How do entities covered by HIPAA handle data breaches?

by | Jun 4, 2023 | HIPAA News and Advice

Entities covered by HIPAA are required to handle data breaches involving PHI by promptly conducting a risk assessment to determine the extent of the breach, notifying affected individuals and, in some cases, the media and the U.S. Department of Health and Human Services, implementing necessary safeguards to mitigate further breaches, and documenting the breach and response process to ensure compliance with breach notification requirements and to continuously improve security measures. The HIPAA Breach Notification Rule provides a framework that outlines the necessary steps and protocols to be followed in the event of a data breach.

Actions Taken by Entities Covered by HIPAADescription
Risk AssessmentPromptly conduct a thorough risk assessment upon discovering a potential data breach.
Evaluate the breach’s nature, extent, and potential impact on PHI.
Notification to Affected IndividualsTimely and accurately notify individuals whose PHI has been compromised.
Describe the breach, exposed information, and potential risks.
Advise on risk mitigation steps.
Reporting to Regulatory AuthoritiesFor breaches affecting 500+ individuals, report to the U.S. Department of Health and Human Services (HHS).
In some cases, media notification is also required.
Safeguard ImplementationImplement appropriate safeguards to prevent further breaches and protect PHI.
Address identified vulnerabilities and enhance security measures.
DocumentationMaintain records of breach and response efforts.
Include breach details, risks, mitigation steps, and communications with relevant parties.
Non-Compliance ConsequencesFailure to comply can result in fines, reputation damage, and legal implications.
Continuous ImprovementLearn from breaches to enhance security strategies and preventive actions.
Patient Trust and PrivacyBuild patient trust by demonstrating a commitment to privacy and security.
Transparent communication during breaches.
Legal and Regulatory ComplianceMandatory compliance with HIPAA breach notification requirements
Overall ImpactEffective breach handling minimizes negative impact on individuals and the organization.
Mitigate risks and damages.
Staff HIPAA TrainingTrain staff in breach response protocols to empower effective action.
Data Breach PreventionWork on preventing data breaches through security measures and risk assessment.
Public Relations StrategyDevelop a PR strategy for managing communication and public perception during significant breaches.
Collaboration with ExpertsCollaborate with cybersecurity, legal, and communication experts to deal with complex breach situations.
Table: Necessary Actions by HIPAA-Covered Entities in Handling Data Breaches

When a potential data breach is discovered, covered entities are required to initiate a thorough risk assessment promptly. This assessment involves evaluating the nature and extent of the breach, including the type of PHI involved, the likelihood of the PHI being compromised, and the potential impact on affected individuals. This assessment serves as the foundation for determining the appropriate course of action and the level of response required. Following a data breach, it is required to provide timely and accurate notification to the individuals whose PHI has been compromised. The breach notification must include a description of the breach, the types of information exposed, the potential risks and harms resulting from the breach, and the steps that affected individuals should take to mitigate these risks. The breach notification should be clear, concise, and easily comprehensible to ensure that patients are fully informed about the situation.

Covered entities may also be required to notify the U.S. Department of Health and Human Services (HHS) and, in certain cases, the media. The specific reporting requirements depend on the size of the breach; breaches affecting fewer than 500 individuals can be reported annually to HHS, while breaches affecting 500 or more individuals must be reported to HHS and potentially to the media as well. This level of reporting transparency not only ensures accountability but also serves to inform the public and other stakeholders about potential vulnerabilities and risks in the healthcare sector.

To mitigate further breaches and prevent similar incidents from occurring, covered entities need to implement appropriate safeguards. This involves identifying and addressing the vulnerabilities that led to the breach, reviewing and enhancing security measures, and implementing corrective actions to prevent future breaches. The goal is to improve data security and protect PHI from unauthorized access, use, or disclosure. The breach response process necessitates the documentation of the incident and the subsequent actions taken. Covered entities need to maintain a record of all breaches, including the nature of the breach, the potential risks identified during the risk assessment, the steps taken to mitigate those risks, and any communications made with affected individuals, regulatory authorities, and other relevant parties. Thorough documentation ensures compliance with breach notification requirements and the internal auditing and continuous improvement of security measures. Non-compliance with HIPAA breach notification requirements and failure to appropriately handle a data breach can result in substantial financial penalties, reputational damage, and legal consequences. These consequences stress the importance of adhering to the established breach response protocols and notification procedures.


Entities covered by HIPAA are entrusted with the responsibility of safeguarding PHI and responding effectively in the event of a data breach. The breach response process involves conducting a risk assessment, notifying affected individuals and potentially regulatory authorities and the media, implementing safeguards to prevent future breaches, and thoroughly documenting the breach and response efforts. Adhering to these procedures not only ensures compliance with HIPAA regulations but also builds patient trust, protects patient privacy, and contributes to the overall integrity of the healthcare system.

HIPAA Covered Entity Topics

What is the definition of a HIPAA-covered entity?
How does an organization determine if it is a HIPAA-covered entity?
Are all healthcare providers considered HIPAA-covered entities?
What obligations does an entity covered by HIPAA have concerning patient data?
Do insurance companies fall under the category of entities covered by HIPAA?
What is a covered entity under HIPAA?
Who would not be considered a covered entity under HIPAA?
Is an employer a covered entity under HIPAA?
Who should HIPAA complaints be directed to within the covered entity?
What are the penalties for a HIPAA-covered entity that breaches patient confidentiality?
Are health technology companies automatically considered HIPAA-covered entities?
What distinguishes a HIPAA entity from non-covered entities?
Can a HIPAA-covered entity share medical records with another such entity without patient consent?
How often should HIPAA-covered entities review their compliance procedures?
What types of training must employees of an entity covered by HIPAA undergo?
How do entities covered by HIPAA handle data breaches?
What is the role of a privacy officer in a HIPAA-covered entity?
Are dental practices considered HIPAA-covered entities?
Can a patient sue a HIPAA-covered entity for a data breach?
How are HIPAA-covered entities audited for compliance?
What are the reporting obligations of a HIPAA entity in case of data exposure?
How do third-party vendors interact with HIPAA-covered entities?
Can a business associate be considered a HIPAA-covered entity?
How should a HIPAA entity respond to unauthorized access to protected health information?
What security measures must entities covered by HIPAA implement?
Are there exemptions for certain types of entities covered by HIPAA?
How long must a HIPAA-covered entity retain medical records?
What patient rights are recognized by entities covered by HIPAA concerning their personal data?
Are telemedicine platforms typically classified as HIPAA-covered entities?
What distinguishes business associates from HIPAA-covered entities?
How can patients file complaints against a HIPAA entity?
What is the significance of the Notice of Privacy Practices for a HIPAA-covered entity?
How do international medical tourism practices intersect with HIPAA-covered entities?
Are there specific encryption standards that a HIPAA-covered entity must adhere to?
How do federal and state laws regarding patient privacy relate to HIPAA-covered entities?
How do HIPAA-covered entities handle minor patient information?
Are pharmacies and drug stores universally categorized as HIPAA-covered entities?
How can a HIPAA-covered entity ensure compliance when integrating new technologies?
What are the key differences between a HIPAA-covered entity and a HIPAA business associate?
Are research institutions always considered HIPAA-covered entities?
What are the boundaries of marketing activities for an entity covered by HIPAA?
Can cloud service providers be classified as HIPAA-covered entities?
How should a HIPAA entity prepare for an official audit or review?
What documentation is essential for a HIPAA-covered entity’s compliance processes?
How often do regulations impacting HIPAA-covered entities get updated?
Do educational institutions fall under the scope of entities covered by HIPAA?
How do mobile health apps and digital health tools intersect with HIPAA-covered entities?
What is the role of electronic health record systems in a HIPAA-covered entity?
How does the Health Information Exchange (HIE) network impact HIPAA-covered entities?
Are mental health professionals bound by the same rules as other HIPAA-covered entities?
How do mergers and acquisitions impact the status of a HIPAA-covered entity?
Can patients access all their health data held by a HIPAA-covered entity?
Are billing and invoicing data handled differently by entities covered by HIPAA than medical data?
3 Steps To HIPAA Compliance

Step 1 : Download Checklist.

Step 2 : Review Your Business

Step 3 : Get Compliant!

Our HIPAA compliance checklist will outline everything your organization needs to become fully HIPAA compliant. Fill in the form below to download it now.

View our privacy policy