The HIPAA minimum necessary rule is one of the essential provisions of HIPAA.
Generally, HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. In short, it states that covered entities including health care providers, insurance companies, and associated businesses can manage and access the necessary amount of private health information to accomplish a particular task.
In case of HIPAA violation, healthcare companies and organizations can get fined up to $25,000 per violation category.
But what are HIPAA minimum necessary standards, exactly?
It is an essential act that covers all the entities and businesses to protect health care information. It restricts the use and disclosure of health information for achieving a particular purpose.
For example, the disclosure of protected health information to an associated business that performs the services on behalf of a covered entity.
It's the covered entity's responsibility to make efforts and ensure that the essential personal protected healthcare information is not available for disclosure to the associated business.
Below, we’ll be exploring what is the HIPAA minimum necessary rule in more detail, how it works, and what else you need to know.
Here’s what we’ll cover:
- What Is The HIPAA Minimum Necessary Rule And How Does It Work?
- When Does The HIPAA Minimum Necessary Rule Not Apply? (6 Exceptions To Consider)
- 7 Steps To Implement The HIPAA Minimum Necessary Standard In Your Healthcare Organization
- Automatically Generating HIPAA Compliant Sensitive Healthcare Documents
What Is The HIPAA Minimum Necessary Rule And How Does It Work?
The HIPAA minimum necessary rule is applicable for protecting the disclosure of PHI (Protected Health Information).
Personal healthcare information is under the HIPAA privacy rule. However, the HIPAA rule is applicable for:
- Obtaining access to ePHI by covered entities to business associates and all other entities.
- Requesting the PHI from all covered entities.
HIPAA and its regulations do not define the term ‘’reasonable effort’’ and the ‘’minimum amount of information necessary’’. The HIPPA and its regulations are enforced by the Department of Health and Human Services, which defines these terms with relevant guidance.
The guidelines help understand the covered entities and demonstrate how to implement the minimum necessary standard rules for practices and protect personal information.
All the entities develop their standards according to HIPAA's standards for using and disclosing the policies and procedures. It applies to healthcare organizations, including associated businesses and the workforce.
So, what is the minimum necessary rule, exactly?
The HIPAA Minimum Necessary Standard policy is applicable and identifies that:
- The persons and classes within the covered healthcare entity who are searching and need the information for proceeding with their job duties.
- The different types and entities help to protect the health information and also disclose it where necessary.
- Require the appropriate conditions, including necessary workforce members, access for required disclosure of personal health information.
See our guide on how to create HIPAA-compliant direct mail for more info.
There is substantial room for interpretation of the terms ‘’reasonable’’ and ‘’necessary’’ leading to confusion.
What are reasonable efforts when it comes to HIPAA minimum necessary rule?
With the use of these terms, it is up to the covered entity how much information will be disclosed and what effort will be made to prevent access to the information.
Generally, these terms refer to protecting the necessary information and making efforts to restrict information access.
Organizations should aim to provide respect to their customers and protect their information. See our guide on healthcare document management best practices for practical steps on how to do that.
Keep in mind that any decision in the organization has rational justification and reflects the capabilities of the covered entity. It is also beneficial for privacy and security risks.
When Does The HIPAA Minimum Necessary Rule Not Apply? (6 Exceptions To Consider)
The HIPAA minimum necessary rule is not applicable for every situation.
There are 6 main exceptions to the HIPAA minimum necessary rules that make it non-applicable to protect the information.
These exceptions include:
- Disclosing personal health information at the request of the healthcare provider. It is only applicable when the information is necessary for providing the treatment.
- Disclosing of individual information that is under the provision of HIPAA privacy rule. It includes all data of an individual exercising his rights and wants access to obtain the information copy. The provided information is under the maintenance of a record set. Keep in mind that it also has the exception of psychotherapy notes and civil or criminal information.
- Disclosing of information to an authorization under the HIPAA rules.
- The provision of personal healthcare information of the HHS as the details in 45 CFR Part 160 subpart C.
- Disclosing and using necessary information in compliance with HIPAA rules.
- Disclosing required information to law according to their requirement.
Now, let’s take a closer look at how to use the HIPAA minimum necessary standard practically.
7 Steps To Implement The HIPAA Minimum Necessary Standard In Your Healthcare Organization
Implementing the HIPAA minimum necessary standard for an organization is not the same for everyone.
There are specific steps that you should follow and then implement the HIPAA.
Here’s how you can implement the minimum necessary standard tip for your healthcare organization.
Make a written policy
To begin, you must create a written policy that specifies the HIPAA Minimum Necessary Standard. It should also include how to apply it to your organization, and what are its exceptions.
Ensure every team member is aware of the rules
You need to make sure that your employees are well versed with its rules and have a clear understanding of its importance for your organization.
Implement a training program
Set the mandatory standards for every job position that can be accessed, including the information type and its use under the disclosure policy.
Ensure that the organization trains every employee on the requirement for protecting personal health information. They should know what they can do and what is the right way.
Formulate the right policies
Develop the necessary enforcement policies, including the sanctions for violating organizations' rules. Also, make sure that you have the system for reporting the alerts while implementing the HIPAA. Organizations can also hire their privacy officers for dealing with suspicious activity.
Create documents and maintain all records that demonstrate compliance with the HIPAA Minimum Necessary Standard. The changes to your company's policy or training, as well as the people involved in implementing those policies and training, are all part of this.
Fortunately, there are certain healthcare documents you can generate automatically, such as:
- Patient information records.
- Responsibilities and rights documents.
- Informed patient consent documents.
- Invoices and other financial documents.
- Test results.
- Insurance claims and documents.
- Standard communication forms.
- And more.
Be sure to also see if document automation is possible for you.
Monitor and implement access
You should possess logs for monitoring data access, as well as use software tools for this purpose. Furthermore, implementing Just-In-Time Access (JIT) to limit data access depending on the need/use of that PHI is a great idea.
Alert the compliance team when there is a violation
You should set up alerts that notify you when any of your employees try to access PHI. The alarms prevent such violations. This way you can better address verification for regulatory compliance potential violations before they can lead to serious harm.
Finally, one last thing you need to know about is automatically generating HIPAA-compliant documents within your healthcare organization.
Automatically Generating HIPAA Compliant Sensitive Healthcare Documents
Healthcare information is equally important as all other information, including social security numbers.
If you’re managing a lot of confidential information documents daily at scale, things might get complicated. For that, you’ll need to:
- Track what kind of documents are needed.
- Find the right software.
- Implement and scale your document generation strategy.
All while making sure that you’re:
- Following proper document management system control protocols.
- Creating document tracking for clear communication.
- Showing industry-standard compliance (HIPAA, FINRA risk management, etc.).
- Making necessary requirement changes and updating organization guidelines as needed.
- Collaborating with your employees and healthcare professionals online as needed.
- Making the most out of your system integrations.
This might seem like a lot. Which is why you need the right document generation and storage system for your healthcare brand.
For more information on that, be sure to see how Inkit helps healthcare organizations automatically generate and store HIPAA-compliant documents at scale. Whether you need to process 10 patient consent documents or 100,000+ customer statements.
HIPPA or Health Insurance Portability and Accountability Act strives to maintain and protect the information for the betterment of patients. It is equally beneficial for all the associated businesses to protect the information.
As a healthcare organization, it’s essential you have the right protocols and business practices that you’re HIPAA-compliant. As well as that you’re following the minimum necessary standard rule for the accountability law.
Hope this guide to the minimum necessary rule was helpful!