Updated April 11, 2025
Healthcare organizations have unique cybersecurity requirements. At the top of this list is HIPAA compliance when handling PHI (protected health information). Developing and maintaining a robust defense posture is only possible through continuous testing. The foundation for this is penetration testing, a proactive way to thwart cyberattacks. Before you start your first or next one, you’ll want to review this HIPAA penetration testing checklist.
In this post, we’ll look at the requirements and best practices for HIPAA penetration testing and provide you with a checklist to keep the focus on the most crucial security measures.
Is Penetration Testing a Requirement of HIPAA?
HIPAA does not explicitly require penetration testing for compliance. However, HIPAA standard 164.308(a)(8) does require periodic assessments of IT networks and systems to help healthcare providers prevent cyber attacks. A penetration test is considered a periodic assessment that proves due diligence and care for anyone handling PHI.
Penetration testing can heighten your awareness of vulnerabilities. As a result of a pen test, you can quickly remediate these things. So, while it’s not a defined procedure, adopting it is a calculated way to safeguard PHI.
How Penetration Testing Keeps Your Healthcare Organization More Secure
The objective of penetration testing is for good hackers to uncover weaknesses and security gaps. A simulated attack on your network, in the most realistic way, delivers an abundance of insights into the health of your cybersecurity processes and defenses.
The framework of your pen test can be Black Box, Gray Box, or White Box. Here are the differences.
- Black Box Penetration Testing, also known as Opaque Box, is when Hackers have no information about the internal system structure and look for areas to exploit.
- Gray Box Penetration Testing, also known as Semi-Opaque Box: Testers have some context relating to the target system, such as code, algorithms, data structure, or credentials. Those carrying out the exercise create test cases based on the system’s architectural diagram.
- White Box Penetration Testing, also known as Transparent Box, involves Hackers having access to systems and artifacts, such as source code and containers. They can often infiltrate servers running the network.
Every pen test, no matter the type, is distinct. The methods used can be broad and varied. A HIPAA penetration test has nuances aligned with compliance requirements. Within HIPAA, three rules define protocols.
The HIPAA Privacy Rule
The HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and PHI. It requires specific safeguards to maintain the privacy of this data and limits how it can be used and disclosed without authorization. The rule provides context on these permitted cases and when individuals need to give permission.
Another critical part of the rule is that it gives people rights over their PHI and the ability to review it. This guideline defines to whom HIPAA applies within three categories: health plans, healthcare providers, and healthcare clearinghouses.
Regarding pen testing, your process should align with checking and ensuring data remains private and only used in permissible ways.
The HIPAA Security Rule
The HIPAA Security Rule expands the scope of Privacy Rule protections. Its main points involve ensuring PHI’s confidentiality, availability, and integrity. One mandatory component under this rule is developing risk management capabilities. To meet this requirement, you may undergo a HIPAA security risk analysis.
HHS (Health and Human Services) and OCR (Office for Civil Rights), whose duty is to enforce HIPAA, offer guidance on security risk analysis. It has five major points:
- Assessment of potential risks and vulnerabilities relating to the confidentiality, integrity, and availability of ePHI (electronic PHI)
- Regular reviews of how an organization is complying with HIPAA
- Identifying how an organization creates, receives, maintains, and transmits ePHI
- Determining how third parties and vendors with access to ePHI create, receive, maintain, and transmit ePHI
- Defining all the threats relating to data security, including human (internal and external), natural (hurricanes, flooding, earthquakes, etc.), and environmental (physical and cyber)
The Security Rule also defines administrative, physical, and technical safeguards. This part of HIPAA is the one you can most align with pen testing. With its many checks and evaluations, pen testing is essential for compliance.
Breach Notification Rule
The third part of the rule framework is the Breach Notification Rule. It’s different from the previous rules because it outlines what you must do if a security incident occurs with a PHI breach. It specifies what your response must be in terms of notification. Those include the following:
- Individual notice: You must advise any parties impacted by a breach within 60 days.
- Secretary notice: You must notify the HHS Secretary of the breach within 60 days.
- Media notice: If the breach affects more than 500 people, you must disclose this to media outlets within 60 days.
A pen test will reveal what could lead to a data breach. In your simulation, you can test out your workflows for breach notifications. Doing so will provide clarity into any issues in the process.
These three rules offer guardrails on how to remain secure and compliant. With pen testing, you can meet the requirements and go beyond the minimum. Now, it’s time to build your checklist.
Optimizing Pen Tests for HIPAA Rules
Before revealing the HIPAA penetration testing checklist, there are a few more holistic points. The pen test performed should align with the Privacy Rule and Security Rule. Here are some topics to discuss with pen testers.
- Request a focus on specific types of PHI within your network during the reconnaissance and planning phase.
- Emphasize the need for testers to strategize how to compromise it, which should involve multilayered attacks.
- The HIPAA pen test should isolate and define how hackers’ attack patterns break the Privacy and Security Rule requirements.
- Ask for information on what traces and trackers hackers may leave behind after they withdraw for later re-entry. This data will support your compliance with the Breach Notification Rule.
- Convey that the report provided post-pen test should review the findings relevant to the HIPAA rules and feature measures you should take to patch up these vulnerabilities.
Now, it’s time to create your checklist.
HIPAA Penetration Testing Checklist
Here are the major categories that should be on your checklist.
Annual Audits and Assessments: What Have You Conducted and What Did You Learn?
Before a pen test, you should note what required audits you completed that year, per HHS OCR. These include HIPAA security risk assessments, security and privacy standards audits, assets and devices, and physical sites.
Addressing what you already know from these audits will be crucial in getting the most out of your pen test:
- It will discern if you’ve made appropriate fixes from remediation plans.
- The test offers you more context on a specific issue.
- It will assess the quality of your audits.
Choosing a Pen Test: Access and Types
As defined above, hackers have three ways to carry out pen tests. You’ll likely choose Gray Box for a HIPAA penetration test, providing the testers with some information. They’ll need this to align what they test with and how they test with HIPAA rules.
As for the type of pen test, you can focus on areas in your IT infrastructure, including web applications, network security, and cloud security. All three of these areas are going to interact with ePHI. You can also test IoT security if that applies to your organization. Social engineering is another option.
Vendor and Business Associate Facets
A pen test identifies issues in your digital footprint, but part of that is when you exchange or transmit data with your vendors and business associates. With the increase in supply chain attacks, your pen test should evaluate these interactions. You’ll have insight into your side of the transaction and if there are any problems you can remediate or if you need to notify other parties about concerns.
Defining a Persistent Presence
In the maintain access phase of a pen test, hackers will attempt to stay and create a persistent presence. This is important because real cybercriminals want to achieve this so they can either control your data through ransomware or keep coming back for more valuable data without your knowledge. Understanding how a persistent presence can occur helps you fortify your monitoring program.
The Results: How Will You Remediate?
The end of a pen test comes with a detailed report. They include the identified vulnerabilities, how they obtained, extracted, or manipulated ePHI, and how long they could remain undetected. This valuable information will be the foundation of your remediation plan. The firm that performs your pen test can support you in developing a plan to remedy the problems and define when to retest.
Learn More About HIPAA Compliance Pen Testing
This checklist provides you with parameters to consider during a pen test. The organization you hire to hack you should follow these and more. Additionally, working with a firm specializing in HIPAA will deliver the best results. Blue Goat Cyber offers healthcare pen testing with years of experience and expertise.
Learn more about our pen test services and how to get started.
HIPAA Compliance and Penetration Testing FAQs
Please schedule a 30-minute Discovery Session with us.
HIPAA identifiers serve various important purposes within the healthcare industry. These identifiers are essential for ensuring easy access to information to provide high-quality care services.
One key use of HIPAA identifiers is to balance protecting patient rights and enabling efficiency for covered entities. HIPAA compliance outlines specific circumstances where using and disclosing protected health information (PHI) without patient authorization is permissible. These circumstances include:
1. Conducting quality assessment and improvement activities: HIPAA identifiers allow healthcare organizations to assess and enhance patient care quality.
2. Developing clinical guidelines: With HIPAA identifiers, healthcare professionals can create evidence-based guidelines to promote efficient and effective medical practices.
3. Conducting patient safety activities per applicable regulations: HIPAA identifiers help perform activities that aim to ensure patient safety and adhere to relevant regulations.
4. Conducting population-based activities to improve health or reduce healthcare costs: By utilizing HIPAA identifiers, healthcare entities can engage in initiatives to improve public health or reduce healthcare expenses at a broader level.
5. Developing protocols: HIPAA identifiers enable the development of protocols that assist healthcare providers in delivering consistent and standardized care.
6. Conducting case management and care coordination: HIPAA identifiers facilitate effective case management and coordination of care among different healthcare professionals involved in a patient's treatment.
7. Contacting healthcare providers and patients to inquire about treatment alternatives: With the help of HIPAA identifiers, healthcare organizations can reach out to providers and patients to discuss alternative treatment options or gather additional information relevant to patient care.
8. Reviewing qualifications of healthcare professionals: HIPAA identifiers play a role in evaluating the qualifications and competence of healthcare professionals to ensure the delivery of high-quality care.
9. Evaluating the performance of healthcare providers or health plans: HIPAA identifiers assist in assessing the performance and effectiveness of healthcare providers and health plans to ensure optimal outcomes and patient satisfaction.
10. Conducting training programs or credentialing activities: Utilizing HIPAA identifiers, healthcare organizations can organize training programs and activities to enhance the skills and qualifications of healthcare professionals.
11. Supporting fraud and abuse detection and compliance programs: HIPAA identifiers aid in implementing fraud detection and compliance programs to safeguard against unlawful activities within the healthcare sector.
The "Wall of Shame" has faced criticism due to concerns over the way it handles organizations' cybersecurity breaches. Some argue that the portal tends to focus solely on the negative aspects of a breach, potentially causing long-term damage to a company's reputation. Critics suggest that the "Wall of Shame" fails to acknowledge or emphasize the positive steps that organizations may have taken to rectify their cybersecurity vulnerabilities after experiencing an incident. This lack of recognition for corrective actions and good-faith efforts to enhance cybersecurity practices could be seen as unfair and unbalanced in portraying organizations in the aftermath of a breach.
HIPAA, the Health Insurance Portability and Accountability Act, is the cornerstone of patient privacy in the United States. It sets the standard for protecting sensitive patient data. Any entity covered by HIPAA must ensure the confidentiality, integrity, and availability of all the protected health information (PHI) it handles.
When there’s a breach, HIPAA requires these entities to report it, especially if it affects many individuals. That’s where the OCR Wall of Shame comes into play. It’s a transparency tool, showing the public how and where PHI breaches happen.
Furthermore, under the Health Insurance Portability and Accountability Act (HIPAA), covered entities and their business associates are mandated to report any breaches to the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR). If the reported breach impacts more than 500 individuals, additional ramifications and consequences are triggered. This stringent regulation ensures that breaches are promptly reported and dealt with in accordance with HIPAA guidelines.
Under HIPAA, 18 identifiers classify data as Protected Health Information (PHI). These identifiers encompass a wide range of information that can be used to identify an individual. The list includes commonly recognized identifiers such as names, addresses, and social security numbers. However, it goes beyond these basic details and encompasses other data points like geographic information smaller than a state, dates (excluding year) related to an individual, phone numbers, fax numbers, email addresses, and more.
In addition to these, the list also includes less commonly known identifiers such as medical record numbers, health insurance beneficiary numbers, account numbers, certificate/license numbers, vehicle identifiers and serial numbers, device identifiers and serial numbers, web URLs, IP addresses, biometric identifiers like finger and voiceprints, and full-face photographic images. It even encompasses any unique identifying number, characteristic, or code associated with an individual.
By providing this comprehensive list, Your article ensures that all relevant and potential patient identifiers are covered. It offers a thorough understanding of PHI under HIPAA regulations, highlighting the importance of safeguarding these identifiers to protect patient privacy and confidentiality.
In the intricate landscape of healthcare data and privacy, understanding and correctly handling Protected Health Information (PHI) is crucial for adherence to regulations and preserving patient trust and safety. This is particularly vital in light of the Health Insurance Portability and Accountability Act (HIPAA). Let's explore PHI, its 18 identifiers, the potential repercussions of non-compliance, and the specific data not considered a HIPAA identifier.
PHI encompasses any data in a healthcare context that can be used to identify an individual, combined with information about their health status, provision of healthcare, or payment for healthcare services. Under HIPAA, 18 identifiers classify data as PHI, including names, geographic information smaller than a state, dates (excluding year) related to an individual, phone numbers, fax numbers, email addresses, social security numbers, medical record numbers, health insurance beneficiary numbers, account numbers, certificate/license numbers, vehicle identifiers and serial numbers, device identifiers and serial numbers, web URLs, IP addresses, biometric identifiers like finger and voiceprints, full-face photographic images, and any unique identifying number, characteristic, or code.
However, it is important to note that not all data falls within the scope of HIPAA identifiers. De-identified data or health information that cannot be used to identify an individual or provide a reasonable base to identify them is not considered a HIPAA identifier. This type of data, known as de-identified data, does not fall within the 18 identifiers specified by HIPAA. Additionally, de-identified data has been determined by an expert using a statistical or scientific method to have a very low chance of being used individually or in combination with others to identify a person. As a result, HIPAA laws do not apply to de-identified data.
Understanding the distinction between PHI and de-identified data is essential for healthcare organizations and individuals who handle health information. It ensures compliance with HIPAA regulations and safeguards patient privacy while balancing the need for data utilization in healthcare research and analysis.
HIPAA, or the Health Insurance Portability and Accountability Act, is a U.S. law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals, and other health care providers. Developed by the Department of Health and Human Services, these standards aim to improve the efficiency and effectiveness of the health care system.
Who Needs to Comply with HIPAA?
Covered Entities: This is the primary group that needs to adhere to HIPAA. They include:
- Health Plans: Insurance companies, health maintenance organizations (HMOs), employer-sponsored health plans, and government programs like Medicare and Medicaid.
- Healthcare Providers: This encompasses doctors, clinics, psychologists, dentists, chiropractors, nursing homes, and pharmacies that transmit health information in electronic form in connection with transactions for which HHS has adopted standards.
- Healthcare Clearinghouses: Entities that process nonstandard health information they receive from another entity into a standard format or vice versa.
Business Associates: These are individuals or entities that perform certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. This could include consultants, billing companies, IT service providers like Blue Goat Cyber, especially when dealing with medical device security assessment and testing services, and others who have access to protected health information (PHI).
Common causes of data breaches in the healthcare industry include a significant number of breaches resulting from outside theft and considerable breaches being caused by internal mistakes or neglect. Insider mistakes leading to data breaches often involve mailing or email errors, such as employees clicking on phishing emails, forwarding emails with sensitive information to personal accounts, and accessing protected health information without authorization. These actions contribute to a notable portion of data breaches in the healthcare sector.
Penetration testing, also known as security testing, should be conducted on a regular basis to ensure the protection of organizations' digital assets. It is generally recommended that all organizations schedule security testing at least once a year. However, it is essential to conduct additional assessments in the event of significant infrastructure changes, prior to important events such as product launches, mergers, or acquisitions.
For organizations with large IT estates, high volumes of personal and financial data processing, or strict compliance requirements, more frequent pen tests are strongly encouraged. Such organizations should consider conducting penetration testing with a higher frequency to continually assess and strengthen their security measures.
To further enhance security practices, organizations can adopt agile pen testing or continuous pen testing. Unlike traditional pen testing, which occurs at specific intervals, agile pen testing integrates regular testing into the software development lifecycle (SDLC). This approach ensures that security assessments are conducted consistently throughout the development process, aligning with the release schedule of new features. By doing so, organizations can proactively address any vulnerabilities and mitigate risks to customers, without significantly impacting product release cycles.
Penetration Testing as a Service (PTaaS) is a dynamic approach to cybersecurity where regular and systematic penetration tests are conducted to assess the security of an organization's IT infrastructure. Unlike traditional penetration testing, which is typically performed as a one-time assessment, PTaaS offers ongoing testing and monitoring, allowing for continuous identification and remediation of vulnerabilities.
Key aspects of PTaaS include:
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Regular Testing Cycles: PTaaS involves conducting penetration tests at predetermined intervals, such as monthly or quarterly. This regularity ensures that new or previously undetected vulnerabilities are identified and addressed promptly.
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Updated Threat Intelligence: As cyber threats evolve rapidly, PTaaS providers stay abreast of the latest threat landscapes. This ensures that each test is relevant and effective against the most current types of attacks.
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Continuous Improvement: By receiving regular feedback and insights from these tests, organizations can continually improve their security postures. This process includes patching vulnerabilities, updating security policies, and enhancing defense mechanisms.
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Comprehensive Reporting and Support: PTaaS typically includes detailed reporting on the findings of each test, along with expert recommendations for remediation. Ongoing support and consultation are often part of the service to help organizations respond effectively to identified issues.
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Cost-Effectiveness and Budget Predictability: With an annual contract and monthly payment options, PTaaS allows organizations to budget more effectively for their cybersecurity needs, avoiding the potentially higher costs of one-off penetration tests.
Cloud penetration testing is a specialized and crucial process involving comprehensive security assessments on cloud and hybrid environments. It is crucial to address organizations' shared responsibility challenges while using cloud services. Identifying and addressing vulnerabilities ensures that critical assets are protected and not left exposed to potential threats.
Cloud penetration testing involves simulating real-world attacks to identify and exploit vulnerabilities within the cloud infrastructure, applications, or configurations. It goes beyond traditional security measures by specifically targeting cloud-specific risks and assessing the effectiveness of an organization's security controls in a cloud environment.
The importance of cloud penetration testing lies in its ability to uncover security weaknesses that might be overlooked during regular security audits. As organizations increasingly adopt cloud services, they share the responsibility of ensuring the security of their data and assets with the cloud service provider. This shared responsibility model often poses challenges regarding who is accountable for various security aspects.
Cloud penetration testing not only helps in understanding the level of security provided by the cloud service provider but also provides insights into potential weaknesses within an organization's configurations or applications. By proactively identifying these vulnerabilities, organizations can take necessary steps to mitigate risks and strengthen their security posture.
These terms refer to the amount of information shared with the testers beforehand. Black box testing is like a real-world hacker attack where the tester has no prior knowledge of the system. It's a true test of how an actual attack might unfold. Gray box testing is a mix, where some information is given - this can lead to a more focused testing process. White box testing is the most thorough, where testers have full knowledge of the infrastructure. It's like giving someone the blueprint of a building and asking them to find every possible way in. Each type offers different insights and is chosen based on the specific testing objectives.
When choosing a pen test provider, you'll want to consider several important factors to ensure your organization's highest level of cybersecurity.
Selecting the right pen test provider is crucial for your organization's security. It's about identifying vulnerabilities and having a partner who can help you remediate them effectively. To make an informed decision, here's what you should look for:
Expertise and Certifications: One of the key factors to consider is the expertise of the pen testers. Look for providers with a team of experts holding certifications such as CISSP (Certified Information Systems Security Professional), CSSLP (Certified Secure Software Life Cycle Professional), OSWE (Offensive Security Web Expert), OSCP (Offensive Security Certified Professional), CRTE (Certified Red Team Expert), CBBH (Certified Bug Bounty Hunter), CRTL (Certified Red Team Lead), and CARTP (Certified Azure Red Team Professional). These certifications demonstrate a high level of knowledge and competence in the field.
Comprehensive Testing Services: The cybersecurity landscape constantly evolves, and threats are becoming more sophisticated. To stay ahead, you need a provider with expertise and resources to test your systems comprehensively. Look for a pen test provider like Blue Goat Cyber that offers testing across various areas, including internal and external infrastructure, wireless networks, web applications, mobile applications, network builds, and configurations. This ensures a holistic evaluation of your organization's security posture.
Post-Test Care and Guidance: Identifying vulnerabilities is not enough; you need a partner who can help you address them effectively. Consider what happens after the testing phase. A reputable pen test provider should offer comprehensive post-test care, including actionable outputs, prioritized remediation guidance, and strategic security advice. This support is crucial for making long-term improvements to your cybersecurity posture.
Tangible Benefits: By choosing a pen test provider like Blue Goat Cyber, you ensure that you receive a comprehensive evaluation of your security posture. This extends to various areas, including internal and external infrastructure, wireless networks, web and mobile applications, network configurations, and more. The expertise and certifications of their team guarantee a thorough assessment.
We follow a seven phase methodology designed to maximize our efficiency, minimize risk, and provide complete and accurate results. The overarching seven phases of the methodology are:
- Planning and Preparation
- Reconnaissance / Discovery
- Vulnerability Enumeration / Analysis
- Initial Exploitation
- Expanding Foothold / Post-Exploitation
- Cleanup
- Report Generation
An External Black-Box Penetration Test, also known as a Black Box Test, primarily focuses on identifying vulnerabilities in external IT systems that external attackers could exploit. This testing approach aims to simulate real-world attack scenarios, mimicking the actions of adversaries without actual threats or risks.
During an External Black-Box Pen Test, ethical hackers attempt to exploit weaknesses in network security from an external perspective. This form of testing does not involve internal assessments, which means it may provide a limited scope of insights. However, it is crucial to note that the absence of identified external vulnerabilities does not guarantee complete security.
To gain a comprehensive understanding of the network's resilience, it is recommended to complement the External Black-Box Pen Test with an Internal Black-Box Penetration Test. By combining both approaches, organizations can evaluate the effectiveness of their security measures from both external and internal perspectives.
It is important to acknowledge that external-facing devices and services, such as email, web, VPN, cloud authentication, and cloud storage, are constantly exposed to potential attacks. Therefore, conducting an External Black-Box Pen Test becomes imperative to identify any weaknesses that could compromise the network's confidentiality, availability, or integrity.
Organizations should consider performing External and Internal Black-Box Penetration Tests to ensure a robust security posture. This comprehensive approach allows for a thorough assessment of external vulnerabilities while uncovering potential internal risks. Organizations can strengthen their security defenses by leveraging these testing methodologies and proactively addressing identified weaknesses.
Blue Goat Cyber employs a comprehensive approach to gather intelligence for a penetration test. We begin by actively seeking out relevant information about the targets. This includes identifying the devices, services, and applications the targets utilize. In addition, Blue Goat Cyber meticulously explores potential valid user accounts and executes various actions to uncover valuable data. By conducting this meticulous information-gathering process, Blue Goat Cyber ensures we comprehensively understand the target's infrastructure and potential vulnerabilities for a successful penetration test.
Compliance penetration testing is specially designed to meet the requirements of various regulatory standards. For SOC 2, it's about ensuring that a company's information security measures are in line with the principles set forth by the American Institute of CPAs. In the case of PCI DSS, it's specifically for businesses that handle cardholder information, where regular pen testing is mandated to protect against data breaches. For medical devices regulated by the FDA, pen testing ensures that the devices and their associated software are safe from cyber threats. This type of testing is crucial not just for meeting legal requirements but also for maintaining the trust of customers and stakeholders in industries where data sensitivity is paramount.
