Kusserow on Compliance: Tips for reducing the risk of cyber-attacks

Tim Murphy, former FBI deputy director stated that he rated cyber-attacks as the number one threat facing the country. Threats come from both inside organizations and outside. Insider threats may involve current or former employees or vendors. They may be motivated to steal intellectual property, funds, or simply to cause problems. The danger of employee-related crimes is that they have inside information concerning how things work and have access to data and computer systems. One of the best ways to combat attacks by insiders is to maintain a continuous monitoring of an individual’s public, online activity as well as the internal, network activity to detect changes in behavior. Often, cyber-attackers have patterns of detectable behavior and network activity which can provide indicators of risk, assist in early detection. It is important to know at any given time what are employees doing on the network; who are they dealing with; if they are leaving with data and files; and whether they are violating policy by sharing sensitive information with outsiders. Employee engagement in careless practice is far more common than engagement in malicious practice. Oftentimes carelessness takes the form of simple negligence by clicking on a link in a random email. However, there are ways to mitigate the threats, which can reduce the risk of cyber-attacks by as much as 80 percent, including:

  1. Provide ongoing employee and contractor training on what to do and not to do
  2. Conduct a risk assessment to understand threats presented by an insider
  3. Continuously monitor employee and vendor networks
  4. Update and upgrade software
  5. Use encryption to guard against information being read by unauthorized parties
  6. Establish multi-factor authentication

For more information health care provider cyber-security, contact Dr. Cornelia Dorfschmid at cdorfschmid@strategicm.com or at (703) 535-1419.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: New OCR Guidelines

The HHS Office for Civil Rights (OCR) issued a new guidance which points out a list of 10 violations where Business Associates (BAs) can be held directly liable. The guidance points out that where BAs may not be liable, the covered entity (CE) may be still on the hook for violations of those violations. As such CEs should carefully review their BA Agreements (BAAs) to ensure that they cover requirements that don’t directly apply to BAs but are still enforceable against CEs.

The OCR also notes that large data breaches also continue to dominate the press. The OCR recently cited among recent notable breaches that an EMR and software services provider allowed hackers access to 3.5 million patient records. Touchstone Medical Imaging (TMI), agreed to pay $3 million for a breach involving one of its FTP servers that contained PHI for over 300,000 patients. LabCorp received notice from American Medical Collection Agency (AMCA), a collection firm working on its behalf, regarding unauthorized access of 7.7 million patients’ PHI stored by AMCA. This announcement followed a similar one from Quest Diagnostics, in which they reported that AMCA’s breach affected 11.9 million of its patients.

Updates on OCR enforcement actions can be found at https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/data/enforcement-highlights/index.html

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Compliance officers cite HIPAA as their highest priority

The 2019 Compliance Benchmark Survey respondents reported that compliance officers are finding dealing with data breaches as their highest-ranked priority, with two-thirds of respondents citing HIPAA Security/Cyber-security and over half for HIPAA Privacy as their number one concern. This represented the biggest change since last year’s survey. Coupled with this finding was that nearly 75 percent of respondents reported the compliance office has assumed responsibility for HIPAA Privacy and nearly one-third assumed responsibility for HIPAA Security. So far this year, OCR has reportedly received upwards of a quarter million HIPAA privacy complaints.

The Survey did not focus on privacy laws and regulations emerging on the state level, nor did it provide much understanding on how organizations and compliance offices were responding to the challenges. As such, a separate 2019 survey has been designed to gather that information along with a variety of other issues.  It is designed to provide a general understanding of levels and nature of current commitment to this area.  Those who wish to participate in the 2019 HIPAA Compliance Survey can do so by clicking on the following hyperlink.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Most organizations reported encounters with government authorities

• Most organizations have made disclosures for HIPAA breaches and overpayments
• One third received demand letters
• Other encounters report were with OIG and DOJ

It is widely recognized that regulatory and legal enforcement activities have been increasing over the last few years. The results should be a warning bell to all compliance officers that regulators and enforcement officials are right around the corner, necessitating increased efforts on ongoing monitoring and auditing to mitigate exposure of compliance-related risk areas. In the soon to be released national healthcare “2019 Compliance Benchmark Survey” most respondents reported having encountered issues with government agencies in last five years. Ranking at the top, with nearly two-thirds of the respondents, was disclosure to the HHS Office for Civil Rights (OCR) for breaches of privacy under the Health Insurance Portability and Accountability Act (HIPAA). Over half reported making self-disclosures of overpayments received and addressing audits or investigations by government agencies. One-third reported responding to a demand letter from a government agency or contractor. Serious legal encounters with the government was reported at a much lower level.  One out of five respondents reported self-disclosure to the DOJ, OIG and CMS.  About one out of eight respondents reported their organization being involved in the settlement process with DOJ, self-disclosing to the OIG engagement of sanctioned individuals/entities, and being involved in a settlement process for a corporate integrity agreement (CIA).

The “2019 Compliance Benchmark Survey” report will be available without charge at the upcoming HCCA conference in Boston at Strategic Management Services, Booth 420. 

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.