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Title: Identity Theft Prevention Program-Red Flag Rules
Subject:  Corporate Compliance and Privacy                       
Policy No: CCP: 2017: 01                                                                 
Applies: Rowan School of Osteopathic Medicine       
Issuing Authority:   Dean, RowanSOM
Responsible Officer:   Chief Audit, Compliance & Privacy Officer
Adopted: 03/20/2017
Last Revision: 03/20/2017
Last Reviewed: 03/20/2017

I.     PURPOSE

The purpose of this policy is to ensure that the RowanSOM complies with the Federal Trade Commission’s (FTC) Identity Theft Rules under sections 114 and 315 of the Fair and Accurate Credit Transactions Act (FACT Act).  These regulations are also known as the Red Flags Rule.  Under this policy, RowanSOM shall design a program to detect, prevent and mitigate identity theft in connection with the opening of a covered account or any existing covered account.  This program shall mitigate the risks associated with identity theft and mitigate the effects of identity theft on RowanSOM, its employees, its students, its patients, its constituents and its customers.  This policy also addresses the administration of Perkins Loans, Institutional Loans and the provision of an extended tuition payment plan.

II. 

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  ACCOUNTABILITY

Under the direction of the Dean, the Clinical Dean for Academic and Clinical Affairs, the General Counsel and the Chief Compliance & Privacy Officer shall ensure compliance with this policy. The Dean, Chief Operating Officer of RowanSOM shall implement this policy.

III.

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   APPLICABILITY

This policy applies to the schools and units of RowanSOM, to the RowanSOM Community which includes RowanSOM management, faculty, and other academic personnel, clinical staff, researchers, employees, contractors, agents and others associated with or supporting RowanSOM.

IV.    DEFINITIONS 

1. Account: a continuing relationship established by a person with a financial institution or creditor to obtain a product or service for personal, family, household or business purposes.  Account includes:

   1. An extension of credit, such as services involving a deferred payment, e.g. patient accounts, Perkins Loans and Institutional Loans; and

   2. A deposit account.

2. Covered Account:  the Red Flags Regulations define the term “covered account” to mean:

   1. “an account that a financial institution or creditor offers or maintains, primarily for personal, family, or household purposes that involves or is designed to permit multiple payments or transactions” and

   2. “any other account that the financial institution or creditor offers or maintains for which there is a reasonably foreseeable risk to customers, or to the safety and soundness of the financial institution, or creditor from identity theft, including financial, operational, compliance, reputation, or litigation risks.”

   3. For the purposes of the RowanSOM’s Identity Theft Program, the term “covered account” is extended to include any RowanSOM account or database (financially based or otherwise) for which RowanSOM believes there is a reasonably foreseeable risk to the RowanSOM,  faculty, staff, patients, constituents or customers from identity theft.

3. Credit:  the right granted by a creditor to a debtor to defer payment of debt or to incur debts and defer its payment or to purchase property or services and defer payment therefore.

4. Creditor:  any person who regularly extends, renews, or continues credit; any person who regularly arranges for the extension, renewal, or continuation of credit; or any assignee of an original creditor who participates in the decision to extend, renew, or continue credit. A RowanSOM example of a “creditor” is Patient Accounts.
5. Customer: any person with a covered account with a creditor.  A RowanSOM example of a “customer” is a patient who has been afforded a patient payment plan.
6. Financial Institution:  a State or National bank, a State or Federal savings and loan association, a mutual savings bank, a State or Federal credit union, or any other person that, directly or indirectly, holds a transaction account belonging to a consumer.
7. Identity Theft:  the act of: knowingly obtaining, possessing, buying, or using, the personal identifying information of another:  (i) with the intent to commit any unlawful act including, but not limited to, obtaining or attempting to obtain credit, goods, services or medical information in the name of such other person; and (ii)(a) without the consent of such other person; or (b) without the lawful authority to obtain, possess, buy or use such identifying information.
8. Theft of Services:  includes:  (i) intentionally obtaining services by deception, fraud, coercion, false pretense or any other means to avoid payment for the services; and (ii) having control over the disposition of services to others, knowingly diverts those services to the person's own benefit or to the benefit of another not entitled thereto.
9. Notice of address discrepancy:  a notice sent to a user by a consumer reporting agency pursuant to 15 U.S.C. § 1681(c)(h)(1), that informs the user of a substantial difference between the address for the consumer that the user provided to request the consumer report and the address(es) in the agency’s file for the consumer.
10. Person:  a natural person, a corporation, government or governmental subdivision or agency, trust, estate, partnership, cooperative, or association.
11. Personal Identifying Information:  any information that is requested in conjunction with a covered account that may be used alone, or in conjunction with any other information, to identify a specific person, e.g., credit card account information, debit card information, bank account information and drivers’ license information, social security number, mother’s birth name, and date of birth.
12. Red Flag:  a pattern, practice, or specific activity that indicates the possible existence of Identity Theft.  The FTC regulations provide a list of 26 common red flags; organizations may decide that some of these 26 are not applicable, and/or that other red flags are more useful.
13. Service Provider:  a person that provides a service directly to the financial institution or creditor.
14. Transaction Account:  a deposit or account on which the depositor or account holder is permitted to make withdrawals by a negotiable or transferable instrument, payment orders of withdrawal, telephone transfers, or other similar items for the purpose of making payments or transfers to third persons or others.  Such term includes demand deposits, negotiable order of withdrawal accounts, savings deposits subject to automatic transfers, and share draft accounts.

V.   REFERENCES

1. 45 C.F.R. § 164.512(f)(5) (HIPAA crime on premises); 42 C.F.R. § 2.12 (c)(5)(ii);
2. Fair and Accurate Credit Transactions Act and federal regulations 16 CFR § 681

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1. Attachment A: FTC’s Examples of Red Flags

2. Attachment B: Identity Theft Red Flag and Security Incident Reporting Procedure

3. Attachment C: Identity Alert Form

4. Attachment D: Sample Letter Regarding Patient Misidentification

5. Attachment E: Sample Letter Regarding Identity Theft

6. Attachment F: Sample Letter Regarding Identity Theft Report

ATTACHMENT A

FTC’s Examples of Red Flags

ATTACHMENT B

Identity Theft Red Flag and Security Incident Reporting Procedure

1. Purpose
   1. The purpose of the Identify Theft Red Flag and Security Incident Reporting Procedure is to provide information to assist individuals in (1) detecting, preventing, and mitigating identity theft in connection with the opening of a “covered account” or any existing “covered account” or who believe that a security incident has occurred and (2) reporting a security incident.
2. Background
   1. Security Incident 
      1. The American Recovery and Reinvestment Act (ARRA) requires that any organization that owns computerized data that includes personal information shall disclosure any breach of security of the system following discovery or notification of the breach in the security of the system to whose unencrypted personal information was, or is reasonably believed to have been, acquired by an unauthorized person.
   2. Red Flag Rules
      1. In 2003, the U.S. Congress enacted the Fair and Accurate Credit Transaction Act of 2003 (FACT Act) which required the Federal Trade Commission (FTC) to issue regulations requiring “creditors” to adopt policies and procedures to prevent identify theft.
      2. In 2007, the Federal Trade Commission (FTC) issued a regulation known as the Red Flag Rule. The rule requires “financial institutions” and “creditors” holding “covered accounts” to develop and implement a written identity theft prevention program designed to identify, detect and respond to “Red Flags.”
      3. The Red Flag Rule has been implemented by the Federal Trade Commission (FTC) on August 1, 2009.
3. Definitions
   1. Covered Account
      A covered account is a consumer account designed to permit multiple payments or transactions.  These are accounts where payments are deferred and made by a borrower periodically over time such as a  fee installment payment plan.
   2. Creditor
      A creditor is a person or entity that regularly extends, renews, or continues credit and any person or entity that regularly arranges for the extension, renewal, or continuation of credit. Examples of activities that indicate a college or university is a “creditor” are:
      1. Offering institutional loans to faculty or staff;
      2. Offering a plan for payment of patient services rather than requiring full payment
   3. Personal Information
      This information includes an individual’s first name or first initial and his or her last name in combination with any one or more of the following data elements, when either the name or the data elements are not encrypted or redacted: Social Security Number, driver’s license, health insurance information, medical information, or financial account number such as credit card number, in combination with any required security code, access code, or password that would permit access to an individual’s financial account.
   4. Red Flag
      A red flag is a pattern, practice or specific activity that indicates the possible existence of identity theft.
   5. Security Incident
      A collection of related activities or events which provide evidence that personal information could have been acquired by an unauthorized person.
4. Identification of Red Flags
   1. Broad categories of “Red Flags” include the following:
      1. Alerts – alerts, notifications, or warnings from a consumer reporting agency including fraud alerts, credit freezes, or official notice of address discrepancies.
      2. Suspicious Documents – such as those appearing to be forged or altered, or where the photo ID does not resemble its owner, or an application which appears to have been cut up, re-assembled and photocopied.
      3. Suspicious Personal Identifying Information – such as discrepancies in address, Social Security Number, or other information on file; an address that is a mail-drop, a prison, or is invalid; a phone number that is likely to be a pager or answering service; personal information of others already on file; and/or failure to provide all required information.
      4. Unusual Use or Suspicious Account Activity –such as material changes in payment patterns, notification that the account holder is not receiving mailed statement, or that the account has unauthorized charges;
      5. Notice from Others Indicating Possible Identify Theft–such as the institution receiving notice from a victim of identity theft, law enforcement, or another account holder reports that a fraudulent account was opened.
5. Detection of Red Flags
   1. Detection of Red Flags in connection with the opening of covered accounts as well as existing covered accounts can be made through such methods as:
      1. Obtaining and verifying identity;
      2. Authenticating employees or patients;
      3. Monitoring transactions
   2. A data security incident that results in unauthorized access to an employee’s or patient’s  account record or a notice that an employee or patient  has provided information related to a covered account to someone fraudulently claiming to represent RowanSOM or to a fraudulent web site may heighten the risk of identity theft and should be considered Red Flags.
6. Response to Red Flags
   1. If an employee or patient detects fraudulent activity (a red flag) or if an employee or patient claims to be a victim of identity theft, RowanSOM will respond to and investigate the situation.  If the fraudulent activity involves protected health information (PHI) covered under the HIPAA security standards, RowanSOMwill also apply its existing HIPAA and ARRA security policies and procedures to the response.  If potentially fraudulent activity (a red flag) is detected by an employee or patient of RowanSOM: 
      1. The employee/patient should gather all documentation and report the incident to his or her designated compliance officer.
      2. The compliance officer will determine whether the activity is fraudulent or authentic based upon the evidence presented.
      3.  If the activity is determined to be fraudulent, then RowanSOM should take immediate action.  Actions may include:
         1. Cancel the transaction
         2. Notify appropriate enforcement agencies
         3. Notify the affected employee or patient
         4. Notify affected physician(s)
   2. If an employee or patient claims to be a victim of identity theft:
      1. the employee/patient should be encouraged to file a police report for identity theft if he/she has not done so already
      2. the employee/patient patient should be encouraged to complete the ID Theft Affidavit developed by the FTC, along with supporting documentation  www.ftc.gov/bcp/edu/resources/forms/affidavit.pdf.
   3. If following investigation, it appears that the employee/patient has been a victim of identity theft, RowanSOM will promptly consider what further remedial action/notifications may be needed under the circumstances.
7. Security Incident Reporting
   1. An employee who believes that a security incident has occurred, shall immediately notify their designated compliance officer or call the hotline at 1-855-431-9967. 
   2. Service Providers
8. RowanSOM remains responsible for compliance with the Red Flags Rule even if it outsourced operations to a third party service provider. The written agreement between RowanSOM and the third party service provider shall require the third party to have reasonable policies and procedures designed to detect relevant Red Flags that may arise in the performance of their service provider’s activities. The written agreement must also indicate whether the service provider is responsible for notifying only RowanSOM of the detection of a Red Flag or if the service provider is responsible for implementing appropriate steps to prevent or mitigate identify theft.
9. Training
   1. All employees who process any information related to a covered account shall receive training following appointment on the procedures outlined in this document.  Refresher training may be provided annually.
   2. References:   
      1. Fair and Accurate Credit Transactions Act of 2003 (FACTA)
      2. American Medical Association

ATTACHMENT C

IDENTITY ALERT FORM

This form should be completed by the hospital or other facility personnel when the identity of a patient is questioned, either because of identity theft or patient misidentification.

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PLEASE ATTACH A COPY OF THE RELEVANT PHOTO ID AND FORWARD THE COMPLETED FORM TO THE FACILITY’S PRIVACY OFFICER; REGISTRATION DIRECTOR; SECURITY DIRECTOR; PATIENT ACCOUNT DIRECTOR; AND THE COMPLIANCE OFFICER.

ATTACHMENT D

Identity Theft/Patient Misidentification Policy

Sample Letter Regarding Patient Misidentification

[Date]

[Patient Name]

[Patient Address]

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[Facility]

[Telephone number]

ATTACHMENT E

Identity Theft/Patient Misidentification Policy

Sample Letter Regarding Identity Theft

[Date]

BY CERTIFIED MAIL, RETURN RECEIPT REQUESTED

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