Busting the Top 5 Medical Canvassing Myths

Medical canvassing is one of the most effective tools in modern claims investigations, yet there are many misconceptions about it. Is it legal? Is it a HIPAA violation? Is it just calling random doctors? 

Medical canvassing is an investigative method that helps determine whether a claimant has received medical treatment at any healthcare facility within a defined area and timeframe. It’s a strategic, compliant, and non-invasive way to verify or uncover undisclosed treatment that can impact claim outcomes, reserving accuracy, and fraud detection. 

Given that 66% of U.S. adults take prescription medications and over 129 million have pre-existing conditions, most claimants are likely to have relevant medical histories relevant to their case. In other words, medical canvassing matters now more than ever. 

Despite its value, several myths continue to cloud the truth about medical canvassing.  

Myth #1: “Medical Canvassing is Illegal.”

Medical canvassing is legal. In fact, when performed correctly, it’s fully compliant with federal and state laws across all 50 states. 

Medical canvassing involves contacting healthcare providers within a certain geographic radius to ask a simple, non-invasive question: “Has this individual ever been treated at your facility?” No personal health information (PHI) is requested, and no records are accessed without a signed authorization. 

If medical canvassing follows proper procedures, it’s fully compliant with federal privacy laws, including:

• The Health Insurance Portability and Accountability Act (HIPAA), which governs the use and disclosure of PHI
• The Health Information Technology for Economic and Clinical Health (HITECH) Act, which strengthens privacy and security protections

Furthermore, medical canvassing is a lawful and widely used investigative tool in claims investigations, designed to support claims accuracy and compliance without compromising claimant privacy. 

Myth #2: “Medical Canvassing Violates HIPAA.”

According to the U.S. Department of Health and Human Services (HHS), HIPAA only applies when there’s access, use, or disclosure of PHI. Medical canvassing doesn’t seek records or details. It simply asks whether the provider has seen the individual, yes or no.  

No diagnosis, treatment notes, prescriptions, or clinical details are requested or obtained. Many healthcare providers have standard procedures for answering these types of inquiries without revealing PHI.  

According to HHS,

The Privacy Rule protects all ‘individually identifiable health information’ held or transmitted by a covered entity or its business associate… but does not prohibit general inquiries that do not involve the use or disclosure of PHI.

Myth #3: “Medical Canvassing is Just Cold Calling Clinics.”

Medical canvassing is far from a cold calling operation. Professional investigators leverage multiple data points to identify healthcare facilities that are most likely to have relevant treatment records based on the specifics of the claim. 

Trained investigators use:  

• Historical claims data, such as provider usage and treatment patterns
• Local provider patterns, including known clinics associated with similar cases
• Injury type, such as orthopedic, neurological, etc.
• Geographic proximity, based on the claimant’s home, workplace, or accident location

Example

If a claimant reports an orthopedic injury in a certain ZIP code, canvassing may focus on urgent care centers, chiropractors, orthopedic specialists, pain clinics, or physical therapy providers within a reasonable treatment radius. Investigators may also canvass pharmacies to identify undisclosed prescription use. 

Medical canvassing requires knowledge of healthcare systems, claims investigations, and privacy regulations. It’s not something that can be handled by call centers or junior staff. The most reputable providers use experienced investigative professionals who are trained in both clinical terminology and investigative methodology to ensure accurate, compliant, and actionable results. 

Myth #4: “Medical Canvassing Only Matters in Fraud Cases.”

While medical canvassing is a powerful fraud detection tool, it also plays a critical role in routine claims investigations and case development. 

Here’s how it helps beyond suspected fraud:

• Clarifying treatment history: Many claimants forget where or when they received care, especially in longer-tail cases. Medical canvassing fills in the gaps.
• Verifying timelines: Does the treatment timeline match up with the reported date of injury? Medical canvassing can support or challenge that narrative.
• Supporting reserves and strategy: Understanding the full medical picture, disclosed or not, helps set accurate reserves and assess potential exposure.

Example

Consider a soft tissue case where the claimant alleges only minor injury, but a canvass reveals visits to three pain management clinics and a pharmacy that filled high-dose opioids. That doesn’t prove fraud, but it may change how you approach the claim. 

Even in legitimate claims, medical canvassing adds value by filling in blanks, clarifying care patterns, and strengthening case strategy. 

Myth #5: “Once You Get the Report, That’s the End of It.”

A medical canvass report is not just a box to check. Rather, it’s a tool to act on in claims investigations. In fact, when used correctly, a medical canvass report is often the beginning of deeper claims insight. 

Here’s what claims professionals can do next:  

• Use positive hits to request signed authorizations and retrieve full records
• Escalate to surveillance if treatment patterns don’t match claimant statements
• Order an IME (Independent Medical Exam) to resolve conflicting information
• Refer to SIU when the canvass supports a broader fraud concern
• Adjust reserves based on new care uncovered or disproven treatment history

The best results come when adjusters, nurses, and investigators collaborate on the next steps. Canvassing isn’t the finish line, it’s the launchpad. 

The Truth About Medical Canvassing

Medical canvassing isn’t a legal gray area, a HIPAA violation, or a random guessing game. It’s a strategic, lawful, and incredibly effective component of claims investigations. 

Consider this: about 1.3 million knee replacements, 760,000 hip replacements, and 200,000 shoulder replacements are performed annually. That’s millions of procedures, often tied to pain, mobility issues, or injuries, that could factor into a claim.  

In an industry where every decision can impact cost, risk, and case integrity, medical canvassing brings clarity to complex situations. Whether you’re investigating potential fraud or simply trying to close a claim with confidence, a thorough canvass can provide missing pieces that make all the difference. 

Want to learn more about medical canvassing? Talk to us today. 

Check out our sources:

U.S. Department of Health and Human Services. HITECH Act Enforcement Interim Final Rule. HHS.gov, 17 Oct. 2009, https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html.

U.S. Department of Health and Human Services. Summary of the HIPAA Privacy Rule. HHS.gov, 26 July 2013, https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html.