Navigating the NEXT phase of OCR HIPAA Desk Audits: What You Need to Know
February 17, 2025
OCR has resumed HIPAA desk audits—learn what to expect, how to prepare, and why proactive compliance is your best defense.
Compliance Services
HIPAA Compliance
News & Trends
In February of 2024, the Office for Civil Rights (OCR) under the Department of Health and Human Services (HHS) announced it will conduct periodic HIPAA audits again to ensure compliance with the Privacy, Security, and Breach Notification Rules. Among these, desk audits have become a key tool for evaluating covered entities (CEs) and business associates (BAs).
What Are OCR Desk Audits?
Desk audits are remote evaluations in which OCR requests specific documentation from selected organizations to assess their compliance with HIPAA regulations. Unlike on-site audits, these are conducted entirely online through OCR’s secure portal. The focus is on policies, procedures, and evidence of compliance with HIPAA rules, such as risk assessments, breach notifications, and privacy practices.
Who Can Be Audited?
Both covered entities (i.e., healthcare providers and health plans) and their business associates (i.e., vendors handling protected health information) are eligible for desk audits. Selection can be random or triggered by complaints, reported violations, or other enforcement activities. OCR uses pre-audit screening questionnaires to gather information about potential auditees.
What to Expect During a Desk Audit
Notification: Organizations selected for an audit will receive an email notification from OCR. It’s crucial to monitor your inbox and spam folders for communications from designated OCR email addresses.
Document Submission: Audited entities must submit requested documentation within 10 business days through OCR’s secure portal.
This may include:
- Risk assessments and management plans
- Policies and procedures
- Breach notification letters
- Business associate agreements (BAAs)
- Employee training records
Review Process: OCR auditors analyze the submitted materials to assess compliance. Draft findings are shared with the auditee, who can provide written responses before the final audit report is issued.
How to Prepare for a Desk Audit
Conduct Regular Risk Assessments: Ensure your organization has an up-to-date risk analysis that identifies vulnerabilities and outlines mitigation strategies.
Review Policies and Procedures: Regularly update your HIPAA policies to reflect current practices and regulatory requirements. Ensure they are well-documented and implemented effectively.
Train Employees: Provide comprehensive HIPAA training to all staff members and maintain records of their participation.
Organize Documentation: Keep all compliance-related documents easily accessible, including BAAs, breach logs, and incident response plans.
Prepare for Pre-Audit Screening: Practice filling out OCR’s pre-audit questionnaire to ensure you can provide accurate information promptly if selected.
Key Takeaways
The OCR HIPAA desk audit program is designed not only to enforce compliance but also to identify areas where organizations may need additional guidance. By proactively maintaining robust compliance programs, organizations can reduce risks while demonstrating their commitment to safeguarding protected health information.
Staying prepared is essential—desk audits can happen at any time, and the timeline for response is tight. With proper planning and regular reviews of your HIPAA compliance efforts, your organization will be well-equipped to navigate an audit successfully.
Don't wait for an audit notice—take control of your HIPAA compliance now. Review our expert insights and ensure your organization is prepared for an OCR desk audit.
