HIPAA Risk Assessment Support for Covered Entities and Business Associates
The Fox Group provides HIPAA risk assessment services for healthcare organizations, covered entities, and business associates. Our work in this area has helped numerous clients understand where privacy and security gaps may exist and what practical steps may need attention.
A HIPAA risk assessment can support leadership, compliance, privacy, security, and operations teams that need clearer visibility into PHI and ePHI risk.
Who is it for?
Covered entities and business associates that handle PHI or ePHI.
What does it help clarify?
Gaps in safeguards, documentation, practices, policies, procedures, and training.
What can clients receive?
Findings and recommendations in an executive summary-type report.
What The Fox Group Reviews During a HIPAA Risk Assessment
The assessment helps connect HIPAA requirements to the organization’s actual operations. The Fox Group will review administrative, physical, and technical safeguards, along with supporting policies and procedures.
The exact review scope should reflect the organization’s environment, risk profile, and engagement objectives. Because the Security Rule’s required risk analysis focuses specifically on ePHI, an engagement can be scoped to satisfy that requirement alone or to also address broader HIPAA privacy and breach notification requirements.
| Policies and Procedures | HIPAA privacy and security policies, breach notification procedures, related documentation. |
| Workforce and Security Management | Security responsibilities, workforce clearance,sanctions, termination procedures, reminders and training materials. |
| Access and Technical Safeguards | User IDs, emergency access, automatic log off, encryption, audit controls, integrity, authentication, and transmission security. |
| Monitoring, Incident Response, Training, and Workflow Efficiency | Login monitoring, password management, malware protection, security incidents, and response procedures. |
| Contingency Planning | Data backup, disaster recovery, emergency mode operations, testing, and applications or data criticality analysis. |
| Facility Device and Media Controls | Facility access controls, facility security plans, maintenance, repairs, disposal, reuse, and accountability. |
HIPAA Risk Assessment and HIPAA Security Risk Analysis
The terms HIPAA Risk Assessment, HIPAA Security Risk Assessment, and HIPAA Security Risk Analysis are often used interchangeably in practice. In the HIPAA Security Rule, risk analysis is the formal requirement: 45 C.F.R. § 164.308(a)(1)(ii)(A) requires an accurate and thorough assessment of potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI.
The Fox Group’s HIPAA risk assessment services can help clients address that requirement, while also considering broader HIPAA privacy, security, breach notification, policy, procedure, and training needs when those areas are included in the engagement scope.
Findings, Recommendations, and Follow-Up Support
A HIPAA risk assessment should help the organization understand findings and make better-informed decisions about next steps.
| Report | Clients receive findings and recommendations in an executive summary-type report. |
| Attestation | The Fox Group can provide a letter attesting to completion of a HIPAA risk analysis (the term used in the HIPAA Security Rule) as of the report date. |
| Follow-up | The Fox Group typically provides some remediation support, often involving policies, procedures, and training materials. More extensive work may be separately scoped. |
Need outside support for a HIPAA Risk Assessment or Security Risk Analysis?
Discuss Your HIPAA Risk Assessment Needs
Why Outside Healthcare Compliance Support Matters
Internal teams understand their systems and workflows. Outside healthcare compliance support can help reduce assumptions and bring a broader view of HIPAA privacy and security risk.
Objectivity
Review safeguards and documentation with an outside perspective.
Healthcare Context
Evaluate HIPAA risk in real healthcare operations.
Practical Direction
Connect findings to policies, procedures, training, and compliance decisions.
The goal is to help the organization understand its risk posture and make informed decisions about next steps.
Why Choose the Fox Group
The Fox Group brings healthcare compliance, HIPAA compliance, privacy and security, regulatory review, and compliance program evaluation experience to HIPAA risk assessment work.
Our firm also has experience with outsourced and interim compliance officer support, IRO and CIA-related work, healthcare operators, providers, and business associates.
| Healthcare Perspective | Assessment findings can be connected to broader compliance program decisions. |
| Settings | Experience includes inpatient, outpatient, ancillary service provider, and business associate environments. |
| Consulting Support | Recommendations can inform policies, procedures, safeguards, training, and follow-up work. |
| Professional Backgrounds | Relevant backgrounds may include: healthcare compliance, legal, coding/auditing, public health, and business administration. Credentials may include: JD, CHSP, CPMA, CCS, MPH, and MBA. |
