Medical Check-Ups – How Canal Screens for Fraud

It’s all about red flags and patterns of behavior. As a registered nurse, it’s my job at Canal to review medical claims and identify causation issues, pre-existing conditions, and potential excessive or unnecessary treatment.

My attention is peaked when I see these kinds of issues with medical claims following an accident:

  • A patient is not getting better, despite treatment. In fact, they claim to be getting progressively worse.
  • MRIs or other medical tests look completely clear, but there remain complaints of physical problems.
  • An excessive number of primary care or chiropractic visits.
  • Pre-existing conditions are discovered, which can often be the more likely cause of symptoms than the accident.
  • Over treatment by a medical provider.
  • Video surveillance shows claimed injuries don’t align with actual physical abilities.

In the past year alone, I completed over 200 medical audits, which assisted Canal’s adjusters in achieving cost effective settlement negotiations, pressed claims toward earlier settlement, and supported a decrease in legal expenses; all of which resulted in significant reduction in the cost of claims for Canal insureds. It’s just one step added to our claims process – providing trained medical oversight – but considering the dollars involved, it’s an important safeguard.

A quick look in my files confirms the strength of our process. In one claim the demand from the claimant was $1,000,000 policy limits. I was able to provide the adjuster with my findings from the medical reports emphasizing treatment that was unrelated to the accident; the case settled for $621,500. In another case, we were able to reduce an initial $140,000 claim to a final settlement of $75,000 after our investigation uncovered a pre-existing condition. Sixty-five thousand dollars saved because of medical oversight in claims. Now that’s success!