Medical Canvassing for Private Investigators
Editor’s note: This article was written by Scott Fulmer of Intermountain PI. The opinions expressed here belong to Scott Fulmer.
Medical canvassing is a strategy used in the claims handling process to determine if a work injury is legitimate. It is used by defense attorneys, insurance companies, third-party administrators, and self-insureds in workers’ compensation, disability, and automobile accident claims. With medical canvassing, the objective is to discover any undisclosed medical treatment by the claimant. In other words, medical treatment for an injury that may have occurred prior to or outside of a reported work-related injury claim.
What is a medical canvass?
A medical canvass involves a private investigator making telephonic inquiries at medical facilities in a geographic radius surrounding a claimant’s home or place of employment. This may include medical facilities such as hospitals, pharmacies, pain clinics, urgent care facilities, and chiropractic clinics. Inquiries are conducted to discover if the claimant received treatment at any of these offices. By comparing the providers and dates of treatment, a claims adjuster can determine if an injury is legitimate or whether it stems from a pre-existing condition that occurred outside the scope of employment or the accident.
What information can a medical canvass provide?
With a medical canvass, private investigators telephone medical facilities and voluntarily provide a claimant’s identifiers such as their name and date of birth. Medical personnel can then confirm whether the claimant received treatment at their facility, the dates of treatment, and any upcoming appointments. Keep in mind that whether medical personnel provides all or some of this information depends on their interpretation of HIPAA. While some may be willing, others may cite liability related to HIPAA violations. Additionally, pharmacies can provide what prescriptions were filled and by whom to licensed healthcare practitioners or Law Enforcement officers presenting proper credentials and a valid warrant. This can help to determine if the medication is relevant to the workplace injury or accident.
For example, in a medical canvass a private investigator with an accompanying and properly executed HIPAA release form can:
- Discover undisclosed treatments.
- Determine if treatments occurred before the date of loss.
- Learn if treated injuries are the same as the alleged workplace or vehicle accident injury.
- See if the claimant has a history of injury claims.
- Determine if injuries occurred outside the course of employment.
- Find out if the claimant lied about prior medical treatment
- Determine if treatment from specific periods are actually pre-existing conditions.
As you can see, a medical canvass is a powerful tool. When it comes to insurance defense claims, plaintiff attorneys often selectively withhold information about past or present injuries or treatments. A medical canvass solves this issue. Furthermore, it may reveal upcoming medical appointments allowing an opportunity for surveillance.
What about HIPAA and privacy?
Of course, this begs the question; what about the Health Insurance Portability and Accountability Act (HIPAA)? HIPAA is a federal law enacted by Congress in 1996. It provides privacy protection to certain health data called Protected Health Information (PHI). However, in some cases, HIPAA does not apply to certain health information related to employment, such as with workers’ compensation claims. Having said that, some medical facilities will not release information without a HIPAA authorization form signed by the employee. Because the legislative language of HIPAA is very detailed and relatively complex, medical organizations such as pharmacies, hospitals, and outpatient clinics will be more hesitant to surrender information that could even possibly be construed as legislatively restricted.
When conducting a medical canvass, it is important to make a distinction. The investigator is not requesting medical records. Those records are indeed covered by HIPPA. The canvass is to simply confirm whether or not services were provided. That information is not covered by HIPAA. Unfortunately, staff members at medical facilities are not always knowledgeable about what they can and can’t release. Staff members follow management directives and those managers will often positively respond to requests for appointments made in person by a professional investigator presenting proper ID and a written request printed on attorney letterhead. Let me state categorically that I am not an attorney and this article is not meant to be construed as legal advice. Also, keep in mind that, as is the case with many industries impacted by COVID, organizations are overworked and short-staffed. Healthcare is no different. An investigator making a cold call trying to get this kind of information might be referred to the voicemail of someone at the managerial level. But more likely, such a request would result in a directive to put it in writing and send it to the right person.
Finally, claims adjusters juggle numerous files and operate under strict deadlines. Medical canvassing results must be done quickly. If done correctly, they are one more tool to lower liability and prevent insurance fraud.
About the Author
Notable private investigator Scott Fulmer is the principal and lead investigator at Intermountain PI, the premiere private investigation firm throughout the Intermountain West. Scott is a 30-year veteran private investigator, host of the Intermountain PI Podcast and author of the critically acclaimed true crime memoir, Confessions of a Private Eye. It’s available on Amazon and Barnes and Noble. Find him on the web at www.intermountainpi.com
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