Is a Medical Canvass HIPAA Approved?

Yes, Medical Canvassing is HIPAA approved. The intention behind a canvass is to help determine missing pieces of information regarding the claim in question, not obtain copies of people’s charts or X-Rays.

By Carla Rodriguez | Oct. 16, 2023 | 5 min. read

Is a Medical Canvass HIPAA approved?

Yes! The only information obtained during Medical Canvassing is, dates of treatment, hospital admission, outpatient emergency room admission, prescribing physicians. Information that relates to treatment plans or diagnosis is not obtained. Read more about what a medical canvass is here.

While much can be learned about the when, where, and what of the medical activity of a claimant – those HIPAA laws ensure the more detailed aspects remain in the vault of the medical provider.

For example, they cannot disclose any treatment plans, notes, prognosis, diagnosis, or other restricted details about the treatment the claimant received. These details are considered protected health information (PHI) under HIPAA, and we all must respect the regulations surrounding them. As before, knowing a person received an X-Ray of their foot bones isn’t necessarily needed if all you need to know is that the person received an X-Ray at a podiatrist and also received medication from a nearby pharmacy in relation to that visit.

How is a Medical Canvass performed?

Canvass agents provide the necessary details about the claimant, but they also must take great care to respect the privacy of the person they are requesting information about. We want to make sure that sensitive information remains protected. So, canvassers must also handle this information with the utmost confidentiality and ensure that the providers understand the importance of safeguarding their privacy.

These agents are great at building relationships with doctors offices and are versed in medical jargon. They politely ask the providers if the claimant has received treatment at their facility and if the answer is affirmative, they proceed to confirm the treatment dates. This step is crucial in piecing together the claimant’s medical history and obtaining accurate information for claims adjustment purposes. When approached with care it happens easily and naturally. When sought with an abrupt or deserving attitude, things can go wrong and the information may not be obtained. Who you have performing this for you does matter, make sure you properly investigate your chosen canvassing company.

Geographic anomalies:

Geographic anomalies are another aspect of canvassing – they are when the claimant seeks medical treatment in locations that are unexpected or far from their home. It may be necessary to explore the claimant’s travel patterns, work-related responsibilities, or personal circumstances that may have influenced their choice of treatment facility. By investigating these factors with a canvass, you can gain insights into their decision-making process and evaluate the treatment’s relevance to the reported injury.

It functions like detective work within a specific geographic area around the claimant’s current and/or previous home address. It is performed by calling up various healthcare providers like hospitals, pharmacies, and health clinics.


The Privacy Rule

The privacy rule recognizes the legitimate need involved in the WC systems to have access to individuals health information as authorized by State or other law.

The following are covered entities:

  • Healthcare providers
  • Health plans
  • Healthcare clearinghouses

These covered entities can share PHI to law enforcement if requested to do so by court orders, warrants and subpoenas. What you may not know, is they are also allowed to reveal PHI to facilitate treatment payment or healthcare operations WITHOUT written authorization from the patient. This means you can make a phone call to a PCPs office and ask if John Doe has been showing up for his appointments recently.


Who can perform a Medical Canvass?

Canvassing can be performed by an employer, adjuster representing an employer or an attorney representing employer. At the end of canvassing a comprehensive report is provided.

Triggers for assigning a Medical Canvass

You may be want to use this discovery tool to get a more complete view of the claim if there is:

  • Non disclosure of medical history
  • Injury sustained upon return from vacation
  • Injury within first 60 days of employment (ACA)
  • Unwitnessed injuries
  • History of prior claims
  • Treatment at unusual distance from residence

Good canvassers take extra care to de-identify any PII information right at the beginning of the call. By doing this, they ensure that the provider is not disclosing any sensitive or identifiable information. This protects you legally, and with everything being done transparently you can assure the information obtained can be used to verify your claim.


Next Steps:

After completing your initial canvass and you need more information you can procure a Signed Medical Authorization. SMAs take longer and patients are hesitant to provide them which is why many insurance carriers and third parties prefer to conduct a medical canvass first.

Over the last couple of years we’ve seen more workers transitioning between companies than ever before and health costs on the rise. These facts combine to create a scenario where newer employees, already a higher risk group for work-related injuries, are more likely to have comorbidities and contributing factors increasing severity of any incidents. Medical canvassing for claims involving employees is a quick and effective way to establish a true baseline of that individual’s overall health and medical needs prior to a loss. This information is extremely valuable for determining what is required to return the worker to their pre-loss health level. Make sure you’re informed before treading the world of medical canvassing.


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