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Four Key Elements of HIPAA Compliance Success

May 2025

Every healthcare organization knows that HIPAA compliance is a major priority, but many could manage it far more efficiently. There are strategic steps most companies can take to simplify, streamline, and enhance their program – and achieve full HIPAA compliance with far greater ease.

In this article, you’ll gain clarity on the core requirements of HIPAA and learn practical steps for achieving compliance success, including:

The three core Rules of HIPAA
The best ways to reduce employee compliance errors
The value of always-on compliance remediation

HIPAA 101: An Overview of Regulations

What is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law designed to ensure patients’ health information is private and secure. The law was first introduced in 1996 in an attempt to transform healthcare and ensure patients could maintain health insurance when changing employers.

It has since evolved into a foundational part of healthcare compliance, covering a wide range of factors that impact how healthcare data is created, stored, and transmitted throughout the ever-growing healthcare ecosystem. These requirements apply to all covered entities and any business associate (BA) that uses protected health information (PHI) – and the average organization spends around $120,000 annually on measures to achieve and demonstrate compliance.¹

Why is HIPAA Important?

HIPAA is a foundational part of all healthcare compliance programs for a few clear reasons:

Patient Safety: PHI is often highly sensitive and can be used for a range of nefarious activities – from identity fraud to predatory marketing. A data breach, therefore, puts patients at risk, making HIPAA a basic ethical priority for any covered entity.

Regulatory Compliance: Non-compliance with HIPAA requirements – whether due to an actual data breach or simply a failure to complete regular HIPAA risk assessments – can lead to serious penalties. A single violation can result in fines, along with the threat of jail time for individuals who are deemed to have committed egregious offenses in relation to PHI.
Organizational Integrity: HIPAA non-compliance can have a significant impact on an organization’s reputation. The HHS’s “HIPAA Wall of Shame” helps the public view which organizations have violated patient data privacy and security rights.² Appearing on such lists has the potential to harm patient acquisition and retention, as well making potential new hires wary of your organization.

However, with multiple separate “Rules” and ongoing updates and revisions to the Rules, many organizations find HIPAA overwhelming. One survey found that 60% of organizations were not confident they would pass a HIPAA audit from the Office of Civil Rights (OCR) ³ – and many are not even certain what is required for full HIPAA compliance.

What Are the Key HIPAA Requirements?

The primary requirements of HIPAA can be broken down into the three core “HIPAA Rules”:

1. The Privacy Rule

The HIPAA Privacy Rule sets national standards for the protection of individuals’ medical records and other PHI. It is designed to protect data privacy and security while still enabling the flow of information between relevant systems – protecting patients without compromising care.

A few key requirements of the Privacy Rule include:

Limiting the use and disclosure of PHI to the minimum necessary
Providing patients with notice of privacy practices
Giving patients the right to access and amend their medical records
Requiring written authorization for non-routine disclosures

2. The Security Rule

The HIPAA Security Rule establishes national standards for the protection of electronic PHI (ePHI). It consists of three sets of safeguards required to ensure the confidentiality, integrity, and availability of ePHI:

Administrative Safeguards: Including regular risk assessments, workforce training, and official access control policies to ensure only authorized individuals can access ePHI
Physical Safeguards: Including facility access controls and management of workstations to limit unauthorized individuals’ physical access to systems containing ePHI
Technical Safeguards: Including encryption requirements, secure user authentication, audit controls

3. The Breach Notification Rule

The HIPAA Breach Notification Rule establishes clear responsibilities for covered entities and business associates when a data breach takes place. This covers three different groups:

Affected individuals must be notified without unreasonable delay and in no case later than 60 days after the breach is discovered. They must be given clear information about how the breach took place and what the individual can do to protect themselves – along with an explanation of the steps being taken to mitigate the impact of the breach.
The HHS secretary must also be notified if a breach affects unsecured PHI – meaning data that has not been rendered unusable or indecipherable without authorization. Organizations must also notify the HHS when a breach affects 500 or more people.
The state media must be notified if a breach affects more than 500 patients. The same timeline also applies as to affected individuals.

The Four Keys to HIPAA Compliance Success

HIPAA compliance is clearly highly complex, requiring an extensive array of measures to safeguard patient data. Many smaller covered entities do not even have a compliance team, leaving untrained individuals – often the practice owner – responsible for managing HIPAA compliance. This can be overwhelming, and even larger organizations that do have designated HIPAA roles in place struggle to navigate their requirements.

But this does not need to require an endless number of tasks. Our experience suggests there is a clear “80/20” for HIPAA success – where a small handful of factors have outsized importance for HIPAA compliance. These factors can be covered by the following four steps:

1. Regular Risk Assessments

Many organizations end up with compliance issues due to what can be called “HIPAA blind spots” – gaps or vulnerabilities in their compliance program of which they were unaware. This makes simply increasing the frequency of internal risk assessments or audits a potentially transformative step toward compliance.

While an annual HIPAA risk assessment is mandatory, most organizations would benefit from more frequent evaluations. Running an assessment every three months would deliver substantial improvements for most organizations – but this will require initial efforts to reduce the burden on your internal teams.

Our recommendation is to develop reliable and repeatable systems to evaluate internal processes – from employee HIPAA knowledge to the effectiveness of your Security Rule safeguards. This will mean you are not starting from scratch each time you run an assessment, eliminating internal resistance that may otherwise limit the frequency of assessments. Instead of scrambling to identify what must be done to maintain compliance, your organization will be able to quickly assess and remediate gaps.

2. Increase Workforce Training

The workforce forms a vital part of any HIPAA compliance program – from reporting compliance concerns to ensuring they follow the requirements properly. Employee error is responsible for many data breaches and can be heavily reduced by increasing the frequency and depth of HIPAA training.

This must go beyond mandatory training during the onboarding phase to deliver regular refresher sessions. We recommend requiring staff to undergo training ~~twice~~ bi-annually, along with extra sessions whenever regulations are updated or changed.

Our experience suggests a key factor here is offering flexible training options, ensuring you cater to both in-person and remote employees. This should be supported with:

Real-world scenarios to evaluate HIPAA knowledge and ensure training translates into action
Custom material to match individual employees with the information most relevant to their roles
Assessments to understand the efficacy of training and identify key areas for further education

3. Revise Policies and Procedures

Official policies are vital to reduce confusion around HIPAA requirements and demonstrate compliance. This should include your Codes of Conduct, breach notification policies, and incident response plans. But many organizations rely on policies that were developed many years ago – and may no longer even cover all HIPAA requirements in the wake of more recent updates.

Simply revising your policies can avoid such issues and improve compliance. This does not have to be an effortful process: external partners like Compliance Resource Center offer comprehensive policy templates that can be easily adapted to your specific organizations. Rather than parsing complicated updates – or proposed updates – you can quickly create robust documentation that maps directly onto core requirements.

4. Make Remediation “Always-On”

Many organizations treat HIPAA remediation as a short-term fix, often saved for the post-assessment period. But this leads to a reactive posture that only responds to issues when they have been raised – rather than proactively identifying and resolving them.

Pair regular risk assessments with ongoing remediation to reduce risk and demonstrate your organization’s dedication to best-in-class security. The goal is to build a culture that sees remediation as a standard part of ongoing compliance efforts – and, therefore, stays ahead of emerging vulnerabilities.

Make HIPAA Success Easier with Compliance Resource Center

Every healthcare organization should prioritize HIPAA compliance – but we understand that can feel overwhelming.

That’s why Compliance Resource Center offers vital services to simplify, streamline, and enhance your compliance program. We offer comprehensive policy templates mapped to the latest HIPAA updates, along with training services that ensure your workforce truly understands and meets all HIPAA requirements.

Want to reduce your HIPAA burden – and feel confident at your next audit?

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