Logo of Pediatric Ophthalmology Consultants, Miami, Florida

3200 SW 60 Ct.
Suite 103
Miami, FL 33155
Phone: 305-662-8390
Fax: 305-661-7862

Red Flag Rules

Identity theft prevention and detection and Red Flags Rule compliance

Please note: The information provided in this document does not constitute, and is no substitute for, legal or other professional advice. Seek consultation from legal or other professional advisors for individualized guidance regarding the application of the law to your particular situation or regarding other compliance-related concerns.

Policy

It is the policy of Pediatric Ophthalmology Consultants to follow all federal and state laws and reporting requirements regarding identity theft. Specifically, this policy outlines how Pediatric Ophthalmology Consultants will (1) identify, (2) detect and (3) respond to “red flags.” A “red flag” as defined by this policy includes a pattern, practice, or specific account or record activity that indicates possible identity theft.

It is the policy of Pediatric Ophthalmology Consultants that this Identity theft prevention and detection and Red Flags Rule compliance program is approved by Pediatric Ophthalmology Consultants as of May 1, 2009, and that the policy is reviewed an approved no less annually.

It is the policy of Pediatric Ophthalmology Consultants that Ivonne Goldstein is assigned the responsibility of implementing and maintaining the Red Flags Rule requirements. Furthermore, it is the policy of this Pediatric Ophthalmology Consultants that this individual will be provided sufficient resources and authority to fulfill these responsibilities. At a minimum, it is the policy of Pediatric Ophthalmology Consultants that there will be one individual or job description designated as the privacy official.

It is the policy of Pediatric Ophthalmology Consultants that its business associates must be contractually bound to protect sensitive patient information to the same degree as set forth in this policy. It is also the policy of this Pediatric Ophthalmology Consultants that business associates who violate their agreement will be dealt with first by an attempt to correct the problem, and if that fails, by termination of the agreement and discontinuation of services by the business associate.

It is the policy of Pediatric Ophthalmology Consultants that all members of our workforce have been trained by the May 1, 2009 compliance date on the policies and procedures governing compliance with the Red Flags Rule. It is also the policy of Pediatric Ophthalmology Consultants that new members of our workforce receive training on these matters within a reasonable time after they have joined the workforce. It is the policy of Pediatric Ophthalmology Consultants to provide training should any policy or procedure related to the Red Flags Rule materially change. This training will be provided within a reasonable time after the policy or procedure materially changes. Furthermore, it is the policy of Pediatric Ophthalmology Consultants that training will be document, indicating participants, date and subject matter.

Procedures

I. Identify red flags. In the course of caring for patients, Pediatric Ophthalmology Consultants may encounter inconsistent or suspicious documents, information or activity that may signal identity theft. Pediatric Ophthalmology Consultants identifies the following as potential red flags, and this policy includes procedures describing how to detect and respond to these red flags below:

  1. A complaint or question from a patient based on the patient’s receipt of:
    • A bill for another individual;
    • A bill for a product or service that the patient denies receiving;
    • A bill form a health care provider that the patient never patronized; or
    • A notice of insurance benefits (or explanation of benefits) for health care services never received.
  2. Records showing medical treatment that is inconsistent with a physical examination or with a medical history as reported by the patient.
  3. A complaint or question from a patient about the receipt of a collection notice from a bill collector.
  4. A patient or health insurer report that coverage for legitimate hospital stays is denied because insurance benefits have been depleted or a lifetime cap bas been reached.
  5. A complaint or question from a patient about information added to a credit report by a health care provider or health insurer.
  6. A dispute of a bill by a patient who claims to be the victim of any type of identity theft.
  7. A patient who has an insurance number but never produces an insurance card or other physical document of insurance.
  8. A notice or inquiry from an insurance fraud investigator for a private health insurer or a law enforcement agency, including but not limited to, a Medicare or Medicaid fraud agency.
  9. And any other unexpected related issues.

II. Detect red flags. Pediatric Ophthalmology Consultants practice staff will be alert for discrepancies in documents and patient information that suggest risk of identity theft or fraud. Pediatric Ophthalmology Consultants will verify patient identity, address and insurance coverage at the time of patient registration/check-in.

Procedure:

  1. When a patient calls to request an appointment, the patient will be asked to bring the following at the time of the appointment:
    • Driver’s license or other photo ID;
    • Current health insurance card; and
    • Utility bills or other correspondence showing current residence if the photo ID does not show the patient’s current address.
    • If the patient is a minor, the patient’s parent or guardian should bring the information listed above.
  2. When the patient arrives for the appointment, the patient will be asked to produce the information listed above. This requirement may be waived for patients who have visited the practice within the last six months.
  3. If the patient has not completed the registration form within the last six months, registration staff will verify current information on file and, if appropriate, update the information.
  4. Staff should be alert for the possibility of identity theft in the following situations:
    • The photograph on a driver’s license or other photo ID submitted by the patient does not resemble the patient.
    • The patient submits a driver’s license, insurance card, or other identifying information that appears to be altered or forged.
    • Information on one form of identification the patient submitted is inconsistent with information on another form of identification or with information already in the practice’s records.
    • An address or telephone number is discovered to be incorrect, non-existent or fictitious.
    • The patient fails to provide identifying information or documents.
    • The patient’s signature does not match a signature in the practice’s records.
    • [If your practice collects Social Security number]: The Social Security number or other identifying information that patient provided is the same as identifying information in the practice’s records provided by another individual, or the Social Security number is invalid.

III. Respond to Red Flags. If an employee of Pediatric Ophthalmology Consultants detects fraudulent activity or if a patient claims to be a victim of identity theft, Pediatric Ophthalmology Consultants will respond to and investigate the situation. If the fraudulent activity involves protected health information (PHI) covered under the HIPPA security standards, Pediatric Ophthalmology Consultants will also apply its existing HIPPA security policies and procedures to the response.

Procedure

If potentially fraudulent activity (a red flag) is detected by an employee of Pediatric Ophthalmology Consultants:

  1. The employee should gather all documentation and report the incident to his or her immediate supervisor.
  2. The supervisor will determine whether the activity is fraudulent or authentic.
  3. If the activity is determined to be fraudulent, then Pediatric Ophthalmology Consultants should take immediate action. Actions may include:
    • Cancel the transaction;
    • Notify appropriate law enforcement;
    • Notify the affected patient;
    • Notify affected physician(s); and
    • Assess impact to practice.

If a patient claims to be a victim of identity theft:

  1. The patient should be encouraged to file a police report for identity theft if he/she has not done so already
  2. The patient should be encouraged to complete the ID Theft Affidavit developed by the FTC, along with supporting documentation.
  3. Pediatric Ophthalmology Consultants will compare the patient’s documentation with personal information in the practice’s records.
  4. If following investigation, it appears that the patient has been a victim of identity theft; Pediatric Ophthalmology Consultants will promptly consider what further remedial act/notifications may be needed under the circumstances.
  5. The physician will review the affected patient’s medical record to confirm whether documentation was made in the patient’s medical record that resulted in accurate information in the record. If inaccuracies due to identity theft exist, a notation should be made in the record to indicate identity theft.
  6. The practice medical records staff will determine whether any other records and/or ancillary service providers are linked to in accurate information. Any additional files containing information relevant to identity theft will be removed and appropriate action taken. The patient is responsible for contacting ancillary service providers.
  7. If following investigation, it does not appear that he patient has been a victim of identity theft, Pediatric Ophthalmology Consultants will take whatever action it deems appropriate.