HIPAA Rules for Protected Health Information

A common question regarding HIPAA is whether a covered entity can be fined for violations of the HIPAA rules even if there is no breach of Protected Health Information. Worryingly, the answer is yes. So a clear understanding of the HIPAA rules is necessary to protect your company.


While HIPAA (the Health Insurance Privacy and Accountability Act) has many rules, when people speak of the “HIPAA Rules” they are usually referring to three primary sets of regulations. These “rules” lay out how covered entities are to handle PHI (Protected Health Information). The three main HIPAA Rules are:

  • The Privacy Rule
  • The Security Rule
  • The Breach Notification Rule


The Privacy Rule

The Privacy Rule applies to PHI in any form, including oral, written, and electronic. Under the Privacy Rule, covered entities are responsible for making certain their employees (and business associates) use and/or disclose PHI only for authorized purposes. This means employers must keep their workforce trained to recognize what data is considered PHI and how to handle it appropriately.


Under this rule, covered entities are also responsible for making certain that only as much PHI as is necessary for a given purpose is disclosed. That is, the rule means it is not appropriate to just share entire medical records; only the portion of a record that is necessary for a given task is appropriate to share.


Other areas covered by the Privacy Rule include requirements for Business Associate Agreements (BAAs) with covered entities’ customers, vendors, and partners; standards to de-identification of Protected Health Information (that is, what kinds of information need to be removed from PHI in order to make it appropriate to share); specifications of patients’ rights to their own PHI; and requirements for covered entities to designate a privacy officer, publishing of privacy practices, and more.


The Security Rule

Unlike the Privacy Rule, the Security Rule applies only to electronic PHI. It delineates requirements for administrative, physical, and technical safeguards of electronic PHI and requires publication of documentation that describes the policies and procedures covered entities employ regarding those safeguards.


The Security Rule also specifies how long a covered entity must retain documentation of their Security Rule compliance.


The Breach Notification Rule

The Breach Notification Rule defines a reportable HIPAA breach, states what covered entities must do in case of such a breach, who they must notify, and how soon they must notify them.


This rule also states under what circumstances unauthorized access to encrypted PHI may not be considered a reportable breach.


Ready to Learn More about HIPAA Compliance?


If you’d like to learn more about how HIPAA compliance, Aperio IT will be holding a free Lunch and Learn Event on Wednesday, June 8. Brian Olsen, HIPAA Security Advisor, will be joining us to help answer your concerns about HIPAA regulations. You can find out details and register here to attend.


You can also take a look at our recent HIPAA-related posts: