An essential guide to the HIPAA Minimum Necessary Standard

HIPAA minimum standard cover

The HIPAA Minimum Necessary Rule applies to all Protected Health Information (PHI). And includes physical documents, spreadsheets, films, and printed images, patient data stored or processed electronically, and information communicated verbally.

Every covered entity and business associate must make reasonable efforts to ensure minimal access to Protected Health Information for a particular use. But how does it work in practice? And how can you interpret "reasonable effort" or "minimum necessary disclosure"? Read our complete guide on the HIPAA Minimum Necessary Standard.

The ABC of HIPAA compliance

Let's start with what HIPAA is. Passed in 1996 by the US government, the Health Insurance Portability and Accountability Act (HIPAA) obligates every covered entity to protect sensitive health information. Five HIPAA rules define how healthcare professionals should proceed when they handle sensitive data. One of them, the HIPAA Privacy Rule, outlines patients' rights regarding their health information and regulates who can access it.

What is HIPAA compliance explainer

HIPAA compliance ensures healthcare providers meet the regulatory requirements for Protected Health Information (PHI). For example, an insurance company can only get the reasonably necessary information on a patient's clinical history. Or if a journalist requests a plastic surgeon to disclose their celebrity patient data, they can't do that. In short, every covered entity must follow HIPAA regulations. And restrict access to their PHI.

Why is it critical to be HIPAA-compliant?

HIPAA compliance is essential for healthcare organizations and patients. Here is why: 

  • It ensures healthcare organizations securely handle sensitive information according to the same rules.

  • It gives patients peace of mind about their sensitive data by keeping strict security checks on who can access it and why. 

So, is complying with the HIPAA Privacy Rule important only because of the law? Violating HIPAA rules indeed results in high penalties. Also, HIPAA compliance builds patients' trust and your organization's reputation. And boosts your staff morale. 

What is the HIPAA Minimum Necessary Standard?

The HIPAA Minimum Necessary Standard is a component of the HIPAA Privacy Rule. It states that covered entities must make reasonable efforts to ensure minimum access to physical or electronically protected health information.

But since both terms, "minimum necessary information" and "reasonable efforts," are not defined in HIPAA, what do they mean? They mean that a covered entity can only share necessary information upon request. And decide about the disclosure or restriction of specific parts of information.

Also, the HIPAA Minimum Necessary Standard states that a rational justification for the decision should always follow.

HIPAA minimum necessary standard

Sounds complex? Let's examine some examples to clarify how the HIPAA Minimum Necessary Standard works. 

  • A doctor can only access patient records except for their social security number, billing information, and other sensitive information unrelated to treatment. 

  • A billing specialist can obtain the name of the test that a patient did but not the results.

  • An insurance company can only get information about a patient's records relevant to the request related to the insured event, not the whole medical history.

  • A physician can't disclose a patient's medical diagnosis to unauthorized personnel or third parties. 

Every covered entity must limit unnecessary or inappropriate access and disclosure of their patients’ sensitive data.

When does the HIPAA Minimum Necessary Standard apply?

As we said before, the HIPAA Minimum Necessary Standard applies to all HIPAA-covered entities and healthcare providers, such as:

  • Hospitals.

  • Insurance companies.

  • Healthcare clearing houses.

  • Business associates who provide services to healthcare services providers.

 It compels these organizations to take reasonable actions to limit oversharing of PHI. 

Searching for a HIPAA-compliant cybersecurity service? NordLayer has it! And we can also contribute to your compliance journey!

Exceptions to the HIPAA Minimum Necessary Standard 

There is an exception for every rule. And the HIPAA Minimum Necessary Standard is no different. Here we have six exceptions to the uses and disclosures of PHI. 

1. Patient's access to their medical history

A patient of a covered entity has the right to access their own Protected Health Information. To do so, they need to make a written request.

2. Treatment of a patient

A healthcare provider may access a patient's PHI for the purpose of treatment. It also applies to consultations between providers regarding a patient.

3. The HIPAA rules enforcement

The Department of Health and Human Services asks for a disclosure of PHI based on the HIPAA Enforcement Rule

4. Consent of the person whose PHI is in question

A patient may allow a covered entity to disclose or use their PHI, but he or she must sign an authorization. 

5. Requests required by law

HIPAA-covered entities may disclose PHI without authorization for judicial or administrative proceedings, for example, in adult abuse, neglect, or domestic violence. 

6. Requests required for compliance with HIPAA

It concerns uses or disclosures needed for compliance with the HIPAA Administrative Simplification Rule that ensures consistent electronic communication and data exchange across the U.S. healthcare system.

How to carry out the HIPAA Minimum Necessary Rule in your company

Before implementing the HIPAA Minimum Necessary Standard, check if your organization has adequate policies and procedures. Here is our guide to HIPAA compliance.

Establish your organization's policy

The policy and procedures should identify the following:

  • Who within your organization can access sensitive data to perform their duties

  • The categories or types of PHI 

  • The conditions appropriate to access.  

It’s also crucial to consider the exceptions you must make, to whom they apply, and under what circumstances. 

Control access to PHI and monitor compliance

Develop role-based permissions and determine what information various employees or third parties need. Instal monitoring software solutions to ensure your staff can access only the necessary PHI.

Define your business associate's access to PHI 

Before you sign an agreement with a new business associate, agree on what data they can access. 

Keep documentation

Demonstrate compliance with the HIPAA Minimum Necessary Standard by keeping all the relevant documents, such as policy changes and employee training,

Train employees on HIPAA compliance

Make sure they know how to follow the HIPAA Minimum Necessary Standard and what sensitive data can be transferred, to whom, and in what circumstances. It will help you avoid HIPAA violations.

Who determines the HIPAA Minimum Necessary Standard?

For routine or recurring requests, a covered entity must have a protocol to limit the disclosure of Protected Health Information to the minimum. For non-routine disclosures, covered entities must develop reasonable criteria for determining and limiting the disclosure. Each such request must be reviewed individually.

Here are a few cases when a reasonable judgment is permitted:

  • A researcher asks for information and suitable documentation from an Institutional Review Board or Privacy Board.

  • A workforce member or a covered entity's business associate requests minimum necessary information for a stated purpose.

  • A covered entity asks another entity for minimum necessary information.

  • A public official or an agency needs minimum necessary information for public health purposes. 

How often is the HIPAA Minimum Necessary Standard violated?

Although the exact number of violations is not specified, HHS Enforcement Highlights claims the HIPAA Minimum Necessary Standard violations are the fifth most common non-compliance events. There is also no data on who reports these violations, whether self-reported or submitted by covered entities, patients, or health plan customers.

So, what kind of situations violate the HIPAA Minimum Necessary Rule?

  • A doctor requires access to a patient's medical records to treat them and simultaneously accidentally accesses sensitive data, such as their Social Security number or payment details.

  • A gynecologist gossips with their colleague over lunch about a celebrity patient being pregnant. A cafeteria waitress overhears it, and the Minimum Necessary Rule is violated.

  • An IT professional performs maintenance work on a hospital's database and clicks on a few files with patients' medical records. Since they didn’t have permission, they violated the Minimum Necessary Rule.

  • A nurse reveals information about a patient having hepatitis C in a hallway. If other patients can hear it, they can file a complaint that his PHI was disclosed without permission.

The effects of sharing more than the minimum necessary PHI

The consequences of HIPAA violations are significant. Apart from financial penalties, organizations lose their reputation, patient trust, and their ability to operate a business. Filefax, a medical storage company, agreed to pay$100,000 to settle potential HIPAA violations of the HIPAA Privacy Rule. And although Filefax shut its doors during the Office for Civil Rights investigation, it still didn't escape additional fines and penalties.

However, the Privacy Rule allows incidental or accidental disclosures.

HIPAA disclosures classification

Let's explain it with examples. Suppose an authorized individual, such as a physician, provides a patient's PHI to another authorized person, also a physician, and by mistake, they share records of another patient. In that case, we are talking about accidental disclosure breaking HIPAA rules. What about incidental exposure? A person visiting their relative at the hospital may see another patient's x-ray or can overhear nurses talking about a patient. And in this way, they incidentally access Protected Health Information. 

How can NordLayer help?

Storing patient data in a cloud has become the primary archiving method in the healthcare industry. And healthcare organizations need modern security solutions that help them follow HIPAA regulations.

NordLayer’s policies, standards, and procedures were reviewed by independent assessors who concluded we meet the security objectives outlined in the HIPAA Security Rule. And we have the appropriate measures for securing access to Protected Health Information according to HIPAA requirements.

NordLayer's HIPAA-compliant solutions can protect endpoints with your organization’s sensitive information, adding an extra security layer to access your network, cloud tools, or databases. Contact us if you want to learn more about how we can help.

Disclaimer: This article has been prepared for general informational purposes and is not legal advice. We hope that you will find the information informative and helpful. However, you should use the information in this article at your own risk and consider seeking advice from a professional counsel licensed in your state or country. The materials presented on this site may not reflect the most current legal developments or the law of the jurisdiction in which you reside. This article may be changed, improved, or updated without notice.

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