HIPAA and MIPS Compliance: How One SRA Satisfies Both Requirements

Many healthcare providers and practice managers face a frustrating reality: they’re conducting two separate Security Risk Analyses (SRAs)—one for HIPAA compliance and another for MIPS reporting—when they could do just one.

This redundancy costs time, money, and administrative effort. The good news? The HIPAA Security Rule SRA requirement and the MIPS Performance Improvement SRA measure are fundamentally the same assessment. Both derive from the same regulatory foundation (45 CFR 164.308(a)(1)), require identical core evaluations, and demand the same documentation. A single, well-structured SRA can serve dual purposes, enabling you to satisfy both compliance frameworks simultaneously.

In this guide, we’ll explain why these two requirements overlap completely, how to structure an SRA that meets both standards, what you’ll save by integrating them, and how to ensure your documentation is audit-ready for both HIPAA and MIPS reviewers. If you’re managing compliance for a healthcare practice, this is the efficiency strategy you’ve been looking for. Learn more about integrated HIPAA compliance solutions at our HIPAA compliance solutions page.

Why MIPS and HIPAA SRA Are the Same Assessment

Understanding why these two requirements overlap requires looking at their regulatory origins.

HIPAA’s Foundation: The HIPAA Security Rule (Title II of HIPAA) mandates that covered entities and their business associates conduct a comprehensive Security Risk Analysis as part of their Security Management Process. This requirement is codified in 45 CFR 164.308(a)(1)(ii)(A), which states that organizations must conduct a security evaluation of their systems and facilities to identify potential risks and vulnerabilities to the confidentiality, integrity, and availability (CIA) of electronic protected health information (ePHI).

MIPS’s Requirement: The Merit-based Incentive Payment System (MIPS), part of the Medicare Access and CHIP Reauthorization Act (MACRA), includes a Performance Improvement category that encompasses HIPAA compliance measures. Specifically, the MIPS PI SRA measure requires practitioners to conduct and document a comprehensive security risk analysis of their practice’s IT systems and facilities. The language and scope are nearly identical to HIPAA’s requirement—because they come from the same regulatory mandate.

The Critical Overlap: Both HIPAA and MIPS require you to:

• Identify all systems, networks, and physical locations where ePHI is stored or transmitted
• Assess vulnerabilities and potential threats to data security
• Evaluate existing safeguards and controls
• Document findings, risks, and remediation plans
• Obtain sign-off from leadership
• Maintain the assessment for auditing and compliance verification

Because MIPS borrowed its SRA measure directly from HIPAA’s regulatory framework, these aren’t two separate assessments—they’re one requirement being enforced by two different compliance bodies. The CMS (Centers for Medicare & Medicaid Services) requires the MIPS SRA for payment adjustment purposes, while HHS (Health and Human Services) enforces the HIPAA SRA for breach prevention and privacy protection. But the assessment itself is identical.

Many practices don’t realize this overlap. They hire one consultant to conduct a “HIPAA SRA” and another to conduct a “MIPS SRA,” duplicating effort and incurring unnecessary costs. The integrated approach eliminates this redundancy entirely.

Complete Overlap Analysis: HIPAA vs. MIPS SRA Requirements

The table below illustrates how HIPAA and MIPS SRA requirements align across six critical dimensions:

As this table demonstrates, there is zero daylight between HIPAA and MIPS SRA requirements. Every component that HIPAA mandates is identical to what MIPS requires. This is not coincidental—MIPS incorporated HIPAA’s framework directly into its performance measures.

The implications are clear: conducting a single, well-structured SRA that explicitly addresses both regulatory frameworks eliminates the need for redundant assessments. You conduct one evaluation, gather one set of evidence, and satisfy both compliance bodies simultaneously.

What a Single SRA Must Cover to Satisfy Both HIPAA and MIPS

To ensure your SRA satisfies both HIPAA and MIPS requirements, your assessment must comprehensively address these six core elements:

1. Complete System and Data Inventory

Document every hardware device, software application, network, and physical location where ePHI is stored, processed, or transmitted. This includes:

• Electronic medical record (EMR) systems
• Practice management software
• Backup and archival systems
• Mobile devices (laptops, tablets, phones)
• Network infrastructure (servers, routers, firewalls)
• Cloud services and third-party vendors
• Physical locations (clinic, office, offsite storage)
• Remote access systems and VPNs

Evidence needed: Detailed IT asset inventory, network diagrams, vendor contracts, system administrator documentation.

2. Comprehensive Threat and Vulnerability Assessment

Identify all potential threats—both external (cyberattacks, ransomware, phishing) and internal (employee misconduct, accidental disclosure, inadequate access controls)—and evaluate the likelihood and impact of each.

Evidence needed: Vulnerability scans, penetration test results, security audit reports, threat modeling documentation.

3. Current Safeguard Evaluation

Assess your existing administrative, physical, and technical controls across all systems. Document what protections are currently in place and identify gaps. For MIPS compliance, explicitly reference the HIPAA Security Rule’s 18 required safeguards.

Evidence needed: Policies and procedures, access control logs, firewall rules, encryption certificates, security training records, physical security measures (locks, badge systems, visitor logs).

4. Risk Rating and Prioritization Matrix

For each identified risk, assign a severity rating based on likelihood and potential impact. Create a prioritized list that guides your remediation efforts. Both HIPAA and MIPS expect this structured, quantifiable approach.

Evidence needed: Risk matrix, likelihood × impact scoring, ranked vulnerability list with justifications.

5. Detailed Remediation Action Plan

For each identified risk, specify the corrective action, responsible party, target completion date, and success criteria. Include budget estimates for major remediation efforts (e.g., new firewall, staff training, password manager implementation).

Evidence needed: Action plan with timelines, responsible parties, resource requirements, completion evidence (invoices, certificates, training records).

6. Executive Sign-Off and Annual Review Process

Ensure your practice’s leadership (CEO, Chief Information Officer, Compliance Officer, or equivalent) reviews and formally approves the SRA. Document that your practice commits to implementing remediation actions and will review/update the assessment annually. This demonstrates organizational accountability to both HIPAA OCR (Office for Civil Rights) and CMS.

Evidence needed: Board-approved meeting minutes, signed attestation letter, annual review schedule, update log showing year-over-year changes.

Critical Language for Dual Compliance: When writing your SRA document, use language that explicitly references both regulatory frameworks. For example:

“This Security Risk Analysis is conducted pursuant to 45 CFR 164.308(a)(1)(ii)(A) (HIPAA Security Rule) and the Centers for Medicare & Medicaid Services’ Merit-based Incentive Payment System (MIPS) Performance Improvement requirements. The assessment identifies, documents, and prioritizes security risks to electronic protected health information (ePHI) and establishes a comprehensive remediation plan.”

By explicitly stating both regulatory bases in your SRA documentation, you create clear evidence that your assessment satisfies both HIPAA and MIPS auditors.

Cost Comparison: Separate vs. Integrated SRA

One of the most compelling reasons to integrate your SRA is cost savings. Consider the typical expense of conducting two separate assessments:

*Integrated SRA uses the same effort as a standalone HIPAA SRA because the assessment scope is identical; the savings come from eliminating the second, redundant assessment.

The Bottom Line: By conducting a single, integrated SRA instead of two separate assessments, you save $12,500 to $23,000 in Year 1 and $5,000 to $10,000 annually thereafter. For a 10-provider practice, this can total over $150,000 in cumulative savings over five years. That’s money you can redirect toward actual security improvements—new firewalls, encryption tools, staff training, and incident response capabilities—rather than duplicate compliance work.

SRA Document Structure for Dual Compliance

To ensure your SRA satisfies both HIPAA and MIPS auditors, structure your document with these 10 essential components. This framework ensures you address every requirement of both regulatory bodies in a single, audit-ready document.

1. Executive Summary & Regulatory Basis (1-2 pages)

State that the assessment is conducted under 45 CFR 164.308(a)(1) (HIPAA) and MIPS PI requirements. Identify the organization, assessment dates, assessment team, and scope. Include a high-level summary of key findings and risk categories.

2. Methodology & Scope Definition (2-3 pages)

Describe how the assessment was conducted (interviews, system reviews, vulnerability scans, policy review). Define scope (which systems, locations, and personnel were included). Reference the HIPAA Security Rule’s 18 safeguards and clarify how your assessment evaluates each. Explicitly state that this document satisfies both HIPAA and MIPS requirements.

3. System and Asset Inventory (3-5 pages)

Provide a detailed inventory of all hardware, software, networks, and facilities handling ePHI. Include system descriptions, locations, data types, access permissions, and backup procedures. Use tables and diagrams (network topology) for clarity.

4. Threat & Vulnerability Assessment (5-8 pages)

Identify external threats (ransomware, phishing, data breaches, natural disasters) and internal threats (unauthorized access, accidental disclosure, employee misconduct). For each threat, assess likelihood (high/medium/low) and potential impact (critical/major/minor). Reference industry standards and threat intelligence reports.

5. Current Safeguards & Control Evaluation (8-12 pages)

Evaluate your organization’s existing controls across three categories required by HIPAA and MIPS:

• Administrative Controls: Security management process, information access management, security awareness training, security incident procedures, contingency planning
• Physical Controls: Facility access controls, workstation security, workstation use policies, device and media controls
• Technical Controls: Access controls, audit controls, integrity verification, transmission security, encryption

For each control category, document what safeguards are in place, their effectiveness, and any gaps or deficiencies. This section is critical for both HIPAA OCR and CMS reviewers.

6. Risk Rating & Prioritization Matrix (3-5 pages)

Create a table that ranks all identified risks by severity using a consistent methodology (e.g., likelihood × impact = risk score). Use color coding (red/yellow/green) to highlight critical, high, medium, and low-risk items. This demonstrates a disciplined approach to both HIPAA and MIPS auditors.

Example Risk Matrix Table:

7. Detailed Remediation Action Plan (8-12 pages)

For each identified risk (especially critical and high-priority risks), provide:

• Corrective Action: Specific, measurable steps to address the risk (e.g., “Implement AES-256 encryption on all portable devices by Q2 2026”)
• Responsible Party: Name/title of person accountable
• Target Date: Realistic completion timeline
• Resource Requirements: Budget, personnel, tools needed
• Success Criteria: How you’ll verify the action was completed
• Status: In progress, completed, on hold

This detailed action plan is essential evidence that your organization is taking HIPAA and MIPS obligations seriously and can be shown to auditors as proof of remediation efforts.

8. Business Associate & Vendor Risk Assessment (2-3 pages)

Per HIPAA, you are responsible for the security practices of your vendors, cloud providers, and business associates. Document your assessment of:

• EMR vendor security certifications (SOC 2, ISO 27001)
• Business Associate Agreements (BAAs) in place
• Data backup providers and their security measures
• IT support vendors and remote access controls
• Transcription services and document handling procedures

9. Compliance & Sign-Off Documentation (1-2 pages)

Include formal acknowledgment from your practice’s leadership (CEO, COO, Board, Compliance Officer) affirming that they have reviewed the SRA, understand the identified risks, commit to implementing the remediation plan, and authorize the necessary resources. Include board meeting minutes or a signed attestation letter with dates.

Sample sign-off language:

“We, [Organization Leadership], have reviewed this Security Risk Analysis and the identified risks to our electronic protected health information. We acknowledge our responsibilities under the HIPAA Security Rule (45 CFR 164.308) and MIPS PI requirements, and we authorize the implementation of the remediation action plan outlined in this document. We commit to dedicating necessary resources to complete remediation activities and to reviewing and updating this assessment annually.”

10. Annual Review & Update Log (1-2 pages)

Document your process for annually reviewing and updating the SRA. Include:

• Dates of annual reviews and responsible parties
• Summary of changes since last assessment (new systems, resolved risks, emerging threats)
• Updated risk matrix and remediation status
• Re-certification by leadership

Both HIPAA OCR and CMS expect to see evidence of ongoing, annual SRA updates. This demonstrates that you’re not conducting a “one-and-done” assessment but rather maintaining continuous security management.

How Medcurity Enables Integrated HIPAA + MIPS Assessment

Medcurity has helped over 1,000 healthcare organizations since 2018 conduct compliant, efficient SRAs that satisfy both HIPAA and MIPS requirements simultaneously. Our integrated approach is designed specifically for the overlap we’ve discussed.

Medcurity’s Integrated SRA Process:

1. Pre-Assessment Planning

We begin by identifying your specific compliance obligations—HIPAA, MIPS category involvement, and any state-specific privacy laws. We structure the assessment to explicitly address both regulatory frameworks from the start, eliminating the need for separate efforts.

2. Comprehensive System Audit

Our team conducts interviews with IT staff, system administrators, and practice leadership. We review network diagrams, system configurations, access control logs, and security policies. We perform vulnerability scans and penetration testing to identify real-world threats. All findings are documented with specific references to HIPAA and MIPS requirements.

3. Dual-Framework Risk Analysis

We evaluate all identified risks against both HIPAA’s Security Rule requirements and MIPS PI SRA standards. Our risk matrix explicitly shows how each risk relates to both compliance frameworks, making it easy for auditors from either body to understand your assessment.

4. Integrated Remediation Planning

We create a single action plan that addresses risks prioritized by impact. We include specific language referencing both 45 CFR 164.308 and MIPS PI requirements. Each remediation item includes realistic timelines, resource estimates, and success criteria.

5. Audit-Ready Documentation

Our final SRA report is structured specifically for dual-compliance review. It includes executive summary, threat assessment, control evaluation, risk prioritization, and comprehensive remediation plan—all organized to satisfy both HIPAA OCR and CMS auditors. The document includes explicit regulatory citations so auditors understand that every requirement is addressed.

6. Annual Review & Updates

Medcurity manages your ongoing SRA maintenance. Each year, we update your assessment to reflect changes in your systems, newly identified threats, and completed remediation work. We re-certify the assessment with your leadership and ensure your practice stays audit-ready year-round.

Starting at $499/year, Medcurity’s SRA platform provides templates, guidance, and ongoing advisor support to help your practice maintain a compliant assessment. For organizations requiring full-service assessment and documentation, we offer comprehensive packages tailored to your practice size and complexity.

Learn more about Medcurity’s Security Risk Analysis solutions.

The Critical Distinction: One SRA Covers HIPAA + MIPS PI, But Not All of MIPS

Before concluding, let’s clarify an important point that many practices misunderstand:

What one SRA covers: A single, well-structured SRA satisfies your HIPAA Security Rule obligation AND your MIPS Performance Improvement (PI) SRA measure. This is a significant overlap that eliminates duplicate compliance work.

What one SRA does NOT cover: An SRA is only ONE component of MIPS compliance. MIPS consists of four performance categories:

• Quality (30% of MIPS score): Clinical quality measures (e.g., diabetes screening, blood pressure control, appropriate cancer screening)
• Improvement Activities (15% of MIPS score): Actions you take to improve patient outcomes (e.g., implementing shared decision-making, care coordination)
• Promoting Interoperability (10% of MIPS score): EHR technology use and data sharing capabilities
• Cost (25% of MIPS score, for some participants): Total cost of care metrics

The SRA measure falls within the Improvement Activities category. Completing a comprehensive SRA and implementing remediation improves your MIPS PI score, but you still must address Quality, Improvement Activities (beyond just SRA), and potentially Promoting Interoperability and Cost measures to achieve maximum MIPS performance and avoid payment penalties.

The takeaway: One integrated SRA is a high-impact efficiency win for dual HIPAA + MIPS compliance, but it’s one component of your broader MIPS strategy, not a complete solution for all MIPS reporting. Work with a MIPS-focused advisor to develop your full compliance strategy.

For more guidance on MIPS requirements beyond SRA, see our MACRA/MIPS and SRA resource guide.

Frequently Asked Questions

Can a single SRA really satisfy both HIPAA and MIPS requirements simultaneously?

Yes. Both HIPAA’s Security Rule (45 CFR 164.308) and MIPS’s Performance Improvement SRA measure require identical assessments: system inventory, threat evaluation, control evaluation, risk prioritization, and remediation planning. A single, well-documented SRA that explicitly references both regulatory frameworks satisfies both compliance obligations. The key is ensuring your documentation makes both HIPAA OCR and CMS auditors aware that you’re addressing their specific requirements in one assessment.

How often do we need to update our SRA?

Both HIPAA and MIPS require at least annual review and update of your SRA. If you make significant changes to your IT systems, add new locations, experience a security incident, or identify new threats, you should update your assessment promptly. Medcurity and other SRA providers typically help practices conduct annual updates to keep documentation current and audit-ready.

What if our practice uses multiple vendors and cloud services? Does the SRA still apply to all of them?

Yes. Your SRA must include assessment of all vendors, business associates, and cloud services that handle ePHI. Under HIPAA, you are responsible for your vendors’ security practices. Your SRA should document the security certifications (SOC 2, ISO 27001) of each vendor, confirm that Business Associate Agreements (BAAs) are in place, and assess their compliance with HIPAA requirements. MIPS reviewers will expect to see this vendor assessment documented in your SRA.

Does completing an SRA prevent me from being audited by HIPAA OCR or CMS?

No. An SRA is a foundational compliance requirement, but it doesn’t guarantee you won’t be audited. However, a comprehensive, well-documented SRA with evidence of remediation efforts significantly strengthens your position if audited. It demonstrates that your organization takes security and compliance seriously and can reduce penalties if a breach occurs. Both HIPAA OCR and CMS expect to see a current SRA as evidence of good-faith compliance efforts.

What’s the difference between an SRA and a penetration test?

An SRA is a comprehensive risk assessment that evaluates administrative, physical, and technical controls holistically. A penetration test is a technical-only exercise where security experts attempt to breach your systems to identify vulnerabilities. While an SRA typically includes results from penetration tests (as technical evidence), they are not the same. Your SRA should incorporate penetration test findings but also evaluate your policies, training, physical security, and vendor management—areas a penetration test doesn’t address. For HIPAA and MIPS compliance, you need both: penetration testing results to support the technical portion of your SRA, and comprehensive SRA documentation to demonstrate organizational commitment to security across all control types.

Can we conduct the SRA in-house, or do we need to hire an external firm?

You can conduct an SRA in-house if you have IT staff with security expertise, but external assessment adds credibility. HIPAA OCR and CMS reviewers often view assessments conducted by qualified external firms (especially those with cybersecurity certifications like CISSP or CEH) as more objective and thorough. For small practices with limited IT resources, external assessment is usually more practical. Platforms like Medcurity provide affordable templates and guidance for in-house assessment, with optional advisor support if needed.

Key Takeaways

• HIPAA and MIPS SRA requirements are identical because MIPS incorporated HIPAA’s framework directly. Both derive from 45 CFR 164.308(a)(1).
• One integrated SRA eliminates redundant assessment work, saving $12,500 to $23,000 in Year 1 and $5,000 to $10,000 annually.
• Your SRA must address six core elements: system inventory, threat assessment, control evaluation, risk prioritization, remediation planning, and executive sign-off.
• Proper documentation is critical for dual compliance: Use language that explicitly references both HIPAA and MIPS frameworks so auditors understand your assessment satisfies both.
• An SRA is one component of MIPS, not a complete MIPS solution. You still need to address Quality, Improvement Activities, and other MIPS categories separately.
• Annual review and update of your SRA is required by both HIPAA and MIPS and demonstrates ongoing commitment to security.
• Integrated assessment providers like Medcurity specialize in structuring SRAs for dual HIPAA and MIPS compliance, saving time and ensuring auditor alignment.

By recognizing the overlap between HIPAA and MIPS SRA requirements, you can transform compliance from a costly, redundant burden into an efficient, strategic priority. One assessment, properly documented and maintained, protects your practice against both HIPAA breach liability and MIPS payment penalties. That’s the power of integrated compliance.

Ready to get started? Explore HIPAA compliance solutions, learn more about what a security risk analysis entails, or review our 2026 HIPAA compliance checklist to understand your broader obligations. For smaller practices, our guide to HIPAA compliance for small practices provides practical, scaled guidance. And if you’re ready for a comprehensive assessment, schedule your free integrated SRA consultation with Medcurity.