Medical Canvassing: What Comes Next?

What you will find below:

• What a Medical Canvass Can and Cannot Reveal
• How to Verify and Evaluate Prior Treatment
• When a Peer Review or IME can Provide Additional Context
• Why Proper Documentation Matters

A medical canvass can uncover a prior treatment that changes the direction of a claim. A claimant may have received treatment at a clinic months before the reported loss for an issue involving the same part of the body now at issue. That information matters, but it does not tell the whole story.

Medical canvassing confirms whether a claimant received treatment at a specific facility within a defined time frame. It does not disclose diagnoses, treatment notes, or how an earlier visit relates to a current injury. What happens after the canvass result is where the real investigative work begins.

Remember: It’s a Starting Point, Not a Finding

A confirmed prior visit is supposed to raise a question, but it should not resolve the claim.

The visit could have been for an issue that was fully resolved and has no connection to the current claim. It could involve a pre-existing condition that was aggravated by the reported incident. In some cases, it could reveal an inconsistency that warrants further investigation.

A medical canvass cannot determine which situation applies. Treating the result as proof of fraud, misrepresentation, or a lack of injury can lead to conclusions before the underlying medical information has been reviewed.

The National Association of Insurance Commissioners’ Unfair Claims Settlement Practices Act expects insurers to maintain reasonable standards for prompt investigation and avoid denying a claim without conducting one.

A canvass result, standing alone, is not that investigation. It is a reason to look further.

Verify What Was Found

The next step is usually a formal records request through a signed authorization or, when necessary, a subpoena.

The canvass identifies where to look. The medical records show what was actually treated, how it was diagnosed, and when.

That distinction matters because a “hit” at a facility does not necessarily mean the treatment was related to the claim. It could involve an unrelated issue, a different body system, or care that ultimately has no bearing on the reported injury.

The records need to be reviewed before drawing conclusions about what the prior treatment means for the current claim.

Put it in Medical Context

Medical records can show that a prior condition existed, but they may not establish whether that condition caused, contributed to, or was aggravated by the current injury.

That’s where a medical opinion can help. A peer review or independent medical exam can evaluate the claimant’s history and current condition to determine whether the reported injury is related to the prior condition, the reported incident, or both.

Document the Path, Not Just the Result

Once a medical opinion is obtained, the claim file should show how the decision was reached.

That means documenting what the canvass found, what records were requested and received, what medical opinion was obtained, and how that information supported the claim decision.

This creates a clear record of the investigation and shows how the available evidence led to the final decision. If that decision is later challenged, that documentation can become especially important.

A Fuller Picture, Handled Carefully

Medical canvassing is valuable because it can uncover information that might otherwise go unnoticed. But the canvass itself is only the beginning.

Its value comes from what happens afterward. The information needs to be verified, reviewed in medical context, and documented as part of the broader claim investigation.

When claims professionals treat a canvass as one piece of the investigation rather than a conclusion, they are better positioned to understand the full picture and make a decision that can stand up to scrutiny.

Want to learn more about medical canvassing and how it can support the claims investigation process? Join our upcoming CE on medical canvassing.

Check out our sources:

National Association of Insurance Commissioners. “Unfair Claims Settlement Practices Act.” NAIC Model Laws, content.naic.org/sites/default/files/model-law-900.pdf.

Workers Compensation Research Institute. “WCRI Report: Comorbidities Increase Claim Costs and Duration of Temporary Disability.” WCRI News, wcrinet.org/news/news_info/wcri-report-comorbidities-increase-claim-costs-and-duration-of-temporary-disability.