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Workplace Privacy, Data Management & Security Report

OCR Announces HIPAA Audit Program

Today, the Office for Civil Rights formally announced it is implementing the audit requirement under the American Recovery and Reinvestment Act of 2009, in Section 13411 of the HITECH Act. The agency confirmed that it is piloting a program to perform up to 150 audits of covered entities to assess privacy and security compliance, and that the pilot phase will begin November 2011 and conclude by December 2012.

A new page on OCR’s website answers some helpful questions for covered entities and business associates… 

When Will Audits Begin?

The pilot audit program is a three step process… OCR expects the initial audits to begin in November 2011.The results of the initial audits will inform how the rest of the audits will be conducted…All audits in this pilot will be completed by the end of December, 2012.

Who Will Be Audited?

Every covered entity and business associate is eligible for an audit. Selections in the initial round will be designed to provide a broad assessment of a complex and diverse health care industry. OCR is responsible for selection of the entities that will be audited. OCR will audit as wide a range of types and sizes of covered entities as possible; covered individual and organizational providers of health services, health plans of all sizes and functions, and health care clearinghouses may all be considered for an audit. We expect covered entities to provide the auditors their full cooperation and support and remind them of their cooperation obligations under the HIPAA Enforcement Rule.

Business Associates will be included in future audits.

So, it appears business associates will be spared for the first round of audits.

How Will the Audit Program Work?

The privacy and security performance audit process will include generally familiar audit mechanisms. Entities selected for an audit will be informed by OCR of their selection and asked to provide documentation of their privacy and security compliance efforts.

Accordingly, it is critical that covered entities be sure their policies and procedures are in order, including the new mandates under HITECH, such as breach notification policies.

In this pilot phase, every audit will include a site visit and result in an audit report. During site visits, auditors will interview key personnel and observe processes and operations to help determine compliance. Following the site visit, auditors will develop and share with the entity a draft report; audit reports generally describe how the audit was conducted, what the findings were and what actions the covered entity is taking in response to those findings. Prior to finalizing the report, the covered entity will have the opportunity to discuss concerns and describe corrective actions implemented to address concerns identified. The final report submitted to OCR will incorporate the steps the entity has taken to resolve any compliance issues identified by the audit, as well as describe any best practices of the entity.

Having written policies and procedures clearly is not going to be sufficient to survive an audit. Covered entities will need to be sure their workforce members have been trained and are performing their responsibilities consistent with HIPAA and the organizations’ policies and procedures.

What is the General Timeline for an Audit?

When a covered entity is selected for an audit, OCR will notify the covered entity in writing. The OCR notification letter will introduce the audit contractor, explain the audit process and expectations in more detail, and describe initial document and information requests. It will also specify how and when to return the requested information to the auditor. OCR expects covered entities and business associates who are the subject of the audit to provide requested information within 10 business days of the request for information.

In light of this 10-day time frame, be sure the appropriate persons are on the look out for a notice and prepared to respond in a timely manner. Here is the kind of notice they should be looking for.

OCR expects to notify selected covered entities between 30 and 90 days prior to the anticipated onsite visit. Onsite visits may take between 3 and 10 business days depending upon the complexity of the organization and the auditor’s need to access materials and staff. After fieldwork is completed, the auditor will provide the covered entity with a draft final report; a covered entity will have 10 business days to review and provide written comments back to the auditor. The auditor will complete a final audit report within 30 business days after the covered entity’s response and submit it to OCR.

What Happens After an Audit?

Audits are primarily a compliance improvement activity. OCR will review the final reports, including the findings and actions taken by the audited entity to address findings. The aggregated results of the audits will enable OCR to better understand compliance efforts with particular aspects of the HIPAA Rules. Generally, OCR will use the audit reports to determine what types of technical assistance should be developed, and what types of corrective action are most effective. Should an audit report indicate a serious compliance issue, OCR may initiate a compliance review to address the problem. OCR will not post a listing of audited entities or the findings of an individual audit which clearly identifies the audited entity.

Based on these statements, it appears that the audits are part of an overall learning process for the agency to better guide covered entities and business associates concerning compliance. However, it is not clear what the agency considers "a serious compliance issue."