Key Factors to Write HIPAA Compliance Policies

Duration: 90 Minutes
Instructor: Alice McCart
Webinar Id: 800463


One Attendee


The webinar will explain the process for covered entities and business associates to use to draft, adopt, and implement HIPAA compliance policies. The webinar will begin with a discussion of how to decide, using a gap analysis and a risk analysis, what policies the organization needs, including required, addressable, and other policies. Then, the webinar will cover writing a policy. Writing a policy is easier than one may think. It is a three-step process: researching, drafting, and revising. This webinar will teach you to ask questions, solicit help, collect samples, keep the principles of substance, organization, coherence, style, and correctness in mind while you are drafting, send your draft out for review, incorporate comments, implement the policy, and repeat as necessary. The prospect of developing and writing perhaps as many as 70 policies to attain HIPAA compliance may still seem daunting, but this webinar will teach you how to make a checklist, take it step by step, and enlist the help of others when you need it.

Why should you attend: The majority of the DHHS civil money penalties and settlements in lieu thereof involve, sometimes with other violations, failure to perform a written risk analysis, failure to develop required policies, and failure to conduct adequate HIPAA training. These penalties usually are in the seven-figure range.

Failure to conduct a written risk analysis, adopt required policies, or conduct required training qualifies as "willful neglect," which carries the highest civil money penalty ("CMP") and which penalty cannot be waived by DHHS as can violations due to a reasonable cause. DHHS entered into a settlement with Massachusetts General Hospital for $1 million for a breach involving leaving paper PHI records on a subway. The sanction was because Massachusetts General had not trained its workforce on proper security for PHI taken offsite and did not have a work-at-home policy. Significantly, HIPAA does not even mention working at home; much less specifically require such a policy.

Areas Covered in the Session:

  • Preliminaries
    • Learn how to decide which policies to write and adopt, using gap analysis and risk analysis
    • Learn which policies are required and which are addressable
    • Learn about other policies that your organization may need that are not mentioned in the HIPAA regulations but that organizations have nonetheless been fined for not having
  • Researching
    • Ask questions. Learn why you need to nail down the answers to at least 12 questions before you try to write a policy and how to do so
    • Solicit help. Learn whom to solicit help from both within and outside your organization and when and why and how
    • Collect samples. Learn what samples to collect and from whom
  • Drafting
    • Substance. Learn what substance means and how to achieve it
    • Organization. Learn how to draft a clear beginning, a clear middle, and a clear end
    • Coherence. Learn how to connect your ideas so that readers will not have to wonder where something came from or why
    • Style. Learn how to write for your target audience as simply and clearly as possible
    • Correctness. Learn how to get rid of the static in your writing
  • Revising
    • Review. Learn whom to contact to review your drafts
    • Incorporate. Learn how to resolve disputes and incorporate changes
    • Implement. Learn how to lay out a plan for implementation of the policy, including publishing, distribution, implementing (and perhaps even training the workforce on the policy), and schedule for annual review and revision, if necessary
    • Questions and answers

Who Will Benefit:
  • HIPAA Compliance officers
  • HIPAA Security Officers
  • HIPAA Privacy Officers
  • CFOs, CEOs, COOs and CIOs
  • Human Resources Directors
  • Business Office Managers
  • Speech and Language Pathologists and Audiologists
  • Medical Records Personnel
  • Health Information Management Professionals
  • Health Care Attorneys
  • Patient Accounts Managers

Speaker Profile
Alice M. McCart has been an editor for more than three decades and an attorney admitted to practice law in Illinois since 1993. She has master’s degrees in teaching and journalism and enjoys freelance editing, tutoring, and teaching effective writing to adults. She has held positions in the federal government, in professional associations, in the corporate world, in private law practice, and in HIPAA consulting.

She now lives and works in Overland Park, Kansas, with the law firm of Tomes & Dvorak, Chartered, the HIPAA consulting firm EMR Legal, Inc., and the publishing company Veterans Press, Inc. Also owned by Jonathan P. Tomes and Richard D. Dvorak, EMR Legal is a national HIPAA consulting firm that provides consulting services for clients ranging from a large county government, with different health entities that need HIPAA compliance help, to a small transcription service.

The EMR Legal team has provided consultation to more than 1,000 clients regarding health care regulations since 1998. Veterans Press publishes HIPAA compliance books, CDs, and other tools by Jonathan P. Tomes and others, including The Compliance Guide to HIPAA and the DHHS Regulations and its accompanying HIPAA Documents Resource Center CD, both in their 5th edition (6th edition forthcoming 2014), an integral part of the HIPAA Compliance Library, and his latest two books, The Complete HIPAA Policies and Procedures Guide, with accompanying HIPAA Compliance Sample Policies and Procedures CD, and Your Happy HIPAA Book, among many other books and HIPAA compliance tools, all of which Alice McCart has edited.

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