Adapting Your Practice Model When Reimbursement Gets Cut | EP 23

In this episode of Healthcare Marketing Edge, Tim Bouchard, Owner/CEO of Luminus, and Sam Rayburn, a healthcare sales, consulting, and business development leader, discuss how quickly reimbursement can change and what it means for a practice’s ability to stay viable and grow. Drawing on his experience across wound care, medical labs, and remote patient monitoring, Sam explains how the 2027 wound care cuts left providers unable to profit on the products that heal patients best, why the gray language in billing rules makes decisions harder than they should be, and how many primary care providers are moving toward concierge models to escape the insurance rat race. The conversation emphasizes that sound operational and financial decisions are the foundation for better patient outcomes, stronger reputation, and the growth that follows.

Tim Bouchard (00:34.294)
Welcome to Healthcare Marketing Edge, where we share stories and strategies to grow your practice. I’m Team Bouchard Lumnus, a healthcare marketing agency specializing in helping practices acquire patients and grow their practice. Today we’re connecting something that doesn’t always get linked to marketing, the operational and reimbursement decisions that quietly determine whether your practice can grow and deliver the outcomes worth talking about. Our guest is Sam Rayburn, Healthcare Sales Consulting and Business Development Leader who’s worked across wound care, medical labs, and remote patient monitoring. Sam’s going to show us how to get

The business side, right? All the way from reimbursement to service lines and set up better patient outcomes for a stronger reputation and developing real marketing opportunities. So Sam, welcome to the pod. Why don’t you tell everyone a little bit about who you are and what you do?

Sam Rayburn (01:34.813)
Sure. I appreciate it, Tim. Thank you for having me on again.

you know, with that being said, I’m I’m in quote unquote medical sales. I’ve been in the space for a little bit over five years now. been in a couple of different avenues of the space from you know, as you mentioned, remote patient monitoring, wound care, and then also in the medical lab industry. So been able to see I what I feel like is a lot in a short amount of time. you know, overall it’s been a pretty good experience, but trying to get behind the scenes with

you know, my clients and my providers to try and see what what things really look like on their end has been pretty interesting and eye opening as well. So I’m excited to to be able to hit on on a few different things that I don’t think everyone’s, you know, totally aware of all the time.

Tim Bouchard (02:21.558)
Yeah, let’s jump into a couple of them. I think maybe I can cue it up with what do you think has changed most over the last few years and how has that spun off into some of the things where you’ve seen practices be able to make big improvements?

Sam Rayburn (02:34.678)
So I would say for me personally, and it might have been like this, you know, before I I kinda got into the space in you know early twenty twenty one, but you know, the reimbursement aspect of things kinda changing overnight.

you know, for providers and then also people in, you know, my shoes providing services to providers and their clients, you know, can basically change at the drop of a hat, it kinda seems like. You know, obviously you’ll get a few months, you know, if if something’s gonna change from a year to year aspect, you know, you’ll kinda get a couple of months heads up. But I think the preparation and, you know, trying to figure out how to move forward from there

has been something that, you know, I’ve had to navigate a few of my clients on because I’m trying to figure out we’re like holding hands together, right? Trying to, you know, figure out what is best for them and their patients. So I would say the reimbursement aspect as far as, you know, it just changing, whether it gets cut or added or or kind of whatever the case is, you know, has certainly been interesting. And then I think on the the billing side of things and I am no, you know

professional biller by any means. I’ve got some good people that I work with that I trust and they’ve been fabulous to work with. But you know, in their shoes, it has been hard because a lot of the terminology that is released, whether it’s a, you know, a couple of hundred page document, and they’re looking for basically a couple of sentences, right? So with that being said, they’re, you know, sifting through all these

Tim Bouchard (04:02.51)
Mm.

Sam Rayburn (04:06.373)
you know, words and trying to find what they’re really looking for depending on what their specialty is as far as billing goes. And from there, you know, the language is pretty gray a lot of the time. There’s not black and white, excuse me, as far as being able for them to really say, Hey, I can, you know, specifically do this or specifically can’t do this, you have to interpret a lot more than I feel like you should have to. And I wish that there was some type of

middleman, whether it was, you know, through the insurance departments or through Medicare, whoever it is, to be able to really like speak with, you know, the billing teams that are out there because you know, this is a a point that I’ll kind of have later on, but I I think if you truthfully ask a lot of providers that are out here today if they’re happy with their billing company, a lot of them will say no. Right? I haven’t met too many that are just thrilled with their current situation. With that being said,

Tim Bouchard (04:58.67)
Mm.

Sam Rayburn (05:03.957)
on the back end of it, I don’t know how fair it is for the billing teams to be in the situation that they’re in because things are so gray and they’re not given a black and white wording as far as how things are supposed to be billed out or how things are supposed to look you know, as as far as billing out the those services. So those are just kind of a couple things that I I think have changed a lot in a short amount of

Tim Bouchard (05:26.582)
I mean, you talked about how it’s kind of gotten murky between the insurance and and reimbursements and the practices themselves and that obviously affects the operations side and the business decision side, which you’re starting to get into. But how does that also show up on the patient side too? I’m assuming that also that affects the patient experience if it’s not handled the right way.

Sam Rayburn (05:47.342)
Sure. you know, I in wound care specifically, we’ll just kind of take a an example and something that, you know, I’ve kind of seen on LinkedIn consistently within the last few weeks with some new rulings that have come out for twenty twenty seven. Right. So wound care kind of exploded over the last few years. I d do totally agree that there needed to be some changes made. you know, in in essence there were essentially two hundred products, two hundred plus products that range from about nine hundred dollars

per square centimeter all the way up to five thousand. That, you know, variability was way too high. I think a lot of the products, you know, maybe were coming from Sam’s company and Tim’s company were really similar. Although they were being manufactured maybe from a a different company. the the product was essentially the same. So do I think that that needed to be cut down? Absolutely. I think the reimbursement was too high. But on the back end of that, Medicare was

kind of the one that was approving what the pricing was. So, you know, if I go into Tim’s office and say, Hey, here’s our new product that we’re wanting to release to the market, what we’re wanting to do essentially is, you know, get a certain, you know, we’ll just say five thousand dollars for it. You look into it, do your research, review on it, whole nine yards, and come back and say, you know what, I I think it’s probably more more so about four thousand is what we’d we’d be willing to pay for it. Well, that’s what you approved for it.

Right. I can’t just throw a number out there and it’s gonna get accepted. So I I think they kinda dug themselves a hole unintentionally because the wound care space is is a bad one, especially, you know, I’m in Mississippi. obviously we have our our health challenges that are, you know, all across the state in a few different ways from cardiovascular, which also leans into wound care. But you know, I I think on the back end of all this, the reimbursement basically did a seven twenty for this calendar year.

And with that being said, they have cut it to a poor place where providers, especially, you know, nurse practitioners and PAs that kinda own their own clinic are not in a position to be able to be profitable using those same products. And what we were able to see were some, you know, pretty amazing case studies and different things like that on patients that had wounds for, you know, two plus years that

Sam Rayburn (08:13.751)
you know, use these particular products and were able to heal at a pretty amazing rate. So there needed to definitely be some changes within the industry as far as the the reimbursement goes. I was totally on board with that. Agree with it. But we have now done a seven twenty to where patients are not getting the best products that are on the market because on the back end the you know, doctors offices and owners of these clinics would not be making any type of money off of it.

they’d be losing, you know, in some instances. So, you know, I I think patients are are certainly suffering because of that and we’ve had to, you know, with a few of my clients we’ve had to obviously pivot to a new new product and just truthfully I’ve not seen results be as good as they were previously. And, you know, that’s just kind of the reality of of where we’re at.

Tim Bouchard (09:04.546)
So I’m assuming this is something you’re talking through with pay with practices and and practitioners to help them figure out which product suite can one benefit their patient census and then two also make sure that they’re staying profitable so that the practice can fulfill all the things it needs to f financially to exist, one, and then grow on top of that. how do you help someone navigate that choice along the way for their practice?

Sam Rayburn (09:18.077)
Sure. I think it’s just information and being, you know, I

a relationships guy. I think a lot of people like to say that, but I really do try to get behind the scenes and, you know, spend as much time as I have and and that they have with them. So once, you know, I feel like that relationship’s pretty established, you know, I’m I’m gonna give them as much information to make an educated decision. They went to school for a long time, right? I went to school for a little bit of time, but not that much. And, you know, being able to kind of walk them through what I’ve seen

you know, the different case studies that I I can give and, you know, have access to to give them as well. And, you know, just walking them through what all we have and, you know, kind of looking on, you know, like I said, the case studies have have been something that they look into and kinda make an educated decision for themselves, moving forward from there.

Tim Bouchard (10:29.314)
Now a lot of these practices are doing multiple products too. Do you see a spot where a thin margin reimbursement product that brings a lot of people through the door can help with something like referrals, word of mouth, or patient pool growth over time? Is there still space for that? where you don’t maybe focus on it but you keep it as as something that’s in the in the back pocket.

Sam Rayburn (10:53.963)
Yeah, I mean absolutely. I I think with things changing as quickly as they did, especially in wound care, the providers are at, you know, a place where as long as it’ll just, you know, be a little bit in the green as far as the the end result goes, they are willing to to do it as long as it will help their patients. I mean, you know, they’re they’re just in a situation now where it’s just not

like I said earlier with the billing aspect of things, some of these products are new and so you don’t have a ton of volume to be able to show them, hey, this is consistently what we’re able to do or, hey, this is getting denied a lot because, you know, we’re in a place where billing companies, you know, like I said, they’re in a tough spot too because some of these products are new. They’re learning and navigating challenges at the beginning of the beginning of the year.

billing out new products and you know if something’s getting denied consistently they’re trying to figure out why on the back end too. So you know, I I think that there is still certainly a market for it and they’re able to to be in a place where, you know, I’m trying to give them as much information as possible and as many products as possible, but you know, they’re just trying to learn as we go. And I am too.

Tim Bouchard (12:11.094)
Yeah, and there’s still a there’s still a place for having a product that doesn’t cost you money, obviously, to provide patients, but if you can really lean into the idea that this is still a viable thing that patients need at my practice, and I can have good outcomes for them, which will rub off on the practice as good reviews, word of mouth, more referral feedback coming our way, things like that. That opens up doors for other things along the way too. And

Sam Rayburn (12:19.625)
Sure.

Tim Bouchard (12:40.106)
At this point you were saying there’s a lot of people have similar product lines for these services across practices. So you have to figure out some ways to build differentiators around that. and sometimes even if the margin isn’t there on one, if you can use that as something to lean into and build a reputation off of it, or at least have something else to put out there from a a pr an outcome promise, a a fulfillment of better life, better, you know, whatever afterwards, leaning into that can help.

open up doors for other things too that might have more profitable reimbursements alo along with them. So, you know, that might be something where you’re building up a differentiator set. And another thing you you had talked to me about before we record this was also things like speed to treatment too. It’s not only just what’s profitable in reimbursement, what can I work in through my practice that is a speed to treatment won’t have people backed up and I can play that angle alongside.

Sam Rayburn (13:33.23)
Sure. you know, I I think that’s a great point. With that being said, wound care providers are in a little bit different space than your primary care providers. A lot of our PCPs are in a situation where they’re having to see a lot of patients, right, in a short amount of time.

Tim Bouchard (13:40.745)
the outcomes angle too.

Sam Rayburn (14:02.251)
wound care providers can kinda take their time with each individual patient and be able to really hone in on that particular wound or the issues that that that patient’s having. So, you know, the the time aspect of things, being able to give them a product that may take a couple of minutes to provide, you know, I I think is you know, obviously we still wanna be conscious of them seeing other patients, but, you know, they’re able to take their time

to some degree with being able to spend one on one time with the patient, see what’s really going on, maybe debris a wound, add a product and kinda go from there. you know, but certainly there’s there’s a few different things out there where, you know, the reimbursement aspect we’re not, you know, worried about at all. We’re just trying to get the patient in a you know, a particular place maybe to apply an additional product or to see if, you know, we even have to go that far. So, you know, like I said, a lot of lot of navigation I think through

You know, a few different changes and challenges, but you know, it’s been it’s been pretty interesting.

Tim Bouchard (15:03.074)
Well ne on the I guess on the out outcomes and quality standpoint too, we had mentioned remote patient monitoring before too, and where there might be an opportunity in that for improving outcomes and patient retention lifetime value, all the things that go along with that too. So there might be something where, you know, even if you’re seeing slimmer margins on some products, if you can package it in with something that might be beneficial for the patient and also for your patient retention.

and financial numbers you can start to package together services too.

Sam Rayburn (15:37.45)
Yeah. you know, one of my very close friends, he’s been in the the RPM space since really right around right before COVID kinda happened. So there’s been so many changes. I actually just saw a ruling where, you know

Wound care is essentially gonna stay the same with a lot of those those products. I I saw that RPM is also kinda changing as far as twenty twenty seven goes. And the third party vendors, if you know, well sess you know, example here, but you know, I come into Doctor Tim’s office, you know, he’s got a certain amount of patients. I’m a third party service. What I’ve been able to do up to this point is pitch you on being able to monitor your patients for you. I’ve maybe

got a certain amount of nurses that are under me and what they do is just look at patient data all day long. So although, you know, what we would give the patients maybe like a a fit fit, you know, depending on their their issues, scale, spirometer, different basic things like that that they’ll use and then, you know, our nurses are able to monitor. So moving forward in twenty twenty seven, that will no longer be allowed. I can provide that platform to you, but I cannot monitor your patients for you.

Which, you know, I I I’m still kinda thinking on how I feel about that because I think there’s pros and cons to it. I think if, you know, Dr. Tim gives me, hey Sam, I want your patients to be looking for X, Y, and Z. This is what I’ve seen in my patient population for the last, you know, fifteen or twenty years. I know what I’m looking for, I know what I’m doing, and that’s what I want you to be really focused on. Great. I mean I can cater to that and do all those different things within, you know, our organization and and my my

close friends organization, but you know, I I think that the primary care providers are in such a difficult place and I’ve talked to dozens that are almost feel like they’re in the rat race, right? They got into what they’re doing because they wanted to develop close relationships within a certain community and they wanted to be able to be that local doctor that you can go to for that sinus infection or, you know, for

Tim Bouchard (17:34.872)
Mm.

Sam Rayburn (17:49.548)
you know, the the basic things that you you need, right? prescription refills, all all the different things. But they have gotten cut to a point reimbursement wise on on their side to where they’re only able to spend a few minutes of their time with their patients. Whereas, you know, like I said, they got into it being more so relationship based and wanting to help the community and things like that. They’re still able to do that, but it’s not to the gr degree that they originally got into it for. So

you know, what we have tried to kind of navigate through is going to providers in that situation that are tired of, you know, hey, you need to be seeing patients every, you know, four minutes or six minutes, whatever the time period is that they’re given, and say, Hey, listen, you’re seeing, you know, five thousand patients per year, three thousand patients per year. If we cut that down to let’s just say five hundred and help you navigate into a concierge model.

you’ll be able to spend a heck of a lot my more time with your patients like you want to and why you got into this originally while also being able to harp on the remote patient monitoring aspect if that’s something that they want to do and be able to really have a a full wide range overview of each individual patient and be able to spend that time with them that you want to. So you know with the market kind of changing the way that it has, you know

Some providers are really interested in that and then some are, you know, can’t imagine not seeing a patient that might want might not want to do concierge medicine. And they’ve been seeing that patient for, you know, a long time, fifteen, twenty, twenty five years. These are important relationships to not only the the patients but the providers too, which, you know, I totally understand and respect. But they are just kind of in a in between a rock and a hard place with how to move forward with their practices.

Tim Bouchard (19:43.789)
Yeah, I’m assuming that there’s some if someone wants to make that jump, there’s also some operational and billing and procedural stuff that changes along with that too, to make sure that the processes follow along with that decision to switch approach.

Sam Rayburn (19:57.417)
Sure. Sure. you know, I think a big thing and and some of the people that, you know, we’ve been able to talk to and convert.

have been in situations where they’re tired of dealing with the insurance companies, which I think everyone is a little bit burnt out on that, and being able to just charge a flat fee of, hey, I’m converting into a concierge medicine model. I’d love to have you on, you know, I’ve known you for a long time and I I want you to continue coming to see me and being my patient. It would be a flat rate of, you know, we’ll just say a hundred and fifty dollars. You get four visits per month if you need that. If you don’t, no big deal.

Tim Bouchard (20:10.851)
Mm.

Sam Rayburn (20:36.439)
You get it either way. you know, so I think that’s one aspect for the providers and the owners in particular that has been very interesting for them is not having to deal with insurance as much and having to worry about the charting being just, you know, perfect down to every little sentence and also being able to, you know, just know what you’re gonna be collecting. So what we’re able to kind of pitch them is you’re seeing less patients, but you know, on the back end

able to be a little bit more profitable and not having to worry as much as far as you know the rat race of seeing them for however much time they’re given to be able to see all the patients that they need to in in one day. So yeah. Sure.

Tim Bouchard (21:21.122)
I’ve seen it a lot on the dental side. Dentists are doing this all the time. Just and dental insurance is not quite as catastrophically protec protective or or necessarily protective as regular health insurance too. So it’s almost even easier for them to develop pricing models and things based on the historical data they have of what their patients need. So I’m seeing it a lot on the dental side. and then even when it comes to things like you want to get into wound care or something like remote in home.

nursing contractor groups are going after the concierge model too, as well. trying to pick up people that aren’t interested in going through a practice or or or whatever. So they’re picking up people that are like in postdoc or, you know, whatever it might be, for contract concierge nursing and things like that too. So it’s definitely something that’s popping up more as the friction is building between insurance billing and

Sam Rayburn (22:11.722)
Absolutely. Yeah, I I I mean I think long term that’s where we’re headed. You know, I I think that that will be maybe kind of in between, you know, my age group and, you know

Tim Bouchard (22:18.774)
And margins and and the reimbursements.

Sam Rayburn (22:31.339)
really right around my age route, maybe a little bit north, is kind of where we will certainly be as we age, right? As far as the remote patient monitoring, concierge medicine and things like that, because, you know, from what I’ve seen, I don’t have all the experience in the world, but anytime something gets cut, it usually isn’t, you know, I would say about ninety percent of the time, it’s not gonna go back up. So on the PC P side of things, things are

Still consistently getting cut. And like I said, 2027’s another aspect where they’re having more cuts on their services side. And I I just don’t see a world where they’re going to bump that back up by any means. So I think we will continue to kind of see more concierge medicine pop up and more remote patient monitoring that that those providers are are looking into.

Tim Bouchard (23:20.6)
So let’s say and this might be something good to start to maybe put a bow on this. Let’s say someone’s doing something where they’re seeing lower margins, the reimbursements aren’t quite there, but they have potentially a strength there, or maybe there’s a strength somewhere else they want to lean into more, where would you give someone advice to start with either assessing it or making a decision to potentially pursue a shift?

Sam Rayburn (23:48.844)
I think you’ve gotta be realistic about where you currently are and a lot of providers are just you know, we’ve we’ve mentioned the I’ve mentioned the rat race a couple of times, but being able to actually sit back, eat lunch, look at things, see how you actually feel. Are you wanting to continue with how things are right now? And how long do you think you you can last as far as being able to continue the model that you’re currently on? If you’re happy

Great, I don’t wanna change anything. I wanna you know, the whole goal for me is for things to be easy, for you to be happy and patience to be able to be served in a in a positive manner, right? So, you know, I I think it’s them having to take a look in the mirror and seeing what kind of place that they’re at physically, mentally, and being able to see what the next few years look like for them. Being able to look at the bottom line, you know, as their financials and numbers go. I’ve got you know, a few different

billing teams that I work with that can kinda give them free assessments with where they’re at and where they’re maybe headed and also on the back end, you know, being able to see what that could look like projection wise over the next couple of years. So, you know, it’s it’s you know, especially in PCP it’s not about money for them and I I’m you know, I I love that aspect. They’re really there for the patient, which all providers are. I don’t mean it like that. But

they they really got into it to be a part of the community and and really be there for their local people. And so, you know, I think being able able to really have that conversation with them on the business side, they didn’t get it into it for business, right? They they got in it to help. And so I think, you know, showing them a few different tools that I kinda have access to you know, has been pretty beneficial for them to really look at the whole picture.

Tim Bouchard (25:29.677)
Mm-hmm.

Tim Bouchard (25:42.766)
Very cool. Is there anything I haven’t asked you that you wanted to make sure you mentioned on this topic before we wrap up?

Sam Rayburn (25:45.71)
made a few notes, so let me I I mean I think we’ve pretty much covered everything. You know, I I think we’re just like I said, we’re in a space where the billing aspect for me is is still pretty new and I’m I’m getting educated on it. It’s not something I would go into right, but I’ve got people that I trust. like I said, that kind of

kind of dumb things down for me in in a sense to be able to say, hey, look, these are the changes that are coming. This is what I was able to read. This is what I’m interpreting. Right? Are you seeing the same thing, Sam? You know, they’ll give me the information that, you know, we kinda go over and then I’ll interpret it the way I do and then we’ll have maybe another conversation. Right. But, you know, with that being said, I I just I think that there’s some things in place that we could change for the benefit of every practice and

you know, industries that I’m not even in to where they could interpret things, hey, this is pretty black and white. This is great. You know, I I understand we don’t need to do this or we need to add this to our charting or we need to do this where things are left very gray most of the time that I have seen, right? you know, so I I just I wish that, you know, healthcare is a really important part of our day to day life. I I mean it’s always obviously gonna be here.

So I I wish that the communication aspect of things you know, was in a in a place where it was a little bit better and I didn’t have to interpret wording, right? I’m I’m in a situation where, you know, reading through, you know, a few separate sentences can really make or break a couple of different things and how I’m really talking to my close clients. So, you know, I think that’s the biggest thing that, you know, I’m

Tim Bouchard (27:09.847)
Mm-hmm.

Sam Rayburn (27:36.504)
guess you could say I’m frustrated about is that, you know, I I wish that there was a division or service or anything that could really have that that relationship with these insurance companies to where there’s not any head bumping. You know, let’s work together. I understand that, you know, insurances don’t on the back end wanna get, you know, docked and pay a bunch of money for things that they feel like they shouldn’t have to, but why is this important? You know, doctors aren’t just gonna order lab testing or

this and that just ’cause they want to, right? They want to see what’s really going on underneath the skin. So, you know, I I think that there’s you know, everyone’s got kind of what they’re focused on and, you know, w what they do and don’t want to happen. So I just wish that that communication barrier wasn’t as hard as I feel like it it kinda is.

Tim Bouchard (28:25.964)
Yeah. Well, this has been a very detailed look at the business and operational strategy side of practices. So so thanks for that. But it does it it it affects everything from the growth of the practice to patient outcomes to the choices of where people are getting their their care and and and everything really when you think about it, it kind of starts down at the the foundation. So thanks for at least you know

Sam Rayburn (28:34.413)
Yeah, man, absolutely.

Tim Bouchard (28:51.424)
scratching the surface of it ’cause I that would be a pretty long and probably dry episode if we got into something really detailed on that. So so thanks for that. But why don’t why don’t you tell everyone a little bit about where they can find out more about you and what you have going on.

Sam Rayburn (29:06.823)
Yeah, absolutely. I so I’m on LinkedIn. you know, so Sam Rayburn, I’m I’m out of Oxford, Mississippi, God’s country, right? grew up a a big old miss fan, so I’m I’m still here. but with that being said, certainly can find me on LinkedIn. you’ll be able to to see my headshot and then you know my email is you know my my consulting email would be Sam Rayburn 1996

at hotmail dot com. So either, you know, forms of that, feel free to shoot me a message. you know, I love just, you know, even if it’s not a situation where we can work together, but just being able to kind of spitball as far as, hey Sam, I’m in a different industry. This is what I’m seeing too. You know, I I think it’s important to have those conversations to see where people are struggling and challenging, you know, as far as the situations that we’ve been put in and being able to kind of spitball some different ideas off of

you know, whether it’s a rep or provider or or clinical owner. So feel free to reach out to me. I I enjoy those conversations a lot.

Tim Bouchard (30:12.0)
All right, cool. And listeners, once your operations and service lines are solid and profitable and the way that you want them to be, marketing is how you can turn those things into growth too. So when you’re ready, check out our patient pipeline blueprint session offer. It’s a workshop to uncover how you can attract new patients and convert more inquiries into appointments for your practice. Learn more at luminus.agency/blueprint/. And as always, don’t forget to subscribe to Healthcare Marketing Edge for more insights like this on YouTube, Spotify, and Apple Podcasts.

See you on the next one.