HIPAA Compliance

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a series of regulatory standards outlining the lawful use and disclosure of Protected Health Information (PHI).
HIPAA compliance is regulated by the Department of Health and Human Services (HHS) and enforced by the Office for Civil Rights (OCR). The OCR maintains compliance through routine guidance on emerging healthcare issues and investigations into HIPAA violations.

HIPAA represents an ongoing culture of compliance that healthcare organizations must integrate to ensure the privacy, security, and integrity of protected health information.



HIPAA Privacy Rule

The Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) establish national standards for protecting certain health information.
Issued by the HHS, this rule governs the use and disclosure of individuals’ health information (PHI) by organizations called covered entities and defines individuals’ privacy rights to control their information.

A primary goal of the Privacy Rule is to ensure individuals’ health information is properly protected while allowing for the necessary flow of information to deliver quality healthcare and protect public well-being.
The rule is flexible and comprehensive to address the diverse uses and disclosures of health data in modern healthcare.



Who Needs to Be HIPAA Compliant?

HIPAA defines two main categories of organizations that must comply:

1. Covered Entities

Organizations that collect, create, or transmit PHI electronically, including:

  • Healthcare providers
  • Healthcare clearinghouses
  • Health insurance providers

2. Business Associates

Organizations that handle PHI in the course of performing work for a covered entity, such as:

  • Billing and coding services
  • Cloud storage providers
  • IT vendors handling healthcare data


HIPAA Rules and Regulations

HIPAA compliance encompasses several key rules enacted over the past two decades:

1. HIPAA Privacy Rule

Sets national standards for patients’ rights to PHI.
Key provisions include:

  • Patients’ rights to access their PHI
  • Providers’ rights to deny access under specific conditions
  • Use and Disclosure forms and Notices of Privacy Practices
  • Annual training and documentation of HIPAA policies and procedures

2. HIPAA Security Rule

Establishes standards for maintaining and transmitting electronic PHI (ePHI) securely.
It applies to both covered entities and business associates and requires:

  • Administrative, technical, and physical safeguards
  • Policies for integrity and confidentiality of ePHI
  • Annual risk assessments and training

3. HIPAA Breach Notification Rule

Outlines procedures for reporting breaches of PHI/ePHI:

  • Breaches < 500 individuals: Report to HHS OCR within 60 days after the calendar year’s end
  • Breaches ≥ 500 individuals: Report to HHS OCR, affected individuals, and media within 60 days of discovery
  • All large-scale breaches are listed on the HHS Breach Notification Portal (“Wall of Shame”)

4. HIPAA Omnibus Rule

Extends HIPAA obligations to business associates and mandates Business Associate Agreements (BAAs) before sharing PHI.
BAAs establish security expectations and liability between entities.



HIPAA Compliance Requirements

All covered entities and business associates must adhere to these key requirements:

1. Self-Audits

Annual assessments to identify Administrative, Technical, and Physical gaps in compliance.
A Security Risk Assessment alone does not constitute full compliance.

2. Remediation Plans

Organizations must document and implement plans to resolve identified compliance gaps with clear timelines.

3. Policies, Procedures, and Employee Training

  • Policies must align with HIPAA regulatory standards.
  • Annual updates and employee training are mandatory.
  • Staff must sign attestations confirming understanding of policies.

4. Documentation

All compliance activities—including audits, policies, and breach responses—must be documented for regulatory review.

5. Business Associate Management

  • Maintain a list of all vendors handling PHI.
  • Execute and annually review Business Associate Agreements (BAAs) before sharing PHI.

6. Incident Management

Have a structured process to document and report breaches according to the Breach Notification Rule.



What is a HIPAA Violation?

A HIPAA violation occurs when a covered entity or business associate fails to comply with HIPAA requirements, compromising the integrity or confidentiality of PHI/ePHI.

Not all data breaches are HIPAA violations—only those resulting from noncompliance or negligence.
Violations can lead to fines, investigations, and inclusion on the HHS Wall of Shame, a permanent public record of major breaches.



HIPAA Compliance at Global Health Opinion Inc. (GHO)

At Global Health Opinion Inc. (GHO), we are deeply committed to maintaining full HIPAA compliance to protect patient data and foster trust among clients and partners.
Our adherence to HIPAA reflects our dedication to transparency, accountability, and excellence in healthcare services.



HIPAA Principles Applied at GHO

1. Privacy Rule Compliance

GHO strictly follows the HIPAA Privacy Rule by:

  • Allowing only authorized personnel to access PHI
  • Providing transparent communication about privacy rights
  • Using compliant Use and Disclosure forms and Notices of Privacy Practices

This ensures patient confidentiality and lawful handling of sensitive health data.



2. Security Rule Adherence

GHO upholds the highest security standards for ePHI, implementing:

  • Administrative safeguards: Role-based access, audits, and risk management policies
  • Physical safeguards: Secure data centers and restricted access
  • Technical safeguards: Encryption, secure communication, and regular system updates

These measures minimize cybersecurity risks and protect electronic health data.



3. Breach Notification Rule

GHO maintains a clear and transparent breach response process:

  • Immediate notification to affected individuals
  • Timely reporting to HHS OCR
  • Post-incident reviews to strengthen security measures

This proactive approach ensures the integrity and accountability of our data management.



Compliance Measures at GHO

Self-Audits and Risk Assessments

Annual audits and ongoing risk assessments identify vulnerabilities and strengthen PHI protection.

Policy Development and Training

  • Policies and Procedures are reviewed and updated annually.
  • All employees undergo mandatory HIPAA training and acknowledge understanding of data protection responsibilities.

Documentation and Reporting

GHO keeps detailed records of:

  • Training sessions
  • Audit outcomes
  • Breach management activities

This documentation demonstrates transparency and regulatory compliance.

Business Associate Management

GHO signs and annually reviews BAAs with all third-party vendors handling PHI.
These agreements guarantee secure data handling and regulatory alignment across all partnerships.



HIPAA as an Integral Part of GHO Services

Second Opinions and Peer Reviews

  • All patient consultations and document exchanges occur on secure, HIPAA-compliant platforms.
  • Only authorized specialists access PHI for the purpose of diagnosis and treatment evaluation.

Telemedicine and Mental Health Services

  • Telehealth interactions are encrypted and conducted on privacy-by-design platforms.
  • These systems protect real-time communications and adhere to HIPAA’s strict PHI handling standards.

Technology-Driven Solutions

  • GHO integrates AI and ML tools within HIPAA-compliant frameworks.
  • All vendor technologies are governed by Business Associate Agreements to maintain compliance and ensure end-to-end data security.


Global Health Opinion Inc. (GHO)
Empowering global healthcare decisions through trust, security, and compliance.