Medical Canvassing: 3 Key Tips for Consistent Success

Before diving into the common problems, let’s take a quick look at what medical canvassing is and why it’s important. Medical canvassing involves gathering information from healthcare providers to verify medical treatment and history. It’s an investigative process that can involve contacting hospitals, clinics, and physicians to check whether the claimant’s injuries match the alleged claims.

By conducting thorough canvassing, you can uncover discrepancies, and identify patterns of suspicious behavior all without needing a record retrieval or requesting PHI. But, as with any investigative process, things can go wrong. Let’s break down the three risks to be aware of during a medical canvass.

Inaccurate or Incomplete Information

One of the most common and potentially damaging mistakes in medical canvassing is gathering inaccurate or incomplete information. This can happen for several reasons: miscommunication between the claims adjuster and the medical provider, inadequate data collection, or relying on outdated or unverified information.

• Increased Risk of Fraud: If the data you’re collecting is incomplete or inaccurate, you may miss vital discrepancies that could signal fraud. Missing a piece of information or failing to double-check a healthcare provider’s records can result in a missed opportunity to catch claims early.
• Incorrect Medical Conclusions: Inaccurate information can lead to an incorrect assessment of the injury and treatment plan, which could affect the outcome of the claim. For instance, if a medical provider reports treatments that weren’t actually provided, it could lead to incorrect conclusions about the severity of an injury.

When it comes to verifying medical claims, thoroughness is key. Ensuring the accuracy of the information you gather can make or break the outcome of your investigation. By cross-checking details from multiple sources, leveraging Electronic Health Records (EHR), and requesting comprehensive medical histories, you can mitigate risks and catch discrepancies early. Here are three essential steps to improve the reliability and depth of your medical canvassing efforts.

• Verify Information Multiple Times: Ensure that you cross-check information from multiple sources. For example, when canvassing, confirm the details of the treatment with the healthcare provider, the claimant, and other relevant parties.
• Use Electronic Health Records (EHR): Many healthcare providers use EHR systems that can provide more accurate and up-to-date medical history. Using EHRs, where possible, can help minimize the chances of missing or inaccurate data.
• Get the Full Picture: Don’t just ask about the treatment in question—ask for the full medical history if necessary. This will help you spot discrepancies or red flags that may have otherwise gone unnoticed.

Follow Legal and Privacy Guidelines

Another critical pitfall in medical canvassing is failing to follow legal and privacy guidelines, such as those outlined in the Health Insurance Portability and Accountability Act (HIPAA). You’re likely familiar with these rules, but it’s still easy to overlook the finer details when conducting canvassing efforts, especially when under pressure to move quickly.

• Legal Repercussions: Failure to follow proper privacy laws can result in lawsuits, fines, and other legal consequences. If you share or collect medical information in violation of HIPAA or state regulations, you could face significant penalties. In other words, it’s not worth it!
• Loss of Trust: If a claimant or physician you contact feels their privacy has been violated, it could result in a loss of trust, delays in claim resolution, and even the possibility of a bad faith claim on your hands.

When conducting medical canvassing, it’s crucial to stay compliant with legal and privacy regulations. Understand HIPAA and state laws, secure proper consent from claimants, and limit data requests to what’s necessary. This ensures effective, legally compliant investigations.

• Understand the Law: Before beginning medical canvassing, make sure you fully understand the legal requirements regarding medical information. Stay up-to-date with HIPAA and any state-specific privacy regulations.
• Request Consent: Always ensure that you have the proper consent from the claimant before contacting healthcare providers. This consent should be explicit and documented to ensure you’re fully compliant with privacy laws.
• Limit the Scope: When gathering information, only request data that is necessary for verifying the claim. This helps minimize the risk of violating privacy laws and also streamlines your investigation.

Bias and Subjectivity

In any investigation, bias can be a significant issue. Medical canvassing is no exception. If you have preconceived notions about the validity of a claim or allow personal biases to influence how you conduct your investigation, it can lead to flawed data and inaccurate conclusions.

• Incorrect Findings: Bias can cause you to overlook key pieces of evidence, or worse, to skew the information in a way that supports your initial assumptions. For example, if you expect to find fraud, you might unintentionally focus on finding evidence that fits that narrative, instead of letting the data speak for itself.
• Damage to Relationships: A biased approach can create a lack of trust with claimants, providers, and other stakeholders. If your canvassing feels one-sided or influenced by preconceptions, it can lead to resistance and difficulty gathering the information you need.

Here are some tips to ensure your investigation is thorough and unbiased:

• Use Objective Criteria: Always rely on clear, objective criteria when canvassing. Create a standardized checklist of what information you need to verify and use it consistently across all claims.
• Stay Open-Minded: Approach each case with an open mind. Even if you suspect fraud, make sure to collect and assess all the facts before drawing any conclusions.
• Keep Your Personal Views Separate: Make it a point to separate your personal views from your work. Remain neutral and let the data guide your conclusions. This ensures that your findings are based on facts, not influenced by emotions or assumptions.

While medical canvassing can be a powerful tool for verifying claims, but it’s crucial to approach the process carefully to avoid these common pitfalls. By staying diligent and following best practices, you can ensure that your canvassing efforts are accurate, legally compliant, and free from bias.

If you take anything from today’s blog, remember to always verify! It’s necessary to cross-check and validate your findings with multiple sources to ensure accuracy. The second most important step after this is to always ensure compliance with privacy regulations like HIPAA. If any of the information you gathered from your canvassing was obtained illegally it won’t hold up in court.

By implementing these strategies, you’ll be able to make your canvassing efforts more effective and efficient, ultimately benefiting both your clients and your company.

Click here to learn more about the ins and outs of medical canvassing by talking to one of our operations experts.

Check out our sources:

U.S. Department of Health and Human Services. (2020). “Health Information Privacy.” Retrieved from HHS.gov

Insurance News & Updates. (2020). “The Rise of Medical Canvassing in Claims Adjusting.” Retrieved from InsuranceNews.com