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Is HIPAA enforcing risk analysis more strictly? What small practices need to know

Written by Hushmail | Nov 18, 2025 9:11:34 PM

Estimated reading time: 13 minutes.

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If you run a small or solo practice, HIPAA can feel like one more thing on your plate. You might think enforcement only affects large hospitals or insurers, but that needs to change. Regulators are paying close attention to smaller practices, too.

Enforcement is up across the board, with small practices now firmly in scope. The message from OCR is clear: all healthcare providers, including solo practitioners, must meet the same security standards.

In October 2024, OCR launched a new "risk analysis initiative" specifically designed to audit whether practices are assessing their security risks, one of the most common areas where practices stumble. Combined with proposed Security Rule updates, the regulatory landscape is shifting toward stricter compliance requirements and enforcement.

The good news?

A few simple steps can protect your clients' data and your peace of mind. You don't have to become an IT expert overnight, but regulators do expect you to take concrete steps to protect client information.

This guide will show you exactly what these enforcement trends mean for your practice, what changes are coming, and how simple tools like Hushmail can help you meet key safeguards without overwhelming your existing workflow.

TL;DR: Risk analysis has always been required under HIPAA, but OCR is now enforcing the requirement more strictly. New audits focus on whether small practices are conducting, documenting, and updating their risk assessments. A simple annual review and clear documentation can keep your practice compliant and stress-free.

Table of contents

HIPAA enforcement is increasing. Here's what the numbers show

Last year wasn't kind to healthcare practices that ignored HIPAA requirements. OCR closed 22 enforcement actions with penalties in 2024, collecting $9.9 million, making it the second-highest year in the agency's history.

The good news? Most penalties stem from missing simple, preventable steps, such as not encrypting email or skipping annual risk assessments. You don't need a massive IT department to avoid these fines. You just need to understand what OCR is looking for to show compliance.

👉 Learn more: How to do your HIPAA risk assessment (with template)

Since launching the Risk Analysis Initiative in October 2024, OCR has settled eight enforcement actions, collecting nearly $900,000. While many of these investigations began before the launch of the Initiative, the settlements underscore that failing to conduct and document a risk analysis adequately can lead to enforcement action.

This focused effort is part of a broader trend. The OCR has been increasing its oversight of HIPAA through initiatives such as the Right of Access Initiative, which enforces patients' rights to obtain copies of their records, and the newer Risk Analysis Initiative, focused on preventing data breaches. Size doesn't grant immunity. Even small practices are on the radar.

Small practices are facing fines too: real examples from OCR cases

Let's be clear about who's getting fined. These aren't just massive hospital systems. They're practices just like yours.

In 2020, Dr. Steven Porter, a solo gastroenterologist, was fined $100,000 and entered a 2-year corrective action plan for failing to conduct a risk analysis. This remains one of the clearest examples of how missing basic documentation can lead to severe penalties for a single-provider practice.

More recent cases show the same pattern:

  • Comprehensive Neurology, PC, a small neurology practice, paid $25,000 and entered into a 2-year corrective action plan after ransomware affected all of its patients' records.
  • Vision Upright MRI in California is a small radiology practice. After 21,778 patients' images were exposed on an unsecured server, they paid a $5,000 fine and entered into a 2-year corrective action plan.
  • Deer Oaks Behavioral Health agreed to a $195,000 settlement and a 2-year corrective action plan. Investigators identified gaps in their risk analysis and documentation.

đź’ˇ What do these cases have in common? Every practice failed to conduct a proper risk analysis and document the results before the incident.

These numbers might feel overwhelming, but remember: every practice that got fined was missing basic protections that you can implement this week. You don't need to be perfect; you need to show you're trying.

The real costs of a HIPAA fine go beyond money

Beyond the financial penalty, here's what really happens when OCR issues a fine and you are required to enter into a corrective action plan:

  • Years of government oversight: OCR monitors everything you do, requiring proof of compliance throughout your corrective action plan. It typically lasts 2 to 3 years.
  • Quarterly paperwork: Every 3 months, you must submit detailed reports showing you're following their plan, with documentation proving every security measure is in place.
  • Time drain: Hours spent on compliance documentation for the OCR instead of billable client care.
  • Additional costs: Many practices need to hire lawyers and consultants to deal with the OCR and to manage the reporting requirements, adding thousands more to the true cost of non-compliance.

“The financial penalty is just the beginning. What really impacts small practices is the ongoing oversight and documentation burden. I've seen solo practitioners spend 10-15 hours per quarter just on compliance reporting for years after a settlement. That's time they could have spent with clients.”

Margaret Hales, J.D., CEO of ET&C Group LLC and The HIPAA E-Tool

What OCR looks for in a HIPAA risk analysis

When OCR says they expect an "accurate and thorough assessment of potential risks and vulnerabilities," what they really mean is this:

  • Take stock of where client information lives in your practice
  • Understand how it's protected
  • Figure out what could go wrong
  • Develop and implement mitigation strategies
  • Keep that documentation updated.

Here's what you actually need to document:

đź“„ What to document? đź’ˇ What this means in practice
1. Where your client data lives Every computer, phone, tablet, email account, cloud storage service, and even that old fax machine with a hard drive. If it touches client information, list it.
2. What could go wrong For each place where data lives, write down the threats. Could someone steal that laptop? Could an employee accidentally email client info to the wrong person?
3. What protection you have now Document your current safeguards. Do you use passwords? Is your email encrypted? Do you lock your office?
4. How likely and serious each risk is You don't need complex math here. Just rate risks as low, medium, or high based on probability and impact.
5. Your plan to manage the risks Write down what you will do to reduce each risk. This could include enabling encryption, adding MFA, updating policies, or choosing HIPAA-compliant tools.
6. Written documentation of all this OCR wants to see that you've thought this through. A few pages of clear documentation beat nothing every time.
7. Regular updates Review and update annually, or whenever you make significant changes, such as adding new software or staff.

HIPAA risk analysis explained. What it is and what it is not

There's a lot of confusion about what counts as a proper risk analysis. Some practices think downloading a template and filling in a few blanks is enough. Others assume they need to hire expensive consultants to create a complex document.

The truth is somewhere in between. A risk analysis doesn't need to be complicated, but it does need to be real. Here's what separates a compliant risk analysis from one that will get you in trouble:

A risk analysis is NOT: What it IS:
❌ A checkbox exercise or a generic template âś… Your specific risk assessment based on your actual practice
❌ The same as a HIPAA compliance gap assessment ✅ Understanding what could go wrong (not just what rules you follow)
❌ A one-time activity âś… An ongoing process that is reviewed and updated regularly
❌ Optional for small practices ✅ Required for every covered entity, regardless of size

How to document your HIPAA risk analysis the right way

How you document your risk assessment matters just as much as doing it. OCR auditors know the difference between a hastily completed template and a thoughtful assessment of your actual practice.

Here's what separates adequate documentation from the kind that raises red flags:

What it's NOT What it IS
❌ A generic template you found online ✅ Practice-specific documentation with your actual systems and workflows
❌ Just documenting your EHR system ✅ Documenting ALL systems touching ePHI
❌ Something you can discard after a year ✅ Retained for at least 6 years (OCR can request old analyses)
❌ A document you create once and forget ✅ Regular reviews and updates with dates to prove ongoing compliance

“Most small practices overthink the risk analysis process. You don't need a 50-page report or expensive consultants. OCR wants to see that you understand where your client data lives, what could threaten it, and what you're doing to protect it. A thorough 5-10 page document that's specific to your practice is far more valuable than a generic 100-page template.”

Margaret Hales, J.D., CEO of ET&C Group LLC and The HIPAA E-Tool

Turning common HIPAA mistakes into smart practices

Instead of dwelling on failures, let's focus on what successful practices do right:

  1. Smart practices document everything. While some practices don't write down their risk analysis, documentation is what proves compliance. Keep it simple but thorough.
  2. They customize templates to their reality. Templates can help you get started, but regulators want to see your risk analysis tailored to your specific practice. Add details about your actual systems and workflows.
  3. They remember all data locations. Many practices forget about email accounts, personal devices used for quick client communications, automatic cloud backups, fax machine hard drives, and USB drives. Make a complete inventory.
  4. They manage Business Associates properly. Get signed agreements from every vendor who touches clients' data. This includes your EMR company, billing service, IT support, and even your email provider. Verify they're doing their own risk analyses.
  5. They update after incidents. When something goes wrong—even a minor incident—smart practices document what happened and how they're preventing it from happening again.
  6. They think realistically about their size. You're not too small to be targeted by hackers or audited by OCR. But you're also not expected to have hospital-level security. Right-sized security for your practice is the goal.

Your 30-day HIPAA compliance action plan

You can do this without hiring anyone. Set aside a little time each week, and you'll be compliant before you know it.

Week 1: Map your client data and list your risks

  • Begin by listing all devices and systems that handle client data. This includes computers, phones, tablets, printers, fax machines, email accounts, and cloud storage services.
  • Compile a list of all your Business Associates, such as your EMR vendor, billing company, IT support, answering service, and any other entities that manage your client information.
  • Examine the potential risks associated with each location.
  • Assess the current protections you have in place
  • Evaluate the likelihood and severity of each risk.

By the end of Week 1, you should have a simple, written list of your systems, the risks, and your current safeguards.

đź’ˇ Tip: You can use the free HHS Security Risk Assessment Tool, explore the HIPAA E-Tool for an easy-to-use, practical paid alternative, or follow Hushmail's step-by-step guide to completing a HIPAA risk assessment.

Week 2: Create your plan to manage the risks and put safeguards in place

  • Develop a practical and realistic plan to address the major gaps.
  • Put this plan into action. This may include enabling encryption, enhancing password security, updating policies, transitioning to HIPAA-compliant tools, and obtaining signed Business Associate Agreements (BAA) from all vendors—including adding MFA.

đź’ˇ For email safeguards, this is where Hushmail comes in.

Most small practices start with email encryption because it's an easy safeguard to implement. You can set up encrypted email the same day, addressing one of the most common vulnerabilities that OCR finds.

Learn more: HIPAA technical safeguards explained for your small practice

Week 3: Document your findings

  • Write down what you found in weeks 1 and 2. Document your complete risk analysis findings in plain language.
  • Create a one-page "Security Rules" document (password requirements, locking computers, encrypting emails).
  • Write down "What to do if something goes wrong" (who to call, what to save).
  • Set calendar reminders for annual updates.

👉 Recommended reading: HIPAA documentation requirements for small healthcare practices made simple

Week 4: Train and test

  • Train everyone in your practice on the new procedures—even if it's just you, document that you've reviewed the policies.
  • Test your data backup to ensure you can restore files.
  • Send yourself an encrypted test email.
  • Schedule quarterly reviews to keep everything up to date.

How Hushmail protects your practice from email risks

Email remains one of the biggest security gaps in healthcare. Most breaches involve email compromise, and OCR investigates email encryption in every audit. While encryption is an addressable safeguard, not a required one, practices without it face much higher scrutiny and risk.

Hushmail provides three essential safeguards that address the most common email-related violations:

  1. Encryption that actually works: For messages between Hushmail users, encryption is automatic. For others, you control when to encrypt with a simple toggle.
  2. Secure client forms: Replace unsecured forms with encrypted web forms accessible from any device.
  3. Built-in two-factor authentication: Adds an extra security layer that strengthens your overall security (multi-factor authentication (MFA)).

đź’ˇ These safeguards provided by Hushmail alone would have prevented or significantly reduced roughly 60% of the small practice fines we've discussed. Email breaches, unsecured client communications, and authentication failures are entirely preventable with the right tools and security measures.

Hushmail also includes a signed BAA with all healthcare plans, requires no complex IT configuration, and works with your existing email workflow. At a fraction of the cost of a single OCR fine, it's protection you can implement today.

Preparing for the upcoming HIPAA Security Rule updates

In December 2024, the OCR division of HHS proposed major HIPAA security updates. The proposed changes include mandatory annual Security Rule compliance assessments, the requirement of encryption across all systems, six-month vulnerability scans, and annual penetration tests.

If you've followed the steps above, you're already well on the way to being prepared for these updates. This is the perfect time to get ahead: small steps now will save stress later when the new rules take effect.

Next steps to stay compliant with confidence

If reading about fines and enforcement makes you anxious, you're not alone. Most small practice owners feel overwhelmed by HIPAA requirements. The good news is that compliance doesn't require perfection. It requires showing you're making a genuine effort to protect client information.

Here are 3 actions to take today:

  1. Start your risk analysis using the HHS SRA Tool, the HIPAA E-Tool, or Hushmail’s step-by-step guide.
  2. Check if your email is encrypted. If not, get Hushmail today.
  3. List your Business Associates and request BAAs.

The reality: 22 practices paid fines in 2024, and OCR's Risk Analysis Initiative is currently investigating small practices.

But you have an advantage. You can implement changes in days, not months.

Take the first step toward simpler compliance. Start with encrypted email to protect client information, then add safeguards one at a time. You're not too small to be fined, but you're exactly the right size to get compliant quickly.

Learn how Hushmail for Healthcare helps small practices stay compliant with confidence:

Reviewed by: Margaret Hales, J.D., CEO of ET&C Group LLC and The HIPAA E-Tool, and Steven O. Youngman, VP of Legal and Compliance, Hushmail.