The Month a Doctor Celebrated Collecting 65 Percent

Years ago, when I was running medical clinics, I heard a story that should still unsettle anyone who cares about healthcare sustainability.

A physician proudly told his team that he had just experienced his best month ever. He collected 65 percent of what he billed.

To the doctor, this felt like a win. To anyone outside the system, it sounds absurd.

I tried to ground it for staff by asking a simple question: how would you feel if you worked 40 hours and only got paid for 26? For many clinicians, that is not a hypothetical. It is routine. That reality framed my recent conversation with Reid Zeising, CEO of GAIN, whose company helps providers recover payment for care that has already been delivered. Their work and platform can be found at GainServicing.com.

How the rules quietly changed in the 1990s

The current payment environment did not happen by accident. In the 1990s, insurance claims handling underwent a structural shift. Large carriers adopted aggressive process redesigns that emphasized early low offers and prolonged resistance when claims were challenged. Software tools like Colossus were introduced to standardize injury valuation, a move critics argue suppressed payouts rather than improved fairness.

What followed was predictable. Profits rose sharply, the playbook spread across carriers, and the balance of power shifted away from patients and providers. By 2024, the property and casualty insurance industry was posting net income in the range of $100 to $170 billion, depending on how one-time gains are counted. Whatever the exact number, the conclusion is hard to ignore. The system works very well for insurers.

Why the math no longer works for clinicians

Reid was direct in our conversation. Many government program payments no longer cover the cost of delivering care.

That is not opinion. Medicare physician reimbursement, adjusted for inflation in practice expenses, has fallen roughly 26 to 33 percent since 2001. At the same time, staffing, rent, technology, compliance, and malpractice costs have climbed. When payments fall below cost, doctors either absorb the loss or restrict access.

Commercial insurance does not fix the problem. Hospitals are often paid more than double Medicare rates for the same services, with some states exceeding triple. Those dollars largely flow to facilities, not to independent physicians or small practices. Price variation is massive and only weakly linked to quality, leaving everyone navigating a system with no clear value signal.

From Colossus to AI, and why GAIN pushed back

GAIN did not start as a software company. Reid’s team originally worked in medical receivables, advancing funds so injured patients could receive care while providers waited for settlement. To manage risk, they built internal tracking tools. Then they did something most of the industry never bothered to do. They measured everything.

Case type, jurisdiction, carrier behavior, settlement ranges, and timelines were all analyzed. Over time, that data became infrastructure. Today, GAIN services complex and litigated claims across all 50 states, working with more than 20,000 law firms and over 5,500 providers. AI agents support intake, underwriting, case management, collections, and risk assessment.

The objective is not to out-muscle insurers. It is to close the information gap. As Reid put it, the goal is to match the carrier’s technological advantage with tools that help doctors get paid for care they already delivered.

In practice, that means clinics can know before treatment whether a case profile is likely to settle and roughly at what level. It means medical records and law firm coordination are handled without draining staff time. It also means providers are no longer forced into deep upfront discounts. Instead of selling a claim for 30 cents on the dollar, a clinic might net high 40s to low 50s on collections.

That difference is the line between survival and burnout.

The myths that quietly block access to care

Two phrases continue to distort public understanding: ambulance chaser and frivolous lawsuit.

Reid pointed to the well-known hot coffee case as an example. What most people never hear is that the coffee was served at dangerously high temperatures, hundreds of prior burn complaints existed, and the injured woman initially asked only for her medical bills to be covered. When full facts surface, many so-called runaway verdicts look far more reasonable.

When the public believes most claims are scams, it becomes easier to justify policies that delay, deny, or discount legitimate care. Those beliefs do not hurt insurers. They hurt patients and clinicians.

The human cost of delay and denial

Even after years of coverage expansion, roughly 25 to 27 million Americans remain uninsured. Cost remains the most common reason people avoid coverage or care. When an uninsured or underinsured worker is injured, they cannot wait months for reimbursement. Small medical practices cannot float years of unpaid receivables either.

This is the bind I described in the interview. Clinicians do the work, wait months or years, and often recover only a fraction of what they billed. When I once translated a 65 percent collection rate into 65 percent of a paycheck, front desk staff visibly reacted. Many months were far worse.

What the numbers mean for the next patient

Insurance profitability shows carriers have room to modernize without threatening solvency. Physician reimbursement erosion threatens access, especially in rural and independent practices. Private payment disparities signal a market disconnected from quality. Millions remain uninsured, with cost as the primary barrier.

These are not abstract trends. They determine whether the next injured patient gets seen or turned away.

What could help right now

Data before the visit matters. If a case is likely to settle, clinicians should know upfront. That single insight can open doors for patients otherwise denied care.

Standardization should guide, not dictate. Claims technology must support fair valuation, not suppress it.

Medicare physician payments should be indexed to practice-cost inflation so access does not erode each year.

Price transparency rules need enforcement and usable formats so employers and families can actually compare costs.

No doctor should celebrate collecting 65 percent. No patient should fear that getting care today means a multi-year fight for payment tomorrow. The conversation with Reid Zeising and the work being done at GAIN show that better technology, applied in the right direction, can restore balance. The real issue is not whether we have the tools. It is whether we choose to use them to pay fairly for necessary care when it matters most.