Medical Canvassing: What it Delivers & What’s Next

Medical canvassing can provide major value to claims teams and help surface potential fraud, but only when it’s done correctly and professionally.

At its core, medical canvassing involves contacting pharmacies, clinics, and treatment facilities to ask a limited question: has this individual received treatment here? Investigators do not request diagnoses, procedures, or medical details. The goal is simply to identify where treatment occurred, not what the treatment was.

When conducted properly, this type of limited inquiry can fall within permitted information-sharing practices because it avoids requesting detailed protected health information (PHI). However, compliance considerations still matter, and canvassing should always follow legal, ethical, and company guidelines.

So, what does medical canvassing actually deliver to a claims team?

What Does Medical Canvassing Deliver?

Medical canvassing provides insights that databases, records pulls, and desk investigations often miss.

• Uncovering Undisclosed Treatment: Whether intentional or accidental, some claimants omit providers. That missing information can directly impact causation, liability, and compensability. Canvassing helps verify what treatment sources haven’t been disclosed.
• Identifying Providers Outside Major Databases: Not every clinic feeds into large medical or pharmacy data systems. Small practices, cash-based clinics, and newer facilities often operate off the radar.
• Clarifying Conflicting Information: When pharmacy data, adjuster notes, medical records, and even social media don’t align, canvassing helps resolve discrepancies. It fills in the gaps between what’s documented and what’s actually happening.
• Supporting Early Claim Decisions: A well-timed canvass early in the life of a claim can prevent unnecessary medical spend. Knowing the true scope and timing of treatment helps teams make faster, more accurate decisions.
• Verification of Treatment History: Canvassing can surface prior treatment patterns, pre-existing issues, or overlapping care that changes the medical narrative of a claim.
• Fraud Detection Support: While canvassing alone doesn’t prove fraud, it frequently uncovers red flags, including undisclosed providers, inconsistent treatment timelines, or care patterns that don’t match the reported injury.
• Cost Containment: By identifying the right facilities up front, claims teams avoid chasing irrelevant records and reduce unnecessary record retrieval costs.

If Medical Canvassing Uncovers Red Flags, What Happens Next?

Medical canvassing often marks the point where a claim shifts from routine handling to investigative strategy. A positive hit doesn’t prove fraud on its own, but it gives claims professionals direction. The key is knowing how to act on the uncovered information.

Here’s how claims teams typically move forward:

Use Positive Hits to Request Signed Authorizations and Retrieve Full Records

A canvass confirms where treatment occurred. The next step is understanding why. Once a provider is identified, claims teams can obtain proper authorizations and request complete medical records. These records help establish timelines, prior complaints, pre-existing conditions, and whether treatment is related to the reported injury. This step often clarifies causation questions and can significantly change the medical narrative of a claim.

Compare Treatment Timelines to the Reported Injury

When new providers are discovered, line up the dates of treatment with the date of loss and reported symptoms. Look for:

• Care that began before the reported injury
• Long gaps between the incident and first treatment
• Treatment intensity that seems disproportionate to the mechanism of injury

These inconsistencies may indicate unrelated conditions, symptom magnification, or a need for further medical review.

Escalate to Surveillance When Behavior and Treatment Don’t Align

If medical canvassing reveals frequent or ongoing treatment that suggests significant impairment, but the claimant’s reported activities or presentation tell a different story, surveillance may be appropriate. Medical canvassing helps justify surveillance as a targeted investigative step rather than a speculative one, focusing resources where inconsistencies already exist.

Order an IME to Resolve Medical Disputes

When treatment patterns, diagnoses, or levels of care don’t match the reported injury or objective findings, an IME can provide medical clarity. Medical canvassing often supplies the background information an examining physician needs to assess whether care is reasonable, necessary, and related.

Refer to SIU When Findings Suggest a Broader Concern

One undisclosed provider may be an oversight. Multiple undisclosed facilities, treatment predating the injury, or patterns consistent with known fraud trends raise the stakes. In these cases, canvassing findings help SIU start with a foundation of verified information rather than assumptions.

Why Medical Canvassing Matters

According to estimates from the U.S. Department of Health and Human Services, up to 129 million non-elderly Americans have at least one pre-existing health condition.

With numbers this high, there’s a chance that undeclared treatment or complex medical histories exist in many claims, even when they aren’t immediately apparent. That makes tools like medical canvassing especially valuable: they help claims teams uncover what’s really there, rather than relying solely on claimant-provided information or initial record sets.

See what medical canvassing can uncover for your claims team. Connect with our experts today.

Check out our sources:

Centers for Medicare & Medicaid Services. At Risk: Pre-Existing Conditions Could Affect 1 in 2 Americans. CMS, U.S. Dept. of Health & Human Services, 10 Sept. 2024, https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/preexisting.