Overview

We provide comprehensive consulting support to help you meet and maintain HIPAA compliance.
The US HIPAA is designed to safeguard electronic protected health information (ePHI). Achieving HIPAA compliance can reduce the risk of breaches, enhance customer trust, and bolster overall security. Whether you are a covered entity or a business associate, our team of experienced consultants will guide you through the entire process, offering expert advice at each stage.
Our HIPAA consulting services will greatly enhance your privacy and security measures.
Please call or contact us to get started.

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HIPAA Consulting Engagement Phases

Here is a brief overview of all the phases involved in implementing HIPAA compliance.

Phase I - Scoping that includes understanding the Business, and ePHI Data Processing

Scoping involves the identification of:

Business entities,
Identification of epHI and its flow including lifecycle
Information systems in scope,
Business locations
Data Center and Cloud Services Providers
Users of ePHI

Phase II -
Gap Analysis and Risk Assessment

Based on the outcome of phase I, a combination of approaches is applied by Coral HIPAA security compliance consultants to conduct the gap analysis.

Coral consultants will take a deep dive to assess information flow, current assets and infrastructure and their protection methods.
A session with each organization team in scope to asses their current scope of work and their controls
This helps in the determination of applicable, and the not applicable controls.
This helps in determining the state of applicable controls in red, orange and green - determining their current status.
Coral HIPAA consultants will advise mitigation methods to address the identified gaps.

Phase III - Control - Design, Documentation, Implementation, Measurement, and Risk Management

The implementation journey are based on the number of gaps
Implementation involves discussing each gap with the team and advising changes in the short and long-term
Coral HIPAA Consultants will help in documenting policies and procedures - that will ensure requirements are addressed and implemented.
Each policy documentation or risk undergoes brainstorming with staff to derive at a ‘best-fit’ solution for the organization.

Phase IV -
Training & Brainstorming Sessions

Training of staff involved in HIPAA operations is a key factor in successful HIPAA implementation.
Depending upon the audience, Coral consultants will deliver a combination of training that includes awareness, risk management and standard interpretation.

Phase V -
Measurement of Controls including Internal Audit

Upon the completion of the implementation phase, Coral performs monthly tests of controls to ensure that designed controls are operating effectively.

These tests are conducted across all applicable HIPAA controls that are implemented
A formal report is published for the management team for the overall program effectiveness, especially the newly developed and implemented security controls and practices.

Summary

At this stage:

As a result of undergoing the previous phases, Coral has successfully implemented a HIPAA governance program that includes people, processes, technology and ongoing measurements.
Each of the HIPAA requirements has been completed by a combination of one or more of policy, procedures, responsibilities, reports, records, technology, and automation.
At this stage, the client defined an annual plan of tasks using which they demonstrate their ongoing commitment
At this stage, with all areas of HIPAA compliance being completed, the client can declare itself to be HIPAA compliant.

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Security Coverage

HIPAA Rule covers the following key areas

Administrative Safeguards

Security Management Process
Assigned Security Responsibility
Workforce Security
Information Access Management
Security Awareness and Training
Security Incident Procedures
Contingency Plan
Evaluation
Business Associate Contracts and Other Arrangements

Physical Safeguards

Facility Access Controls
Workstation Use
Workstation Security
Device and Media Controls

Organizational Requirements

Business Associate Contracts or Other Arrangements
Requirements for Group Health Plans

Technical Safeguards

Access Control
Audit Controls
Integrity
Person or Entity Authentication
Transmission Security

HIPAA FAQs

Why Do You Need a HIPAA Consultant?
Healthcare organizations and their business associates are bound by strict regulations to ensure the security and confidentiality of Protected Health Information (PHI). One of the most significant regulations in this domain is the Health Insurance Portability and Accountability Act (HIPAA). Ensuring compliance with HIPAA is not just about avoiding penalties; it’s also about fostering trust with patients and safeguarding sensitive data.

Navigating the complexities of HIPAA compliance can be challenging. This is where a HIPAA consultant becomes invaluable. Below, we explore why you need a HIPAA consultant and how they can ensure your organization remains compliant.
1. Expert Knowledge of HIPAA Regulations
  
  HIPAA regulations are extensive and complex, covering everything from patient rights and privacy to data security and breach notifications. A HIPAA consultant is a trained expert who thoroughly understands these rules, including the latest amendments and interpretations.
  Their expertise helps:
  - Decipher legal jargon and translate it into actionable policies.
  - Identify how specific regulations apply to your organization.
  - Provide tailored solutions to meet compliance requirements.
2. Comprehensive Risk Assessment
  A HIPAA consultant conducts a thorough risk assessment, which is a critical requirement under the HIPAA Security Rule. This involves:
  - Identifying vulnerabilities in your systems and processes.
  - Analyzing the likelihood and impact of potential data breaches.
  - Providing a detailed report with actionable recommendations to mitigate risks.
  By addressing gaps in your security infrastructure, a consultant ensures your organization is prepared to protect PHI effectively.
3. Development and Implementation of Policies
  Every healthcare organization must establish and implement policies that align with HIPAA requirements. A HIPAA consultant assists in:
  - Crafting customized policies and procedures tailored to your operations.
  - Developing contingency plans for emergencies like data breaches or system failures.
  - Ensuring staff are aware of and trained on these policies.
  This proactive approach minimizes the risk of non-compliance and enhances organizational efficiency.
4. Employee Training and Awareness
  HIPAA compliance is a team effort, and all employees must understand their roles in protecting patient information. A consultant offers:
  - Tailored training sessions for different departments.
  - Guidance on best practices, including password management and safe data sharing.
  - Periodic updates to keep employees informed of new developments in HIPAA regulations.
  Training reduces the likelihood of accidental violations and improves overall security awareness.
5. Audit Preparedness
  HIPAA audits can be stressful, especially if your organization is unprepared. Non-compliance can result in hefty fines, reputational damage, and even legal actions. A HIPAA consultant can help:
  - Conduct mock audits to evaluate your compliance readiness.
  - Address potential issues before an official audit occurs.
  - Ensure all documentation and processes are audit-ready.
  With a consultant, you can face audits confidently, knowing your systems meet regulatory standards.
6. Incident Response and Breach Management
  Despite the best preventive measures, breaches can still occur. In such cases, a HIPAA consultant can provide invaluable support by:
  - Helping you follow proper breach notification protocols.
  - Coordinating with authorities and affected individuals to minimize damage.
  - Offering strategies to prevent future incidents.
  Their expertise ensures that breaches are managed in compliance with HIPAA’s strict timelines and reporting requirements.
7. Cost and Time Efficiency
  While hiring a HIPAA consultant involves upfront costs, it ultimately saves time and money by preventing:
  - Fines for non-compliance (which can range from $100 to $50,000 per violation).
  - Lawsuits and reputational damage from data breaches.
  - Wasted resources on ineffective or redundant security measures.
  A consultant streamlines the compliance process, allowing you to focus on your core operations while they handle the complexities.
8. Staying Ahead of Regulatory Changes
  
  Healthcare regulations evolve continuously, and staying updated can be overwhelming. HIPAA consultants monitor these changes and ensure your organization adapts accordingly. Whether it’s new cybersecurity threats or amendments to the HIPAA rule, they keep you ahead of the curve.
A HIPAA consultant brings the expertise, tools, and strategies necessary to navigate the complexities of compliance. From risk assessments to training, audits, and breach management, their support ensures you remain compliant, efficient, and prepared for any challenge.

Investing in a HIPAA consultant isn’t just a regulatory necessity; it’s a strategic move to secure your organization’s future.
What is the HIPAA Privacy Rule?

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 in the United States established a set of rules known as the Privacy Rule, commonly referred to as the HIPAA Privacy Rule. The Privacy Rule's main goal is to safeguard the privacy of individuals' personal health information while maintaining the necessary information flow for healthcare and related reasons.
What is the HIPAA Security Rule?

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 in the United States introduced the HIPAA Security Rule, which is a supplement to the HIPAA Privacy Rule. The Security Rule addresses the safeguards and measures that covered entities and their business associates must put in place to ensure the confidentiality, integrity, and availability of electronic protected health information (ePHI), while the Privacy Rule focuses on safeguarding the privacy of people's health information. Maintaining the trust of patients and clients while guaranteeing the security of electronic health information requires compliance with the HIPAA Security Rule. Similar to the HIPAA Privacy Rule's penalties and fines, non-compliance can result in severe punishment.
Who needs to be HIPAA compliant?
There are two categories of entities here:
- Covered Entities and Business Associates.
- Covered entities are health plans, health care clearinghouses, and health care providers who electronically transmit any health information in connection with transactions for which HHS has adopted standards.
- Business Associates perform certain functions that involve the use or disclosure of protected health information either through services provided to or action taken on behalf of a covered entity.
A HIPAA Business Associate may include:
- A third-party claims processor
- An accounting firm who must access patient data in order to provide services to a healthcare provider
- The attorney for a healthcare provider
- Consultants
- Healthcare clearinghouses that translate claims from non-standard formats to standard formats
- Freelance medical transcriptionists
- Pharmacy benefits managers
What is Protected Health Information under HIPAA?

According to the Health Insurance Portability and Accountability Act (HIPAA), individually identifiable health information created, obtained, maintained, or transmitted by covered companies and their business partners is referred to as Protected Health Information (PHI). PHI is defined as any information—oral, written, or verbal—that relates to a person's past, present, or future physical or mental health condition, to the provision of healthcare to that person, or to the payment for healthcare services that person receives. PHI is delicate and needs to be safeguarded to protect people's privacy and confidentiality.
What is the penalty for HIPAA breach?

The penalties for non-compliance with HIPAA regulations ranges from $100 to $50,000 per violation, depending on the severity of the violation.
What is a HIPAA risk assessment?
A HIPAA risk assessment, also referred to as a HIPAA security risk assessment or a HIPAA risk analysis, is a procedure used by covered entities and their business partners to find potential holes and threats to the privacy, security, and accessibility of protected health information (PHI). A crucial step in adhering to the Health Insurance Portability and Accountability Act (HIPAA) Security Rule is the risk assessment.

The main objectives of a HIPAA risk assessment are as follows:
- Identify Risks
- Evaluate Existing Security Measures
- Determine Risk Levels
- Develop Mitigation Strategies
- Maintain Compliance
Is there a HIPAA certification?

The Office for Civil Rights (OCR), which upholds HIPAA standards, and the U.S. Department of Health and Human Services (HHS) do not offer or support any formal HIPAA compliance certification programs. The implementation of HIPAA compliance is a continuous self-assessment process that is the responsibility of covered businesses and their business associates.

The HIPAA Privacy Rule, Security Rule, and Breach Notification Rule, which specify the rules for protecting Protected Health Information (PHI) and guaranteeing the privacy and security of individual health information, must all be followed in order to be in compliance with HIPAA.

There is no formal certification, however some businesses and private individuals could assert to have programs that offer "HIPAA certification" or "HIPAA compliance certification." However, since there is no formal government-issued HIPAA compliance certification, it is imperative to exercise caution when dealing with such claims.
How long does it take to be HIPAA compliant?

The general rule is 2-6 months depending upon the number of gaps identified and the management budget to close those gaps.

Frequently asked questions by a representative of an organization which wishes to implement HIPAA (Tom), where responses are given by a HIPAA consultant (Carol) and a HIPAA auditor (Rick)

Tom: We wish to start implementing HIPAA and we have several questions, thanks for taking out your time today.

Carol: You are welcome, Tom. I will share my experiences as an implementer.

Rick: And I will answer my experiences of a HIPAA auditor.

Tom: What is HIPAA, and why do we care?
Carol (Consultant):
HIPAA stands for the Health Insurance Portability and Accountability Act. It’s a federal law designed to protect sensitive patient health information (PHI) from being disclosed without the patient’s consent. Organizations care about HIPAA because compliance ensures patient trust, prevents hefty fines for non-compliance, and protects against data breaches.
Rick (Auditor):
From my perspective, we care because HIPAA audits assess how well an organization complies with these regulations. Non-compliance can lead to fines ranging from $100 to $50,000 per violation and even criminal charges, depending on the severity.
Tom: What are HIPAA security requirements?
Carol:
HIPAA Security Rule focuses on safeguarding electronic PHI (ePHI). It has three key safeguard categories:

Administrative Safeguards (policies, procedures, workforce training).

Physical Safeguards (facility access controls, workstation security).

Technical Safeguards (encryption, access controls, audit logs).

Organisational Requirements (Business Associate contracts, requirements for health plans).

Rick:
As an auditor, I evaluate how well these safeguards are implemented. For example, encryption isn't explicitly mandated but is highly recommended as part of risk management. If encryption is not implemented, the organization must justify why and offer an equivalent level of protection.
Tom: What does it mean to be HIPAA compliant?
Carol:
Being HIPAA compliant means implementing and maintaining all required safeguards to ensure the privacy and security of PHI. It involves completing regular risk assessments, training employees, monitoring systems, and maintaining proper documentation.
Rick:
I’d add that compliance is not a one-time task. Organizations must show ongoing compliance by consistently updating policies, addressing vulnerabilities, and responding to new risks or regulatory changes.

Tom: What is the relationship between healthcare and HIPAA?
Carol:
Healthcare organizations, like hospitals, clinics, and insurers, are the primary entities that HIPAA governs because they handle sensitive PHI. HIPAA ensures that healthcare organizations handle patient information responsibly and securely.
Rick:
As an auditor, I look at how healthcare providers balance patient care and data protection. HIPAA directly influences how healthcare entities operate—from patient records to billing systems.

Tom: What is ePHI, and its relationship with HIPAA?
Carol:
ePHI stands for electronic protected health information. It’s any PHI stored or transmitted electronically, such as medical records, lab results, or billing data. The HIPAA Security Rule focuses specifically on protecting ePHI.
Rick:
For audits, we assess how ePHI is safeguarded during storage, transmission, and disposal. For example, we check for encrypted communications and proper disposal methods, such as data wiping.
Tom: To which businesses does HIPAA apply?
Carol:
HIPAA applies to two main groups:

Covered Entities: Healthcare providers, health plans, and clearinghouses.

Business Associates: Vendors or subcontractors who handle PHI on behalf of covered entities, such as IT service providers, billing companies, or cloud storage providers.

Rick:
During audits, I evaluate how both groups manage their HIPAA obligations. Covered entities must ensure that their business associates sign Business Associate Agreements (BAAs) and follow HIPAA rules.
Tom: What are the responsibilities of a HIPAA compliance consultant?
Carol:
My role as a HIPAA compliance consultant helps organizations:

Conduct risk assessments and gap analyses.

Develop policies and procedures for compliance.

Train employees on HIPAA requirements.

Implement technical and administrative safeguards.

Prepare for audits by ensuring documentation and controls are in place.
Tom: What are the responsibilities of a HIPAA security consultant?
Carol:
My role as a HIPAA security consultant focuses specifically on the technical and physical safeguards of HIPAA. They assist with:

Implementing access controls, encryption, and secure data storage.

Conducting vulnerability assessments and penetration testing.

Designing disaster recovery and business continuity plans.

Monitoring and responding to cybersecurity threats.
Tom: What are the responsibilities of a HIPAA compliance auditor?
Rick:
My role as a HIPAA auditor is to assess compliance by:

Reviewing policies, procedures, and safeguards.

Examining evidence of compliance, like access logs and training records.

Identifying gaps and issuing corrective action plans.

Certifying whether the organization is compliant.
Tom: How can we achieve HIPAA compliance for web applications?
Carol:
For web applications:

Encrypt data in transit and at rest.

Implement access controls and user authentication mechanisms.

Use secure hosting providers that comply with HIPAA.

Sign a BAA with third-party vendors (e.g., cloud hosting services).

Regularly perform security testing and vulnerability scans.
Tom: What are the IT security requirements for HIPAA?
Carol:
The key IT security requirements include:

Encryption of ePHI.

Access controls (unique user IDs, automatic log-off).

Audit trails for system activity.

Secure data transmission methods (e.g., TLS, VPNs).

Regular patch management and malware protection.

Rick:
As an auditor, I check for misconfigurations, unpatched systems, and whether proper audit logs are maintained.
Tom: Is there a HIPAA certification?
Carol:
There’s no formal “HIPAA certification”, as it is a legal requirement. However, third-party firms offer HIPAA readiness certifications to demonstrate that an organization has implemented the required safeguards.
Rick:
Remember, during an audit, I evaluate compliance based on actual evidence and adherence to HIPAA requirements.

Tom: What is the difference between HIPAA covered entities vs. business associates?
Carol:
Covered entities directly provide healthcare services, health insurance, or billing services. Business associates are third-party vendors who handle PHI on behalf of covered entities, like IT providers or billing companies.
Rick:
Both are subject to HIPAA, but covered entities bear the responsibility of ensuring business associates comply by signing BAAs and monitoring their activities. This forms part of their supplier risk assessment.
Tom: What are the HIPAA documentation requirements?
Carol:
HIPAA requires documentation for:

Policies and procedures.

Risk assessments.

Employee training records.

Incident response plans.

Audit logs and access reports.

Rick:
Auditors will request these documents during compliance reviews. Incomplete or outdated documentation is a common non-compliance issue.
Tom: What is a HIPAA risk assessment, and who does it?
Carol:
A HIPAA risk assessment identifies potential risks to the confidentiality, integrity, and availability of ePHI. It includes evaluating physical, administrative, and technical safeguards.
Rick:
Risk assessments are often performed by compliance consultants or internal teams, but as an auditor, I review the assessment process and its findings to verify compliance.

If you have any more questions on HIPAA, contact us today to get started