Hi, everyone. This is Lucas Voss with Becker's
Healthcare. Thanks so much for tuning in to
the Becker's Healthcare podcast series. It's great to
have you. Today, we're going to talk about
cutting through
red tape, fixing the friction
in personal injury care. And joining me for
today's discussion is Reid Sizing, CEO of Gaines
Servicing. It's fantastic to have him. Reid, thanks
for being here today.
Thanks so much for having me. Yeah. Absolutely.
It's great to have you. Could you introduce
yourself to our audience and share a little
bit about your work in health care?
Absolutely.
I'm the
founder and CEO of GAIN Servicing.
I've spent the better part of two decades
building companies that really sit at the intersection
of finance, technology,
and health care.
At GAIN, you know, specifically, we focus on
rev cycle management
for health care organizations,
primarily
orthopedics,
pain management,
imaging,
physical therapy,
and the facilities that orthopedists
utilize.
We serve providers in all 50 states, and,
really, the mission, I think, is pretty simple.
We're proud to serve
and help people
access care
that otherwise wouldn't receive it and get doctors
paid faster and more.
Yeah. So they've got to stay
focused on delivering care,
and we just bring a different level of
transparency and accountability
to the rev cycle space.
And it's really resonated, you know, with providers,
especially given lower reimbursements
and financial pressures. Pressures. So just very excited
to be here and share the opportunities.
Yeah. Absolutely. I'm excited to talk about them.
And I'm gonna preface my question here with
the fact that I did
steal this from Reid. I did not come
up with this term, but I love it.
The term medical
sludge, it sort of really captures
the experience a lot of providers face when
navigating personal injury billing.
How would you describe what that looks like
in day to day operations
and really what kind of impact it's having
right now on providers?
I mean, doesn't it sound like what it
looks like? Yes.
I
mean,
really, just think about this for a second.
Sludge is
everything that stands between you
and getting paid fairly
for the care by the way that you
have already delivered.
Mhmm.
It's these redundant
forms. It's the endless follow ups. It's obscure
documentation.
It's the need for
proof of liability and causation,
it's the endless
no's
that not only
health care insurance
companies throw at doctors
but third party liability
carriers as
well. I mean in in the PI space
it can get even worse because
there you're navigating both the health care system
and the legal system each with their own
traps.
Yeah. It can get very specific depending on
where you are. Now this is obviously an
impact that's on the organizational
side of things that you've mentioned.
How is this sludge then in turn also
impacting
patient outcomes?
Well, it's it's both. Right? If you can't
get
now the personal injury space
oftentimes has the freedom for doctors to see
patients and provide the care that they believe
is needed. Mhmm. The risk comes at the
reimbursement
end.
Right. So case characteristics,
jurisdiction, third party liability coverage
all come into play for the probability of
reimbursement.
Yeah. But what is just unbelievably
awful
is for example commercial denials.
You've been in an accident, they're talking about
subrogating a claim,
you've got health insurance and they're denying what
the doctor's recommending for you to get better.
Mhmm. Like that's just ridiculous.
So then second
layer, doctors can see these patients on lean
oftentimes.
Downside is they have to wait
for reimbursement
until the case resolves.
Upside is reimbursements are usually higher than either
commercial or government reimbursement sources.
Yeah. So the duration is more than compensated
for.
But it this sludge
affects
doctors. It affects the doctors' practice groups. I
mean, how many doctors have we spoken to
in physician owned practices,
reimbursements, accounting, and HR issues?
Yeah. Right? So our goal
is to take
all of those from bills, notes, and records
once treatment is provided,
make that accessible to attorneys,
have continuing lean based care available in any
and all specialties that may be needed by
the patient
according to the doctors,
not according to the third party liability carrier,
the health care insurance company. Quite frankly, what
the heck do they know about that other
than reviewing Colossus,
which tells them above x dollars, given y
characteristics,
deny.
Yeah. Yeah. It takes that human piece out
of it that you mentioned in terms of
actually caring for the patient and seeing that
story behind it, which I think is really
key. And and what you've done really nicely
is sort of
unlayer this, right, explaining the different layers to
this. Now I wanna throw another layer on
top of this,
unfortunately,
which is legislation,
right, that that also is involved in this.
You've touched on it a little bit. So
we have SB 68 in Georgia, for example,
SB 30 in Texas. We'll touch on those
in a little bit here. So there's new
attention on all of this, on PI reform
specifically.
What do providers need to know specifically around
these two, and how is this reshaping
reimbursement
and care delivery?
Yep. So
back to reimbursement and care delivery just for
a second and kind of marching through the
sludge
to then deal with the additional layer of
risk provided by legislative initiatives
in various states. Okay?
Providers across the country are drowning in these
receivables, the administrative overheads. You're not just dealing
with complex codes
and endless authorizations.
Right? This is the the sludge literally works
its way through everybody in the practice group.
So it's why rev cycle matters.
It's why doctors I understand when they first
start seeing personal injury patients, it's due to
a relationship
that they have built or they met an
attorney
whose
client chose to see that doctor for care,
and things worked out well. But at scale
that is not what can be done.
This can be a premium reimbursement
source if done right. So
the rev cycle means actively working the stall,
deny, pushing back, right. You get third party
liability carriers
constantly coming in with lowball offers,
right. It is the financial
options that we have available to doctors also
that keeps them solvent while they await on
these ultimate reimbursements.
So when rev cycle is done right, it
reduces that friction. Right? It gives independent practices
a fighting chance
and enables enables them rather to stay solvent
and focus on the care delivery. Mhmm. Right?
And not this administrative
decay.
So it's smarter systems, it's active support,
but now
you're layering on a whole bunch of legislative
challenges.
So, again, we were in I personally was
a cofounder of Americans for Patient Access.
Right? And what that lobbying group nationwide
is doing
is attempting to secure care
for patients in need
regardless of payer source.
It just says what are the options, don't
deny options available for patient care, right. How
do we address
30 plus million Americans who are uninsured
and a 100,000,000
total including that 30
that are under insured or uninsured,
right. Meaning incredibly high deductible plans. I mean,
somebody tells you you got a 10 or
$20,000
deductible
and an overall family, you know, out of
pocket of $25,000.
You you might as well add three zeros
to that. Yeah. It doesn't matter at that
point. It doesn't matter. Tell me it's $25,000,000.
Like, I don't care. Yeah. I'm not coming
up with the $25,
and I'm not coming up with the 25,000,000.
So who cares? Yeah. Exactly. So my point,
insurance companies
have lied
repeatedly,
and it's very effective.
Mayhem, Gekko, Flow,
Chris Paul, Aaron Rogers,
that the the deep voice dude,
whatever they are. Right? These insurance
mouthpieces,
right, that simply are advertising
spending your premium dollars
to try and convince you that somehow they
will be there in your time of need.
Right? Are we kidding ourselves
when what actually happens and how they actually
make money is by holding and investing premium
dollars and not paying them out?
Over a $100,000,000,000
in third party liability carrier profits last year
alone.
Needless to say, we are outspent
in lobbying,
and they've been very successful
utilizing a small portion of that $100,000,000,000
in profits,
which by the way are operating expenses prior
to those profit numbers. Okay? So
hear this out.
Tort reform.
Sounds good.
Why? I I I don't know. Reform. Reform
sounds positive.
Lower premiums.
Well, that that sounds good. How do we
we get lower premium. Yes. If you have
less runaway verdicts,
you'll have lower premiums. Oh, that that sounds
logical. Has it ever happened?
Never.
Never. Tort reform initiatives in any state has
led to continuing rise rising
insurance premiums.
So it's a flat out lie.
So coming back to these initiatives then in
terms of the s p 68 and the
s p 30, it's it's it's about knowing
what exactly they're doing Correct. And and understanding
how they're how they're impacting the organizations itself.
So they've gotten some stuff passed. They got
it passed in Georgia. They didn't get it
quite passed in Texas. But the bottom line
is the insurance lobbying groups are after, quote,
unquote, tort reform. Reform is usually
positive thing. That is not what these initiatives
are, and it is absolutely essential. Sludge does
not stop in health care at sleep seeking
into the lee seeping rather into the legal
system as well. So the litigation
funding bill in Georgia and the health care
bill 68
targeted introduced provisions that could lower reimbursement rates.
Right?
Unrelated
reimbursements.
A non Medicare patient could have Medicare reimbursements
introduced at trial
as a possible reimbursement
for doctors who have provided care for years
without payment.
On what planet
can somebody make a living
receiving Medicare or Medicaid rates two or three
years after the fact?
Right? It is not possible.
So that is what sixty eight and sixty
nine have been passed
and will
be at risk of ultimately lower reimbursement rates.
If it gets too low, what happens?
Doctors just aren't going to see these patients.
Then what happens? A 100,000,000 Americans are going
to be marching to the emergency room for
every ongoing physical therapy treatment that they need.
That is not a cost effective
way to deliver quality care.
So
Absolutely.
These two bills threatened to entrench the worst
kind of system sludge.
It is
unnecessary red tape. It is delayed justice. It
is dwindling
access to care. And while they aim to
increase transparency,
the real world result is more
confusion, less support, and greater risk for those
who can least afford it.
So
it affects the patient outcomes also because doctors
should be treating these patients rather than questioning
whether or not they'll ultimately get paid.
Yeah. There's a there's a lot of layers
to this, and I think understanding what you've
touched on earlier, understanding it is is really,
really key, understanding what the impact is. I
do wanna touch really quickly, before we, wrap
up here. I do wanna get your your
take on technology and the impact it's having.
If you could just really quickly talk a
little bit about,
what it does right now. Is it helping?
Where does it fall short? And how can
leaders approach that that
piece? Yep. So you've got to have technology
based rev cycle
management that also has managed services with human
beings. It cannot all be automated. There are
significant advances that we've made with AI around
predictive analytics for ultimate case
values
case values
ultimately.
So AI enhancements
utilizing case characteristics, jurisdiction, and third party liability
coverage is essential.
At GAIN, we are the the leader in
that space. It is also essential
that we
have humans
managing these services who are sophisticated and knowledgeable
about the legal system because independence
is key. Doctors that hold their own liens
in all of these states with all of
tort reform are in big trouble.
The disclosure issues the idea whether true or
not that they are somehow in cahoots with
the attorneys somehow
taking advantage of these poor insurance companies.
Right? The communications,
what had been paid. The second piece that
is largely dead
is the traditional funding model because in paid
versus incurred legislation
where let's say a doctor was paid 40
or 50¢ on the invoice dollar that would
be the most that the company that bought
it could ever recoup, right. In other words
they'd be out of business.
But these liens can be serviced by an
independent third party servicer
separating, if you will, church and state.
And so
keep the health care practice
at arm's length from the law firms,
give the law firms and patients all sorts
of tools to identify and see lien based
care,
and at GAIN understand,
acquire the necessary case updates,
understand the value of these cases, and maximize
reimbursements for health care providers.
So what do you need to do as
a practice?
First,
audit your PI claims process.
What are your write offs? How accurate are
your case updates? What's your track record? What
are the various attorneys track records? What type
of cases do they represent?
Who's responsible for the follow ups? And then
look for partners who specialize in lean based
revenue cycle management. Don't just add software,
add strategy.
Because in personal injury,
getting paid isn't just about technology,
it's about knowing and being knowledgeable
of the entire game in order to maximize
reimbursement.
Yeah.
And that can really only happen as you've
mentioned in the beginning, which I love. It's
a combination. It's technology and people that are
working together to build these partnerships to make
those connections, which I think is is really,
really key. Reid, it's fantastic to have you.
Thanks so much for taking the time today.
Thanks for all of your insights. This was
a fantastic conversation. You guys do a fantastic
job, and we appreciate you. It's great having
you. We also want to thank our podcast
sponsor, Gain Servicing. You could tune in to
more podcasts from Becker's Healthcare by visiting our
podcast page at beckershospitalreview.com.