Health Information Management

What are our duties, if any, if we believe that one of our business associates has misused PHI?

HIPAA Weekly Advisor, May 23, 2003

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Q: What are our duties, if any, if we believe that one of our business associates has misused PHI?

A: The regulations require that a covered entity take steps to cure the breach or end the violation when it knows of a pattern of activity or practice that constitutes a material breach or violation of the business associate obligations under the contract. A covered entity is not responsible or liable for the actions of its business associates.

If such steps are unsuccessful, the covered entity must

  • terminate the contract, if possible
  • report the problem to HHS, if the contract cannot be terminated

HHS commentary in the privacy rule notes that "knowing" means a covered entity has substantial and credible evidence of a violation. HHS also notes that although this standard relieves the covered entity of the need to actively monitor its business associates, a covered entity nonetheless is expected to investigate when they receive complaints or other information that contain substantial and credible evidence of violations by a business associate, and it must act upon any knowledge of a violation.

HHS does not have the statutory authority to hold business associates liable under the regulations.

Editor's note: Brought to you by attorneys Marty Baxter and Gretchen McBeath at Bricker and Eckler, LLP and The Quality Management Consulting Group, Ltd.. E-mail: mbaxter@bricker.com or gmcbeath@bricker.com



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