In enacting HIPAA, Congress mandated the establishment of Federal standards for the privacy of individually identifiable health information. Under the patchwork of laws existing prior to adoption of HIPAA and the Privacy Rule, personal health information could be distributed—without either notice or authorization—for reasons that had nothing to do with a patient's medical treatment or health care reimbursement. For example, unless otherwise forbidden by State or local law, without the Privacy Rule patient information held by a health plan could, without the patient’s permission, be passed on to a lender who could then deny the patient's application for a home mortgage or a credit card, or to an employer who could use it in personnel decisions. The Privacy Rule establishes a Federal floor of safeguards to protect the confidentiality of medical information. State laws which provide stronger privacy protections apply over and above the new Federal privacy standards.
Applies to all members of the UW-Madison Health Care Component.
This policy addresses noncompliance by employees with UW-Madison’s policies and procedures governing the confidentiality of protected health information under the HIPAA Privacy and Security Rules. For purposes of this policy, the term “employee” includes students in their role as employees (e.g., student hourly, student assistant). For example, a student who is employed as a student hourly to answer phones in a clinical department would be considered an employee.
It is the policy of UW-Madison to take appropriate steps to promote compliance with the requirements for maintaining the confidentiality of protected health information. UW-Madison takes seriously its requirements under HIPAA to protect the confidentiality of protected health information and will respond appropriately to violations of UW-Madison HIPAA policies and procedures.
The appropriate response to such violations will depend on a number of factors including the severity of the violation, the record of the employee, the applicable processes for the employment category, and whether another affiliated entity (e.g., University of Wisconsin Hospital and Clinics, University of Wisconsin Medical Foundation) is responding to the same violation by the same person. The response will be decided after investigating the specific facts of the situation and may include, but is not limited to, such actions as: system changes, additional education, a written reprimand, a suspension, and termination of employment.
Employees and others who are working in UW-Madison facilities who report, in good faith, violations of HIPAA policy requirements shall not be retaliated against. They may report any retaliation to their department chair/director, the dean/director, the Office of Human Resources or the UW-Madison Privacy Officer. If reported to anyone other than the Privacy Officer, it shall be referred to the Privacy Officer. The Privacy Officer shall determine who will investigate the matter.
Failing to comply with this policy may result in discipline for the individual(s) responsible for such non-compliance.
Further, the US Department Health and Human Services (HHS) Office for Civil Rights (OCR) is responsible for enforcing the HIPAA Privacy and Security Rules, and an individual’s non-compliance may result in institutional non- compliance and/or an investigation by OCR. OCR attempts to resolve investigations by obtaining voluntary compliance and entering into Corrective Action Plans and Resolution Agreements. Failures to comply with HIPAA or cooperate with OCR in an investigation may result in civil and/or criminal penalties.
Additional information may be found at www.compliance.wisc.edu/hipaa
09-13-2014: Effective date of the revised policy: 09-13-2014.
03-26-2020: Effective date of the revised policy: 03-26-2020.