The hospital bills didn't find her, but a lawsuit did — plus interest
A MARTÍNEZ, HOST:
It's time for our June Bill of the Month. Dr. Elisabeth Rosenthal is senior contributing editor with our partner KFF Health News. Welcome, doctor.
ELISABETH ROSENTHAL: Oh, good to be back with another outrageous story.
MARTÍNEZ: Absolutely. So who are we meeting today?
ROSENTHAL: Today we're meeting Bethany Birch from Kingsport, Tenn. Her story starts way back in 2016, when her gallbladder was removed. But this is really a story about a medical bill that a patient never received and the expectation, under the Affordable Care Act, that nonprofit hospitals try to connect low-income patients with financial help. And that doesn't always happen.
MARTÍNEZ: All right. Let's go to KFF Health News reporter Bram Sable-Smith, who has Bethany's story.
BRAM SABLE-SMITH: For months, Bethany Birch tried to manage the pain in her chest. Food made it worse, so she took antacids. When that didn't work, she avoided eating. She says this went on for eight months.
BETHANY BIRCH: And I ended up losing, like, 25 pounds at that time because I wasn't eating at all.
SABLE-SMITH: This was back in 2016. One night, the pain just would not go away, so she went to the emergency room. An ultrasound revealed she needed her gallbladder removed.
BIRCH: And they started having me prepped within an hour.
SABLE-SMITH: Bethany was 23, uninsured and her housing situation was unstable. After she was released from the hospital, she spent months crashing with family.
BIRCH: So it was a pretty rough situation 'cause at the time, I didn't have a job. I didn't have a driver's license or anything.
SABLE-SMITH: The hospital she went to is now part of the health system Ballad Health. Ballad says it sent three bills to Bethany, but Bethany says she never received them, probably because the hospital did not know where she lived. Then, two years later, after Bethany was back on her feet, she got a knock at her door. She was served court papers for nearly $12,000 in medical debt for the gallbladder removal, plus a previous trip to the ER.
BIRCH: I was so shaken up. I didn't know what it meant to be, like, sued for that type of thing. I didn't know what would happen.
SABLE-SMITH: Ballad Health operates hospitals in Tennessee and Virginia, and it has a history of suing patients. The New York Times did an analysis and found that in 2018, the same year that Ballad sued Bethany, the health system sued more than 6,700 patients over medical debt. When Bethany had her day in court, she was nervous. She wasn't able to afford a lawyer. She just had her dad for support. She met with the debt collection company representing the hospital and worked out a payment plan. Since then, she's paid over $5,000. But that day in court, the judge also tacked on an interest rate, and that interest has been piling up. By May of this year, she owed another $2,700 just from interest on top of her original bill.
BIRCH: I'm barely chipping away at this debt by paying a hundred dollars a month.
SABLE-SMITH: All nonprofit hospitals are required to have a financial assistance policy, and Bethany might have qualified. A timeline from Ballad shows the hospital knew Bethany was single, uninsured and unemployed when she went to the ER back in 2016. The health system says it did include information about financial assistance in the three bills that Bethany says she did not get. And they say a financial counselor left her a voicemail. Bethany says she did not receive that message either, likely because her pay-as-you-go phone plan did not have funds at the time. Since the court date, Bethany had been making her payments for over four years. Along the way, she tried to settle her debt twice, but with no luck. Then in May, after we started reporting her story, Bethany again offered to settle. This time they settled.
SABLE-SMITH: That was Bram Sable-Smith with our partner KFF Health News. We're back with Elisabeth Rosenthal. Doctor, I knew exactly what Bethany was feeling when she said that she was chipping away at this bill that just didn't seem to get smaller. And it seems like Bethany is someone who needed financial help when she first went to the hospital. So are hospitals required to help here?
ROSENTHAL: Yeah, the Affordable Care Act requires nonprofit hospitals to make, quote-unquote, "reasonable efforts" to determine if a patient qualifies for financial assistance before they take them to court. And that review could have been done - maybe should have been done - before she was sent a bill. Instead, as happened in Bethany's case, it's often bill first, do the financial check later. And it's really not fair to patients.
MARTÍNEZ: And Bethany ultimately was sent information about financial assistance.
ROSENTHAL: Oh, sure. They sent the information, but along with a big bill and after her surgery. And remember, the onus was on Bethany to fill out all these applications for financial help. Gathering all those supporting documents for those forms can be complicated, especially for patients like Bethany who are young, living in unstable circumstances. And really, the complicated applications can scare patients away from applying in the first place.
Now, one good thing is that consumer advocates are pushing hospitals to automatically screen patients to see if they qualify for charity care discounts. And Ballad Health did make that change. The health system now offers what's called presumptive eligibility ever since 2020. That lifts the burden of applying, making it much easier to access the financial assistance you qualify for.
MARTÍNEZ: And then when Bethany landed in court - the backbreaker, which is interest rate that was added to what she already owed. That was the painful part, more than almost maybe anything else.
ROSENTHAL: Yeah, exactly, an extra 7%. That was the default interest rate under Tennessee law at the time of her court judgment. That interest makes it harder for people to dig out of medical debt, which is why we estimate 4 in 10 American adults have it. And because of that court judgment, Bethany didn't qualify for Ballad's new financial assistance program, so - just so unfair.
MARTÍNEZ: Yeah, it seems really unfair. That interest rate really added up before Bethany was able to settle her case.
ROSENTHAL: To help, some states have moved to cap or even ban interest payments on medical debt for low-income patients, which seems the right thing to do. Financial protection experts say our health system needs to find more ways to prevent medical debt from going to court in the first place, though. And, you know, here's one tip for patients. People are shy about asking for financial aid. Don't be afraid, when you're in the hospital, to ask if you qualify. When faced with huge medical bills like we see in the U.S., many people worry they won't qualify for help. But, in fact, because the bills are so big, many patients do.
MARTÍNEZ: And you don't know if you qualify unless you ask, right?
ROSENTHAL: Right. So ask first before you get the bill.
MARTÍNEZ: Dr. Elisabeth Rosenthal, thank you very much.
ROSENTHAL: Thank you.
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