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HIPAA Training Requirements

Published January 17, 2024

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HIPAA Training is a crucial obligation imposed on organizations by the Security and Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA). Ensuring compliance with HIPAA regulations requires organizations to prioritize training and dedicating resources to equip all employees with the essential skills, knowledge, and awareness.

While organizations can devise their own training programs, the law specifies certain training requirements. Adhering to these requirements aids organizations in designing effective training programs that enhance understanding and promote compliance with HIPAA.

What is HIPAA and HIPAA Training?

HIPAA is a major healthcare data-related regulation within the United States. One of its primary purposes is to protect personal health information (PHI) by placing a wide array of requirements and mandates that must be adhered to by both covered entities and business associates.

For the organizations, i.e. covered entities and business associates, the HIPAA training means the implementation of various security features and educational programs designed to instruct staff, including employees, contractors, and other third-party individuals, on the policies and procedures mandated by HIPAA. This HIPAA training is extremely important since it constitutes a significant portion of an organization’s HIPAA compliance journey.

Read on to learn more about HIPAA Training, such as the objectives of such training, the regulatory requirements, best practices, and the consequences of insufficient HIPAA training.

Objectives of HIPAA Training

For organizations, HIPAA training can have multiple objectives.

Most importantly, proactive HIPAA training ensures all employees are adequately trained in best practices to support covered entities and business associates’ operations and avoid HIPAA violations. Done consistently over time, such training gives organizations a better understanding of how their HIPAA compliance has evolved and eliminates any deficiencies and blindspots accordingly.

Furthermore, it allows the employees to understand all the mechanisms and measures in place within their organization, such as risk assessments, user-role-based access governance, and multi-factor authentication (MFA) to guarantee all functions are being performed in a HIPAA-compliant manner.

Lastly, the training helps demonstrate to regulatory bodies that an organization takes HIPAA compliance seriously. Hence, all HIPAA training-related activities should be carefully documented for both internal use and regulatory reasons.

What Industries Require HIPAA Training

Individuals, organizations, and agencies that fall under the definition of a ‘covered entity’ must comply with this HIPAA requirement. Covered entities under HIPAA include the following categories:

1. Health Plans

These include Individual or group plans that provide or pay the cost of medical care. The health plans may include the following:

  • Health insurance companies.
  • Health maintenance organizations.
  • Employer-sponsored health plans.
  • Government programs that pay for health care, like Medicare, Medicaid, and military and veterans’ health programs.

2. Healthcare Providers

These individuals or entities who electronically transmit health information in connection with certain transactions. These transactions include claims, benefit eligibility inquiries, referral authorization requests, or other transactions for which HHS has established standards under the HIPAA Transactions Rule. The health care providers include but are not limited to doctors, psychologists, dentists, clinics, pharmacies, nursing homes, etc.

3. Healthcare Clearinghouses

Entities that process nonstandard information they receive from another entity into a standard format or data content, or vice versa. Healthcare clearinghouses may include billing services, repricing companies, community health management information systems, and value-added networks and switches if these entities perform clearinghouse functions.

In addition to the covered entities, HIPAA applies to ‘business associates’, which refers to an individual or entity that performs certain functions on behalf of a covered entity that entails the use or disclosure of PHI.

What are the HIPAA Training Requirements?

Under HIPAA, the Security Rule (45 CFR §164.308) and the Privacy Rule (45 CFR §164.530) require subject organizations to conduct HIPAA training as discussed below.

The Privacy Rule Training Standard

The Privacy Rule training standards start with the ‘Policies and Procedures”- standard of the Administrative Requirements. As per this standard, a covered entity is obligated to establish and implement policies and procedures pertaining to protected health information in accordance with the Privacy Rule and Breach Notification Rule. To ensure such compliance, the policies and procedures must be reasonably designed, considering the size and the type of activities that relate to protected health information undertaken by a covered entity.

Moreover, the Privacy Rule mandates the covered entities to provide appropriate training to all its members. This training is essential to ensure a comprehensive understanding of the established policies and procedures, enabling effective execution of their respective roles. Covered entities are required to provide training to both existing and new workforce members, as well as individuals affected by material changes in policies.

Additionally, the Privacy Rule stipulates that a covered entity must designate a privacy official responsible for developing and implementing privacy policies. Furthermore, a designated contact person or office is necessary to handle complaints and provide information about the notice requirements.

The Security Rule Training Standard

In contrast to the Privacy Rule, the Security Rule adopts a more direct and explicit approach in outlining training-related obligations for covered entities and business associates. The Security Rule mandates the covered entities to establish policies and procedures aimed at preventing, detecting, containing, and correcting security violations. Additionally, it emphasizes the enforcement of appropriate sanctions against workforce members who do not adhere to the established security policies and procedures.

Furthermore, the Security Rule underscores the necessity for organizations to institute a comprehensive security awareness and training program for all members of their workforce, including management. The implementation specifics include:

  • Periodic security updates.
  • Procedures for guarding against detecting and reporting malicious software.
  • Procedures for monitoring log-in attempts and reporting discrepancies.
  • Procedures for creating, changing, and safeguarding passwords.

Consequences of Inadequate HIPAA Training

As far as regulatory fines are concerned, there is no direct penalty. Organizations that carry out inadequate training or do not conduct any HIPAA training at all are not liable to receive any regulatory consequences.

However, as elaborated earlier, the primary purpose of HIPAA training is to appropriately train the employees and the staff within an organization to ensure all internal practices minimize any possible chances of a security incident or a possible HIPAA violation.

As far as proactiveness is concerned, HIPAA training offers organizations the best chance to guarantee the safety and privacy of their PHI and create a culture within the organization that places HIPAA-compliant practices at the forefront.

Best Practices for HIPAA Compliance Training

As mentioned, there’s no hard and set method for conducting HIPAA training. Organizations are given tremendous freedom to design their own training programs that adequately inculcate HIPAA requirements.

However, some basic elements any subject organization can include in its HIPAA training include the following:

  • HIPAA Rules - HIPAA is an extensive regulation with several different Rules placing different obligations upon employees. Understanding these Rules is the foundation for any organization’s attempts to ensure complete HIPAA compliance.
  • HIPAA Violations - A HIPAA training session should provide employees with all potential HIPAA violations that may occur in addition to the immediate and long-term regulatory consequences of these violations.
  • Threats to Data - It is vital that all employees be made thoroughly aware of all immediate and potential threats to PHI. Knowing these threats is the first step towards eventually addressing and mitigating the potential harm posed by these threats.
  • Emergency Situations - HIPAA allows certain provisions to be waived in an emergency. The nature and extent of these waivers depend on the nature of the emergency and the direct implications for PHI. All training sessions should cover such emergencies thoroughly.
  • Updates - HIPAA, like any other regulation, may undergo additions and updates. Each training should adequately cover all such updates since the last training session to ensure all employees are aware of any changes that may impact them.
  • HIPAA Compliance Checklist - A HIPAA compliance checklist, like any other checklist, will be helpful for employees to cross-check whether they’ve undertaken all the procedural requirements they’re subject to under HIPAA and make any amendments if necessary.

Why Choose Securiti

HIPAA is a highly complex and comprehensive regulation that places extensive obligations upon subject organizations. This is understandable since the regulation covers organizations' responsibilities toward protecting their users' PHI.

However, aiming to comply with these obligations traditionally would strain resources tremendously. Automation offers a more effective and efficient alternative.

This is where Securiti can help.

Securiti is the pioneer of the Data Command Center, a centralized platform that enables the safe use of data and GenAI. It provides unified data intelligence, controls, and orchestration across hybrid multicloud environments. Additionally, Securiti has a plethora of other modules and solutions that are designed to ensure an organization can adequately address any of its data security, privacy, governance, and compliance obligations under any major regulation.

Request a demo today and learn more about how Securiti can help your organization's HIPAA compliance journey.

Here are some other commonly asked questions you may have:

While the core principles of HIPAA training are consistent, the specifics may vary based on an employee's role and responsibilities. Tailored training ensures that each staff member receives relevant information to perform his functions efficiently within the organization. Eventually, such decisions depend on how an organization plans to conduct its HIPAA training.

There’s no direct answer to this question since the exact time and duration of the training depends entirely on the organization’s approach to the overall training and other factors such as the depth of training.

Ideally, all new employees must undergo HIPAA training by the first few weeks of joining.

Most organizations usually delegate all training responsibilities to the HR department, where a compliance officer is tasked with developing the training resources and ensuring that all such resources are updated.

There is no legal requirement to conduct HIPAA training annually. However, HIPAA training should be conducted annually to ensure all employees remain updated on the most recent regulatory changes and compliance practices. 

HIPAA training covers aspects such as PHI privacy, security measures, HIPAA compliance requirements, its violations, subsequent penalties, the organization’s policies and procedures, and employee responsibilities.

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