What Is a HIPAA Security Risk Assessment & Why Is It Important?

HIPAA Security Risk Assessments: What They Are and Why They Matter

A typical security risk assessment performs three functions:

1. Review existing security of protected health information

2. Identify threats and vulnerabilities

3. Assess risk for likelihood and impact

Upon completion, a typical security risk assessment report will provide recommendations for mitigating security risk and monitoring results. Your report will include the following items for review:

1. Questions you were asked in the assessment

2. Risks found, expressed as “TVS” or “Threat Vulnerability Statements”

3. Risk rating of each threat, often defined as “Low”, “Medium”, or “High”

4. Existing control measures applied (answers to the questions that were asked)

5. Recommended control measures (RCM), pre-designated by the ONC

Once you have the report, the next step is implementing the recommendations. This might mean updating security policies, strengthening protections, or training staff to handle risks more effectively.

HIPAA requires security risk assessments. Regular assessments help maintain compliance with safeguards that protect patient information. HIPAA recommends conducting these assessments at least once a year or when you make significant changes to systems, policies, or technology.

Vulnerabilities can lead to breaches of sensitive information, which have the following repercussions listed by HIPAA:

• Settlements

• Fines ranging anywhere from $100 - $50,000 per violation or per medical record

• Criminal penalties including imprisonment (depending on the nature of the violation)

• Exclusion from Medicare

The severity of these penalties depends on the level of negligence. Unintentional violations typically result in lower fines, while repeated or willful violations can lead to the highest penalties and legal action.

Note: It’s crucial to address identified issues ASAP, especially if you participate in the MACRA programs (MIPS & APMs). During an audit, your most recent security risk assessment will be one of the first things they’ll ask for.

How Can You Prevent HIPAA Security Problems?

Risks come from insecure processes, people, or technology. Here are some basic steps you can take to ensure compliance:

1. DOCUMENT any and all steps you take to manage risks

2. Employee training - HIPAA, OSHA, and Texas House Bill 300

• You have 90 days to either verify or provide this training to new employees

3. 24/7 monitoring over your local IT infrastructure

• Consider remote monitoring and management of IT to catch problems ASAP

4. Operate your network as a simple workgroup environment rather than domain based network

If you work with a risk assessment expert, you’ll receive personalized recommendations based on your full assessment.

HIPAA Security Risk Assessment Checklist for Small Physician Practices

A security risk assessment helps uncover vulnerabilities that could put patient information at risk. While reviewing risks internally is a good first step, a more detailed assessment provides a clearer picture of potential security gaps. 

Below are some common questions in a security risk assessment for physician practices. You can start by reviewing these questions internally, but it is highly recommended that you get an assessment from an objective, experienced third party to maintain compliance.

Protecting Patient Data With a HIPAA Security Risk Assessment Checklist

A HIPAA Security Risk Assessment is more than just checking a compliance box – it’s about keeping patient information safe and maintaining trust in your practice. Addressing risks early helps prevent costly problems.

Regular assessments strengthen security measures and support compliance with HIPAA regulations. Bringing in a third-party expert can provide a thorough review, helping to catch issues that might otherwise go unnoticed. Prioritizing security protects both patient data and the long-term stability of your practice.

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