Medical Canvassing Use Case for Claims

Medical canvassing aims to uncover medical treatment the claimant may not be sharing. It’s important to know if medical treatment related to the work claim injury occurred before the date of loss.

What is the date of loss?

The day an insurance claim was filed due to an incident. For example, it will be the day your slip and fall at work happened or the day of your fender bender.
This case study explores medical canvassing from a claim’s investigation standpoint, highlighting its benefits, applications, and real-world impact.

What is Medical Canvassing?

The process typically includes contacting healthcare providers, pharmacies, and other relevant entities to obtain a complete medical history. You’re looking for verification that the claimant’s injuries weren’t preexisting conditions.

The need for medical canvassing stems from the high payouts that come from work comp settlements. Before committing to a payout amount you must confirm all the evidence you’ve been shown is accurate and inclusive.

Lines of Business Susceptible to Claims:

• Auto Insurance/Auto Bodily Injury: Medical records canvassing is critical for investigating personal injury claims stemming from auto accidents. Uncovering prior injuries, pre-existing conditions, and treatment gaps helps accurately assess claims and identify fraud.
• Homeowners Insurance: Homeowners carriers routinely order canvasses for slip-and-fall and liability injury claims on residential properties. Full medical histories are compared against details of the claimed accident.
• Workers’ Compensation Claims: Work comp insurers need to investigate occupational injury claims. Canvassers uncover prior workplace injuries, health conditions, and activities that may impact causation assessments.
• Disability Insurance: Pre-existing conditions and earnings activities may be revealed during disability claim canvassing. This protects against fraudulent or exaggerated claims.
• Life Insurance: Canvassing deceased policyholders help identify undisclosed health conditions during contestability investigations before death claim payouts.

Case Study: Nationwide Insurance Company

A nationwide insurance company, a leading provider of health and disability insurance faced an influx of challenges when verifying the accuracy of medical information provided by claimants. High-value claims were constant and the company needed to enhance its claims investigation process.

Implementation Phase:

The insurance carrier partners with a reputable medical canvassing agency to implement a proactive approach to claims investigation. Their medical canvassing team identified cases with a high potential for fraud due to discrepancies.

The medical canvassers reach out to healthcare facilities, physicians, and other relevant parties such as gyms or pharmacies to gather information on the claimant’s medical history. this includes any details about past treatments, surgeries, prescriptions, and ongoing medical conditions.

The data is then carefully analyzed in conjunction with the claimant’s provided medical records. Any discrepancies in information are flagged for further review.

Results of Better Claims Canvassing:

1. Fraud Prevention: Medical canvassing helped identify cases where claimants had provided inaccurate information. This hands-on approach reduced fraud and saved nationwide companies a substantial amount of financial resources
2. Improved Claims Accuracy: By cross-referencing new information to that provided by the claimant a more accurate assessment was achieved. This led to an increase in customer trust and fairer, evidence-backed claim settlements.
3. Seamless Claims Process: Quick access to comprehensive medical information allowed for faster decision-making, reducing the time required to process claims.
4. Comprehensive Risk Management: The insights gained through medical canvassing that was done professionally and ethically contributed to better risk management. Indentifying pre-existing conditions and undisclosed medical treatments allowed the insurance company to adjust premiums and coverage more effectively.

Streamline the Overall Claims Process

The goal of medical canvassing is to identify cases where additional verification is needed. Many times adjusters will have a hunch or red-flagged cases they could use some help with but just haven’t found the right vendor yet. This includes high-value claims, claims with unclear or incomplete medical documentation, or other medical canvassing red flags. Medical Canvassers are trained to navigate complex medical records and are experts in leading the conversation to obtain them. They know how to communicate with nurses and doctors and comply with privacy regulations aka HIPAA. By proactively seeking additional information insurance companies can avoid fraud, improve claims accuracy, and streamline their overall claims process. As the insurance industry evolves, fraudsters are also upping their game. The strategic use of innovative tools like medical canvassing is a minimum requirement to maintain trust, ensure fairness, and sustain the financial health of your industry.