HIPAA Audits And Enforcement For 2019 - Current Issues & Focus For HIPAA Compliance

Training Format: OnDemand Webinar

Webinar Time: Available All Day

Speaker(s): Jim Sheldon-Dean

Webinar Date: Tuesday, October 15, 2019

Training Duration : 90 minutes

Training Material Download : Training Material (Password Required) (1.27 MB)


Untitled Document

The New HIPAA Audit and Enforcement Program 2019 -  New Focus New Process

The random HIPAA Compliance Audit program had a year of trial audits in 2012.  The US Department of Health and Human Services reviewed the results of that work and performed a second round of audits, this time including HIPAA Business Associates, beginning in 2016 and concluding in 2017.  The law calls for a permanent Audit program, but HHS has indicated that the HIPAA audit program will be on hold for at least the time being, and that the next product will be a report on best practices learned in the audits conducted so far.  But that doesn’t mean there will be no enforcement of the HIPAA rules.  In fact, preparing for a HIPAA Audit is one of the best ways to be ready to respond to any enforcement action, and going through an internal HIPAA Audit will help you find issues before they become problems that can lead to penalties.

Knowing what questions are likely to be asked and have been asked at prior HIPAA compliance audits can make preparing for and surviving a HIPAA audit or enforcement review much easier.  USDHHS has published an updated, July 2018 protocol for the HIPAA audits, so it is possible to know how to prepare for an audit or enforcement review.  Nearly any health care covered entity may be subject to an audit or enforcement investigation; all entities need to know what kinds of questions they’ll be asked, what information they'll need to provide and how to prevent issues that could lead to violations and fines. 

In this session , Jim will discuss the HIPAA audit program and how it works, and discuss the areas that caused the most issues in the 2012 audits and the areas that were targeted in the 2016 audits.  He will explore what kind of issues were most prevalent and what kind of entities had the most problems, and show where entities need to improve their compliance the most.  He will also explore the typical risk issues that lead to breaches of health information and see how those issues may be targets for auditors and enforcement action in the future.

In addition, he will explore the latest guidance and upcoming new changes to the rules that will need to be reflected in policy and practice in order to avoid HIPAA violations resulting in enforcement. Topics like providing individuals access to their records, and providing an accounting of disclosures of protected health information are under pressure to see changes, particularly in light of the proposed Information Blocking rules that address access to information.


In 90 min session, Jim will discuss and:

  • Examine the updated 2018 HIPAA Audit Protocol as well as other questionnaires that have been used in the past and may be used to help prepare an organization for a future review. 
  • Present methods for using the contents of the HIPAA Audit Protocol to build your own compliance plan by extracting the contents and relating your compliance activities and documentation directly to the questions that might be asked, thereby creating a compliance management tool to ensure continued compliance improvement.
  • Review the contents of the 2018 HIPAA Audit Protocol to show what documentation needs to be on hand should your organization be selected for an audit or enforcement action. 
  • Explain the enforcement regulations and the recent changes that increase fines and create new penalty levels, including new penalties for willful neglect of compliance that begin at $10,000. 
  • Documentation requirements for compliance will be explored and a framework of security policies necessary for compliance will be presented.
  • The results of prior HHS audits (and their penalties) will be discussed, including recent actions involving multi-million dollar fines and settlements. 
  • A plan for attaining compliance will be presented.  The steps to follow to prepare for an audit and respond to an audit request will be outlined. 
  • In addition, upcoming trends in information security risks will be discussed so you can start to plan for the work you'll need to do to stay in compliance and keep patient information private and secure.


  • The HIPAA Random Audit program is being refocused and redefined to make it more relevant to finding and correcting some of the most prevalent security and privacy compliance issues, based on the experience gained in the 2012 and 2016 audits and in the HIPAA Breach Notification process.
  • Fines and penalties for violations of the HIPAA regulations have been significantly increased and now include mandatory fines for willful neglect of the rules that begin at $10,000 minimum and can reach $50,000 per day.
  • New changes upcoming in the rules will create new compliance challenges and require new procedures to avoid violations in the areas of patient access to information and the provision of an accounting of disclosures.
  • Potential changes to rules on obtaining a signature when providing a HIPAA Notice of Privacy Practices could inadvertently create new compliance challenges under the Telephone Consumer Protection Act of 1991.
  • Find out what HHS OCR is likely to ask you if you are selected for an audit or enforcement review, and what you'll have to have prepared already when they do.
  • Learn how HIPAA Audits and HIPAA enforcement activity are related, and how being prepared for an audit can help an organization respond to enforcement inquiries.
  • The HIPAA Audit Protocol will be examined along with the sets of questions asked at other HIPAA audits previously.
  • Find out what the rules are that you need to comply with and what policies you can adopt that can help you come into compliance.
  • Learn how having a good compliance process can help you stay compliant more easily.
  • Find out what you'll need to have documented to survive an audit or enforcement review and avoid fines.
  • Learn how to use the contents of the HIPAA Audit Protocol as the foundation of your compliance activities and documentation.
  • HIPAA enforcement activities and settlements, including the most recent wave of settlements, will be explained.
Who Should Attend?

Medical offices, practice groups, hospitals, academic medical centers, insurers, business associates (shredding, data storage, systems vendors, billing services, etc.).  The titles are:

  • Compliance Director
  • CEO
  • Privacy Officer
  • HIPAA Privacy Officer
  • HIPAA Security Officer
  • Information Systems Manager
  • HIPAA Officer
  • HR Director
  • Chief Information Officer
  • Health Information Manager
  • Healthcare Counsel/lawyer
  • Office Manager
  • Contracts Manager
  • Counsel


JIM SHELDON-DEAN ,B.S CE (summa cum Laude), MST

Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities. He is a frequent speaker regarding HIPAA, including speaking engagements at numerous regional an.. Read More >>



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