What is Healthcare Compliance? Exploring a Core Concept in Care Delivery

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A smiling female health information manager gathers information from a young female patient at a hospital admissions desk.

Protecting patient data is a top priority for the healthcare industry. Organizations can face serious penalties if patient data is compromised. In fact, they may be penalized for violating the regulations of the Health Insurance Portability and Accountability Act (HIPAA). Penalties can range from $100 to $1.5 million, according to the American Medical Association.

Healthcare compliance plays an important role in both patient care and the daily clinical operations of service providers. It is important that organizations seek out professionals who have a detailed knowledge of healthcare compliance.

Professionals with an advanced degree in health information management are well positioned to pursue rewarding careers in the field—managing the many challenges involved in overseeing a facility’s compliance in an evolving regulatory and technological landscape.

Healthcare Compliance at a Glance

What is healthcare compliance? Healthcare compliance can be defined as an organization abiding by both state and federal regulations, laws and procedures pertaining to healthcare practices. State and federal regulations such as HIPAA, and organizations such as the Occupational Safety and Health Administration (OSHA), are responsible for ensuring healthcare organizations comply with state and federal laws and regulations. HIPAA and OSHA audit these organizations to protect patient privacy and personal information, as well as the safety of patients and healthcare workers.

As previously mentioned, healthcare organizations need to ensure their processes and procedures are HIPAA compliant. Professionals with a background in healthcare compliance are well qualified to take on this responsibility. These professionals must prioritize HIPAA requirements and ensure that the organization provides systems and procedures that secure Protected Health Information (PHI). They also must be familiar with the four major sections of the HIPAA compliance checklist: HIPAA Privacy and Security Rules, HIPAA Omnibus Rule, HIPAA Breach Notification Rule and the HIPAA Enforcement Rule.

  • HIPAA Privacy and Security Rules: Provide the standards for safeguarding electronic personal health records. Healthcare organizations are required to implement limits on what information can be disclosed, as well as provide patients the legal right to their health information.
  • HIPAA Omnibus Rule: Requires that all businesses and contractors working for a healthcare organization sign Business Associate Agreements. These agreements require HIPAA compliant safeguards while partnering with healthcare organizations.
  • HIPAA Breach Notification Rule: Requires healthcare organizations to notify patients if their health records have been compromised. Furthermore, the covered entities—hospitals, healthcare organizations, clinics, etc.—must contact patients within 60 days of the breach, according to the HIPAA Journal.
  • HIPAA Enforcement Rule: Outlines the penalties a covered entity can face when there is a breach or violation.

The role of OSHA with respect to covered healthcare entities primarily involves instituting standard operating procedures to protect employees. OSHA relays safety measures that can be used to ensure employees are protected from health hazards, such as infectious materials or bloodborne pathogens. OSHA also directs how employees should properly don personal protective equipment (PPE) when dealing with patients. This not only keeps medical professionals safe, but also protects patients.

Healthcare compliance also extends to peripheral elements of care delivery, such as patient billing and managed care contracting.

Managed care contracting involves health insurance options that patients can choose. When patients switch health insurance providers, it is important that healthcare compliance professionals institute safeguards and security during the transition process. Safeguards include encrypting the data so if it is compromised, it cannot be deciphered without an encryption key. Moreover, patient billing must also be HIPAA compliant to provide a safe and secure payment system.

Healthcare Information Technology and Healthcare Compliance

Information technology—including patient recordkeeping and patient portal access—informs the way in which health information management professionals address a facility’s healthcare compliance strategy. They must use technological security measures that protect their network to address the specific technological hurdles that HIPAA compliance imposes on information technology. The reliance on technology for electronic health records (EHR), patient billing, and medical devices serves to increase security risk.

Healthcare data is especially vulnerable in larger organizations where hundreds of employees may have access to sensitive information. In these settings, cybersecurity should be a top priority for health compliance managers, because a HIPAA violation can put the financial security of an organization and patient safety at risk. There are certain safeguards that health compliance managers can use to protect client data. They can train employees to effectively access data and develop an understanding of HIPAA compliance.

Moreover, they can utilize software that provides each employee with a unique identifier (UID) that allows them to access proprietary information related to their position. Software can also be installed so computers shut off after a period of inactivity. This prevents unauthorized personnel from accessing data. Lastly, all data should be encrypted to prevent and mitigate a security breach, which safeguards protected health information and other HIPAA compliant data.

The Essential Skills Behind Effective Healthcare Compliance

For health information managers, healthcare compliance means possessing the skills to integrate healthcare compliance into a facility’s care delivery system. These abilities include technical and computer-related skills, as well as “soft-skills” such as problem solving and interpersonal communication.

●  Technical/computer-related: Health information managers should have a working knowledge of computer software, such as EHR software, medical database software and telemedicine software. Moreover, they must have the technical skills to operate and monitor billing and data systems.

● Problem-solving: These professionals must be effective problem solvers to address HIPAA complaint complications that may arise from data breaches or transfers of PHI to other systems. They must also develop systems that can mitigate risk and are HIPPA compliant.

● Interpersonal skills: Health information managers must be skilled communicators able to clearly relay information to medical professionals, IT specialists and patients. They are also responsible for effectively communicating company policies and procedures to employees.

How an Understanding of Healthcare Compliance Prepares Professionals for Rewarding Careers

Healthcare compliance is an integral part of the healthcare industry. With the advent of information technology, a background in healthcare compliance can equip professionals to become leaders in the field as health information managers.

The University of Illinois at Chicago online Master of Science in Health Information Management is designed to prepare students to meet the challenges of healthcare compliance. The program offers the opportunity to develop a deep understanding of healthcare compliance and industry-specific skills through a robust and focused curriculum.

Discover how the University of Illinois at Chicago online Master of Science in Health Information Management can help you make your mark in healthcare compliance and health information management.

Recommended Readings

Applying Technology To Improve Healthcare: What Is Healthcare IT?IT at the Executive Level: What Is a Chief Information Officer?What Are Information Systems and How Do They Benefit Healthcare?


American Medical Association, HIPAA Violations and Enforcement

Digital Guardian, What is HIPAA Compliance? 2019 HIPAA Requirements

Healthcare Business & Technology, Healthcare Compliance and Cybersecurity: Examining the Needs

HIPAA Journal, HIPAA Compliance Checklist

HIPAA Journal, The Use of Technology and HIPAA Compliance

Journal of AHIMA, “Aligning Governance, Risk, and Compliance”

Journal of AHIMA, “Red Flags for HIPAA Policy Compliance”

Medicaid and CHIP Payment and Access Commission, Key Federal Program Accountability Requirements in Medicaid Managed Care