HIPAA SRA: Don’t Risk Fines is more than a catchy title. It is a serious warning. Every healthcare organization that handles electronic patient data must complete a HIPAA Security Risk Analysis (SRA) each year. Failing to do this can lead to large fines, lost revenue, and damaged trust.

The HIPAA Security Rule requires you to look closely at how you protect electronic protected health information, or ePHI. You must find the risks, decide how serious they are, and fix them. This careful review is your SRA. It is not optional. It is the foundation of security under the HIPAA Security Rule.

This blog explains why the SRA matters, how federal programs like MACRA MIPS depend on it, and how partners like Taino Consultants and EPICompliance can help you stay ahead.

HIPAA Security Risk Analysis: The Law, Not a Suggestion

First, let’s be clear. The HIPAA Security Risk Analysis is required by law. If you are a Covered Entity or a Business Associate, you must do an SRA. This includes medical practices, hospitals, home health agencies, billing companies, IT vendors, lawyers, and many others that touch ePHI.

The Security Rule says you must:

• Evaluate risks and vulnerabilities to ePHI.
• Implement reasonable and appropriate safeguards.

Risk analysis is the first step in that process and must be documented and kept for at least six years.

Because of this, failing to complete an SRA by year-end is not only risky. It is illegal. The government treats it as a basic requirement for doing business in healthcare.

What Is a HIPAA Security Risk Analysis in Plain Language?

Think of the HIPAA Security Risk Analysis as a yearly “checkup” for your data.

You:

1. Find all ePHI. You list every place electronic patient data lives or travels. This includes EHRs, laptops, cloud systems, billing platforms, email, and even old servers.
2. Identify threats and vulnerabilities. You ask, “What could go wrong here?” Examples include hackers, stolen laptops, weak passwords, phishing emails, or staff using personal devices.
3. Review safeguards. You look at current protections. These include passwords, access rules, locks on doors, firewalls, backups, and staff training.
4. Assess risk levels. You decide how likely each bad event is and how much damage it could cause.
5. Plan fixes and document everything. You write down the findings, the risk levels, and how you plan to reduce each risk.
6. Repeat at least once a year. You must do this every year and when major changes happen, like new systems or a merger.

When you do this well, you protect patients, your license, and your organization’s future.

Three Layers of HIPAA Protection

The SRA touches all three safeguard areas under the HIPAA Security Rule:

Administrative safeguards
You look at policies, procedures, training, and who is in charge of security.

Physical safeguards
You review building security, device locks, and how you store and dispose of hardware.

Technical safeguards
You examine access controls, audit logs, encryption, and how you control remote access.

Your HIPAA SRA pulls together all three, then shows where gaps remain.

MACRA, MIPS, and the SRA: Why Payments Depend on “Yes”

Now let’s connect the SRA to your Medicare payments.

MACRA changed how Medicare pays clinicians. Instead of paying only for volume, Medicare now rewards quality, technology use, and security through the Merit-based Incentive Payment System (MIPS).

One major MIPS area is Promoting Interoperability (PI). To participate, clinicians must attest “YES” to having conducted or reviewed a Security Risk Analysis during the calendar year and to having addressed security updates and deficiencies.

So:

• No SRA = No PI measure.
• No PI measure can mean fewer points and lower Medicare payments.
• Long term, repeated failures can mean penalties and extra scrutiny.

If you attest “YES” without a real SRA, you are not just cutting corners. You may be committing fraud.

The Laws Behind a False “Yes”

When an organization checks “YES” to the SRA question without a valid, documented SRA, several federal laws can apply, including:

1. False Claims Act (31 U.S.C. §§ 3729–3733) – submitting false information to get paid more.
2. Healthcare fraud statute (18 U.S.C. § 1347) – schemes to defraud healthcare benefit programs.
3. Wire fraud statute (18 U.S.C. § 1343) – using electronic systems to carry out a fraud scheme.
4. False statements in healthcare matters (18 U.S.C. § 1035) – false statements related to health services.

Attesting “YES” without a real SRA can be seen as:

• Giving false information to the government.
• Using that false information over the internet.
• Doing so to receive higher Medicare payments.

In that case, CMS may demand repayment of extra funds, add penalties, and refer the case for investigation or prosecution.

Real Enforcement: What Happens When You Skip the SRA

Federal enforcement is not theory. It is very real. Many organizations have paid large penalties because they failed to complete a proper risk analysis or ignored known risks.

Here are examples drawn from public enforcement reports:

These cases show a clear pattern. When organizations do not perform or act on a proper SRA, fines often jump into the hundreds of thousands or even millions of dollars.

Six-Year Lookback: Why Documentation and Retention Matter

HIPAA requires you to keep documentation of required actions, assessments, and policies for at least six years from the date they were created or last in effect. That includes your SRA and risk management records.

This means the government can ask for your SRA documents going back six years. If you cannot show them, regulators may treat it as if the SRA never happened.

Therefore:

• Complete your SRA every year.
• Keep copies of each version, along with your Security Management Plan.
• Store those records securely and make them easy to retrieve.

This applies to Covered Entities and Business Associates alike.

What a Proper SRA Should Look Like

A proper SRA is not a one-page checklist. It is a detailed, structured review that ties directly to the HIPAA Security Rule.

A strong SRA should:

• Cover all systems that create, receive, maintain, or transmit ePHI.
• Map where data flows across your network and vendors.
• Identify threats and existing safeguards.
• Assign risk levels based on likelihood and impact.
• Recommend specific actions with timelines and owners.
• Feed into a documented Security Management Plan.

It should be written in clear language that leadership and staff can understand, not buried in technical jargon.

Taino Consultants SRA: A Practical Gold Standard

Taino Consultants Inc. (TC Inc.) offers an SRA model that checks all these boxes and goes even further. Their methodology examines over three hundred data points based on every HIPAA Security Standard and Specification.

The Taino Consultants SRA includes:

• Detailed equipment and asset inventory.
• Review of training records and workforce practices.
• Business Associate and vendor risk evaluation.
• Analysis of policies, procedures, and technical controls.
• A concise Security Management Plan tailored to your findings.

Because the checklist is so detailed, it helps you uncover subtle risks that many tools miss. It also gives you a clear action roadmap instead of a confusing pile of notes.

This year, the TC Inc. SRA also includes recommendations tied to the proposed 2025 HIPAA Security changes. That means you do not just meet today’s standards. You also prepare for what may be coming next.

Personal Perspective: Compliance with Help, Not Fear

Many healthcare professionals tell us they feel alone with compliance. They worry about audits, but they also feel too busy to fix everything.

Here is the good news. You do not need to handle HIPAA SRA: Don’t Risk Fines by yourself. Partners like Taino Consultants walk through the SRA process with you, step by step. They help translate regulations into plain language and practical plans your team can follow.

At the same time, EPICompliance gives you tools, online training, and task tracking that keep your program on track all year. Together, these resources help you protect patients, your staff, and your organization’s reputation.

Call to Action: Schedule Your SRA with Taino Consultants

If you handle patient data, a HIPAA Security Risk Analysis is not optional. It is a yearly legal requirement backed by real fines, payment impacts, and, in some cases, fraud investigations.

Now is the best time to act. Before year-end, schedule your SRA with Taino Consultants. Their 300-plus-point assessment, Security Management Plan, and 2025-focused recommendations will help you:

• Satisfy HIPAA Security Rule expectations.
• Support your MACRA MIPS attestation with strong documentation.
• Reduce breach risk and avoid devastating penalties.

Then, keep learning all year with EPICompliance training, tools, and webcasts.

Conclusion: Stay Ready, Not Afraid

HIPAA SRA: Don’t Risk Fines is more than a slogan. It is a reminder to stay proactive. A thorough, documented SRA protects your patients, your license, and your organization’s future.

Take control now: review, refresh, and actively manage your program. For quick, practical guidance, see EPICompliance webcasts (Watch on YouTube).