Since the inception of the Health Insurance Portability and Accountability Act in 1996, covered entities have had to navigate its murky waters.
Last year, the Department of Health and Human Services Office for Civil Rights filed 22 HIPAA resolution agreements totaling over $1.12 million in settlement fines. In the past two months, penalties have surpassed that number, with two settlements totaling $1.27 million. This trend points to HHS becoming more stringent with its enforcement. This could also be driven by increased ransomware attacks and opportunistic nation-state adversaries eyeing the industry as a target.
The HIPAA Security Rule has left many of us wanting more. The vague nature of the rule leaves much of the compliance requirements up for interpretation. It was written to ensure healthcare organizations are doing what is necessary to protect electronic protected health information – yet there is no explicit mention of penetration testing.
HIPAA is notorious for telling security leaders what needs to be done to achieve compliance without explaining how to get there. Let’s eliminate the gray area and examine penetration testing’s critical role in HIPAA compliance.
What is HIPAA pentesting?
Let’s start off with a harsh truth: There is no such thing as a “HIPAA pentest.” Though we often see the term used in marketing, pentesting has long been an unwritten component within the HIPAA Security Rule.
The following items within the administrative safeguards section touch on security testing criteria:
- Standard 45 CFR 164.308(a)(1)(i): Security management process. Implement policies and procedures to prevent, detect, contain, and correct security violations.
- Implementation specifications 45 CFR 164.308(a)(1)(ii)(A): Risk analysis (Required). Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity or business associate.
- Standard 45 CFR 164.308(a)(8): Evaluation. Perform a periodic technical and nontechnical evaluation, based initially upon the standards implemented under this rule and, subsequently, in response to environmental or operational changes affecting the security of electronic protected health information, that establishes the extent to which a covered entity's or business associate's security policies and procedures meet the requirements of this subpart.
Here, you will find standards and implementation specifications around workforce security, information access management, security awareness training, and contingency planning. These can be evaluated and validated through various offensive security engagements, such as pentesting, red teams, breach and attack simulation, or social engineering.
While HIPAA does a great job of highlighting the requirements clearly, here is a checklist to help you meet the needs of Security Rule.
HIPAA pentesting checklist
- Continuous penetration testing: HIPAA requires “periodic” evaluations, particularly in response to environmental or operational changes. The rate of change in healthcare environments has increased exponentially over the years. Continuous pentesting can take the form of more frequent tests enabled by a penetration testing as a service (PTaaS) delivery model or through an attack surface management platform. As a rule of thumb, critical moments of change could include version upgrades of software that houses ePHI or architecture changes. At the very least, perform penetration tests quarterly.
- Risk prioritization, with an emphasis on application security: Are you targeting the applications that pose the most significant risk to your sensitive health information? A pentest that meets HIPAA standards should continue beyond vulnerability discovery. Whether you are pentesting internally or working with a third-party partner, work together to identify which application pentests should be prioritized – and, more importantly, align on vulnerability severity definitions and remediation timelines based on your organization’s risk profile.
- Validation of security controls: It is important to note that pentests can and should be used to validate your security controls. Are your pentests alerting you to flaws and policy gaps within your identity and access management, threat detection, and other security controls implemented? Additionally, consider breach and attack simulation (BAS) platforms to help evaluate and improve the effectiveness of your detective controls.
- Comprehensive reporting and historical data: Standard 45 CFR 164.316(a) in the HIPAA Security Rule highlights policies, procedures, and documentation requirements. According to the standard, healthcare organizations must maintain a written record of each action, activity, or assessment. They also must retain documentation for six years from its creation.
The relationship between pentesting and privacy
HIPAA and other privacy regulations (GDPR, FERPA, CPRA) are in place to protect data from being exposed to unintended recipients. To accomplish this, all these require an organization's IT infrastructure to be secure.
As privacy regulations and standards have evolved, if you are compliant with PCI DSS and are HITRUST certified, you will likely be HIPAA compliant. Both are significantly more prescriptive and actionable than the HIPAA rules.
Pentesting is used to identify how a hacker can gain access to an environment and provide an organization with a roadmap to address those vulnerabilities and findings. It does not inherently make you secure; it makes you aware of your flaws.
With frequent pentesting, organizations can check that they have successfully remedied known issues and identify any new concerns due to new equipment, configuration changes, or even missed patches on software or hardware.
A proactive approach to HIPAA compliance
Security and IT teams should approach HIPAA with a foundational mindset. The requirements outline what you should already be doing and thinking about continuously.
Mature healthcare organizations have comprehensive vulnerability management and pentesting programs in place. Pentesting is a decisive first step towards compliance – when done right.
View the Complete Guide to Ransomware Attacks in Healthcare below: