Obtaining valid authorizations for disclosure is a significant area of risk for many organizations. Often, staff members handling disclosures don't understand the requirements?especially regarding when authorizations are needed and who can legally sign them. This chapter takes a comprehensive look at authorizations, including required elements, when they're needed, when they're not needed, who can sign them, and the need to screen outside authorizations.
Q: I perform monthly HIPAA audits of computer systems at the medical group where I am employed. I recently started auditing physicians and allied health professionals who are credentialed members of our medical staff.
As required by The Joint Commission, a board of directors should regularly assess its performance, appropriateness of board and committee processes and charter fulfillment, adequacy of meeting structures and goals, communication with management, and other governance structures and activities. Generally, boards and their committees complete this assessment through self-surveys, internal audits, or collection of results as performed by legal services. Assessment results can lead to changes in board processes, with the goal of adapting to changing risks and environmental requirements, and improvements in governance.
Mergers and acquisitions in the healthcare industry are often decided upon and negotiated by C-suite staff with involvement from security and IT professionals. However, significant security implications must be considered by both parties prior to, during, and after a merger or acquisition. Security officers are often best suited to dig deep into the information security standards of a facility to identify risks and develop a plan for streamlining security programs between the acquirer and the organization being acquired.
Q: You are reviewing a computer-generated insurance claim before it is sent to the insurance carrier, and you happen to notice the patient's name on the claim?it's an old friend of yours. You quickly read the code for the diagnosis. Is this a breach of confidentiality?
