Specializing in Healthcare Compliance

Compliance & Audit

Healthcare Compliance Isn’t Optional—It’s Mission-Critical

Whether your organization delivers hospice, palliative, geriatric, skilled nursing, or specialized care for veterans, individuals with disabilities, or pediatric populations—compliance is no longer a box to check. It is the foundation of your operational survival.

Today’s healthcare providers face an unprecedented level of scrutiny. If you bill Medicare, Medicaid, or private insurers, you are subject to aggressive enforcement by CMS, HHS, and private payers. That means:

Mandatory HIPAA compliance
Ongoing Security Risk Analyses (SRAs)
Full audit readiness
Adherence to NIST, HITRUST, and healthcare-specific documentation protocols

Failing to meet these requirements isn’t just a technical issue—it’s a direct threat to your funding, operations, and license to operate.

HCCP: National Compliance Support for Hospice Providers: Healthcare Compliance Certification Professionals (HCCP) exists solely to help hospice and post-acute care providers stay ahead of these evolving requirements.

We deliver national, concierge-level compliance certification services that equip healthcare organizations with the tools, documentation, and strategies required to:

Pass CMS, HHS, and private payer audits
Achieve and maintain HIPAA compliance
Conduct and remediate Security Risk Analyses (SRAs)
Align with NIST, HITRUST, and privacy mandates
Protect Medicare and Medicaid reimbursement
Sustain operational and financial integrity

Our team partners directly with provider leadership, compliance officers, and MSPs to embed regulatory discipline into your operations—ensuring that your organization is structured, documented, and prepared to stand up to oversight.

Compliance = Revenue Protection

In today’s regulatory environment, noncompliance leads to consequences:

Payment suspensions
Civil monetary penalties
Involuntary termination from Medicare or Medicaid programs

Even a single documentation lapse or outdated risk assessment can trigger a full-scale audit.

At HCCP, we don’t believe in one-size-fits-all checklists. Every provider receives tailored attention, structured support, and high-accountability guidance to secure compliance and defend funding.

To Get Paid by Medicare/Medicaid, Providers Must:

✅Conduct a current Security Risk Analysis (SRA)
✅ Be fully HIPAA-compliant
✅Maintain audit-ready documentation
✅Follow strict data security, privacy, and reporting protocols

HIPAA – Required

HIPAA: Two Core Rules Driving Compliance & Cybersecurity

HIPAA Privacy Rule
Governs the permissible uses and disclosures of PHI, ensuring patient rights and confidentiality.
HIPAA Security Rule
Requires Covered Entities and Business Associates to implement a comprehensive framework of safeguards for electronic PHI (ePHI):

✅ Formal risk assessments

✅ Strong access controls and user authentication

✅ Encryption of data in transit and at rest

✅ Defined incident response and breach

✅ Ongoing workforce training

✅ Written breach notification protocols

Your Risk Is Real. Your Response Must Be Decisive.

The failure to meet even one of these obligations can result in:

Audit findings
Funding suspension
Civil monetary penalties
Public breach notifications
Termination from Medicare/Medicaid participation

At Healthcare Compliance Certification Professionals (HCCP), we don’t just identify gaps—we close them. We operationalize compliance, train your workforce, prepare your documentation, and ensure your organization is both audit-ready and breach-resilient.

CMS Safeguards – Required

Compliance Isn’t Optional—It’s a Federal Mandate

If your hospice organization receives reimbursement from Medicareor Medicaid, you are legally required to implement and maintain robust administrative, technical, and physical safeguards to protect Protected Health Information (PHI) and electronic PHI (ePHI).

These requirements are not advisory—they are binding conditions of participation under federal law.

CMS mandates strict compliance with:

HIPAA Privacy, Security, and Breach Notification Rules
Regulating the use, disclosure, and safeguarding of patient health information.
The HITECH Act
Expands HIPAA by mandating breach notification, increasing federal enforcement authority, and authorizing tiered civil monetary penalties for noncompliance—up to $1.9 million per violation category, per year.
42 CFR Part 2
Requires additional privacy protections for substance use disorder (SUD) treatment records—above and beyond standard HIPAA provisions—impacting many palliative and hospice care settings.
Periodic Security Risk Analyses (SRAs)
Required under HIPAA, the HITECH Act, and CMS's Promoting Interoperability program. These risk assessments must be current, documented, and address evolving cyber threats and system vulnerabilities.

CMS Reimbursement

What Medicare & Medicaid Require for Reimbursement

Healthcare providers that receive Medicare or Medicaid reimbursement must meet strict federal compliance standards—these are enforced by CMS (Centers for Medicare & Medicaid Services), HHS (U.S. Department of Health and Human Services), and the OCR (Office for Civil Rights). These requirements are not optional—failure to comply can lead to denied claims, recoupments, civil penalties, or exclusion from government programs.

What’s at Stake: Enforcement, Penalties, and Funding Risks Noncompliance is not a technicality—it’s a regulatory violation with measurable financial and operational consequences. Providers that fail to meet these requirements may face:

Civil monetary penalties (CMPs) issued by the HHS Office for Civil Rights (OCR)
Loss of Medicare/Medicaid eligibility
CMS or state-level recoupment of funds
Public breach notifications and reputational damage
Increased frequency of audits, corrective action plans, and long-term oversight

HIPAA Compliance (Mandatory)

HIPAA is a condition of participation in all CMS programs. To remain eligible, providers must protect patient health data (ePHI/PHI), implement administrative, physical, and technical safeguards, and maintain up-to-date privacy and access control policies. Conducting and documenting a Security Risk Analysis (SRA) is a foundational HIPAA requirement.

Security Risk Analysis (Mandatory)

An annual SRA is required under the HIPAA Security Rule and Promoting Interoperability programs. Providers must identify and document risks to ePHI, implement mitigation plans, and show ongoing security improvements. A missing or outdated SRA can result in incentive loss or compliance penalties.

HITECH Act Compliance (Mandatory)

The HITECH Act strengthens HIPAA by tying EHR usage to compliance. It requires providers to report breaches, maintain audit trails, and encrypt protected health data—ensuring accountability in electronic systems.

Requirements & Strongly Recommended

Breach Notification Rule – Required

Under HIPAA and HITECH, any breach involving 500+ individuals must be reported to:
- HHS within 60 days
- Affected individuals
- Sometimes the media

NIST Cybersecurity Framework (NIST CSF) – Strongly Recommended

Referenced in HIPAA Security Rule guidance as a best practice.
Used to:
- Identify and manage cybersecurity risks
- Improve infrastructure protection
- Prepare for audits and cyber events

CMS encourages alignment with NIST standards, especially NIST SP 800-53 and NIST SP 800-66 Rev. 1 (which maps directly to HIPAA).

What’s Not Federally Required—but Increasingly Expected

In today’s healthcare environment, many private payers, insurers, and strategic partners expect providers to adopt enhanced cybersecurity and compliance frameworks—even when they aren’t federally mandated.

NIST 800-53 / 800-66 – Aligns with HIPAA; commonly referenced in audits and by partners
HITRUST CSF – A widely accepted framework, often required by payers and business associates
SOC 2 / ISO 27001 – Optional, but demonstrates a mature security posture for organizations working with sensitive data

Mandatory Rules

CMS Program Integrity Rules (Mandatory)

Providers must implement programs to detect and prevent fraud, waste, and abuse, and ensure timely, complete, and accurate documentation. CMS requires breach reporting procedures, FWA training, and strong data security practices. Noncompliance can lead to investigations, fines, or criminal charges.

Audit Readiness (Mandatory)

Providers must be ready for CMS and HHS audits—including TPE, RAC, UPIC/ZPIC, and HIPAA audits. Readiness includes maintaining compliance documentation, risk assessments, workforce training records, incident response plans, and Business Associate Agreements (BAAs).

State Medicaid Requirements (Mandatory, Varies by State)

Medicaid providers must also meet state-specific security and health IT standards, which may include additional encryption policies, data-sharing agreements, or state-level compliance programs.

OCR and CMS Audits – Required Compliance

Both random and complaint-driven audits check for:
- Security risk analysis documentation
- Policies and procedures
- Business Associate Agreements
- Employee training logs
- Breach response and documentation

Eligible & Compliant

To remain eligible and operational, healthcare providers must meet key compliance and security requirements established by HHS, CMS, and OCR to avoid audit failures, financial penalties, and the loss of Medicare and Medicaid funding.

Conduct Annual HIPAA Security Risk Analyses (SRAs) to identify vulnerabilities and update controls.
Establish and Maintain Policies & Procedures for HIPAA Privacy, Security, and Breach Notification.
Train All Staff Annually on HIPAA, cybersecurity, and incident response—before they access PHI.
Maintain Comprehensive, Accurate Documentation for patient care, billing, and compliance activities.
Implement Access Controls & Maintain Audit Logs to track all PHI access.
Ensure Billing and Coding Compliance using accurate CPT/ICD codes and justifiable services.
Perform Regular Internal Audits to proactively catch and correct compliance gaps.
Maintain Audit Readiness with organized records available for routine, unannounced, or investigative audits.
Secure Valid Business Associate Agreements (BAAs) with all vendors handling PHI.
Encrypt Data and Secure Backups for PHI at rest and in transit, with routine restoration testing.
Stay Updated on Regulatory Changes from HHS, CMS, and OCR and adjust practices accordingly.
Establish a Documented Incident Response Plan with clear timelines and notification protocols.

Special Note

Recent audits by the U.S. Department of Health and Human Services (HHS) have revealed that over 80% of covered entities and business associates failed to conduct a proper Security Risk Analysis (SRA), a critical requirement under the Health Insurance Portability and Accountability Act (HIPAA).

While specific data on the percentage of healthcare providers failing Medicare audits solely due to incomplete SRAs, the high failure rate in SRAs suggests a significant compliance gap that could impact audit outcomes.

It's important to note that failing to perform or adequately document an SRA can lead to substantial consequences, including financial penalties and the loss of Medicare and Medicaid funding. For instance, organizations that did not meet the Meaningful Use or Merit-based Incentive Payment System requirements due to inadequate SRAs faced significant reimbursement penalties.

Given these findings, healthcare providers should prioritize conducting comprehensive and up-to-date SRAs to ensure compliance and safeguard their funding sources.

HCCP provides national, non-clinical compliance and certification support services exclusively to hospice providers, including HIPAA, Security Risk Assessments (SRA), Medicare documentation, staff training, and audit preparedness. Based in Maryland.

HCCP does not provide medical care and operates independently from the Centers for Medicare & Medicaid Services (CMS), the U.S. Department of Health and Human Services (HHS), and other regulatory agencies. Our role is to help hospice organizations meet and maintain Medicare compliance standards with confidence, clarity, and accountability.