Author: GAIN Servicing
One in three Americans couldn’t cover one month of living expenses with savings. At least one in four Americans have no emergency savings. Over 30 million Americans are uninsured.
“Those people also deserve care,” said Reid Zeising, GAIN’s CEO and Founder. And, if someone gets hurt “through no fault of their own…you stand almost no chance of receiving the same care that I would given the health insurance that I have.”
GAIN, for context, “is the largest revenue cycle management company handling litigated and complex claims,” Zeising said. In practice, that means “attempting to collect for health care providers on patients that they otherwise wouldn’t have received payment for.” The work, he said, includes “services to the uninsured, the underinsured and those really disadvantaged by the system as it works.”
In relation to GAIN’s mission, below, we highlight four things to know about the state of personal injury from Zeising’s appearance on the Breakfast Leadership Network.
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1) Incentives drive the healthcare system
“Let’s just call it what it is,” Zeising said. The healthcare system is “driven by money.” He added that “the way the politics set up is it’s run by money and it’s run by lobbying interests.” In his view, that imbalance determines outcomes: “We spend millions, they spend billions. Who has more influence? They do. End of story.”
2) The insurance business model rewards paying out less than it takes in
“You take in premiums, you invest those premiums and you pay out less than that total,” Zeising said. “End of story.” That, he argued, is why “the incentives are not aligned with the policyholder.”
3) Because government reimbursement is not profitable, other claim types subsidize the gap
“Let’s be clear,” Zeising said. “Medicare and Medicaid claims for the vast majority of CPT codes are not profitable for doctors.” So, he said, “commercial insurance, workers comp, personal injury, etc. are all compensating for the subsidies that doctors provide those government agencies.”
How wide can this gap be, exactly? Said Zeising: “You could have single digit Medicaid reimbursements,” “mid-teens to perhaps 20s for Medicare,” and “mid-20s to perhaps 30s for commercial.” For litigated and complex claims, he added, “we work in all 50 states, you’re probably averaging closer to 50%.”
The bottom line? “They are simply not being paid for the services that they’re providing.”
4) Technology is how GAIN reduces uncertainty in a world built on delay
Zeising described building a software platform for us to manage our own receivables, tracking lawsuits and litigation and filings and dockets and other case updates to assure that we could get repaid at settlement.
Then came the data layer. “I started to gather data,” he said, including case characteristics, jurisdiction, and third party liability carrier, who was the counterparty. “All to predict what these cases would settle for and what dollars would be available to reimburse either lien holders or doctors,” he explained.
Doctors typically get paid 2 to 6 weeks after a personal injury case settles, as medical liens are resolved during the final disbursement phase. But settlements themselves can take years to negotiate. What’s next? Making sure providers don’t have to carry all this burden themselves.
Circling back to GAIN’s ongoing impact to combat this challenge, Zeising says its foundation supports what he calls a service model that takes operational weight off providers. “I will service these,” Zeising said. “I will get the case updates. I will communicate with the law firms.”
The goal? To support providers’ ability to treat patients while waiting for outcomes: “I will help you with all of your needs for access to care.” He added, “I will provide bills, notes, and records for free to those who need them,” and “provide that service simply for a percent of collections.”
The time factor is the pressure point. “There’s duration risk,” Zeising said, and “duration… hurts cash flow for doctors.”
Final Thoughts
Today, said Zeising, GAIN’s servicing platform uses “artificial intelligence on intake underwriting case management as well as risk management the collections the settlement and the reimbursements,” and that it is “permeated throughout our organization in every single step.”
He also pointed to internal adoption: “Most of our 150 employees utilize agents themselves,” he said, adding, “we have many more employees than we do the 150 or so that we have… with the utilization of AI.”
The Bottom Line?
Ultimately, litigated and complex claims expose a system built on misaligned incentives and long delays, and the work of getting providers paid depends on removing operational friction so care is not dictated by who can afford to wait.
Full interview here on the Breakfast Leadership Network: How AI is Disrupting Healthcare RCM and Exposing Insurance Claim Denials.