safeguards to protect your organization from liability. Register now for actionable insights!
What You'll Learn?
Website HIPAA Compliance
New Prohibition of Tracking Technologies (Meta Pixel, Google Analytics)
Social Media HIPAA compliance
Facebook – common violations - Terms of Use – Prohibited
Facebook Terms of Use and Posts Prohibited by Facebook
How to use Facebook in compliance with HIPAA and Facebook’s Terms
Reviews by patients posted on Internet platforms
What you may do
What you must not do
This webinar explains HIPAA Compliance Safeguards allowing Health Care Providers to do effective Internet-based marketing and comply with HIPAA.
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https://conferencepanel.com/conference/new-hipaa-compliance-for-web-sites-tracking-technologies-social-media-patient-reviews
Nursing Standards in Hospital Accreditation: CMS Guidelines 2024Conference Panel
Ensure your hospital's nursing services comply with CMS Conditions of Participation (CoPs) to maintain Medicare and Medicaid reimbursement eligibility. Join our webinar as we delve into crucial aspects of the CoP manual, including plans of care, staffing requirements, policy changes for outpatient departments, documentation standards, supervision protocols, nursing leadership expectations, and more.
Discover the latest updates and anticipated interpretive guidelines for the nursing chapter of the CoPs, addressing areas frequently cited in compliance assessments. With nursing services cited over 8,900 times in recent reports, understanding these regulations is paramount.
We'll also explore past changes in nursing regulations, such as medication timing, standing orders, blood transfusions, IV medication administration, self-medication protocols, and drug order procedures. Stay informed about evolving non-discrimination regulations under Section 1557 and other manual sections affecting nursing practices.
Don't miss this opportunity to ensure your hospital's nursing services meet regulatory standards and optimize patient care. Register now to stay ahead of compliance requirements and enhance your facility's operations.
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https://conferencepanel.com/conference/nursing-standards-cms-condition-of-participation-for-hospitals
Implementing CMS Hospital QAPI Guidelines for 2024Conference Panel
Explore the significance of Quality Assessment and Performance Improvement (QAPI) programs in Medicare-certified hospitals, focusing on the updated CMS standards and interpretive guidelines. Learn about essential requirements, assessment areas, and hospital leadership's role in ensuring compliance and enhancing patient safety.
Title: Understanding CMS Hospital QAPI Standards and Guidelines: Key Elements for Implementation and Compliance
Description: Explore the significance of Quality Assessment and Performance Improvement (QAPI) programs in Medicare-certified hospitals, focusing on the updated CMS standards and interpretive guidelines. Learn about essential requirements, areas of assessment, and the role of hospital leadership in ensuring compliance and enhancing patient safety.
Quality Assessment and Performance Improvement (QAPI) Conditions of Participation deficiencies rank among the top three cited issues for Medicare-certified hospitals, highlighting the critical need for robust QAPI programs. CMS emphasizes the pivotal role of well-designed and maintained QAPI initiatives in enhancing patient care quality, reducing medical errors, and fostering a safer healthcare environment.
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https://conferencepanel.com/conference/cms-hospital-qapi-standards-2024
Exploring the Revised Medicare 855 Enrollment Form for 2024Conference Panel
Navigating Medicare enrollment for mental health providers (MFTs and MHCs) in 2024 is complex and time-consuming. This webinar provides guidance on eligibility, form types (CMS 855), key terminology, required documentation, fees, PTAN linkage, common errors, and best practices. Proper understanding of application type, NPI type, PECOS requirements, taxonomy designations, and PAR vs. NON-PAR status is crucial to avoid cash flow delays and other systemic issues. With expert guidance, providers can ensure accurate submission and smooth enrollment with Medicare.
Understand the CMS 855 enrollment submission process for 2024.
Recall CMS 855A, 855B, and 855I Application requirements for 2024.
Recall the most complicated sections on the 855 applications for 2024.
Recall strategies to complete 855 forms accurately for 2024.
Recall ancillary documentation required with 855 enrollment submissions for 2024.
Avoid common rejections and errors with 855 form submissions.
Recall best practice tips for 855 form submissions for 2024.
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https://conferencepanel.com/conference/navigating-the-2024-medicare-855-enrolments-form-updates
Demystifying Shared Care and "Incident To" Billing: 2024 UpdatesConference Panel
This webinar aims to elucidate the changes for the year 2024 concerning billing for shared and incident care services. Furthermore, it will delineate the requisite documentation requirements essential for both shared and incident care billing scenarios.
By attending this webinar, healthcare providers can gain a comprehensive understanding of the evolving CMS policies and the intricacies of billing for shared and incident care. Armed with this knowledge, they can adopt proper billing practices and uphold the requisite documentation standards, thereby minimizing the risk of audits, paybacks, and reimbursement delays.
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https://conferencepanel.com/conference/secrets-to-correctly-billing-shared-care-and-incident-to-services-in-2024
Ensure smooth reimbursement by staying informed on "CPT Code Changes for 2024." Provider responsibility is paramount, given limited insurer education on annual updates. Office staff should comprehend procedures, documentation for compliance, and insurer policies on medical necessity, prior authorization, and coverage. The presentation will elucidate the 2024 highlights, empowering attendees to adeptly apply changes adeptly, mitigating delayed or denied claims, and preserving office cash flow.
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https://conferencepanel.com/conference/cpt-changes-2024
Decoding the Latest Changes in the 2024 Medicare Physician Fee Schedule (MPFS...Conference Panel
The 2024 Medicare Physician Fee Schedule (MPFS) Final Rule introduces extensive changes, including substantial cuts to the 2024 conversion factor, updates to the Medicare Economic Index, and significant alterations to Evaluation and Management (E/M) services. The revisions extend to code valuations and various quality reporting programs. Faced with record-breaking inflation, physician and provider organizations are expressing outrage and advocating for urgent congressional action and payment reform. In response, a webinar has been organized to thoroughly dissect these updates, offering healthcare professionals actionable insights to navigate the complexities effectively. The session aims to empower participants with tangible information that can be immediately applied in response to the unprecedented changes in the healthcare landscape.
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https://conferencepanel.com/conference/navigating-the-2024-medicare-physician-fee-schedule-mpfs-final-rule-updates
Provider Enrollment Excellence: A Strategic Program GuideConference Panel
This comprehensive webinar, led by expert Cati Harris, CBCS, is tailored for individuals new to credentialing, those involved in building a credentialing program, or anyone looking to refresh their credentialing skill set. The course covers essential topics in provider enrollment, offering valuable insights and practical guidance.
Participants will gain knowledge on provider credential verification, the setup and maintenance of crucial systems such as CAQH, NPPES, PECOS, and I&A, CV verification, application preparation, review and submission processes, identification of red flags, linking providers to existing contracts, re-verification procedures, and ongoing provider file maintenance. The webinar also includes a FAQ section and guidance on establishing a successful provider enrollment program.
As a bonus, attendees will receive multiple free printable and customizable forms for provider enrollment. The webinar concludes with a live Q&A session, providing participants with the opportunity to have their specific questions addressed. Whether you are new to credentialing or seeking to enhance your existing knowledge, this webinar offers a detailed view of provider enrollment, maintenance, and the development of successful programs.
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https://conferencepanel.com/conference/a-guide-to-provider-enrollment-and-building-a-successful-provider-enrollment-program
What Physicians Need to Know: CMS Final Rules 2024Conference Panel
The CMS proposed rule for physician payment and coding changes sets the tone for the upcoming year. Attending this update ensures you are well-informed about the latest regulatory changes affecting healthcare services. Understanding the modifications proposed by CMS allows providers to adapt their coding practices, ensuring accurate reimbursement for the services they provide.
Knowledge of issues that were not implemented for 2023 provides valuable insights into what CMS is considering for the following year. This foresight enables strategic planning for 2024, allowing healthcare professionals to anticipate and prepare for potential changes. This year's update promises significant changes to key areas such as EM services, splits/shared care, remote patient monitoring (RPM), and complex chronic care management (CCM).
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https://conferencepanel.com/conference/cms-physician-final-rules-for-2024-find-out-what-cms-has-finalized-from-the-proposed-rules
A Deep Dive into 2023: Hospital CoPs and Best Practices for History and Physi...Conference Panel
We are excited to invite you to an informative webinar that will address recent changes in CMS regulations concerning History and Physicals (H&P) for healthy outpatients. The evolving landscape of healthcare policies requires hospitals to stay abreast of alterations in guidelines to ensure compliance.
Why Attend:
Stay informed about recent changes in CMS regulations.
Learn how to develop a comprehensive policy addressing H&P requirements.
Ensure compliance with The Joint Commission and DNV standards.
Gain insights into common deficiencies and strategies for improvement.
Please register for the webinar to secure your spot. We look forward to your participation in this essential webinar that will equip your hospital with the knowledge and tools needed to navigate the evolving landscape of History and Physical requirements.
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https://conferencepanel.com/conference/history-and-physicals-meeting-hospital-cops-in-2023
Demystifying the 2024 OIG Audit Selection CriteriaConference Panel
In today's webinar, we will delve into the essential regulatory bodies that play a pivotal role in ensuring healthcare compliance. We'll break down the intricacies of audits and investigations, offering insights into the various routes they can take. We'll also examine the OIG's 2024 work plan, shedding light on the key areas of focus, and spotlight emerging audit trends and potential audit targets for the year ahead. Additionally, we'll pinpoint actionable protocols for addressing compliance issues, dissect recent advisory opinions from the OIG, outline the fundamental components of a robust compliance plan, and provide valuable best practices to thrive in 2024.
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https://conferencepanel.com/conference/navigating-the-2024-oig-audit-targets
CMS Preventive Services for Medicare Patients refers to the Centers for Medicare & Medicaid Services (CMS) programs that provide preventive healthcare services to Medicare beneficiaries. These services are designed to detect and address health issues early, helping seniors maintain their well-being and potentially reducing healthcare costs in the long run. Preventive services covered by Medicare may include vaccinations, screenings, annual wellness visits, and counseling on various health-related topics. These services are essential for promoting the health and longevity of Medicare patients while preventing more serious and costly medical conditions.
The webinar is designed to provide information and guidance to healthcare providers and professionals on preventive services covered by Medicare for their patients. These services are aimed at helping Medicare patients maintain and improve their health by identifying and preventing illnesses or conditions. The webinar likely covers topics such as eligibility, coding, billing, and updates on preventive services guidelines for Medicare beneficiaries. It is a resource to keep healthcare providers updated on Medicare's preventive care offerings.
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https://conferencepanel.com/conference/cms-preventive-services-medicare-patients
Part B Unpacking the 2023 CMS Hospital Infection Prevention MandatesConference Panel
The CMS Hospital Infection Prevention, Control, and Antibiotic Stewardship Program - CMS Compliance Requirements 2023 - Part B refers to a specific aspect of regulatory requirements in the healthcare industry. In this context:
"CMS" stands for the Centers for Medicare & Medicaid Services, a federal agency that administers various healthcare programs and sets compliance standards for healthcare providers.
"Hospital Infection Prevention & Control" pertains to measures and protocols aimed at preventing and controlling the spread of infections within hospital settings.
"Part B" likely indicates a specific section or aspect of the compliance guidelines for infection prevention and control in hospitals.
This topic suggests that healthcare providers, particularly hospitals, need to navigate and comply with the updated regulations and guidelines related to infection prevention and control set forth by CMS in 2023. Compliance is crucial for ensuring patient safety and maintaining eligibility for Medicare and Medicaid reimbursements.
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https://conferencepanel.com/conference/the-cms-hospital-infection-prevention-and-control-and-antibiotic-stewardship-program-cms-compliance-requirements-2023
Part A Unpacking the 2023 CMS Hospital Infection Prevention MandatesConference Panel
The CMS Hospital Infection Prevention and Control program is a vital initiative for healthcare facilities to ensure patient safety and reduce the spread of infections. In 2023, CMS compliance requirements for this program emphasize the need for hospitals to implement rigorous infection control measures, maintain stringent hygiene standards, and promote antibiotic stewardship to prevent the emergence of antibiotic-resistant strains of bacteria. Hospitals must adhere to these requirements to maintain their CMS certification and provide high-quality, safe patient care.
Learning Objectives:-
Recall the standard and new interpretive guidelines for infection prevention and control
Relate key requirements for an infection prevention and control program
Identify the requirements for infection prevention and Antibiotic Stewardship lead
Describe what CMS requires for safe injection practices and sharps safety
Discuss that CMS has a final infection control worksheet
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https://conferencepanel.com/conference/the-cms-hospital-infection-prevention-and-control-and-antibiotic-stewardship-program-cms-compliance-requirements-2023
Key Elements of CMS Emergency Preparedness RegulationsConference Panel
CMS regulatory requirements and TJC compliance are essential for healthcare organizations to establish robust emergency preparedness programs. These programs help ensure patients', staff, and community safety during emergencies and disasters while maintaining the organizations' eligibility for federal funding and accreditation status. Healthcare providers must continually assess, update, and test their emergency preparedness plans to meet these requirements and standards.
Healthcare organizations must meet both CMS and TJC requirements to ensure compliance with federal regulations and maintain accreditation. These requirements are designed to enhance patient safety and the ability of healthcare facilities to respond effectively to emergencies, including natural disasters, infectious disease outbreaks, and other crises. Regular updates and revisions to these requirements may occur, so healthcare providers need to stay informed and adapt their emergency preparedness programs accordingly.
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Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Breaking Down the Latest HIPAA Modifications: What's New in 2024 and Beyond
1. HIPAA Changes for 2024 and
Beyond
Conference Panel
Wednesday, December 6, 2023
by
Mark R. Brengelman, JD, MA
Attorney at Law
Frankfort, Kentucky 1
2. About Mark R. Brengelman
• Holds Bachelor's and Master's Degrees in Philosophy from Emory University, Atlanta,
Georgia
• Earned a Juris Doctorate from the University of Kentucky College of Law, Lexington,
Kentucky
• Served out a successful twenty-year career with state government in Kentucky,
including…. now in private practice since 2012
• Was a former Assistant Attorney General assigned to multiple state licensure boards in
health care and other professions – General Counsel and Prosecuting Attorney
• Has presented Continuing Education for over 50 national and state organizations and
private companies, including the Kentucky Office of the Attorney General, the Kentucky
Bar Association, the National Attorneys General Training and Research Institute, the
Federation of Associations of Regulatory Boards, and eight of its member associations in
psychology, physical therapy, dentistry, nursing, veterinary medicine, emergency medical
services, state licensed contractors, and athletic trainers
• Has represented all three branches of state government and now a local municipality in
governmental ethics and now a state licensure board
Represents:
• licensees before state boards and in other professional matters
• two state licensure boards
• parents and kids in confidential child abuse and neglect cases, termination
of parental rights, and adoption proceedings
I help health care practitioners, kids/parents, and government agencies
navigate the law and ethics and make the rules understandable as applied to
them.
3. Based upon the content of this program, you will be able effectively to identify:
• Introduction to federal regulatory process-notice and comment rulemaking
• Overview of proposed HIPAA Privacy Rule changes for 2023
• Why these 2023 changes are extended into 2024
• HIPAA security and privacy-what’s the difference anymore
• Training your employees-what’s really required
• Cybersecurity-why it’s more important now
• Self-audits, remediation, and implementation of improvements
• Best practices for responding to a security incident
• Lessons learned from the most recent cyberattack investigation
• Cybersecurity sanctions policies to support HIPAA compliance
• Conclusion: avoiding risk and liability with best practices to anticipate HIPAA changes for 2024 but not yet
in effect
HIPAA changes for 2024 and beyond
3
4. Disclaimer! Goals of the content of this program – what this does and does not cover:
• Does provide a broad overview of anticipated proposed HIPAA changes for 2024 in the federal notice and
comment rulemaking system
• Does not cover everything about anticipated proposed HIPAA changes for 2024 – current proposed rule
changes in 2023 consisted of 48 pages in the Federal Register!
• Does educate the person attending to ask the right questions in their own profession/health care entity
about changes in compliance with federal law under HIPAA to look for in 2024
• Additional disclaimer – I do not work in the area of federal administrative rulemaking (state rulemaking,
yes), and I do not work daily in the area of HIPAA compliance; I work in professional licensure and
regulation of health care professionals – all aspects touch in some part on HIPAA as to confidentiality
HIPAA changes for 2024 and beyond
4
5. Introduction to HIPAA changes for 2024 and beyond – we start with 2023 rule changes:
• Why start in 2023?
• The Department of Health and Human Services published proposed amendments to HIPAA to further safeguard the privacy
of reproductive health care information in 2023 – April 17, 2023
• This was the biggest change in the proposed rules in…..how long?
• Comments were due sixty days later by June 16, 2023; nearly 26,000 comments were filed; some publicly released and
searchable (more to come? all to come?) – preliminary conclusions from the comments
• This is somewhat old data
• Why were these proposed rule changes significant?
• Incorporated guidance documents into the law
• Responded to the U.S. Supreme Court’s Dobbs v. Jackson Women's Health Organization decision on abortion recognizing
state-by-state differences – even more so now in 2023/2024;
• Example: Ohio constitutional amendment
• The proposed amended HIPAA rule prohibits the use and disclosure of this information for certain criminal, civil, and
administrative investigations and proceedings where reproductive health care is legal in the state that it was provided or
under federal law
• This HIPAA update would preempt contrary state law in these narrow situations -- for 2023, there are also proposed
corresponding changes, such as to the requirements for notices of privacy practices and requiring attestations for certain
requests for information potentially related to reproductive health care
HIPAA changes for 2024 and beyond
5
6. Existing guidance and why that is not enough:
• After the Supreme Court officially published the Dobbs v. Jackson Women's Health Organization decision on June 24, 2022,
the federal Department for Health and Human Services published two guidance documents related to the privacy of
reproductive health care information
• What is a guidance document? Does it have the force of law? Yes and no….
• Guidance documents are suggestions to individuals regarding how to comply with the law - while helpful, the Department for
Health and Human Services could only provide increased HIPAA protections through notice-and-comment rulemaking – it
had to change the black and white law (you can’t be found guilty of not following guidance)
• Guidance documents – a “pet peeve” of mine in the law for state agencies
• Example: “use a secure digital platform” – guidance document says that 16-bit, double-ended encryption is “secure”
• But only “the law” can mandate 16-bit, double-ended encryption as being required under the law
• While the guidance document can give a safe-harbor provision basically saying “if you use 16-bit, double-ended encryption,”
then you won’t get in trouble with us;” after all, it may be the case that 8-bit, double encryption is sufficient
• The first guidance document identified how HIPAA currently applies to the privacy of reproductive health care information,
emphasizing that it permits but does not require disclosures of this information – state law may apply here both for or
against release – HIPAA allows for state law to apply (i.e., mandatory reporting of child abuse/neglect)
HIPAA changes for 2024 and beyond
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7. Existing guidance and why that is not enough:
• The second guidance document clarified that HIPAA does not apply to health information on consumer devices
or stored with most consumer apps, which is otherwise the existing HIPAA laws – we should know this
• Why is this important? Lots of information on these apps – not private! Subject to subpoena without any
HIPAA privacy protections at all
• In conclusion for our introduction, these proposed changes for 2023 and extending in to 2024 will involve next
steps for covered entities and business associates alike
• This is still on-going! No time limit to publish the final rule – covered entities will have 180 days to comply fully
with any changes (hint: employee training is important!)
• See webinar dated October 3, 2023: “HIPAA and Proposed Changes for 2023”
HIPAA changes for 2024 and beyond
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8. HIPAA security and privacy – what’s the difference?
• Security and privacy concepts are merging – result of evolution of Electronic Health Records and direct
patient access on secured health care applications (apps) on your smartphone;
• Privacy and security were two distinct concepts – now, the two rules seem to be alike in many ways
• Patients more clearly have a right in 2024 to have direct access to their own medical records
• In the absence of direct access, covered entities have to respond to individual and specific requests, to
verify the identity of the person requesting the medical record, and to handle correctly medical records
data with third parties
• Note: this has always been true with Business Associates, and smartphone apps raise this liability
HIPAA changes for 2024 and beyond
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9. Training your employees – what’s really required?
• Initial training vs. training as needed – is annual training the solution to the latter?
• Needs to address cyber-awareness and especially phishing;
• Focus on phishing: even law firms are vulnerable; Example: pulling the plug (literally)
• Examples: spoofing an e-mail from a valid sender (who’s been hacked) with general instructions;
• Examples: spoofing an e-mail from a valid sender (who’s been hacked) with specific instructions, like a
bank transfer notice;
• Health care is the most vulnerable to cyber hackers; two-factor identification is the easiest, most efficient
way to protect sensitive information
• Employee and worker education are critical – must include all employees and volunteers
• Differentiate between workers who have direct access to medical records/PHI vs. others
• Why is this important? Facility liability for all workers!
• Cyberattacks are growing and are more sophisticated – even my own PCP office!
• Minimal standards: identify signs of attack or phishing; correctly report the incident, and; take steps to
safeguard against threats
HIPAA changes for 2024 and beyond
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10. Cybersecurity best practices – why’s it more important now?
• New changes and updated standards are now grounds for government enforcement;
• Data protection – designed to prevent data breaches and data theft;
• Why health care data is so valuable;
• Must conduct a Security Risk Assessment;
• See webinar “How to Conduct a HIPAA Risk Assessment and the Surprising Danger of Not Doing One;”
June 15, 2023
• Spoiler alert: the surprising danger of not doing one was that the government held it against you in a
HIPAA investigation – as a practical matter, a risk assessment may have caught the problem first
HIPAA changes for 2024 and beyond
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11. Best practices for responding to a security incident:
• Health and Human Services lists all breaches reported to HHS within the last 24 months that are under
some kind of investigation;
• Note: investigations either exonerate or implicate – “innocent until proven guilty;”
• Monitor this list to gauge the current state of cyberattacks and data breaches;
• Prevention: review all Information Technology and computer assets and compile a list
• Example: new technology – cast made of the foot using a computer tablet and high-resolution camera;
• Analyze once detected: watch for attack and breach indicators; if a possible breach is detected, then
review all IT devices and re-secure them
• Example: your main Personal Computer is hacked; spreads to a smartphone when someone uses their
smartphone to check business e-mail . . . because the main computers are down
• Contain, eradicate, and recover
• Stop the attack (IT containment plan);
• Eradicate the breach (removing malware, resetting passwords, completing all necessary software
updates)
• Restore your systems using most-recent back-up if necessary, and resume business as usual;
• Post-incident review: very little time spent on this; review the incident and use it for future instruction;
improve your response plan – update your current procedures;
HIPAA changes for 2024 and beyond
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12. Lessons learned from the most recent cyberattack investigation:
• Barely 30 days ago, HHS settled a ransomware cyberattack investigation involving a Business Associate;
• Entity was “Doctor’s Management Services,” a Massachusetts medical management company that
provided medical billing and payor credentialing services;
• Large breach report affecting the electronic medical records of 206K persons - $100K settlement;
• Ransomware – type of malware (malicious, unauthorized software) that denies access to the user’s own
data (usually encrypting it with a computer key used by the hacker) until a ransom is paid;
• First ever ransomware settlement agreement that HHS has reached (October was cybersecurity
awareness month);
• Investigation showed:
• Evidence of potential failures to determine risks/vulnerabilities;
• Insufficient monitoring of health information systems’ activity to protect against cyberattack;
• Lack of policies and procedures in place to implement the HIPAA Security Rule to protect confidentiality,
integrity, and availability of electronic Protected Health Information;
• Outcome: $100K fine; government monitoring for three years; implementation of a corrective action plan
including Risk Analysis to identify problems; Risk Management Plan to fix them; update written policies
and procedures; provide workforce training on HIPAA policies and procedures
HIPAA changes for 2024 and beyond
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13. Cybersecurity sanctions policies to support HIPAA compliance:
• From HSS directly – part of its Threat Brief detailing types of social engineering that hackers use to gain
control and access to healthcare information systems and data;
• Recommended protective measures: “hold every department accountable” – sanction policies;
• Apply to your own Human Resources and employees/workers/volunteers;
• Prediction: lack of a sanctions policy will be used against you in a future investigation involving a breach
that is traceable to a single person or persons
• The Privacy Rule requires covered entities to “have and apply appropriate sanctions against members of
its workforce who fail to comply with the privacy policies and procedures of the covered entity or the
requirements of [the Privacy Rule] or [the Breach Notification Rule] of this part.”
• The Security Rule requires covered entities and business associates to: “[a]pply appropriate sanctions
against workforce members who fail to comply with the security policies and procedures of the covered
entity or business associate.”
• Elements include the functions of a sanctions policy, the content of what a sanction policy would look like,
and the execution of sanctioning consistently within an organization
• This is beyond the scope of today’s presentation – could be another entire webinar
• Applicability to a single health care practitioner as a covered entity?
HIPAA changes for 2024 and beyond
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14. Conclusion: Summary and tips for avoiding liability and risk with coming HIPAA changes for 2024:
For individual health care practitioners:
• As to state law: read and understand your profession’s practice act and know what current practice
standards are and current confidentiality in general under state law – usually the standards are very broad
in professional licensure, but more detailed in mental health professions
• Use a nationally recognized and “HIPAA compliant” software and medical records system – it may allow
you to flag and to separate PHI related to reproductive health care
• Train all your staff and re-train them when HIPAA changes
• Note: what I do drills down only to a single health care practitioner as a covered entity
HIPAA changes for 2024 and beyond
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15. Conclusion: Summary and tips for avoiding liability and risk with coming HIPAA changes:
For health care facilities:
• Know your HIPAA confidentiality and coming changes or hire someone who does – your facility is liable
• Have regular training on HIPAA rules for everyone (employees/volunteers) – recommended annual
training for anyone who has access to PHI – especially for facilities that provide reproductive health care
• Document your facility’s Risk Assessments accurately to include these changes – that is your best
defense to a federal HIPAA investigation that will mitigate damages if there is a security breach or
improper disclosure of PHI on reproductive health care
• Large entities will have their own IT and HIPAA compliance offices, so just do that!
HIPAA changes for 2024 and beyond
15
16. Did we get to cover all the following?
• Introduction to federal regulatory process-notice and comment rulemaking
• Overview of proposed HIPAA Privacy Rule changes for 2023
• Why these 2023 changes are extended into 2024
• HIPAA security and privacy-what’s the difference anymore
• Training your employees-what’s really required
• Cybersecurity-why it’s more important now
• Self-audits, remediation, and implementation of improvements
• Best practices for responding to a security incident
• Lessons learned from the most recent cyberattack investigation
• Cybersecurity sanctions policies to support HIPAA compliance
• Conclusion: avoiding risk and liability with best practices to anticipate HIPAA changes for 2024 but not yet
in effect
HIPAA changes for 2024 and beyond
16