Steering Clear of Pitfalls in a MARS-E Audit

Within the landscape of information security, the Minimum Acceptable Risk Standards for Exchanges (MARS-E) is a vital framework for health exchanges that seeks to uphold the integrity, privacy, and confidentiality of Personally Identifiable Information (PII). However, the path to a successful MARS-E audit can be strewn with potential pitfalls that may cause organizations to falter. In this Peak Post, we identify recurring errors across various MARS-E control families and provide strategies to circumvent them, facilitating a smoother journey towards MARS-E compliance.

Addressing Common MARS-E Mistakes

Access Control (AC)

Common Mistake: An all-too-familiar challenge faced during MARS-E audits is unauthorized access to protected data due to improperly implemented access controls.

Strategy to Counteract: Formulate and enforce a comprehensive access control policy centered on the principle of least privilege. Regularly review and adjust user roles and access privileges to curtail the risk of unauthorized data access. Automated tools can be used to track access control changes, providing a clearer oversight of who has access to what. This, coupled with the implementation of strong password policies and session controls, can further bolster your organization’s access control mechanisms.

Awareness and Training (AT)

Common Mistake: Inadequate training often leads to employees inadvertently causing security breaches due to a lack of understanding of MARS-E standards.

Strategy to Counteract: Adopt a systematic approach to security training, providing all staff who handle PII with regular, comprehensive instruction. Establishing a security-focused culture can ensure every team member comprehends their role in securing sensitive data. To make training more effective, it should be tailored to the role and responsibility of each employee, and use real-life examples when possible. Continually evaluate the effectiveness of the training and make improvements as needed.

Audit and Accountability (AU)

Common Mistake: Absence of a methodical auditing and real-time monitoring mechanism leaves organizations reactive rather than proactive when it comes to data breaches.

Strategy to Counteract: Implement a rigorous auditing system and real-time monitoring to ensure your organization stays on the front foot in terms of data security. Regular review of system logs and access logs can help detect any anomalies early, reducing the potential impact of breaches. Automated auditing solutions can help streamline this process and provide early warning alerts. An incident tracking system can also provide valuable insights into recurring problems.

Security Assessment and Authorization (CA)

Common Mistake: Failing to perform frequent and detailed security assessments can leave organizations unprepared to tackle emerging threats.

Strategy to Counteract: Ensure security controls are regularly evaluated and updated to combat new threats. The best defense against evolving threats is a continually evolving security control system. This process should involve a thorough review of the existing security measures, identifying gaps, and deciding on the necessary updates or changes. Always document these changes for future reference and audits.

Configuration Management (CM)

Common Mistake: System misconfigurations can unintentionally provide opportunities for malicious actors to exploit and breach data.

Strategy to Counteract: Emphasize the importance of strict configuration management processes. Regular system checks and fine-tuning of configurations are essential to prevent potential security gaps. Make use of automated configuration management tools to help track and control changes to your IT environment. Maintaining a standard configuration across all systems can also reduce complexity and the likelihood of errors.

Contingency Planning (CP)

Common Mistake: Lack of a comprehensive, detailed contingency plan can lead to unnecessary downtime or loss of data in the event of an incident.

Strategy to Counteract: Formulate an all-encompassing contingency plan that spells out the recovery steps in the face of diverse scenarios. Frequent testing and updating are crucial to ensure the plan remains effective. A strong plan should include a disaster recovery strategy, a business continuity plan, and procedures for regular data backups. It is also wise to cross-train staff so they can step in during an emergency.

Identification and Authentication (IA)

Common Mistake: Weak or insufficient authentication mechanisms can make it easy for unauthorized users to gain access to sensitive data.

Strategy to Counteract: Employ multi-factor authentication to strengthen security at the access points. Regularly review your authentication methods to discover and fix potential vulnerabilities. Consider implementing biometrics or hardware tokens for sensitive systems. Additionally, account lockouts after a certain number of failed login attempts can help prevent brute-force attacks.

Incident Response (IR)

Common Mistake: A poorly designed or missing incident response plan can escalate the fallout from a data breach.

Strategy to Counteract: Develop a comprehensive incident response plan that outlines the specific steps to be taken when a breach occurs. Regularly testing and updating this plan ensures it stays current and effective. The plan should include clear communication lines, roles, and responsibilities, as well as procedures for mitigating damage, investigating breaches, and notifying affected parties.

Maintenance (MA)

Common Mistake: Inadequate system maintenance can lead to unpatched vulnerabilities, making systems an easy target for security breaches.

Strategy to Counteract: Maintenance and updates must be carried out regularly to ensure optimal security. This includes system cleanup, patching, and hardware checks. Automate updates where possible, and keep a tight schedule for maintenance activities. Ensure backup systems are in place to minimize downtime during maintenance.

Media Protection (MP)

Common Mistake: Insufficient protection of data during transit, storage, or disposal can open the door to unauthorized access and data breaches.

Strategy to Counteract: Adopt robust measures for data protection at all stages. This includes encryption of data at rest and in transit, secure storage practices, and secure disposal of obsolete data. Consider using secure VPNs for data in transit and invest in secure storage systems. Always verify that obsolete data is permanently and irretrievably destroyed.

Physical and Environmental Protection (PE)

Common Mistake: Neglecting physical and environmental threats can lead to unauthorized physical access, system damage, and data loss.

Strategy to Counteract: Incorporate physical security measures such as restricted access to facilities and safeguards against environmental hazards like fire or flood. Security cameras, biometric access controls, and visitor management systems can enhance physical security. Ensure you have safeguards against environmental risks, such as UPS systems for power outages and fire suppression systems.

Planning (PL), Personnel Security (PS), and Program Management (PM)

Common Mistake: Absence of a holistic, organization-wide security strategy can leave your organization vulnerable to security breaches.

Strategy to Counteract: Adopt an organization-wide approach to security planning, ensuring security considerations permeate all levels of your operations. This includes thorough background checks on personnel with access to sensitive data, security considerations in project management, and a long-term strategic vision for security. Regular security briefings can help keep all staff aware of the importance of security in their daily activities.

Risk Assessment (RA)

Common Mistake: Shallow risk assessments can result in unidentified threats and vulnerabilities, leaving the organization exposed.

Strategy to Counteract: Undertake comprehensive risk assessments on a regular basis. The insights from these assessments should guide the evolution of your security strategy and control implementation. These assessments should consider both internal and external threats and should be conducted by personnel with the necessary experience and expertise. Document the findings of each assessment for future reference and follow-up.

System and Services Acquisition (SA)

Common Mistake: Procuring systems or services without comprehensive security assessments can introduce vulnerabilities.

Strategy to Counteract: Make security a priority during procurement. Carry out thorough security evaluations of vendors and their products or services. Establish strong contractual agreements around security responsibilities, and ensure that any procured software meets your organization’s security requirements before integration into your systems.

System and Communications Protection (SC)

Common Mistake: Failure to secure data communications can lead to interception of sensitive data by unauthorized parties.

Strategy to Counteract: Implement robust encryption for all data communications and isolate sensitive systems where necessary. Regularly update encryption protocols to keep up with evolving standards. Additionally, firewalls and intrusion detection/prevention systems can help protect your network.

System and Information Integrity (SI)

Common Mistake: Neglecting to continuously monitor system and data integrity can result in breaches going unnoticed until it’s too late.

Strategy to Counteract: Deploy controls that continuously monitor the integrity of systems and data, coupled with real-time alerts to detect potential breaches swiftly. Use checksums or hashing algorithms to verify data integrity. Regular system scans can help identify anomalies that might indicate a breach.


By recognizing these common pitfalls and implementing these strategies, organizations can navigate the path to MARS-E compliance more effectively, safeguarding their operations, and protecting their systems and their users’ sensitive data.

Please reach out if you would like to learn more about how Audit Peak can assist you with your MARS-E compliance or for a free consultation. WE WILL TAKE YOU TO THE PEAK.