🏥 Healthcare Compliance

HIPAA
Compliance

HIPAA violations cost Ohio healthcare organizations millions in penalties and reputational damage each year. Securafy's COMPLY-CARE program makes continuous HIPAA compliance manageable, documented, and audit-ready — without adding IT staff.

What Is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) establishes national standards for protecting sensitive patient health information — called Protected Health Information (PHI) or electronic PHI (ePHI). Any organization that creates, receives, maintains, or transmits PHI is a Covered Entity or Business Associate subject to HIPAA.

The HIPAA Security Rule requires administrative, physical, and technical safeguards to protect ePHI. The Privacy Rule governs how PHI is used and disclosed. The Breach Notification Rule requires prompt notification when ePHI is compromised.

In December 2024, OCR released proposed updates to the HIPAA Security Rule — the first major update since 2013. The proposed changes require multi-factor authentication, encryption of all ePHI, documented vulnerability management programs, and 72-hour breach notification. Ohio healthcare organizations must begin preparing now.

"HIPAA isn't just about policy documents — it's about technical controls that are tested, documented, and verifiable."

$100
Per-violation penalty (minimum) — up to $50,000
$1.9M
Average OCR settlement for negligent compliance
60
Days to report breaches affecting 500+ individuals
72hr
Proposed breach notification window (2024 update)
Who Must Comply

HIPAA Covered Entities & Business Associates

HIPAA applies far more broadly than most organizations realize. If you handle PHI in any form, you are likely subject to HIPAA requirements.

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Healthcare Providers

Physicians, dentists, hospitals, clinics, nursing homes, pharmacies, and any provider that transmits health information electronically — including patient billing.

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Health Plans

Health insurance companies, HMOs, company health plans, Medicare, Medicaid, and other government programs that pay for healthcare.

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Healthcare Clearinghouses

Entities that process non-standard health information into standard formats, including billing services and community health information systems.

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Business Associates

IT vendors, MSPs, billing companies, lawyers, consultants, and any third party that creates, receives, maintains, or transmits PHI on behalf of a covered entity. This includes Securafy — we sign a BAA with every healthcare client.

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Veterinary Practices

Ohio veterinary practices handling client/patient records that interface with insurance or referral networks should review their HIPAA exposure with legal counsel.

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Legal & Accounting Firms

Law firms and accounting firms that receive medical records, handle healthcare billing disputes, or process patient financial information are subject to Business Associate requirements.

Key Requirements

The Three HIPAA Rules

HIPAA compliance is built on three interlocking rules, each covering different aspects of PHI protection.

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Security Rule — Administrative Safeguards

Risk analysis and management, workforce training, access management, contingency planning, audit controls, and policies governing how ePHI is accessed, used, and protected.

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Security Rule — Technical Safeguards

Access controls, audit logs, data integrity controls, encryption of ePHI in transit and at rest, automatic logoff, multi-factor authentication (proposed mandatory in 2024 update).

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Security Rule — Physical Safeguards

Facility access controls, workstation security policies, device and media controls — covering everything from server room access to portable device management.

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Privacy Rule

Governs how PHI may be used and disclosed. Requires patient authorizations, Notice of Privacy Practices, minimum necessary standards, and patient rights to access their own records.

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Breach Notification Rule

Requires notification to affected individuals (within 60 days), HHS, and in large breaches, the media. Proposed 2024 rule reduces this to 72 hours for breaches affecting 100+ individuals.

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Business Associate Agreements

Every vendor who touches PHI must sign a BAA before receiving access. Covered entities are liable for BA breaches if proper BAAs weren't in place. Securafy provides a HIPAA-compliant BAA as standard.

How Securafy Helps

HIPAA Compliance Made Manageable

Securafy's COMPLY-CARE program provides continuous HIPAA compliance — not just a one-time checklist. We are a HIPAA-compliant Business Associate and provide BAAs to every healthcare client as standard practice.

Annual HIPAA Risk Analysis

OCR requires a thorough, accurate, and organization-wide risk analysis. We conduct a documented risk analysis that identifies all ePHI locations, threats, vulnerabilities, and current control gaps — producing the documentation OCR wants to see.

Technical Safeguard Implementation

MFA deployment, ePHI encryption at rest and in transit, access control management, automatic workstation lockout, audit log configuration, and email security — all configured and maintained on your behalf.

Security Awareness Training

HIPAA requires documented workforce training. Our security awareness platform delivers HIPAA-specific training, phishing simulations, and compliance certificates — automatically tracked and reportable for OCR audits.

Incident Response & Breach Notification

When a security event occurs, we contain, investigate, and document the incident. We help determine breach notification obligations and prepare the required HHS notifications and patient communications.

Vendor & BAA Management

We audit your third-party vendor relationships to identify unexecuted BAAs, manage BAA lifecycle, and ensure every vendor with ePHI access meets HIPAA Security Rule requirements.

Policy & Procedure Library

We develop and maintain your complete HIPAA policy suite — Security Officer designation, workforce sanctions, contingency plans, disaster recovery procedures, and all required documentation.

Common Questions

HIPAA FAQ

Does HIPAA apply to my small medical practice?
Yes. Any healthcare provider that transmits health information electronically — including for billing — is a Covered Entity regardless of size. Small practices face the same requirements as large hospitals, though OCR takes organizational size into account when setting penalties.
What triggers an OCR HIPAA investigation?
Breach notifications (required when 500+ individuals are affected), patient complaints, and random desk audits. OCR investigates every breach notification report affecting 500+ individuals in a state. Most investigations focus on whether a proper risk analysis was conducted and whether reasonable safeguards were in place.
What are the 2024 HIPAA Security Rule updates?
OCR's proposed 2024 updates would make MFA mandatory, require encryption of all ePHI in transit and at rest, mandate documented vulnerability management programs, require annual technical testing of all security controls, and shorten breach notification timelines. While still proposed, organizations should begin implementing these controls now.
Does signing a BAA mean we're HIPAA compliant?
No. A BAA is a contractual agreement that your vendor will protect PHI appropriately — but it doesn't make either party compliant. Compliance requires implementing all required administrative, physical, and technical safeguards. A BAA without actual controls in place provides little protection in an OCR investigation.

Ready to Become
Audit-ready?

Securafy builds and maintains compliance programs for Columbus and Cleveland, Ohio businesses. Prevention-First. Compliance-Ready. Award-Winning.

Free Compliance Assessment COMPLY-CARE Services
📍 Columbus & Cleveland, Ohio

Official Regulatory Resources