Basics of HIPAA compliance for therapists

HIPAA regulations are in place to safeguard patients' protected health information (PHI). By complying with HIPAA, therapists demonstrate their commitment to protecting their patient's sensitive information and avoiding penalties relating to HIPAA violations. 

HIPAA regulations 

Privacy rule

The Privacy Rule establishes standards for the protection of PHI. It outlines how PHI should be used and disclosed, as well as the requirements for obtaining patient consent and authorization. Therapists must adhere to these standards to ensure the privacy and confidentiality of patient information.

Security rule

The Security Rule sets forth standards for the security of ePHI. It requires therapists to implement administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of ePHI. These safeguards include access controls, encryption, contingency planning, and ongoing risk assessments.

Breach notification rule

The Breach Notification Rule requires therapists to notify affected individuals, the Secretary of Health and Human Services, and in some cases, the media, in the event of a breach of unsecured PHI. Therapists must conduct a risk assessment to determine if a violation has occurred and take appropriate actions to mitigate harm to individuals affected by the breach.

Enforcement rule

The Enforcement Rule outlines the procedures and penalties for HIPAA non-compliance. It establishes the authority of the Office for Civil Rights (OCR) to investigate complaints, conduct audits, and impose civil monetary penalties for violations. Therapists should ensure they understand the potential consequences of non-compliance with HIPAA regulations.

Patient information considered PHI

PHI refers to individually identifiable health information held or transmitted by covered entities or business associates. PHI includes various types of patient information, such as:

• Personal identification
• Medical history
• Billing and payment data
• Mental health information
• Correspondence and communications

Go deeper: 

• Psychotherapy notes and HIPAA
• What are the 18 PHI identifiers?

Permissible uses and disclosures of PHI

Therapists have permission to use and disclose PHI without patient authorization for treatment purposes, including coordinating care with other healthcare providers. 

It can also be used and disclosed for billing, payment, and healthcare operations, such as quality improvement and research (with appropriate safeguards).

Therapists can legally disclose PHI for reporting abuse or responding to court orders. In certain situations, they may share it with public health authorities for disease surveillance and law enforcement officials. When disclosing PHI to business associates, therapists must have written agreements in place to safeguard patient privacy.

In all instances of using and disclosing data, therapists should follow the minimum necessary standard, which means accessing and disclosing only the minimum amount of PHI necessary for the intended purpose. This helps protect patient privacy while allowing for necessary information sharing.

Methods of ensuring HIPAA compliance

1. Designate a privacy officer: Appoint someone in your practice as the Privacy Officer responsible for overseeing HIPAA compliance. 
2. Perform a risk assessment: Assess physical security, electronic systems, data storage, and employee practices. Identify vulnerabilities and develop a plan to mitigate those risks.
3. Secure physical environment: Implement physical safeguards to protect PHI in your practice. Control access to areas where PHI is stored or accessed, use locked file cabinets or rooms, and securely dispose of paper documents containing PHI.
4. Implement technical safeguards: Secure your electronic systems and data. Use up-to-date antivirus software, firewalls, and encryption to protect ePHI. 
5. Establish business associate agreements: If you work with vendors or service providers who have access to PHI, enter into written agreements with them to ensure they meet HIPAA requirements. 
6. Provide notice of privacy practices: Develop and distribute a Notice of Privacy Practices to patients. Clearly explain their rights, how their PHI is used and disclosed, and how they can exercise their privacy rights. Make the notice easily accessible in your practice and on your website.
7. Respond to incidents and breaches: Develop an incident response plan that outlines the steps to take in the event of a security incident or breach. Establish procedures for assessing and mitigating the impact of an incident and for notifying individuals and appropriate authorities as required.
8. Make use of HIPAA compliant software: Using HIPAA compliant software makes activities such as communicating and storing data easier. These could include HIPAA compliant email services such as Paubox. 

Potential penalties for HIPAA violations by therapists

Therapists who violate HIPAA regulations can face significant penalties, including civil monetary penalties and criminal penalties. These range from civil to criminal penalties. The civil penalties come with fines ranging between $100 to $50,000 per violation, with an annual maximum of $1.5 million. 

On the other hand, criminal penalties can result in fines and imprisonment, with penalties ranging from $50,000 and one year of imprisonment for wrongful disclosure of PHI up to $250,000 and 10 years of imprisonment for obtaining or disclosing PHI with malicious intent. Therapists may also face state licensing actions, leading to disciplinary measures such as suspension or revocation of their professional license.

Related: Understanding HIPAA violations and breaches