{"id":2941,"date":"2023-08-02T09:51:59","date_gmt":"2023-08-02T09:51:59","guid":{"rendered":"https:\/\/www.empowerelearning.com\/blog\/?p=2941"},"modified":"2023-11-23T06:37:05","modified_gmt":"2023-11-23T06:37:05","slug":"the-three-rules-of-hipaa-the-basics-you-need-to-know","status":"publish","type":"post","link":"https:\/\/www.empowerelearning.com\/blog\/the-three-rules-of-hipaa-the-basics-you-need-to-know\/","title":{"rendered":"Understanding HIPAA Privacy Rule : The Three Fundamental Rules to Keep in Mind"},"content":{"rendered":"<p><span style=\"font-weight: 400;\">Neglecting the three HIPAA rules can lead to large fines, loss of face, and for an employee worker \u2013 loss of job. Businesses can lose up to 1.5 million dollars as fines. So, if you are covered under <a href=\"https:\/\/www.empowerelearning.com\/blog\/who-should-take-hipaa-training-and-why-its-so-important\/\">HIPAA<\/a>, you must comply with the <strong>three HIPAA rules<\/strong>.<\/span><\/p>\n<h3><b>Why the 3 rules of HIPAA are necessary<\/b><\/h3>\n<p><span style=\"font-weight: 400;\">When discussing HIPAA, you may often come across references to three critical rules: the Privacy Rule, the Security Rule, and the Breach Notification Rule.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Why are these rules so significant? Non-compliance can lead to large civil monetary fines, reaching up to $1.5 million, or even criminal sanctions. Furthermore, breaches can tarnish your organization&#8217;s reputation. Hence, if your enterprise falls under the category of a covered entity as per HIPAA, adhering to these three rules is paramount.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">To ensure clarity, let&#8217;s dive deeper into the specifics of each rule and the necessary measures for compliance.<\/span><\/p>\n<h3><b>Who needs to comply with the 3 HIPAA rules?<\/b><\/h3>\n<p><span style=\"font-weight: 400;\">Every entity dealing with Protected Health Information (PHI) is required to comply with these rules. This includes Healthcare providers, from large hospitals to private practices. Health insurance companies and clearinghouses. Business associates of the above entities can range from billing companies to software providers.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Even if an entity doesn&#8217;t directly deal with patients, but they handle, transmit, or store PHI in any manner, they are bound by HIPAA&#8217;s regulations.<\/span><\/p>\n<h2><b>The three HIPAA rules<\/b><\/h2>\n<p><img decoding=\"async\" class=\"size-full wp-image-4032 aligncenter\" src=\"https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Three-Rules-for-HIPAA-Requirements.jpg\" alt=\"Three-Rules-for-HIPAA-Requirements\" width=\"740\" height=\"740\" srcset=\"https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Three-Rules-for-HIPAA-Requirements.jpg 740w, https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Three-Rules-for-HIPAA-Requirements-300x300.jpg 300w, https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Three-Rules-for-HIPAA-Requirements-150x150.jpg 150w, https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Three-Rules-for-HIPAA-Requirements-370x370.jpg 370w, https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Three-Rules-for-HIPAA-Requirements-270x270.jpg 270w\" sizes=\"(max-width: 740px) 100vw, 740px\" \/><\/p>\n<p><span style=\"font-weight: 400;\">The Health Insurance Portability and Accountability Act (<a href=\"https:\/\/www.cdc.gov\/phlp\/publications\/topic\/hipaa.html\" target=\"_blank\" rel=\"noopener noreferrer nofollow\">HIPAA<\/a>) lays out three rules for protecting patient health information.\u00a0\u00a0<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The Privacy Rule\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The Security Rule<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The Breach Notification Rule<\/span><\/li>\n<\/ol>\n<p><span style=\"font-weight: 400;\">These three rules set national standards for the purpose. These standards address the issue of protecting health information, which could be used for identifying a person.\u00a0<\/span><\/p>\n<h3><b>1. The Privacy Rule<\/b><\/h3>\n<p><span style=\"font-weight: 400;\">The standards set by the Privacy rule address subjects such as:\u00a0<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Which organizations must follow the HIPAA standards<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">What is protected health information (PHI)<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">How organizations can share and use PHI<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Permitted usage and disclosure of PHI<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Patient&#8217;s rights over their health information<\/span><\/li>\n<\/ol>\n<p><span style=\"font-weight: 400;\">Healthcare entities covered by HIPAA include:<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Health plans\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Health care clearinghouses\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Health care providers\u00a0<\/span><\/li>\n<\/ol>\n<p><span style=\"font-weight: 400;\">HIPAA also applies to business associates who conduct healthcare transactions for covered entities.\u00a0<\/span><\/p>\n<h3><b>Usage and disclosure limitations\u00a0<\/b><\/h3>\n<p><span style=\"font-weight: 400;\">The privacy rule restricts the usage of health information which could identify a person (PHI). Covered entities cannot use or disclose PHI unless:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">It&#8217;s permitted under the Privacy rule, or<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The individual has authorized it in writing.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">The Privacy rule does not restrict de-identified health information.\u00a0<\/span><\/p>\n<p><img decoding=\"async\" class=\"aligncenter wp-image-3947 size-full\" src=\"https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Hippa-Rules.jpg\" alt=\"Hippa-Rules\" width=\"740\" height=\"300\" srcset=\"https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Hippa-Rules.jpg 740w, https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Hippa-Rules-300x122.jpg 300w, https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Hippa-Rules-370x150.jpg 370w, https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Hippa-Rules-270x109.jpg 270w\" sizes=\"(max-width: 740px) 100vw, 740px\" \/><\/p>\n<h3><b>2. The Security Rule<\/b><\/h3>\n<p><span style=\"font-weight: 400;\">The security rule sets the standards for the protection of PHI in electronic format (ePHI).\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">The Security rule standards cover:<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Which organizations must follow the security rule<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">What health information is protected under the security rule<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">What safeguards must be in place for the purpose<\/span><\/li>\n<\/ol>\n<p><span style=\"font-weight: 400;\">The security rule covers all healthcare providers who use ePHI. It also covers business associates of such providers.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">All the covered entities must protect all ePHI that they create, receive, store, or send. They must:\u00a0<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Ensure the confidentiality, integrity, and availability of the PHI<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Protect the ePHI against all threats to its security and integrity\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Protect it against impermissible use or disclosure<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Train employees, and ensure compliance with the security rule<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Adapt suitable policies and procedures<\/span><\/li>\n<\/ol>\n<p><span style=\"font-weight: 400;\">The covered entities are also required to perform risk analysis and create a risk management plan to mitigate the risk to ePHI.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">The risk analysis process should at least include the following steps.\u00a0<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Identify potential risks to patient health information<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Create a risk management plan\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Put in place administrative, physical, and technical safeguards<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Conduct <a href=\"https:\/\/www.empowerelearning.com\/online-hipaa-training\/\" target=\"_blank\" rel=\"noopener noreferrer\">HIPAA training<\/a>, and train workers to follow HIPAA policies and procedures<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Document their risk analysis process<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Conduct risk analysis yearly to identify and mitigate new risks<\/span><\/li>\n<\/ol>\n<h3><strong>3. The breach notification rule\u00a0<\/strong><\/h3>\n<p><span style=\"font-weight: 400;\">HIPAA considers all PHI usage or disclosures that aren\u2019t permitted under the Privacy rule as a breach.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">The breach notification rule requires covered entities to send alerts upon discovery of a breach. Once a covered entity becomes aware of a <a href=\"https:\/\/www.empowerelearning.com\/blog\/hipaa-breach-when-you-dont-need-to-report-and-how-to-handle-a-hipaa-breach\/\">breach<\/a>, the alerts have to be sent within next 60 days.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Covered entities are required to alert:<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Affected individuals<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Health and Human Services (HHS)<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Media, if necessary<\/span><\/li>\n<\/ol>\n<p><span style=\"font-weight: 400;\">Business associates of a covered entity need to alert their covered entity too.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">If the breach affects more than 500 people, the HHS must be notified immediately. The HHS would post it on their website. The covered entity would also need to post the message on their website.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Organizations may also choose not to send alerts, but only if they can prove that there is a low probability of the PHI being compromised.\u00a0<\/span><\/p>\n<p><span>[Also Read: <a href=\"https:\/\/www.empowerelearning.com\/blog\/what-is-hipaa-compliance\/\">Understanding HIPAA \u2013 Comprehensive Guide to HIPAA Compliance<\/a>]<\/span><\/p>\n<p><b>Breaking Down the Breach Notification Rule<\/b><\/p>\n<p><span style=\"font-weight: 400;\">This rule is particularly pertinent in the event of a data breach. Entities are obligated to:<\/span><\/p>\n<ol>\n<li><b> Individual notice:<\/b><span style=\"font-weight: 400;\"> Should a breach occur, affected individuals must be notified without undue delay, and in any case, no later than 60 days following the discovery of the breach. This notice should ideally be provided in writing and must contain details about the breach, the type of information compromised, steps individuals should take, and contact information for questions.<\/span><\/li>\n<li><b>Media notice<\/b><span style=\"font-weight: 400;\">: For breaches affecting more than 500 residents of a state or jurisdiction, entities are required to notify prominent media outlets in that region. This serves to inform and protect a large group of affected individuals who might not get the notification directly.<\/span><\/li>\n<li><b>Notice to the Secretary<\/b><span style=\"font-weight: 400;\">: Lastly, entities must inform the Secretary of Health &amp; Human Services about the breach. If the breach affects more than 500 individuals, this notification must be immediate. For breaches affecting fewer people, entities can maintain a log and submit it annually.<\/span><\/li>\n<\/ol>\n<p><a href=\"https:\/\/www.empowerelearning.com\/free-demo\/\"><img decoding=\"async\" class=\"aligncenter wp-image-4033 size-full\" src=\"https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Simplify-Hipaa-Compliance.jpg\" alt=\"Simplify-Hipaa-Compliance.\" width=\"740\" height=\"150\" srcset=\"https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Simplify-Hipaa-Compliance.jpg 740w, https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Simplify-Hipaa-Compliance-300x61.jpg 300w, https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Simplify-Hipaa-Compliance-370x75.jpg 370w, https:\/\/www.empowerelearning.com\/blog\/wp-content\/uploads\/2020\/05\/Simplify-Hipaa-Compliance-270x55.jpg 270w\" sizes=\"(max-width: 740px) 100vw, 740px\" \/><\/a><\/p>\n<h3><b>Reportable Breaches and Exceptions<\/b><\/h3>\n<p><span style=\"font-weight: 400;\">Organizations should consider all impermissible uses and disclosures as a breach of PHI. But, they need to send alerts only for unsecured PHI. Besides this, the breach notification rule is flexible under three more circumstances.<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">If it was unintentional or done in good faith, and was within the scope of the authority.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">If it was done unintentionally between two people permitted to access the PHI.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The organization has a good faith belief that the person to whom the disclosure was made would not be able to retain the PHI.<\/span><\/li>\n<\/ol>\n<p><span style=\"font-weight: 400;\">In any case, the organization should ensure that such incidents don\u2019t reoccur.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\"><a href=\"https:\/\/www.empowerelearning.com\/blog\/why-you-need-to-comply-with-the-hipaa-rules-data-breach-costs-1-5-million-to-athens-orthopedic\/\">Breach alerts<\/a> are required only for unsecured PHI. If you secured it as specified by this <\/span><span style=\"font-weight: 400;\">guidance<\/span><span style=\"font-weight: 400;\">, then you don\u2019t need to send the alerts.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">The HHS Office for Civil Rights enforces the three HIPAA rules. Violations of the HIPAA rules may result in <\/span><span style=\"font-weight: 400;\">fines and penalties<\/span><span style=\"font-weight: 400;\">. In some cases, criminal penalties may also apply.\u00a0<\/span><\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Neglecting the three HIPAA rules can lead to large fines, loss of face, and for an employee worker \u2013 loss of job. Businesses can lose up to 1.5 million dollars as fines. So, if you are covered under HIPAA, you must comply with the three HIPAA rules. Why the 3 rules of HIPAA are necessary [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":4031,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5,138,140,9,139],"tags":[77,28,288],"class_list":["post-2941","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-education","category-elearning","category-empower","category-hipaa","category-lms","tag-hipaa","tag-hipaa-compliance-training","tag-three-hipaa-rules"],"_links":{"self":[{"href":"https:\/\/www.empowerelearning.com\/blog\/wp-json\/wp\/v2\/posts\/2941","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.empowerelearning.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.empowerelearning.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.empowerelearning.com\/blog\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.empowerelearning.com\/blog\/wp-json\/wp\/v2\/comments?post=2941"}],"version-history":[{"count":0,"href":"https:\/\/www.empowerelearning.com\/blog\/wp-json\/wp\/v2\/posts\/2941\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.empowerelearning.com\/blog\/wp-json\/wp\/v2\/media\/4031"}],"wp:attachment":[{"href":"https:\/\/www.empowerelearning.com\/blog\/wp-json\/wp\/v2\/media?parent=2941"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.empowerelearning.com\/blog\/wp-json\/wp\/v2\/categories?post=2941"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.empowerelearning.com\/blog\/wp-json\/wp\/v2\/tags?post=2941"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}