What Is the Minimum Necessary Rule In HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) exists to protect patient information and keep their most personal details private.

It places limits on sharing between providers and contractors and sets a standard for cybersecurity to protect data from hackers. The rules themselves are broad and often vague. Still, several standards guide HIPAA enforcement that makes the legislation more straightforward.

HIPAA’s minimum necessary rule is one of those guiding concepts. The concept pops up throughout the legislation as it relates to protected health information (PHI) kept and stored.

What is the HIPAA minimum necessary rule and what does it mean for your business? Keep reading to find out.

What Does Minimum Necessary Mean?

Unlike much of HIPAA, “minimum necessary” comes with a formal definition applied every time the legislation uses the word.

Here’s what the law says word-for-word:

“A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of protected health information need to accomplish the intended purpose of the use, disclosure.”

Why Does HIPAA Use the Minimum Necessary Rule?

An unfathomable amount of personal data exists in the health care system, and much of it gets shared between Covered Entities and Business Associates.

The minimum necessary standard principle tries to prevent HIPAA violations by stopping the flow of unnecessary information in the first place. In other words, a provider can’t wrongfully disclose data or accidentally create a breach if they don’t share the data in the first place.

HIPAA’s rule impacts both data collection and data sharing. For example, a patient intake form should not include questions about the patient’s salary or financial status unless required for treatment. The information is unnecessary and could damage the patient’s privacy.

Alternatively, doctors cannot share patient details with doctors who are not participating in the treatment of that patient. The rule applies even if the second doctor works within the same organization or even department the patient access treatment in.

No one outside the treatment team should have an opportunity to access the data on their own unless given privileges, usually to participate fully in caring for the patient.

How the Rule Works

Upholding the minimum necessary rule is up to you and your organizational policies. Here’s where things get tricky.

Healthcare organizations must create and implement the appropriate policies and complementary procedures that:

  • Reflect its practice
  • Make sense for its workforce
  • Work with security practices

Each organization’s policies differ according to the scope and scale of operation. However, the systems should always identify three principles: who requires access to PHI, what PHI they need, and when access is justifiable under the law.

Are There Exceptions to the Minimum Necessary Rule?

Yes, exceptions to the rule apply in specific scenarios. However, rather than thinking of them as exceptions, it’s easier to switch your mindset to thinking of them as being unregulated by the rule because all other HIPAA rules still apply.

If you participate in one of the following scenarios, the minimum necessary rule doesn’t impede your ability to share files:

  • Requests from health care providers treating the patient
  • Requests from the individual who owns the data (the subject of treatment)
  • Requests from the subject patient’s authorized representative
  • Uses specifically authorized by the patient in the file
  • Investigatory requests from the Department of Health and Human Services during enforcement, complaint, or compliance procedures
  • Disclosures mandated by law
  • Disclosures required by HIPAA Transactions Rule

In all other cases or when there is reasonable doubt, use the minimum necessary rule.

Creating a Minimum Necessary Policy

Adherence to the law and protecting patients mandates a dedicated minimum necessary rule policy. Each policy is unique to the organization or department depending on its size, scope, and technology deployed.

However, the policy text should include several essential parts including:

  • Rationale
  • When the rule applies
  • When the rule no longer applies
  • Access to PHI by organizational workforce
  • Disclosure policy
  • Definitions
  • Contact

Here’s what you might include in each piece of the policy text:

Rationale

State in clear terms why the system exists and the reasoning for the policy.

When the Rule Applies

Cover the three HIPAA circumstances when the rule applies including:

  • Internal use
  • External use
  • Covered entity exchanges

Add in rules that apply within your organization for a comprehensive look.

When the Rule No Longer Applies

Note each of the scenarios where the rule does not apply. These scenarios are listed earlier in the text above.

Access to PHI by the Workforce

The access or use section should outline each group of health care workers and their access or use rights. Be sure to add coverage for each of the following groups when applicable:

  • Physicians
  • Nursing staff
  • Ancillary staff
    • Medical assistants
    • Support staff
    • Laboratory staff
    • Pharmacy staff
  • Administrative staff
    • Health information management
    • IT
    • HR
    • Compliance
    • Administrative staff
    • Business offices
    • Quality assurance
  • Students
  • Authorized individuals in the organized health care arrangement (OHCA)
  • Researchers
  • Authorized business associates

Add an addendum to the section noting that the list is not inclusive and modifications may occur as necessary.

Note who in the organization holds responsibility for identifying and notifying workforce members about access. Often, the Chief Medical Information Officer (CMIO) completes this task. Add a section outlining the relevant person’s authorities and job duties

Disclosure Policies

Your organization should already have a PHI disclosure policy in place. Include it here for added clarity.

Definitions

Define any essential terms used. Include HIPAA terms like covered entity, protected health information, and minimum necessary in addition to local terms and acronyms.

Contact

Add the HIPAA Compliance office or any other relevant contact details to the policy.

Moving Forward

The minimum necessary rule protects patients by limiting the sharing of information between parties. It’s a useful standard that all healthcare workers should ask themselves before working with data.

Avoiding HIPAA violations and upholding the minimum necessary standard requires a straightforward policy. Do you have questions about creating a policy that suits your organization? Contact us with questions. We’re here to help.

HIPAA Security Reminders

 

HIPAA Security Suite has developed a weekly HIPAA Security Reminder series that’s FREE for all of us who are responsible for, or engaged in, the use and protection of PHI.

Pursuant to Section 164.308(a)(5) of the HIPAA Security Rule, the Standard states: Implement a security awareness and training program for all members of its workforce (including management).

This standard is part of our Best Practices Recommendations for HIPAA Security Suite users, but it’s available for FREE to anyone who wants to comply with HIPAA using the easiest, best tools available.

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