Identity and access management controls

The identity and access management controls requirement means you must govern who gets access to healthcare systems and data, restrict access to least privilege, and regularly verify that privileged access and authentication controls (including MFA for critical systems) work as intended. Operationalize it by documenting access rules, implementing technical controls, and producing audit-ready evidence of provisioning, reviews, and enforcement ¹.

Key takeaways:

• Define and enforce least privilege for users, admins, service accounts, and third parties across systems that handle sensitive healthcare data ¹.
• Require MFA for critical systems and run recurring privileged access reviews with documented outcomes and remediation ¹.
• Keep evidence that proves the control operates: access tickets, review attestations, logs, and exception approvals ¹.

Identity and access management failures are a repeatable root cause of healthcare security incidents: the wrong person gets access, a former workforce member keeps access, a shared admin credential persists, or a third party account is not governed. HICP’s identity and access management controls requirement is short, but auditors and incident responders interpret it broadly: you need governance (policy, ownership, defined process), technical enforcement (least privilege and MFA where it matters), and proof the program runs (reviews, logs, and remediation) ¹.

This page is written for a Compliance Officer, CCO, or GRC lead who needs to translate the requirement into an executable plan. You will find: plain-English interpretation, applicability, a step-by-step build sheet, required evidence, common audit questions, implementation pitfalls, and a practical 30/60/90-day execution plan. The goal is simple: reduce preventable access risk while producing clean, repeatable artifacts that withstand internal audit, customer security reviews, and regulator scrutiny ¹.

Regulatory text

Requirement (HICP-06): “Apply healthcare-focused identity and access governance controls.” ¹

What the operator must do: Implement identity governance and access controls appropriate for healthcare environments. In practice, that means (a) define who should have access to what, (b) enforce least privilege, (c) add stronger authentication controls (notably MFA) for critical systems, (d) control and review privileged access, and (e) keep evidence that these controls are active and reviewed ¹.

Plain-English interpretation (what “good” looks like)

You can explain your access model in one page and defend it in an audit:

• You know your systems of record for identity (HR, directory, IAM, EHR admin console), and you can trace a user from hire to termination.
• Access is intentional. Users are placed into roles/groups mapped to job functions. Direct permission grants are exceptions, not the norm.
• Privileged access is treated differently. Admin rights require tighter approvals, MFA, logging, and frequent review.
• MFA is required for critical systems and remote/administrative access paths ¹.
• Reviews happen and drive change. When reviewers find inappropriate access, you remove it and keep the record.

Who it applies to

Entity scope: Healthcare organizations implementing HICP practices ¹.

Operational scope (where to apply it):

• Systems that store, process, or transmit sensitive healthcare data (for many organizations, that includes EHR/EMR, patient portals, billing/revenue cycle, scheduling, imaging, collaboration systems, endpoint management, and key cloud workloads).
• Identity infrastructure (directory services, SSO/IAM, MFA platform).
• Privileged access paths (server admin, cloud consoles, network devices, security tooling, backup consoles).
• Third party access that reaches your environment (support portals, managed service providers, consultants, billing partners). Treat third party accounts as identities with lifecycle controls, not as “vendor exceptions.”

What you actually need to do (step-by-step)

1) Define control owners and the access governance boundary

1. Assign an IAM control owner (often Security or IT) and a business approver owner (often department leadership) for role-based access decisions.
2. List in-scope systems and identify which are “critical systems” for MFA and privileged oversight ¹.
3. Decide your authoritative source for joiner/mover/leaver events (usually HRIS) and how it feeds identity systems.

Deliverable: IAM responsibility matrix (RACI) and in-scope application inventory tagged for “critical” and “privileged” access.

2) Build or refine role-based access (RBAC) and least privilege

1. For each critical system, define standard roles aligned to job functions (nursing, billing, help desk, security admin, etc.).
2. Map roles to groups in your directory/IAM and make groups the default provisioning mechanism.
3. Create an exception process for direct permission grants, including: justification, compensating controls, end date, and re-approval cadence.
4. Lock down shared accounts. If they must exist (legacy appliances), document ownership, require MFA where possible, rotate secrets, and restrict network paths.

Acceptance test: A manager request results in group-based access; you can show why a user has access without reading free-text notes.

3) Treat privileged access as a separate control plane

1. Define “privileged” clearly: domain admin, EHR admin, cloud tenant admin, firewall admin, database admin, backup admin, security tool admin.
2. Require separate admin accounts (no day-to-day email browsing from the same identity used for admin actions).
3. Implement MFA for privileged actions and for critical systems ¹.
4. Centralize privileged authentication and logging where feasible (SSO, PAM, or at minimum, directory groups + logging).

Practical minimum: Even without a full PAM rollout, you can enforce admin group membership controls, MFA, and documented review.

4) Implement access lifecycle controls (joiner/mover/leaver)

1. Provisioning: Require ticketed requests with business approval for non-standard access. Standard role assignment can be automated based on job code/department.
2. Changes: When someone moves roles, remove prior access before granting new access where feasible (especially for sensitive clinical or billing permissions).
3. Deprovisioning: Terminations disable accounts quickly, including remote access, EHR accounts, and third party portals tied to the user.

Evidence strategy: Make the ticketing system the book of record for approvals and timestamps.

5) Run recurring access reviews that create remediation

1. Establish two review types:
   • Privileged access review (admins, emergency access, break-glass accounts).
   • Critical system access review (EHR, patient portal admin, billing admin, security tools).
2. Define reviewer expectations: reviewers must confirm appropriateness and attest, not just click “approve all.”
3. Track remediation: removals, role adjustments, exception renewals, and policy updates.

Tip: Keep a standing “access review findings” log; it becomes your audit narrative.

6) Make MFA coverage provable for critical systems

1. List critical systems and each system’s MFA enforcement method (SSO policy, native MFA, conditional access).
2. Configure policies to prevent bypass (service accounts, legacy protocols, local accounts).
3. Document exceptions (clinical downtime workflows, shared device constraints) with compensating controls and sunset dates.

Artifact: MFA coverage matrix for critical systems ¹.

Required evidence and artifacts to retain

Maintain artifacts that show both design (what you intended) and operation (what actually happened):

Governance

• IAM policy/standard: least privilege, MFA expectations, privileged access rules ¹.
• Role catalog and access matrix for critical systems.
• Exception register (who, what, why, compensating controls, end date, approver).

Operations

• Provisioning/deprovisioning tickets (joiner/mover/leaver), including approvals.
• Admin group membership change records.
• Access review packets: reviewer list, population, results, attestations, and remediation actions.
• MFA enforcement evidence: conditional access policies, screenshots/config exports, and sample authentication logs for critical systems.
• Third party access records: sponsor approval, scope, access method, termination evidence.

Logging/monitoring

• Logs showing privileged authentication and administrative actions where available.
• Evidence that logs are retained and can be produced upon request (align retention with your internal policy).

Common exam/audit questions and hangups

Auditors tend to probe “show me” points:

• “How do you define ‘critical systems’ and which systems are in scope for MFA?” ¹
• “Show a terminated user and prove access was removed everywhere relevant.”
• “List all privileged accounts. Who approved them? When were they last reviewed?”
• “Do you have shared admin accounts? If yes, why, and what controls compensate?”
• “How do you govern third party access and ensure it’s removed when the engagement ends?”
• “Can you explain why User X has access Y without reverse-engineering permissions?”

Hangup: Organizations often have policies but cannot produce review outputs or remediation proof. The requirement is governance plus operation ¹.

Frequent implementation mistakes (and how to avoid them)

1. MFA “enabled” but not “enforced.” Avoid relying on per-user toggles or optional enrollment. Use enforceable policies tied to critical systems ¹.
2. Privilege sprawl via nesting and inherited groups. Document group design and periodically review group nesting; keep admin membership small and justified.
3. Service accounts ignored. Inventory service accounts, define owners, rotate secrets, and restrict permissions. Treat them as identities that need governance.
4. Access reviews that rubber-stamp. Require reviewers to certify job-function alignment and remove access where uncertain. Track and close findings.
5. Third party access treated as “IT will handle it.” Require a business sponsor, define scope, and set an end date. Review third party privileged access the same way as internal admins.

Enforcement context and risk implications

HICP is guidance from HHS’s 405(d) program and is widely used to express reasonable cybersecurity practices in healthcare ¹. Even without a specific enforcement case cited here, IAM weaknesses create predictable breach narratives: unauthorized access, insufficient access termination controls, and poor administrative account governance. In practice, your risk is not only a security event; it is also the inability to prove you governed access in a defensible way when asked by customers, auditors, or oversight bodies ¹.

Practical 30/60/90-day execution plan

First 30 days: establish scope, baseline, and quick wins

• Name IAM control owner and approvers; publish an IAM control charter.
• Inventory critical systems and privileged access points; tag MFA-required systems ¹.
• Turn on MFA for the highest-risk pathways you can control quickly (SSO admins, remote access, cloud console).
• Export current privileged group membership; start a privileged access review immediately.
• Create an exceptions register and stop granting “permanent exceptions” without end dates.

Days 31–60: standardize provisioning and reviews

• Define standard roles for top critical systems; convert ad hoc permissions to groups.
• Implement joiner/mover/leaver workflow in tickets or IAM tooling; require business approval for non-standard access.
• Formalize recurring privileged access reviews and critical system access reviews; set reviewer instructions and remediation SLAs.
• Document third party access governance: sponsor, scope, authentication method, and termination steps.

Days 61–90: harden, automate, and make it audit-ready

• Close gaps: service account inventory, shared accounts remediation plan, legacy protocol MFA bypasses.
• Produce an “IAM evidence pack” template: policy, critical system list, MFA matrix, review outputs, sample tickets, exception log ¹.
• Conduct a tabletop audit: pick random users/admins and prove access justification, approvals, MFA status, and review coverage.
• If you need scale, consider using Daydream to manage control evidence collection and keep access review and exception artifacts consistent across systems and third parties.

Frequently Asked Questions

What counts as a “critical system” for MFA and tighter access control?

Treat systems as critical if compromise would expose sensitive healthcare data, disrupt patient care, or grant broad administrative control. Document your criteria and maintain a list you can defend ¹.

How do we handle clinicians who resist MFA due to workflow impact?

Start with MFA on remote and administrative access paths, then expand with clinician-friendly methods (push, FIDO2) and device-based conditional access. If you must grant exceptions, document compensating controls and an end date ¹.

Do we need a full PAM tool to meet this requirement?

No. You need governed privileged access: controlled admin group membership, MFA for privileged access to critical systems, logging, and recurring reviews with remediation ¹.

How should we treat third party support accounts?

Require a business sponsor, define scope, require MFA where possible, and set an end date tied to the engagement. Review third party privileged access with the same rigor as internal privileged access ¹.

What evidence is most persuasive in an audit?

Completed access review packages (with findings and removals), MFA policy enforcement screenshots/config exports for critical systems, and sample provisioning/deprovisioning tickets showing approvals and timestamps ¹.

We have legacy apps that can’t do SSO or MFA. What’s the minimum defensible approach?

Restrict network access, limit accounts to least privilege, control admin access tightly, monitor logins, and document a modernization plan with interim compensating controls. Keep exceptions explicit and time-bound ¹.

Related compliance topics

• 2025 SEC Marketing Rule Examination Focus Areas
• Access and identity controls
• Access Control (AC)
• Access control and identity discipline
• Access control lifecycle management

Footnotes

1. HHS 405(d) HICP