3 Threat & HIPAA Security Risk Assessment Approaches To Ensure Compliance

Business associates & covered entities should familiarize themselves with several important terms such as threats, vulnerabilities, or risks. So, they can better understand the HIPAA security risk assessment processes.

Therefore, a risk assessment is necessary to identify the vulnerabilities and potential threats to protected health information (PHI) and the correlated risks. It includes a thorough evaluation of the possible threats to the availability, confidentiality, and integrity of any PHI that a practice manages whether electronically or physically. 

The evaluation must address both non-technical or technical vulnerabilities covering all locations where PHI is collected, created, processed, or stored. 

hipaa security risk assessment

Gap Assessments vs. Risk Assessments

Gap assessments are designed in a way that identifies the controls which may be missing from a security posture of an organization. Various practices complete HIPAA gap assessments of how their current control fits according to the regulatory demands. 

The OCR (Office for Civil Rights) specifies that gap assessments do not meet the standards for formal risk analysis because they do not include HIPAA security risk assessments

Determine Possibility of Threat Occurrence 
According to the security rule practices must take accountability for the potential risk probability to PHI. Combined with the initial list of threats, the outcomes of this evaluation will affect the determination. The output of this part should be documentation of all vulnerabilities and threats that may impact the data of medical practice. 

Three Categories of Threats
Treat is defined as, ‘’the potential for a thing or person to exercise (intentionally exploit or accidentally trigger) a particular vulnerability’’. There are various types of threats that happen within an operating environment or information system. General categories of threats consist of;   

● Human Threats
These are caused by humans & may involve unintentional (inaccurate or deletion of data entry & inadvertent data entry) and intentional ( unauthorized access to e-PHI, malicious software upload, and network and computer-based attacks) actions. 

● Natural Threats
Such as tornadoes, floods, landslides, and earthquakes. 

● Environmental Threats
Such as liquid leakage, chemicals, pollution, and power failures.

Potential Impact of Threat Occurrence

A practice must assess the potential impact emerging from exploiting a specific vulnerability or a triggering threat. It should use a quantitative and qualitative method or a sequence of the two arrangements to estimate the influence on the practice.

Who Can Complete a HIPAA Security Risk Assessment?

The HIPAA risk assessment requirement applies to both business associates and covered entities. Medical practices that don’t complete risk assessment mostly don’t comply with HIPAA. 

The most commonly investigated HIPAA compliance issue by the OCR is the lack of an appropriate vulnerability assessment. Risk assessment is a must for covered entities seeking Medicaid or Medicare incentives under the MIPS Programs/ Promoting Interoperability/Meaningful Use, etc. 

Risk Assessments of HIPAA Breach

After a healthcare data breach, the OCR also requires practices to complete a risk assessment. This provides a steady process for determining whether the breach was resolved? & there are ways to prevent future incidents? Healthcare organizations must document the following points prior to a breach assessment:
  • To what extent the risk was mitigated? 
  • What was the extent and nature of the PHI that was included? 
  • Did the PHI was viewed or acquired? 
  • Who was the unauthorized person that utilizes, access, or receives the PHI? 

Significance Of Risk-Based Approaches to Ensure Compliance

● Recognize:
You can identify areas where you are falling behind by taking a risk-based approach. It helps you determine those critical gaps effectively. 

● Evaluate:
Utilize pre-built HIPAA-specific templates to perform risk assessments that can directly align with the HIPAA’ three sections. 

● Alleviate:
You can make sure that your efforts are aligned with HIPAA’s requirements. This keeps your facility protected from penalties and enables you to mitigate the risk of falling out of compliance proactively.

● Monitor:
Maintaining compliance irrespective of achieving is quite difficult. But it is integral to monitor your efforts consistently. 

● Correlate:
Compliance is not confined to one procedure of your medical practice. From medical billing to coding to claim submission to revenue cycle management. All procedures of your RCM must comply with HIPAA.

● Insights:
You must have automatically built an audit trail of your work. Moreover, this will enable you to streamline workflow and get comprehensive reporting to overview analytics.

Leverage Results of a HIPAA Security Risk Assessment

Practice must implement and address the risks after an effective risk analysis. In some cases, a practice may require designing and implementing new control groups. While in other cases, remediation can be simple as a small update to existing plans.

In addition to this, vulnerabilities that pose a lower threat can be resolved later while those that are likely to exploit should be addressed first. Medical facilities should regularly evaluate their long-term risk management strategy beyond initial remediation. It not only relates to HIPAA compliance but also industry, federal, state-specific regulations must be satisfied. 

Regarding organization-wide information security programs their strategy must involve key decisions like;
  • Ongoing testing/monitoring strategies. 
  • The desired response to risk (e.g avoidance, acceptance, sharing, mitigation, or transfer).
  • Conformance to enterprise security architectures. 
  • Selection protocol for third-party billing partners and advanced technologies. 

Third-party HIPAA Security Risk Assessment 

When you hire third-party service providers, their specialized HIPAA-complaint management teams provide you several key benefits, such as;
  • Enable you to better protect your people, assets, and information. 
  • Access to niche-specific knowledgeable industry experts. 
  • Security incident reporting guidelines and incident monitors. 
  • The application of industry best practices to reduce risk. 
  • Visibility into associated risks and unknown vulnerabilities.
  • Evaluation of existing procedures and security policies. 
  • Absolute module-based security risk analyses. 
  • With each module covered, risk assessments are made taking into account:
  • Reduce the probability and severity of the possible breaches.
  • Taking the expected steps to meet regulatory and organizational security requirements.


HIPAA security risk assessments strengthen a medical practice. It helps a practice create new security requirements, identify security vulnerabilities, conduct due diligence, spend cybersecurity budgets more intelligently, and improve communication. Outsourcing to a HIPAA-compliant medical billing company enables you to have a security risk assessment. It helps you automate the entire workflows and help you employ the right personnel in the compliance procedure. 

HIPAA-compliant specialists help you in decision-making and ensure remediation actions that take place following a security event. They can improve the security posture of your healthcare business, which is crucial in an increasingly insecure era.

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