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Scott Gima

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Making Recognized Security Practices work for you

Posted by Scott Gima on 11/30/22 10:15 AM

One Big Thing

IImplementation of Recognized Security Practices (RSPs) for at least 12 months provide covered entities and business associates with the opportunity to reduce fines and penalties for violations of the HIPAA security rule.


On January 5, 2021, Congress passed an amendment to the HITECH Act that requires the OCR to take into account the Recognized Security Practices of covered entities and business associates when they are able to show that RSPs have been in use for the 12 months prior to a HIPAA breach incident.

If RSPs are in place, the OCR may mitigate fines and remedies and allow an early and favorable termination of an audit..

Over the past months, the amendment has generated questions related to the uncertainty about what constitutes RSPs, and how to demonstrate their implementation. In response, on October 31, 2022, HHS-OCR released a video that addresses some of these concerns about RSPs.

What Are Recognized Security Practices?

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Topics: HIPAA, security, compliance

Health System Ransomware Attack Lingers…

Posted by Scott Gima on 11/22/22 10:08 AM

CommonSpirit hospitals reported IT issues on October 3rd with a response that included taking systems offline, including their electronic medical records. CommonSpirit has 140 hospitals in 21 states.

According to, based on website information, hospitals in seven states have been impacted. Scheduling issues and procedure delays have been reported.

Systems being restored. On November 9, CommonSpirit announced that it continued to “work diligently to bring systems online and restore functionality as quickly and safely as possible, including electronic health records….” We know that, after the attack, many clinicians were unable to access medical records, and patient access to the MyChart portal was impacted.

Why it matters: There are no details on whether there has been a data breach of PHI – CommonSpirit says a forensic investigation is ongoing. But the news reports provide a clear picture of the operational impact that occurs in response to a ransomware attack – IT systems and applications have to be taken down to contain the impact or spread of the attack.

Security risk analysis and business continuity planning. A business continuity plan prepares your organization to respond quickly with temporary procedures and measures to continue key operational tasks and get systems back online as quickly as possible.

What to do: Identify and prioritize tasks that include but are not limited to electronic medical records (scheduling, documentation, orders, medications, and communication), communication, payroll, billing, collections, and food and supply ordering.

Every critical task must be reviewed to minimize patient risk. For example: a new medication order. What steps are now needed to get a new medication order from the physician to the bedside? Will human runners be needed? How and who will review, transcribe, and double check orders to prevent errors?

Email – don’t under estimate its impact. Business continuity takes a hit when email is inaccessible. Is your inbox your de facto “to do” list? Imagine how you are going to be able to tackle routine tasks without access to your inbox. Don’t overlook other email folders, as well as the inability to communicate by email for at least a couple of weeks if not longer….

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Topics: HIPAA, security, compliance

$5 Million hospice therapy false claims settlement

Posted by Scott Gima on 10/18/22 11:50 AM

A whistleblower complaint by a hospice employee led to a $5.59 million settlement. Allegations include:
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Topics: Compliance Basics, Penalties and Enforcement, false claims, hospice

Has your HIPAA security program addressed Callback Phishing?

Posted by Scott Gima on 8/30/22 8:45 AM

callback phishing

What is Callback Phishing?

CrowdStrike, a third-party cybersecurity firm, recently disclosed a new phishing tech support campaign. Hackers send out a fake email from a reputable cybersecurity firm (like CrowdStrike). The email falsely claims your business had a cybersecurity event and is working with the company’s security department to address a possible issue with the employee’s workstation. The letter asks the employee to urgently call a provided phone number to resolve the issue on their workstation.

If a call is made, the hackers will trick the caller into installing remote desktop software. Once given access, the hacker now has access to the user’s workstation and will attempt to move through the network to initiate a ransomware attack.


A New Version of an Old Scam

This tech support phishing attack is a new twist on an old scam. A May 2022 blog post discussed a FTC alert on Senior Tech Support Scams, which happened to a family member.

It is highly likely that these emails will get into an inbox because they contain no malicious links or attachments which diminishes the effectiveness of spam or anti-phishing filters.


Use your HIPAA training program to increase awareness

Training and education is the most effective method to prevent callback phishing attempts. A phishing reporting policy may be a worthwhile addition to your HIPAA and/or cybersecurity policies. Here are some simple training reminders:


  • Do not call the number provided. Assume any email from a well-known cybersecurity firm like CrowdStrike is a phishing email, especially if the email alleges a breach of your environment and requests an urgent call back.
  • Follow your organization’s phishing reporting policy. Call or forward the email to your Security Officer and/or IT department and let them handle the matter. If it is legitimate, they will let you know.
  • Pat yourself on the back, you just prevented a phishing attack.


Update your HIPAA Security Risk Analysis

Revisit and update your HIPAA Security Risk Analysis. Add callback phishing as a threat where appropriate. Document your anticipated mitigation strategies including training. Lastly, document when each mitigation effort has been implemented, and include dates so progress can be easily understood.

MPA can handle your HIPAA Security Risk Analysis

The HIPAA Security Risk Analysis is a lot to tackle. We all know it’s even more challenging to accomplish during COVID times. MPA can conduct your HIPAA Security Risk Analysis, saving you time and improving your security. Reply to this email to learn more information.

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Topics: Training and Education, HIPAA, security, risk analysis

Compliance lessons from recent fraud cases

Posted by Scott Gima on 7/20/22 9:15 AM


Outlier billing patterns will get you noticed!

A New York ENT physician was convicted of filing false claims with Medicare and Medicaid. The physician submitted claims totaling about $585,000 to Medicare and Medicaid and was paid roughly $191,000.

The fraudulent act was upcoding of ear exams or ear wax removal to an incision procedure of the external ear. An analysis of Medicare and Medicaid data identified this physician’s billing was an outlier and was found to be the highest biller for this procedure in the State of New York. 

Compliance lesson: Enforcement agencies are actively using data analytics to identify, investigate and prosecute providers with unusual billing activity – and so should you. Audit your claims regularly to identify potential false claims, so they can be corrected and/or reported.


Mole billing fraud scheme totals $4.1 million in false claims over 7 years

The second case involves a Chicago physician who conducted cancer screenings on moles that were removed from his patients. The US Attorney’s office in the Northern District of Illinois recently filed charges in the US District Court in Chicago. The press release includes the allegation that the physician removed more moles from patients than was medically necessary, totaling $4.1 million in fraudulent payments between 2015 and 2021.

But how does a simple case of removing one mole but billing for removing multiple moles leads to $4.1 million? Well, it turns out that the scheme was, shall we say, creative. Here is what was included in the charge document:

  • More moles were removed that were medically necessary
  • If multiple moles were removed from one area of the body, false documentation would be created to indicate that the moles were removed from different areas of the body
  • When multiple moles were removed from a patient, the specimens would not be submitted immediately to pathology
  • The practice would instead submit one specimen at a time to pathology on different days
  • False documentation was created to show the removal of a single mole on different visits
  • Some of the fraudulent visits were submitted on days when the physician was out of town
  • Fraudulent documentation was submitted in response to Medicare audits

That is how you collect $4.1 million in false claims over a seven-year period.

Compliance Lesson: Examples like this fall into the category of “truth is stranger than fiction.” It is impossible to draft policies and train staff on for every possible compliance risk scenario. The goal of an effective compliance program is to train employees and staff to trust their instincts – if something does not seem right, notify the compliance officer directly or anonymously.


How well is your compliance program performing?

Find out with MPA's compliance program assessments.

Learn more.

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Topics: Penalties and Enforcement, Billing and Claims Submission

Cold Hard HIPAA Stats: Where Do You Stand?

Posted by Scott Gima on 5/25/22 1:15 PM

HIPAA risks change constantly – and so must our response to them. The latest HIPAA statistics reveal how HIPAA risk is shifting (and increasing):

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Topics: HIPAA, security

Compliance Lessons from the Phillies: Own Your Mistakes and We’ve Got Your Back

Posted by Scott Gima on 5/17/22 8:45 AM

Alec Bohm, a third overall pick in the 2018 draft, is playing his third season with the Phillies. On April 11, against the Mets, Bohm was playing third base and committed three throwing errors early in the game. In the second inning, the Philadelphia fans mockingly cheered Bohm after a clean fielding play for an out. While walking back to third base, the TV broadcast captures Bohm telling shortstop Didi Gregorius, “I ****ing hate this place.”

Wow. Was he talking about the fans, the city, the situation right then and there? This is one of those “fork in the road” events that could turn a young player with a promising career into an exiled player. Just give social media the chance. The Phillies came back from a 4-run deficit to win the game with five runs in the 8th, which ironically started off with a walk to Bohm. But the comeback was clearly not the story of the game. In the clubhouse after the game, the reporters gathered around Bohm to hear what he had to say. Keep in mind that the video of what Alec Bohm said to his shortstop was not 100% clear. This is what he had to say:

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Topics: compliance

When Senior Tech Support Scams are a Cybersecurity/HIPAA Issue

Posted by Scott Gima on 5/10/22 9:45 AM

The FTC regularly sends out consumer alerts on various scams. Turbo Tax’s “free” tax service and car dealer junk add-on fees are just a couple of recent alerts. Many times, these emails hit the trash bin after reading the subject line. This morning, my inbox had the FTC’s latest alert: Shutting Down Tech Support Scams. This morning was different – I opened the email and read the alert. Why? Because an older family member was a victim of a tech support scam.

First, let me tell you about my family member’s experience with a tech support scam. Some of the facts have been changed to protect the family member’s identity. But to make it easier, let’s call my family member Mom. Mom and Dad are retired and in their 80s. A few years ago, my family went to Mom and Dad’s house for Thanksgiving. While there, other siblings and cousins are discussing possible Christmas gifts, so I jump on Mom’s computer to do a little online shopping.

In the bottom right-hand corner, the Windows task bar typically has a bunch of icons that show programs that are loaded on startup. Mom’s taskbar showed a TeamViewer icon. TeamViewer is a legitimate remote desktop program that is typically used by tech support people to obtain remote access to a workstation, computer or laptop. I recognized the icon because TeamViewer has been used by our own company’s tech support. But there is no reason for Mom to have this program on her home computer. So I start asking questions and this is what I learned.

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Topics: HIPAA, security

What the Russia-Ukraine Conflict Means for Your Cybersecurity

Posted by Scott Gima on 3/22/22 8:15 AM


I recently had a conversation with Scott Wolff, President and owner of LanServ, a St. Louis IT and managed service provider. Scott was a recent guest expert for a MPA webinar that discussed HIPAA Security Risk Assessment and cybersecurity.

I asked Scott if there has been an increase in cyber threat activity as a result of the Russian invasion of Ukraine. Surprisingly, Scott has so far found a significant decrease in hacker activity with his clients. Maybe all the hackers are focused on Russia and Ukraine, but regardless of the reason, it is very easy for organizations to let their guard down.

Coincidently, the same thing was discussed earlier this week with some members of Congress who received a briefing on the elevated Russia cyber threat to the US. Former Cybersecurity and Infrastructure Security Agency (CISA) Director Chris Krebs led the briefing which was closed to the public. The Washington Post was able to speak to Krebs after the briefing. He is worried about complacency. He told the Post “We have been talking with some alarm for weeks, if not months, about the potential Russian threat and fatigue is real and the desensitization to ongoing activities that are happening elsewhere is real.”

Krebs also stated: “the Russian cyberthreat as especially elevated now because Putin has already demonstrated he’s willing to cross Western red lines by invading Ukraine.”

I agree with Krebs. Just because cyberattacks have not yet occurred against the United States, organizational efforts to improve cybersecurity should continue and be responsive to new threats. This is especially true for critical infrastructure entities including health care providers.

I asked Scott Wolff, President/Director of IT Operations for LanServ, Inc., for his take on the situation:

The current reduction in cyber security events started a few weeks ago, and appears to coincide with the Russian invasion of Ukraine.  To many of us this may provide a much needed break from responding to the high volume increase in cyber security events over the last few years, and thus take the time to kick back and breathe a little bit. 

However, I am approaching this temporary reduction in events as a “quiet before the storm scenario.”  Currently, I am spending even more time than normal implementing additional security measures, as well as learning from the Russian cyber-attacks against Ukraine to build future cyber defenses should these same cyber-attacks be used against us.  There is no better time than now to assess your overall network system security, and user password hygiene before the storm potentially heads back this way.

What you can do

Discuss cyber threats with your IT team or managed service provider. The Cybersecurity and Infrastructure Security Agency (CISA) provides security updates and free resources. With a high threat level, now is the perfect time to update your HIPAA Security Risk Analysis.

Need more HIPAA help? MPA can help with t he HIPAA Security Risk Analysis.

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Topics: HIPAA, security, compliance

Healthcare Provider Ransomware Risk is Elevated – What Do We Do???

Posted by Scott Gima on 11/5/20 10:00 AM

On October 28, a joint cybersecurity advisory was issued by the Cybersecurity and Infrastructure Security Agency (CISA), the Federal Bureau of Investigation (FBI), and the Department of Health and Human Services (HHS) that provided a warning of imminent ransomware attacks to U.S. hospitals and healthcare providers.

This advisory provides technical information on the methods used by the hackers so healthcare providers can better protect themselves. In particular, the advisory mentioned the hackers’ use of Ryuk and Conti ransomware.

Leading up to this advisory, Universal Health Services was a recent target of a ransomware attack in late September. UHS is a large health care provider with 26 hospitals in the U.S., Puerto Rico and the U.K. It is believed that the Ryuk ransomware was used in the attack.

I don’t know about you, but for me, a non-IT person, the technical details are way over my head. However, the user awareness best practices are relevant to anybody who uses a workstation or laptop. Here are the user awareness best practices found in the advisory (direct quote):

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Topics: HIPAA, data breach, security, compliance

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