HIPAA Compliance Checklist for Medical Office Phone Systems (2025 Updated)

You undoubtedly know the ins and outs of HIPAA compliance for electronic health records and data storage. You may even have a HIPAA compliance checklist for electronic protected health information (ePHI). In today’s world of frequent cybersecurity attacks and ransomware, it’s difficult to work in the healthcare industry without being reminded of its importance almost daily.

Talking on the phone, however, is a different affair. So common an act, it’s much easier to violate HIPAA without even a thought. Did you leave a voice message with someone’s name and test results? Can other people hear you when you’re talking?

Without even knowing it, you or someone in your office may breach HIPAA regulations, which can result in legal issues and hefty fines.

Here, we’ll look at best practices and what HIPAA compliance is as it relates to phone usage.

Understanding the Core HIPAA Rules for Communications

The key principles and HIPAA communication rules center on verifying the identity of the person you’re speaking to and limiting the information you share over the phone to the minimum and essential. You and your staff also need to be very careful when talking to a relative. PHI can only be shared with authorized individuals, including legal guardians, a healthcare power of attorney, and family members, with documented patient consent.

Do not disclose PHI until you’ve received two forms of identification, such as their date of birth, address, full name, or the last four digits of their social security number.

The Essential HIPAA Compliance Checklist for Your Phone System

The HIPAA compliance checklist includes technical, administrative, and physical safeguards. These safeguards are designed to prevent unauthorized access, destruction, or disclosure of PHI.

Technical Safeguards

Technical safeguards are defined as the technology you use when protecting PHI.

Encrypting data in transit and at rest

Data encryption converts data into meaningless text that cannot be deciphered if targeted by hackers, whether in transit and moving between devices or when stored and at rest.

Access controls and user authentication

Multi-factor authentication (MFA) provides a secondary layer of access security. Lack of MFA has been a significant contributor to several of the largest data breaches.

Role-based access controls assign user privileges and enforce the principle of least privilege. This principle ensures that users receive only the minimum access necessary to perform their jobs.

Audit trails and activity logs

Activity logs track access to data, establishing an audit trail. They are records of activity on a system that stores ePHI, ensuring compliance with relevant regulations. Regarding phone calls, these logs track activity, including who listened to a recorded call.

Secure messaging and voicemail-to-email

Voicemails must have restricted access controls. Additionally, staff should not leave sensitive patient data in voicemails.

Voicemail-to-email converts patient voicemails into text transcripts and sends them via email. While this process streamlines workflows and improves efficiency, the service provider must have storage compliance and security features to protect ePHI.

Secure messaging also includes text messages and requires that any text messages containing ePHI must be sent through an encrypted, secure, and compliant channel.

Administrative Safeguards

Administrative safeguards refer to the procedures and policies you have in place to protect your patients’ health information.

Business Associate Agreements (BAAs) with your provider

While this requirement is easily overlooked, it’s essential to include it in your HIPAA compliance checklist. Your phone service provider must sign a BAA. This agreement is a contract requiring them to protect patient information. Should a breach occur, both you and the phone company are responsible for addressing it, including mitigating harm and investigating the incident.

Staff training on HIPAA protocols

According to the philosopher, Thomas Reid, “The chain is only as strong as its weakest link.” Nothing is truer in the field of HIPAA compliance. One employee who uses an unsecured personal device to disclose PHI or leaves a message with a family member that contains sensitive patient data results in a HIPAA violation. Training is one of the most critical components of a HIPAA compliance checklist.

Risk analysis and management

A yearly risk analysis should include your phone systems and other communication channels. This process identifies vulnerabilities and threats to PHI. Risk management is a continuous process that involves implementing appropriate security measures to address potential risks.

Disaster recovery and backup plans

HIPAA-compliant disaster recovery and backup plans are set in place to restore and protect ePHI in the event of a disruption such as a cyberattack. A backup plan may include retrievable copies of any ePHI on the phone system. A disaster recovery plan outlines the steps you will take to restore your data and phone systems after a disruption.

Physical & Technical Safeguards

These safeguards limit access to devices, areas, and hardware.

Securing physical devices

It’s important to secure any device used to access ePHI on your phone system. These measures include access control for workstations and ensuring they are located in a secure area. Implement protocols that define how physical devices, such as phones, are used or moved. Make sure any of these devices are encrypted.

Controlling access to equipment

Use role-based access control, which limits access to phone functions based on the minimum information required for each user to perform their job. For instance, someone in billing should not have access to clinical call recordings.

Common Pitfalls and How to Avoid Them

One of the most common pitfalls is discussing a patient’s information over the phone when other people in the waiting room can hear. For instance, you may state their name when verifying their identity and then share test results. To avoid this HIPAA violation, you can set aside a private room when calling a patient and discussing their PHI.

Another area of concern is leaving voicemails. For instance, leaving a message like, “Your Lipitor is ready,” is considered non-compliant. Instead, leave a generic message, like your medication is ready for pickup.

The Role of a Specialized Medical Answering Service

A specialized medical answering service ensures HIPAA compliance by thoroughly training its operators on handling sensitive PHI and adhering to standard practices to safeguard the information. Whether scheduling appointments or taking messages, our virtual assistants use best practices in HIPAA compliance.

Whenever you are using a third-party, such as a medical answering service, ensure they sign a Business Associate Agreement (BAA) to hold them accountable for protecting PHI. They should also use phone systems that have encrypted data storage, restricted call access, and secure HIPAA-compliant VoIP services.

At notifyMD®, we are HIPAA compliant and HITRUST certified, demonstrating the highest standards in patient data protection. Today, the HITRUST Common Security Framework is the most widely used security and privacy program in the healthcare industry. To learn more about HIPAA compliance and working with our medical answering service, contact notifyMD® today.