What is the HIPAA Minimum Necessary Standard?

September 2, 2024

Table of Content

• Introduction 
• What is HIPAA’s minimum-necessary Standard?
• Understanding PHI
• Who Needs to Be HIPAA-Compliant?
• What does it mean to follow the minimum necessary standard?
• How Does the Minimum Necessary Requirement Rule Work?
• How Can You Comply with HIPAA Minimum Necessary Standard Rule?
• When does the HIPAA minimum necessary standard not apply?
• Who Determines the Minimum Necessary Standard?
• Stay Compliant and Spread Awareness

Did you know that the healthcare industry is one of the most vulnerable sectors when it comes to data breaches and cyber-attacks? If a healthcare organization fails to meet the minimum necessary standard, it could face fines of $50,000 or more. In fact, penalties for HIPAA violations can cost over $1500000, based on the type of breach. For instance, the largest American health data breach exposed the PHI of nearly 79 million people, resulting in an expensive fine of $16 million. 

In today’s digital landscape, healthcare providers have access to an abundance of patient information. However, it doesn’t mean that every healthcare provider needs access to all patient information all the time. This is where the HIPAA Minimum Necessary Rule comes into the picture.

The HIPAA minimum necessary standard applies to maintain the integrity of all healthcare services by safeguarding patient’s privacy. But what is the minimum necessary rule, and how can you comply with it? Read on to find out.

What is HIPAA’s minimum-necessary Standard?

The HIPAA Minimum Necessary Standard is a requirement under the Health Insurance Portability and Accountability Act (HIPAA) for covered entities and businesses associated with limiting/ceasing the use, disclosure, and request of PHI (Protected Health Information) to the minimum necessary to achieve the intended purpose. 

HIPAA compliance is regulated by the Department of Health and Human Services (HHS) and enforced by the Office for Civil Rights. 

Understanding PHI

PHI, or Protected Health Information, is any demographic information that can be used to identify a client or patient of a HIPAA-regulated entity. Common parameters of PHI include names, addresses, phone numbers, social security numbers, medical records, financial information, and full facial photos, among others.  PHI, when transmitted, stored, or accessed electronically as EHR (Electronic Health Records), also falls under the HIPAA regular standards. 

Read More: What is Protected Health Information? 

Who Needs to Be HIPAA-Compliant?

The HIPAA minimum necessary standard applies to two types of organizations,

Covered Entities 

 A Covered Entity is any facility or related organization that collects, crates, or transmits PHI electronically. Healthcare organizations that are considered to be covered entities include healthcare providers, healthcare clearinghouses, and health insurance providers.

Business Associates 

 A Business Associate is defined as any organization that encounters PHI in any way throughout the work that it has been contracted to perform on behalf of the particular covered entity. There are various examples of businesses associated with their wide scope of services. It includes handling, transmitting, or processing PHI. Some common examples of business associates are,

• Billing companies
• Practice management firms
• Third-party consultants
• EHR (Electronic Health Record) Platforms
• IT Providers
• Faxing Companies
• Shredding Companies
• Physical Storage Providers
• Cloud Storage Providers
• Email Hosting Services
• Attorneys
• Associates

What does it mean to follow the minimum necessary standard?

As a healthcare organization, a part of a covered entity, or a business associate, you must develop and implement policies and practices that are appropriate for your organization and reflect your business practices and workforce. The policies and procedures must identify who needs access to PHI to carry out their job role, the categories of PHI required, and the conditions where the access is suitable.

For instance, a hospital can permit the doctors, nurses, or others involved in the treatment to have full access to the patient’s medical record. When the entire medical record is given access to any other individual, the organization’s policies and procedures must state it so explicitly with legible justification. 

How Does the Minimum Necessary Requirement Rule Work?

The minimum necessary rules guide healthcare providers to comply with HIPAA standards. They require covered entities and business associates to limit the use, disclosure, and request of PHI (Protected Health Information) to the minimum necessary to yield the intended purposes. Here’s how the rule works in practice.

• Evaluation of PHI—Covered entities must evaluate their practices and identify the minimum amount of PHI necessary to perform a particular activity or function. This means that only those specific individuals or departments need access to PHI.
• Job Responsibilities—Access to PHI must also be limited according to your job’s responsibilities. The covered entities must assign the roles and responsibilities to workforce members and grant access to PHI only to the individuals who require it to perform their jobs.
• Unique User Identifications – Covered entities should also implement unique user identification for every workforce member to help them track access to PHI.
• Audit controls—The covered entities should also implement audit controls periodically to monitor the individuals who have access to PHI. This will help them identify any unauthorized access to PHI and address potential security breaches immediately.
• Authorization – The covered entity must obtain proper authentication from patients before using or disclosing their PHI, except for certain purposes or indices, including treatment, payment, or healthcare operations.

Overall, the minimum HIPAA necessary rule is designed to protect the privacy and security of PHI while allowing entities and business associates to perform essential functions. By limiting access to the records, you can readily reduce the risk of data breaches and unauthorized disclosures while maintaining the patient’s trust and confidentiality. 

How Can You Comply with HIPAA Minimum Necessary Standard Rule?

Under the HIPAA minimum necessary standard, the terms ‘reasonable’ and ‘necessary’ are open to interpretation. Your organization should determine what information should be kept private and what should need restricted access under proper justification. However, to ensure that you are complying with the standard regulations, there are some basic steps to follow.

• Conduct a Risk Assessment—Identify and assess the risks associated with the use and disclosure of PHI within the organization. This will help you decide which information is necessary to perform specific functions and how to limit access to the record.
• Develop Policies and Procedures—Establish precise policies and procedures that reasonably limit the use, disclosure, and request of PHI to the minimum necessary to accomplish a specific task or activity. The policies must be communicated to every professional in the workforce and updated whenever necessary.
• Train workforce—Train every member of the workforce, including employees, contractors, and volunteers, regarding the HIPAA minimum necessary rules and regulations and your policies and procedures. Proper HIPAA training will ensure that everyone has a better understanding of their role and responsibility in safeguarding PHI.
• Implement Technical Protection—Implement technical protective measures, such as controls and audit trails, to protect PHI. This will assure your organization that only authorized individuals will have access to the PHI and notify you immediately about any unauthorized access or disclosure.
• Review and Revise Policy—Regularly review and revise your organization’s policies and procedures to ensure they are up-to-date and effective. This includes periodic risk assessments and training sessions to address any new risks or changes within the entity.
• Document Compliance—As a last step, make sure to properly document every action implemented to comply with the HIPAA minimum necessary rule. This will help you demonstrate your dedication to compliance in the event of an audit or investigation. 

When does the HIPAA minimum necessary standard not apply?

Certain exceptions to HIPAA apply to specific scenarios. However, rather than thinking of them as exceptions, it’s simple to think of them as unregulated by the rule because every other HIPAA rule still applies. 

If you engage in one of the following scenarios, the HIPAA minimum necessary rule will not impede your ability to share files. 

• Requests from healthcare providers treating the patient
• Request from the individual who has the ownership of the data (the primary subject of the treatment)
• Requests from the subject patients’ authorized representative.
• Uses specifically authorized by the particular patient in the file. 
• Investigatory requests from the Department of Health and Human Services during enforcement, complaint, or compliance procedures.
• Disclosures mandated by law.
• Disclosures required by HIPAA transaction rule. 

Who Determines the Minimum Necessary Standard?

Under specific circumstances, a covered entity may rely on the judgment or decision of its business associates or other parties to require the disclosure of the minimum information that is required. In layman’s terms,  the HIPAA minimum necessary standard applies to covered entities depending on the other parties concerning the minimum necessary standard. The reliance is permitted, but it should be reasonable under certain circumstances. It includes,

• Another covered entity making the request
• A public agency or official stating that the information required is the minimum necessary for public health purposes
• A request from a professional member of the reputable workforce or a business associate of a covered entity who states the data is required as a minimum necessary source for legible purposes.
• An authentic researcher requesting the information with appropriate documentation from the privacy board or an institutional review board (IRB).

Read More: The HIPAA Minimum Necessary Rule Standard

Stay Compliant and Spread Awareness

Privacy and confidentiality are the two most important pillars of patient safety. Adhering to the minimum standard will help your team remain compliant year-round and avoid devastating financial repercussions. Through a series of interlocking regulator rules, the HIPAA minimum necessary standard applies to the living culture of healthcare organizations to protect the privacy, security, and integrity of protected health information.  

 Remember, when you take the appropriate steps to comply with HIPAA, you will not only be able to avoid the risk of data breaches, but you will also build trust with your patients!