PCI Compliance vs. HIPAA Compliance: What Care Management Practices Need to Know

When you run a care management practice, patient advocacy business, or healthcare agency, protecting your clients is at the heart of everything you do. 

But these days, caring for clients isn’t just about healthcare plans and home visits. 

It’s also about keeping their most personal information safe from data breaches and security slip-ups.

(It’s almost an invisible layer that makes your already stressful job a little more stressful)

If you’ve ever set up a new client portal, set up online payment processing, or chosen care management software, you’ve almost certainly run into two major compliance acronyms: 

PCI DSS and HIPAA.

While both exist to safeguard sensitive digital information, they cover entirely different types of data, follow separate sets of rules, and are enforced by completely different groups. 

Confusing the two can lead to serious problems. 

Why?

Because assuming that being compliant with one automatically checks the box for the other can leave your practice vulnerable to huge fines. What’s even worse is that you can lose the trust of your clients if there is a serious data breach. (Like what happened during the UnitedHealth data breach in 2024)

Let’s break down what PCI and HIPAA compliance actually mean for your day-to-day operations, how they overlap, and how you can keep your practice completely secure on both fronts.

The Basics: What Do PCI and HIPAA Actually Do?

To keep things simple, it helps to look at the main job of each standard.

What is PCI DSS?

PCI DSS stands for the Payment Card Industry Data Security Standard.

Back in 2004, the major credit card companies (Visa, Mastercard, American Express, Discover, and JCB) got together and created a shared set of security rules. 

Why?

Because they wanted to protect cardholders from fraud and identity theft whenever they swipe, insert, or type in a payment card.

• The Target Data: Credit, debit, and prepaid card details (card numbers, expiration dates, security codes/CVVs, and cardholder names).
• Who Sets the Rules? The PCI Security Standards Council (PCI SSC).
• Who It Applies To: Any business or practice that accepts, processes, or stores credit card payments, regardless of how big or small you are.

What is HIPAA?

HIPAA stands for the Health Insurance Portability and Accountability Act.

Unlike PCI, which is an industry agreement, HIPAA is a U.S. federal law passed by Congress in 1996. 

Its Security and Privacy Rules dictate how healthcare providers, case managers, and their vendor partners handle sensitive personal health details.

• The Target Data: Protected Health Information (PHI or ePHI when stored electronically). This includes medical records, treatment plans, case notes, and any personal details tied to a client’s health condition.
• Who Sets the Rules? The U.S. Department of Health and Human Services (HHS) and its Office for Civil Rights (OCR).
• Who It Applies To: Healthcare providers, health plans, care managers, and the vendors (Business Associates) who handle health data on their behalf.

PCI vs. HIPAA: A Quick Side-by-Side Comparison

If you’re looking for a quick cheat sheet to share with your team, here is how the two compare across the board:

Feature	PCI DSS Compliance	HIPAA Compliance
What is it?	Private industry standard set by card networks	United States federal law
Main Focus	Financial transactions & credit card security	Client health privacy & medical record security
Protected Data	Card numbers (PANs), CVVs, expiration dates	Case notes, care plans, diagnosis codes, medical history
Who Enforces It?	Credit card brands & merchant banks	HHS Office for Civil Rights (OCR) & federal courts
Vendor Contracts	Merchant agreements & payment processor terms	Business Associate Agreements (BAAs)
Proof of Compliance	Self-Assessment Questionnaires (SAQs) or QSA audits	Regular internal risk assessments (no official “certification”)
Penalties	Bank fines, loss of card processing abilities	Federal fines (up to $2M+/year) and potential criminal charges

Getting Under the Hood: Key Differences Every Practice Should Know

1. The Scope of the Data

PCI DSS has a very tight focus: it cares strictly about credit card numbers and security codes. 

If you use an external, secure payment gateway where card numbers never touch your local computers or servers, your PCI compliance workload stays very light.

HIPAA, on the other hand, covers a broad spectrum of data. 

It protects 18 specific identifiers such as: client names, addresses, birth dates, Social Security numbers, and photos whenever they are linked to care details. 

Because care managers write case notes, track care plans, and communicate with families daily, ePHI flows through almost every part of your agency’s digital setup.

2. How Rules Are Prescribed

PCI DSS is famously specific. 

Its standard outlines 12 precise, technical requirements grouped under 6 main goals like:

1. Build and maintain a secure network (firewalls, vendor defaults).
2. Protect cardholder data (encryption in transit and at rest).
3. Maintain a vulnerability management program (anti-malware, secure systems).
4. Implement strong access control measures (need-to-know access, unique IDs, Multi-Factor Authentication).
5. Regularly monitor and test networks (logging, vulnerability scans).
6. Maintain an information security policy.

HIPAA is much more flexible and risk-based. 

Instead of telling you exactly what software or firewall brand to buy, HIPAA requires you to put reasonable Administrative, Physical, and Technical Safeguards in place based on the size and complexity of your practice.

3. The Myth of “Compliance Certification”

Here’s a common trap many healthcare professionals fall into: believing a vendor who claims to be “100% HIPAA Certified.”

• For PCI DSS: You actually can validate compliance through formal channels, such as completing an annual Self-Assessment Questionnaire (SAQ) or hiring a Qualified Security Assessor (QSA).
• For HIPAA: The federal government does not offer or recognize any official “HIPAA Certification.” Achieving HIPAA compliance isn’t a one-time test you pass; it’s an ongoing operational effort that involves conducting regular risk assessments, training your staff, and signing Business Associate Agreements (BAAs) with software vendors.

Where Healthcare and Payments Meet in Care Management

As a care manager or patient advocate, you operate right where PCI and HIPAA overlap every single day.

Imagine a standard workflow in your agency:

1. You meet with a client, write detailed case notes, and update their care plan (ePHI governed by HIPAA).
2. At the end of the month, you generate an invoice for your care coordination hours (Billing data governed by HIPAA).
3. The client’s family member pays the bill online using a credit card (Payment data governed by PCI DSS).

Because these two worlds touch so closely, it’s easy to make a small mistake that breaches both standards.

Common Mistakes to Avoid

• Writing Credit Cards in Case Notes: Never type a client’s credit card number or CVV code into standard case notes, email threads, or intake forms. If you do, you inadvertently pull your entire client database into the strict scope of PCI DSS.
• Using Consumer Payment Apps: Taking payments through standard consumer apps that refuse to sign a Business Associate Agreement (BAA) can trigger serious HIPAA violations, even if the payment itself seems secure.
• Assuming One Covers the Other: Just because a payment gateway is fully PCI compliant doesn’t mean it’s HIPAA compliant. If payment descriptions include sensitive medical services or patient names without a signed BAA in place, you could still face regulatory penalties.

What Happens If You Aren’t Compliant?

Neither framework turns a blind eye to security slip-ups, but the consequences look a bit different for each.

Consequences of PCI Non-Compliance

Because PCI DSS is enforced through credit card companies and banks, penalties hit your business directly in the wallet and operational workflow:

• Monthly Fines: Banks can issue recurring monthly fines ranging from $5,000 to $100,000 until non-compliance issues are resolved.
• Higher Fees: Payment processors can raise your transaction fees or require expensive physical audits.
• Loss of Card Processing: In severe cases, banks will simply close your merchant account, leaving you unable to accept credit card payments altogether.

Consequences of HIPAA Non-Compliance

Because HIPAA is federal law, violations carry heavy legal weight enforced by the Office for Civil Rights (OCR).

Civil penalties are broken down into four tiers based on how the violation occurred:

Violation Tier	Statutory Culpability Standard	Fine Per Violation	Annual Cap
Tier 1 (Did Not Know)	Did not know and, by exercising reasonable diligence, would not have known.	$137 to $68,928	Up to $2,067,813
Tier 2 (Reasonable Cause)	Knew, or by exercising reasonable diligence would have known, but lacked willful neglect.	$1,379 to $68,928	Up to $2,067,813
Tier 3 (Willful Neglect – Corrected)	Acted with conscious or intentional neglect, but corrected the issue within 30 days.	$13,785 to $68,928	Up to $2,067,813
Tier 4 (Willful Neglect – Uncorrected)	Acted with conscious or intentional neglect, and failed to correct within 30 days.	Min. $68,928	Up to $2,067,813

(Note: Statutory penalty amounts are inflation-adjusted annually by HHS.)

Apart from mere monetary fines, criminal penalties enforced by the U.S. The Department of Justice (DOJ) can apply for intentional offenses, including fines up to $250,000 and up to 10 years in prison for knowingly obtaining or disclosing individually identifiable health information under false pretenses or for commercial advantage.

4 Practical Steps to Keep Your Practice Secure

You don’t need a massive IT department to keep your client data safe. Here are four practical habits you can start implementing today:

1. Keep Payment Data Separate from Care Notes: Always handle credit card details through a dedicated, tokenized payment portal. Never store card numbers in general client files or intake notes.
2. Always Get Signed BAAs: Before adopting any software, cloud storage provider, or billing system that touches client info, make sure they will sign a Business Associate Agreement (BAA).
3. Use Role-Based Permissions: Limit who on your team can see what. A staff member sending out billing statements doesn’t need to read clinical assessment notes, and field care team members don’t need access to client payment tokens.
4. Run an Annual Risk Checkup: Set aside time once a year to review how data flows through your practice, update staff training, review user access logs, and complete your yearly PCI self-assessment.

How Purpose-Built Software Makes Compliance Easier

Trying to manage HIPAA guidelines, PCI requirements, and day-to-day client care all on your own can feel overwhelming. 

That’s why using software engineered specifically for care management makes such a huge difference.

Tools like My Junna take the guesswork out of compliance by building security directly into your everyday workflow:

• HIPAA-Compliant Care Coordination: Keep case notes, care plans, and face sheets fully secure with built-in administrative and technical safeguards.
• Streamlined Billing Integrations: Easily invoice clients and handle payments using secure features that keep financial data separate from health records. 
• Smart Access Controls: Control access level permissions so your team members only see the specific information they need to do their jobs effectively.

By choosing platforms built with care management in mind, you protect your clients’ privacy, stay compliant with both PCI and HIPAA, and spend less time worrying about regulations and more time delivering great care.

In short:

While PCI DSS protects payment card transactions and HIPAA safeguards personal health information, both frameworks share a common goal which is protecting people by securing their data. 

By separating payment details from clinical notes, securing BAAs with vendors, and utilizing purpose-built practice management tools, care management practices can protect both their clients and their business operations.

Using compliant software not only protects your clients but it also gives you peace of  mind and protects your personal assets.  

It is much easier to pay a monthly subscription of $120 than to pay a $70 000 fine.