Hospitals Are Losing Millions on PI Patients. Here’s How to Fix It. by Eliezer Nerenberg

Hospitals spend real money to get injured patients through the door—especially through the emergency department. But here’s the problem I see over and over again:

A patient comes into the ER after a motor vehicle accident. The hospital treats them. Then the patient leaves, hires an attorney, and receives the rest of their care somewhere else—often through whatever network the attorney already uses. In many cases, the patient never comes back to the hospital system for follow-ups, imaging, ortho, PT, injections, or surgery.

That’s not just a continuity-of-care issue. It’s a revenue issue. And it’s bigger than most hospital leaders realize.

I often describe it like this: hospitals are spending money “to kick the ball into play,” but they don’t have a plan to pick it up afterward.

This is fixable—without spending more on marketing. But it requires something hospitals rarely have today: an operational “closed loop” for personal injury (PI) and third-party liability (TPL) patients after discharge.

Why PI patients are different (and why traditional hospital workflows break)

PI/TPL patients don’t behave like traditional insured patients—and they don’t move through the revenue cycle like insured patients, either.

With insured care, the system is built for predictability: eligibility checks, coding, payer rules, contracted rates, defined appeal processes, and relatively standardized timelines. With PI/TPL, it’s often the opposite: payment is case-driven, attorney-driven, documentation-heavy, and timeline-uncertain. That uncertainty can stretch payment cycles and increase write-offs if the case isn’t managed proactively. (Bottom line: PI workflows can’t be run with “normal” billing rules.)

Most hospitals do have strong clinical infrastructure. Most hospitals do have strong insurance billing teams. But PI/TPL is a separate discipline. When it’s treated like “just another account type,” revenue leaks out in three predictable places:

At intake (PI not identified early, or key information not captured)
After discharge (no structured follow-up or in-network scheduling path)
In the back end (no specialized servicing for liens/LOPs/records/negotiations and attorney communications)

If you don’t intentionally build a PI pathway, the attorney ecosystem will build one for you—outside your system.

The part hospitals don’t measure: post-ER “patient leakage”

Most hospitals measure ED volume. Many measure readmissions. Some measure downstream referrals.

But very few hospitals measure this specific question:

Of the accident victims we treat in the ER, how many return to us (or stay with us) for follow-up care once they retain counsel?

In my experience, that’s where millions are lost—because downstream services are often the most valuable services. And once the patient has an attorney, the “default route” is rarely the hospital system unless the hospital has already made continuity easy and aligned the administrative pieces that make PI care work.

Hospitals also operate in an environment where margins are under constant pressure, and financial performance is highly sensitive to bad debt, charity care, and reimbursement shortfalls. That’s exactly why “recoverable” PI/TPL revenue matters: when it’s handled correctly, it can be the difference between writing off an account and collecting appropriately for care delivered.

The real issue: hospitals don’t have PI infrastructure that matches their clinical capabilities

I’ll put it bluntly: hospitals are not “bad” at PI care. They’re under-built for the medical-legal interface.

That interface requires:

Tight documentation and records workflows
Proactive patient communication and follow-up scheduling
Specialized account servicing (not generic billing)
A compliant way to coordinate with attorneys
Visibility into the case lifecycle so the hospital isn’t operating blind

In the physician world—especially orthopedics—this problem is obvious. Doctors like PI because reimbursement can be higher, but they hate it because payment is slow, unpredictable, and operationally painful.

Hospitals face the same reality, just at a larger scale.

A tactical fix: build a PI Patient Retention & Recovery Program

Here’s what I recommend hospitals implement. It’s not theoretical; it’s operational. And it’s designed to be layered onto what you already have.

This sounds basic, but it’s the foundation. Intake must capture:

Accident details (MVA, slip-and-fall, workplace, etc.)
Third-party coverage signals (auto med pay, liability carrier if known)
Attorney status (do they have one yet?)
Best contact and consent for follow-up

The critical detail: many ER accident victims do not have an attorney at the time of treatment.

That means the hospital has a short window where the patient’s next step is still influenceable through service and clarity (not sales).

1. Schedule the next appointment before the patient leaves

If the patient needs follow-up, don’t leave it to chance.

Hospitals should build an “accident follow-up” workflow that:

Schedules ortho / neuro / imaging / PT as appropriate
Provides the patient a single point of contact
Makes it easy to stay in-network (directions, instructions, phone/text reminders)

This is the clinical equivalent of what strong retail organizations do: you don’t just acquire the customer—you guide the next step.

2. Put the PI back-end into a specialized servicing track

This is where most hospital systems break.

PI/TPL accounts require disciplined servicing:

Document collection (complete records, bills, narratives when needed)
Lien/LOP workflows where appropriate (and compliant)
Attorney communications and status tracking
Negotiation processes that preserve value without creating friction
Consistent follow-up so cases don’t die quietly on someone’s desk

This is exactly why I believe the future of this industry is shifting away from “funding” and toward transparent servicing—because interests can be aligned without the behind-closed-doors dynamics that make the market messy.

(And from a practical standpoint: most standard RCM organizations don’t touch TPL/PI at all, which tells you how specialized it is.)

3. Create a compliant “attorney on-ramp” that supports continuity of care

This is the controversial part—but it shouldn’t be.

If a patient doesn’t yet have an attorney, hospitals can offer educational guidance and, where appropriate and compliant, a list of options—without steering, without quid pro quo, and with patient choice preserved. The goal isn’t to “capture” the legal relationship; it’s to prevent the hospital from being cut out of the care plan once counsel is retained.

The vision I have is simple: if the hospital has a retention program and the right servicing support, patients can be connected with attorneys who understand the importance of sending patients back for medically appropriate follow-up—so the hospital isn’t treated like a one-time ER stop.

Important note: hospitals should always run this through compliance and legal counsel (Stark, AKS, state rules, and local policy all matter). The principle here is continuity and transparency, not kickbacks or exclusivity.

4. Make it measurable (and managed like a service line)

If you can’t measure it, you can’t improve it.

At minimum, track:

% of ED accident patients tagged PI/TPL
% scheduled for follow-up before discharge
% who complete first follow-up visit in-system
Downstream revenue retained (imaging, ortho, PT, surgery)
PI/TPL A/R aging and recovery rates
Average time to resolution/collection for TPL accounts

Hospitals already manage service lines with this kind of rigor. PI/TPL should be treated the same way—because the leakage is real.

Why this matters right now

Hospitals are operating in an environment of intense economic pressure, including reimbursement shortfalls and rising costs. At the same time, competition for patients has pushed marketing and advertising spend upward across the industry—including hospital advertising that’s been studied academically and in major medical journals.

When you combine:

competitive spend to attract patients, and
weak post-discharge PI infrastructure, and
the reality that attorneys can redirect downstream care quickly,

…you get a predictable outcome: hospitals pay to acquire the patient, then lose the patient’s downstream value.

Where Gain fits (without the fluff)

My role at Gain is focused on business development and scaling servicing—because I’ve spent enough years watching how broken the old model can be when incentives aren’t aligned.

Practically, what we help healthcare providers do is:

operationalize PI/TPL servicing so accounts don’t languish
build transparency into the case lifecycle (so providers aren’t guessing)
reduce administrative drag for clinical teams and revenue cycle teams
and, where appropriate, help support referral alignment so continuity is possible—not accidental.

Or said more simply: hospitals shouldn’t spend millions getting the ball into play, then fumble it at discharge.

They can retain those patients, monetize their investment, and get paid appropriately for the care they provide—if they build the right infrastructure.