Let us cut to the chase: according to the rules of the Health Insurance Portability and Accountable Act, all covered entities and businesses must name a HIPAA Privacy Officer.
With so many changes occurring with HIPAA, the role of the Privacy Officer is becoming increasingly important. Today, they must have a larger skill set and be able to meet more stringent demands than ever before. Ever-changing technology and new regulations have made protecting PHI (protected health information) a challenging job, and this is a trend that will likely continue.
Suppose you have a small or mid-sized business or organization. In that case, chances are you probably aren't hiring a privacy officer, and the role is likely given to someone who already has other duties, such as the practice or office manager. Whether you hire someone exclusively for this role or just add it to someone's duties, finding the right person to ensure HIPAA compliance is a must.
Before diving into finding the right Privacy Officer, it's a good idea to learn more about their role and what their duties include.
Duties and Responsibilities of a HIPAA Privacy Officer
Your organization’s HIPAA Privacy Officer is responsible for overseeing all activities related to developing, implementing, and maintaining your organization's compliance with HIPAA based on the applicable state and federal laws.
The person appointed to this position is also in charge of the privacy program for your organization, which will inform the security processes and privacy policies for your organization. The goal of the practices is to reduce risk while ensuring PHI confidentiality.
The HIPAA Privacy Officer you hire or appoint will have multiple responsibilities, including the following:
- Adopt necessary procedures and policies to remain compliant with HIPAA Privacy Rule
- Update procedures and policies each year
- Provide the notice of privacy practices to all patients or clients
- Notify changes or modifications
- Notify individuals covered by health plans about the availability of privacy practices
- Monitor all covered items to ensure compliance with privacy procedures and policies
- Collect BAAs (Business Associate Agreements) from all business associates
- Update BAAs when needed
- Oversee and implement client and employee privacy rights
- Ensure HIPAA related information and documents are accurate and updated
- Answer any HIPAA related questions from clients or employees
- Coordinate training for employees that handle PHI
- Work closely with the security officer and legal counsel
- Institute any corrective action if HIPAA breaches or mistakes occur
- Receive and respond to all complaints of non-compliance to the HIPAA privacy rule
As you can see, the Privacy Officer you hire or appoint has a big job and multiple responsibilities. This illustrates why it is so important to find the right person for the job.
HIPAA Privacy Officer vs. HIPAA Compliance Officer
To guarantee that you comply with HIPAA, you need to ensure that someone is specifically appointed to oversee HIPAA compliance. Sometimes, the Privacy officer is referred to as a Compliance Officer. Essentially, this is the same position and the individual has the same responsibilities.
The actual role and tasks your HIPAA Privacy Officer must take on depend on how much PHI is used, created, or maintained and on the size and resources available to your organization.
Important Qualifications and Habits for a HIPAA Privacy Officer
Now that you know the role and responsibilities of a Privacy Officer, you need to know the qualifications and habits of someone who is good at this job.
1. Commitment to Being Proactive
If you have ever worked in compliance, you understand how true the statement "act or be acted upon" is. There are two basic types of compliance overall (including HIPAA Compliance)
HIPAA compliance):
- Proactive
- Reactive
Your compliance program will include both; however, the more compliance work that is handled proactively, the less that needs to be done reactively.
For example, there are many people in the role of Privacy Officer that live by the statement, "it's not if a HIPAA breach will occur, but when." Unfortunately, there is truth in this statement when trying to prevent a potential breach down the road. It is not always possible to do.
It is necessary to find someone who will take the necessary proactive steps and prepare by having a mitigation plan before the breach occurs.
2. Interpersonal Relations
Your HIPAA Privacy Officer won't just work behind the scenes. They must also handle any client complaints related to HIPAA compliance that occur.
Because of this, the person in this position must be sympathetic and compassionate when dealing with client concerns. When dealing with disagreements, kindness and understanding go a long way. Also, if your organization offers any type of healthcare coverage, you must have a HIPAA plan in place if you want to protect your team's health information.
Along with providing client help and information, the same is true for employees. Questions and concerns related to HIPAA compliance come to the Privacy Officer, which means you must have someone with the ability to build and maintain interpersonal relationships.
3. HIPAA Knowledge and Expertise
The HIPAA Privacy Officer you appoint or hire must have a thorough understanding of HIPAA law. This individual will become your company's go-to person for HIPAA-related concerns, questions, and potential violations.
The Privacy Officer must remain abreast of all news and updates related to HIPAA and attend seminars and training. They must understand HIPAA compliance requires time and planning. You must ensure the Privacy Officer has the knowledge, resources, and drive to ensure the company remains compliant.
It is not just the HIPAA law that your Privacy Officer needs to know when it comes to knowledge and expertise. They should be knowledgeable about other things, too.
What Is and Is Not PHI and ePHI
All types of PHI that are created, stored, received, or transferred electronically is ePHI. Your Privacy Officer needs to understand how to handle ePHI within the company to build an ePHI plan to help maintain the high level of security required.
The Officer also needs to use their knowledge of federal and state HIPAA regulations and their knowledge of the technologies at their organization to develop a plan that protects the ePHI of the company from any possible risk or threat.
Understanding of Data Security Best Practices
Data security refers to protecting information from all types of loss due to unauthorized access, theft, corruption, or negligence. Quality data protection strategies can guard your business assets in the form of personal health information and business data. are, you may also find yourself in the crosshairs of GDPR and CPRA along with HIPAA.
Ability to Create and Oversee Compliance Training Programs for HIPAA
Developing and overseeing training programs is another important component of the Privacy Officer's job in making sure a business is HIPAA compliant. Training programs need to focus on making sure employees fully understand all security risks related to PHI and ePHI (mentioned above) within the company's strong operations. Training needs to include new employee orientation and updated training for existing employees.
Conducting Risk Assessments
Privacy Officers need to be able to conduct an annual risk assessment that will evaluate the overall status of the business's HIPAA compliance. Audits need to be conducted regularly and may require the assistance of a third-party service to ensure all elements are compliant.
Incident Management and Contingency Plan
If a breach of PHI occurs, it is up to the Privacy Officer to act immediately. They should have plans and processes in place that can be quickly used if a breach were to occur, this is often called a Contingency Plan.
Any breaches need to be investigated to determine how or why it occurred, and then the necessary actions should be taken to fix them.
4. Organizational Skills
As the name implies, the Officer oversees all HIPAA compliance. With that comes significant attention to detail. When you implement a HIPAA compliance program, it can be an ongoing and complex process.
The details matter.
With a small or medium-sized business, the role of Privacy Officer is likely given to someone who has other responsibilities. Just be careful because this person needs to oversee the compliance program while handling other tasks. Because of this, you must have someone who is organized.
5. An IT Background
Having someone with an IT background is recommended because they will better understand their job duties. However, many of the HIPAA Privacy Officer's responsibilities will be new, no matter their background. Because of this, anyone appointed to this position will likely require some type of training.
HIPAA Privacy Officer FAQs
As a business owner, fully understanding the role of a Privacy Officer is a must to ensure the right person is found for the job. However, you may still have questions about their role and abilities. Some of the most common questions asked (and answers) can be found below.
What Is the Purpose of a HIPAA Privacy Officer?
In the past, healthcare service providers were not properly protecting patient information. Because of this, the government created the HIPAA Security and Privacy Rules. These rules require an organization to appoint one or several Privacy Officers always to ensure organizational compliance.
Companies must have formal policies in place to recognize and designate the person in the business who is given this official job. Because it is the executives who are ultimately responsible for the compliance and well-being of the company, they must also appoint the HIPAA Privacy Officers.
What qualifications are necessary to work as a HIPAA Privacy Officer?
It isn't necessary for the person working as an Officer to have specific qualifications. However, it is best to find someone who has a master's degree education and HIPAA Compliance training.
Are HIPAA Privacy Officers needed for every state your business operates in?
HIPAA doesn't require your business to have a Privacy Officer in every state. Still, if you have a privacy officer representing a multi-state organization, they need to have full knowledge of the state's security and privacy laws. In a state where security and privacy laws are more stringent than HIPAA's specific laws, the state laws will take precedence.
Can your business's legal team handle HIPAA Privacy Officer duties?
While this is possible, you need to ensure a person on that team is named the Privacy Officer. This is necessary for accountability purposes and to ensure that it is one point of contact for public inquiries.
What happens if the HIPAA Privacy Officer fails at their duties?
It doesn't matter if you have an outsourced or in-house Officer; HIPAA compliance is, in the end, the responsibility of the business's senior management team. Because of this, senior managers need to regularly communicate with the Privacy Officer to fully understand their efforts and feel confident they are maintaining full HIPAA compliance.
The Bottom Line
Whomever your organization appoints to be the Privacy Officer needs to ensure employees are fully aware of the organizational and individual HIPAA obligations. Any employee who may come into contact with PHI must know how to protect it, too.
Because of this, annual training should be a top priority for all workers, including Business Associates, contractors, permanent workers, temporary workers, and volunteers.
While it may delegate some responsibilities to others in the organization, it is imperative that a Privacy Officer is named and the one responsible for HIPAA compliance. They should also hold themselves and the company's bigger compliance program to a high standard. Compliance is something that is essential for the overall safety and protection of your business and business data.
HIPAA compliance can be complex. If someone isn't fully aware of what it entails or its laws, they are not suited for this position. The consequences of being non-compliant are steep, which is why it is so important that you find the right person or third-party entity for the role of HIPAA Privacy Officer. While this may require some time and effort on the part of senior management, it will pay off for the business in the long run.
