Define your HIPAA Audit Scope

Overview

Define your HIPAA Audit Scope to set the boundaries of the audit and identify the object in focus.

The object can include the people, data, system, or product in review. The scope definition allows the auditors to focus on an aspect of the organization rather than the whole. It is important to clearly define the scope of review for your given audit.

Determining your HIPAA audit scope requires your organization to specify the product, the data, the systems, vendors, and type of scope.

This article guides you on how to determine each scope item. A table listing each item is provided below to use as a template for this exercise.

Learn more about TrustCloud’s TrustOps for HIPAA!

Product(s) in scope

For a Software as a Service (SaaS) provider, the scope is typically the software application(s) offered to clients. Some organizations have multiple products, and it is important to define what product is in focus and what product isn’t for your HIPAA.

Data in scope

In order to identify the data in scope, the ideal step is to focus on the type of data and people that flow through the product or service identified. For a SaaS provider, it’s typically all the data held in it (i.e., customer data, etc.) and the people that support it, such as vendors and employees.

Systems in scope

To identify all your systems in scope, take an inventory of all the various systems and internal controls that are critical to delivering your service or product in scope. This can include email and Slack. The key is to focus on the systems and tools that are essential to delivering your service / product. Production systems have a direct impact on your product or service in lieu of non-production systems.

For HR systems, focus on systems that manage employee onboarding and training processes. Everything else, such as time off requests and benefits, is out of scope since it is not critical to delivering a service or product.

For a SaaS provider, it’s typically all the infrastructure that hosts it and the procedures that support it, such as AWS, Github, JIRA, etc.

Vendors in scope

In order to identify the vendors in scope, focus on the critical vendors, such as cloud hosting and production related organizations used to support the product or service in scope.

Are you a business associate or a covered entity?

Scoping changes drastically based on whether you qualify as a covered entity or a business associate.

Covered entities include:

1. Healthcare providers such as hospitals, clinics, doctors offices, pharmacies, and home health agencies.
2. Health plans such as government programs that pay for healthcare, health insurance companies, health maintenance programs, and military and veterans’ health programs.
3. Healthcare clearinghouses, i.e., organizations that act as the go-betweens for healthcare providers and insurance providers.

Business Associates perform services on behalf of covered entities and include, but are not limited to:

1. Third-party administrators
2. Billing companies
3. Transcriptionists
4. Cloud service providers
5. Data storage firms – electronic and physical records
6. EHR providers
7. Consultants
8. Pharmacy benefits managers
9. Claims processors
10. Collections agencies
11. Medical device manufacturers

Use the HHS question and answer decision tool to determine whether your organization is a Business Associate or a Covered Entity. This is a determination that must occur with your Legal department.

HIPAA Rule in scope

The HIPAA regulation is composed of three rules: Privacy, Security, and Breach notification.

1. Security Rule is mandatory for both covered entities and business associates
2. Privacy Rule is mandatory for covered entity only
3. The breach notification rule is mandatory for covered entity and optional for business associates

HIPAA Audit Scope guidance template

Scoping guidance

Provide a detailed description of your organization’s products or services. Focus on the product or service under review

Provide the type of data and people that flows through the product or service under review

Please provide the list of systems / tools that flow through or support the product or service under review

Please provide the list of critical vendors being used to support the product or service under review

Confirm your HIPAA identity ·       Covered Entity ·       Business Associate

Confirm your HIPAA audit scope. ·       Security Rule (Mandatory) ·       Breach Notification Rule – (Optional) for Business Associate & (Mandatory) for Covered Entity  ·       Privacy Rule – (Optional) for Business Associate & (Mandatory) for Covered Entity