The HIPAA Minimum Necessary Standard: an essential guide

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 protected health information upon request. And decide about the disclosure or restriction of specific parts of electronic protected health information.

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

HIPAA Minimum Necessary Standard
  • 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 associate entities who provide services to healthcare services providers.

Here is how the HIPAA Minimum Necessary Standard works: it mandates that entities limit their use or disclosure of Protected Health Information (PHI) to the bare minimum required. This applies to all PHI, whether digital or physical, like files on USBs and laptops.

For instance, in a clinic with multiple providers, only the physician treating the patient should access their records. Similarly, if a hospital's coding department needs patient information for pre-authorization, they should only access the necessary details.

This standard extends to communications between staff and patient interactions in offices. It ensures that only essential PHI is shared, safeguarding patient privacy across various platforms.

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.

Exceptions to the HIPAA Minimum Necessary Standard

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 with reasonable criteria.

2. Treatment of a patient

A healthcare provider may access a patient's PHI for 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.

Best methods to implement the Minimum Necessary Standard

While the Minimum Necessary Standard seems pretty self-explanatory, this doesn’t mean that all methods are equally effective when implementing it. Below, we compiled a list of the best of them.

HIPAA Minimum Necessary Standard best practices

1. Define scope and access criteria

Begin by delineating the scope of necessary data for specific roles within your organization. Not everyone needs access to all data. For example, a healthcare provider may need access to a patient's medical history but not their financial information.

2. Use role-based permissions

Implement role-based access control (RBAC) to grant permissions according to the user's role. It's like giving a chef access to the kitchen but not the entire restaurant.

3. Regular audits

Conduct routine or recurring requests for audits to ensure compliance. It's akin to checking the locks on doors regularly – it ensures that only authorized personnel have access.

4. Tighten data request protocols

Establish strict protocols for requesting data. Ensure requests are funneled through a secure process, similar to having a single, guarded entrance to a facility.

5. Employ data anonymization techniques

When full data access isn't necessary, anonymize it. Think of it as blurring out faces in a crowd; the crowd's size can be estimated without identifying individuals.

6. Train staff

Educate your team on the importance of the Minimum Necessary Standard, much like teaching drivers to respect speed limits for safety. Each workforce member and business associate should be aware of the importance of HIPAA compliance.

7. Encrypted data storage and transmission

Ensure data is encrypted both in rest and in transit – a strategy comparable to sending sealed letters instead of postcards.

8. Update policies regularly

The threat landscape and data use cases evolve, so keep your policies fresh and relevant, as if updating maps for new roads and routes.

9. Employ Least Privilege Principle

The Least Privilege Principle means giving users the lowest level of data access that they can still use to perform their job, akin to carrying only the key to one's office, not the entire building.

10. Document procedures and rationale

Keep clear records of data access procedures and the rationale behind them. It's like keeping a guestbook at a private event – it tracks who accessed what and why.

Note that before implementation of the HIPAA Minimum Necessary Standard, organizations should have policies and procedures already established. They 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.

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 HIPAA 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 Privacy Rule incidental disclosure vs accidental disclosure

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.

Disclaimer: This article is for informational purposes only and not legal advice. Use it at your own risk and consider consulting a licensed professional for legal matters. Content may not be up-to-date or applicable to your jurisdiction and is subject to change without notice.