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Hi, everyone. This is Lucas Voss with Becker's

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Healthcare. Thanks so much for tuning in to

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the Becker's Healthcare podcast series. It's great to

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have you. Today, we're going to talk about

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cutting through

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red tape, fixing the friction

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in personal injury care. And joining me for

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today's discussion is Reid Sizing, CEO of Gaines

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Servicing. It's fantastic to have him. Reid, thanks

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for being here today.

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Thanks so much for having me. Yeah. Absolutely.

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It's great to have you. Could you introduce

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yourself to our audience and share a little

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bit about your work in health care?

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Absolutely.

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I'm the

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founder and CEO of GAIN Servicing.

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I've spent the better part of two decades

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building companies that really sit at the intersection

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of finance, technology,

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and health care.

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At GAIN, you know, specifically, we focus on

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rev cycle management

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for health care organizations,

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primarily

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orthopedics,

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pain management,

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imaging,

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physical therapy,

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and the facilities that orthopedists

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utilize.

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We serve providers in all 50 states, and,

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really, the mission, I think, is pretty simple.

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We're proud to serve

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and help people

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access care

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that otherwise wouldn't receive it and get doctors

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paid faster and more.

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Yeah. So they've got to stay

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focused on delivering care,

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and we just bring a different level of

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transparency and accountability

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to the rev cycle space.

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And it's really resonated, you know, with providers,

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especially given lower reimbursements

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and financial pressures. Pressures. So just very excited

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to be here and share the opportunities.

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Yeah. Absolutely. I'm excited to talk about them.

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And I'm gonna preface my question here with

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the fact that I did

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steal this from Reid. I did not come

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up with this term, but I love it.

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The term medical

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sludge, it sort of really captures

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the experience a lot of providers face when

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navigating personal injury billing.

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How would you describe what that looks like

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in day to day operations

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and really what kind of impact it's having

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right now on providers?

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I mean, doesn't it sound like what it

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looks like? Yes.

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I

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mean,

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really, just think about this for a second.

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Sludge is

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everything that stands between you

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and getting paid fairly

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for the care by the way that you

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have already delivered.

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Mhmm.

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It's these redundant

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forms. It's the endless follow ups. It's obscure

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documentation.

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It's the need for

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proof of liability and causation,

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it's the endless

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no's

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that not only

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health care insurance

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companies throw at doctors

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but third party liability

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carriers as

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well. I mean in in the PI space

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it can get even worse because

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there you're navigating both the health care system

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and the legal system each with their own

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traps.

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Yeah. It can get very specific depending on

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where you are. Now this is obviously an

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impact that's on the organizational

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side of things that you've mentioned.

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How is this sludge then in turn also

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impacting

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patient outcomes?

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Well, it's it's both. Right? If you can't

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get

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now the personal injury space

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oftentimes has the freedom for doctors to see

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patients and provide the care that they believe

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is needed. Mhmm. The risk comes at the

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reimbursement

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end.

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Right. So case characteristics,

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jurisdiction, third party liability coverage

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all come into play for the probability of

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reimbursement.

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Yeah. But what is just unbelievably

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awful

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is for example commercial denials.

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You've been in an accident, they're talking about

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subrogating a claim,

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you've got health insurance and they're denying what

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the doctor's recommending for you to get better.

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Mhmm. Like that's just ridiculous.

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So then second

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layer, doctors can see these patients on lean

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oftentimes.

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Downside is they have to wait

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for reimbursement

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until the case resolves.

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Upside is reimbursements are usually higher than either

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commercial or government reimbursement sources.

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Yeah. So the duration is more than compensated

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for.

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But it this sludge

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affects

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doctors. It affects the doctors' practice groups. I

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mean, how many doctors have we spoken to

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in physician owned practices,

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reimbursements, accounting, and HR issues?

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Yeah. Right? So our goal

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is to take

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all of those from bills, notes, and records

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once treatment is provided,

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make that accessible to attorneys,

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have continuing lean based care available in any

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and all specialties that may be needed by

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the patient

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according to the doctors,

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not according to the third party liability carrier,

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the health care insurance company. Quite frankly, what

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the heck do they know about that other

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than reviewing Colossus,

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which tells them above x dollars, given y

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characteristics,

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deny.

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Yeah. Yeah. It takes that human piece out

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of it that you mentioned in terms of

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actually caring for the patient and seeing that

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story behind it, which I think is really

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key. And and what you've done really nicely

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is sort of

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unlayer this, right, explaining the different layers to

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this. Now I wanna throw another layer on

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top of this,

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unfortunately,

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which is legislation,

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right, that that also is involved in this.

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You've touched on it a little bit. So

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we have SB 68 in Georgia, for example,

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SB 30 in Texas. We'll touch on those

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in a little bit here. So there's new

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attention on all of this, on PI reform

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specifically.

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What do providers need to know specifically around

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these two, and how is this reshaping

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reimbursement

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and care delivery?

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Yep. So

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back to reimbursement and care delivery just for

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a second and kind of marching through the

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sludge

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to then deal with the additional layer of

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risk provided by legislative initiatives

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in various states. Okay?

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Providers across the country are drowning in these

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receivables, the administrative overheads. You're not just dealing

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with complex codes

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and endless authorizations.

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Right? This is the the sludge literally works

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its way through everybody in the practice group.

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So it's why rev cycle matters.

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It's why doctors I understand when they first

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start seeing personal injury patients, it's due to

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a relationship

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that they have built or they met an

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attorney

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whose

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client chose to see that doctor for care,

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and things worked out well. But at scale

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that is not what can be done.

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This can be a premium reimbursement

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source if done right. So

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the rev cycle means actively working the stall,

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deny, pushing back, right. You get third party

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liability carriers

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constantly coming in with lowball offers,

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right. It is the financial

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options that we have available to doctors also

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that keeps them solvent while they await on

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these ultimate reimbursements.

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So when rev cycle is done right, it

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reduces that friction. Right? It gives independent practices

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a fighting chance

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and enables enables them rather to stay solvent

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and focus on the care delivery. Mhmm. Right?

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And not this administrative

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decay.

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So it's smarter systems, it's active support,

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but now

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you're layering on a whole bunch of legislative

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challenges.

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So, again, we were in I personally was

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a cofounder of Americans for Patient Access.

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Right? And what that lobbying group nationwide

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is doing

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is attempting to secure care

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for patients in need

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regardless of payer source.

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It just says what are the options, don't

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deny options available for patient care, right. How

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do we address

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30 plus million Americans who are uninsured

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and a 100,000,000

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total including that 30

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that are under insured or uninsured,

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right. Meaning incredibly high deductible plans. I mean,

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somebody tells you you got a 10 or

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$20,000

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deductible

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and an overall family, you know, out of

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pocket of $25,000.

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You you might as well add three zeros

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to that. Yeah. It doesn't matter at that

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point. It doesn't matter. Tell me it's $25,000,000.

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Like, I don't care. Yeah. I'm not coming

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up with the $25,

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and I'm not coming up with the 25,000,000.

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So who cares? Yeah. Exactly. So my point,

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insurance companies

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have lied

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repeatedly,

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and it's very effective.

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Mayhem, Gekko, Flow,

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Chris Paul, Aaron Rogers,

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that the the deep voice dude,

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whatever they are. Right? These insurance

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mouthpieces,

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right, that simply are advertising

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spending your premium dollars

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to try and convince you that somehow they

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will be there in your time of need.

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Right? Are we kidding ourselves

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when what actually happens and how they actually

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make money is by holding and investing premium

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dollars and not paying them out?

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Over a $100,000,000,000

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in third party liability carrier profits last year

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alone.

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Needless to say, we are outspent

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in lobbying,

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and they've been very successful

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utilizing a small portion of that $100,000,000,000

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in profits,

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which by the way are operating expenses prior

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to those profit numbers. Okay? So

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hear this out.

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Tort reform.

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Sounds good.

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Why? I I I don't know. Reform. Reform

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sounds positive.

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Lower premiums.

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Well, that that sounds good. How do we

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we get lower premium. Yes. If you have

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less runaway verdicts,

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you'll have lower premiums. Oh, that that sounds

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logical. Has it ever happened?

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Never.

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Never. Tort reform initiatives in any state has

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led to continuing rise rising

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insurance premiums.

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So it's a flat out lie.

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So coming back to these initiatives then in

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terms of the s p 68 and the

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s p 30, it's it's it's about knowing

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what exactly they're doing Correct. And and understanding

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how they're how they're impacting the organizations itself.

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So they've gotten some stuff passed. They got

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it passed in Georgia. They didn't get it

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quite passed in Texas. But the bottom line

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is the insurance lobbying groups are after, quote,

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unquote, tort reform. Reform is usually

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positive thing. That is not what these initiatives

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are, and it is absolutely essential. Sludge does

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not stop in health care at sleep seeking

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into the lee seeping rather into the legal

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system as well. So the litigation

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funding bill in Georgia and the health care

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bill 68

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targeted introduced provisions that could lower reimbursement rates.

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Right?

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Unrelated

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reimbursements.

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A non Medicare patient could have Medicare reimbursements

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introduced at trial

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as a possible reimbursement

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for doctors who have provided care for years

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without payment.

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On what planet

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can somebody make a living

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receiving Medicare or Medicaid rates two or three

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years after the fact?

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Right? It is not possible.

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So that is what sixty eight and sixty

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nine have been passed

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and will

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be at risk of ultimately lower reimbursement rates.

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If it gets too low, what happens?

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Doctors just aren't going to see these patients.

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Then what happens? A 100,000,000 Americans are going

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to be marching to the emergency room for

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every ongoing physical therapy treatment that they need.

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That is not a cost effective

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way to deliver quality care.

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So

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Absolutely.

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These two bills threatened to entrench the worst

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kind of system sludge.

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It is

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unnecessary red tape. It is delayed justice. It

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is dwindling

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access to care. And while they aim to

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increase transparency,

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the real world result is more

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confusion, less support, and greater risk for those

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who can least afford it.

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So

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it affects the patient outcomes also because doctors

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should be treating these patients rather than questioning

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whether or not they'll ultimately get paid.

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Yeah. There's a there's a lot of layers

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to this, and I think understanding what you've

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touched on earlier, understanding it is is really,

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really key, understanding what the impact is. I

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do wanna touch really quickly, before we, wrap

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up here. I do wanna get your your

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take on technology and the impact it's having.

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If you could just really quickly talk a

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little bit about,

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what it does right now. Is it helping?

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Where does it fall short? And how can

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leaders approach that that

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piece? Yep. So you've got to have technology

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based rev cycle

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management that also has managed services with human

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beings. It cannot all be automated. There are

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significant advances that we've made with AI around

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predictive analytics for ultimate case

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values

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case values

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ultimately.

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So AI enhancements

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utilizing case characteristics, jurisdiction, and third party liability

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coverage is essential.

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At GAIN, we are the the leader in

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that space. It is also essential

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that we

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have humans

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managing these services who are sophisticated and knowledgeable

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about the legal system because independence

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is key. Doctors that hold their own liens

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in all of these states with all of

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tort reform are in big trouble.

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The disclosure issues the idea whether true or

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not that they are somehow in cahoots with

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the attorneys somehow

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taking advantage of these poor insurance companies.

379
00:14:30,454 --> 00:14:31,754
Right? The communications,

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what had been paid. The second piece that

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is largely dead

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is the traditional funding model because in paid

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versus incurred legislation

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where let's say a doctor was paid 40

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00:14:43,379 --> 00:14:46,259
or 50¢ on the invoice dollar that would

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be the most that the company that bought

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00:14:48,179 --> 00:14:50,340
it could ever recoup, right. In other words

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00:14:50,340 --> 00:14:51,480
they'd be out of business.

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00:14:52,179 --> 00:14:54,500
But these liens can be serviced by an

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00:14:54,500 --> 00:14:56,444
independent third party servicer

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separating, if you will, church and state.

392
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And so

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00:15:01,144 --> 00:15:02,764
keep the health care practice

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00:15:03,065 --> 00:15:05,485
at arm's length from the law firms,

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give the law firms and patients all sorts

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of tools to identify and see lien based

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00:15:10,985 --> 00:15:11,429
care,

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00:15:12,230 --> 00:15:13,850
and at GAIN understand,

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00:15:14,629 --> 00:15:16,649
acquire the necessary case updates,

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00:15:17,110 --> 00:15:19,529
understand the value of these cases, and maximize

401
00:15:19,589 --> 00:15:21,450
reimbursements for health care providers.

402
00:15:22,070 --> 00:15:23,509
So what do you need to do as

403
00:15:23,509 --> 00:15:24,169
a practice?

404
00:15:24,710 --> 00:15:25,210
First,

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00:15:25,625 --> 00:15:27,565
audit your PI claims process.

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00:15:28,024 --> 00:15:29,704
What are your write offs? How accurate are

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00:15:29,704 --> 00:15:32,264
your case updates? What's your track record? What

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00:15:32,264 --> 00:15:34,985
are the various attorneys track records? What type

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00:15:34,985 --> 00:15:36,605
of cases do they represent?

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00:15:36,985 --> 00:15:39,809
Who's responsible for the follow ups? And then

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00:15:39,809 --> 00:15:42,690
look for partners who specialize in lean based

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00:15:42,690 --> 00:15:45,670
revenue cycle management. Don't just add software,

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00:15:46,450 --> 00:15:47,269
add strategy.

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Because in personal injury,

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00:15:50,210 --> 00:15:52,309
getting paid isn't just about technology,

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00:15:52,769 --> 00:15:54,470
it's about knowing and being knowledgeable

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00:15:54,794 --> 00:15:57,214
of the entire game in order to maximize

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reimbursement.

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00:15:58,315 --> 00:15:58,815
Yeah.

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00:15:59,195 --> 00:16:00,875
And that can really only happen as you've

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00:16:00,875 --> 00:16:02,394
mentioned in the beginning, which I love. It's

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00:16:02,394 --> 00:16:04,714
a combination. It's technology and people that are

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00:16:04,714 --> 00:16:06,714
working together to build these partnerships to make

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00:16:06,714 --> 00:16:08,794
those connections, which I think is is really,

425
00:16:08,794 --> 00:16:11,210
really key. Reid, it's fantastic to have you.

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00:16:11,210 --> 00:16:12,970
Thanks so much for taking the time today.

427
00:16:12,970 --> 00:16:14,490
Thanks for all of your insights. This was

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00:16:14,490 --> 00:16:17,129
a fantastic conversation. You guys do a fantastic

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00:16:17,129 --> 00:16:19,450
job, and we appreciate you. It's great having

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00:16:19,450 --> 00:16:21,049
you. We also want to thank our podcast

431
00:16:21,049 --> 00:16:22,836
sponsor, Gain Servicing. You could tune in to

432
00:16:22,836 --> 00:16:25,076
more podcasts from Becker's Healthcare by visiting our

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00:16:25,076 --> 00:16:28,376
podcast page at beckershospitalreview.com.