American hospitals turn to bedside, emergency room debt-collectors

In the NYT, Jessica Silver-Greenberg writes about hospitals who "embed" debt-collectors in their emergency rooms and patient care. These debt collectors are indistinguishable from other hospital employees for patients, and they harass recovering patients at their bedsides about their ability to pay, and advise emergency-room patients not to seek care they can't afford. The debt collectors work for Accretive Health, "the nation’s largest collectors of medical debts."

To patients, the debt collectors may look indistinguishable from hospital employees, may demand they pay outstanding bills and may discourage them from seeking emergency care at all, even using scripts like those in collection boiler rooms, according to the documents and employees interviewed by The New York Times.

In some cases, the company’s workers had access to health information while persuading patients to pay overdue bills, possibly in violation of federal privacy laws, the documents indicate.

Debt Collector Is Faulted for Tough Tactics in Hospitals (via Naked Capitalism)


      1. The pathetic part is, it’s the working class and lower-middle-class mugs who’ve spent the past 30 years voting for those two and their successors who’ll be among the hardest hit by the consequences of their policies.

  1. While I am sure this type of thing takes place, I wonder how common it actually is. I’ve only been an ER nurse for a short time, but at my employer and at both of the ER sites I did clinical rotations through, I never once saw an instance of someone being denied or discouraged against obtaining medical care. Quite the opposite. At my hospital, I’m not even aware of whether or not the patient has coverage and neither is the doctor who is making the decision about what type of care to provide and admittance to the hospital floor.

    In particular, I’ve seen day laborers (very likely undocumented and uninsured, but I don’t know for sure) brought in with traumatic injuries who were given top priority and rushed to surgery. It’s a beautiful thing actually, how quickly we provide life/limb saving care to people, regardless of their ability to pay.

    Of course, I’m certainly not claiming that all hospitals are like this.

    1. I am a outsider, but my understanding is that ER care can’t be refused. But once the ER care has been taken care off, the long term is very much “elective”.

      1. Oddly enough the point at which cancer patients are deemed “incurable” tends to correlate with the month in which they run out of money.

    2.  You don’t see emergency care being denied because it can’t be denied. Hippocratic Oath and some legal stuff. This is where people get the idea to cry about “illegal immigrants” getting free healthcare. The thing is, anyone in this country can do this, including undocumented immigrants, poor, and even the rich.

      Where people can be readily declined medical care without repercussions is non-emergency care. If I were to go to my family MD and indicated I could not pay, they would turn me away.

      It wouldn’t surprise me to see debt collectors at emergency room bedsides attempting to collect, though.

    3. The ER here is very particular about getting a credit card number before they see you.

      1. If your hospital’s ER requires a credit card before seeing you, it would be a violation of EMTALA law. EMTALA requires emergency departments to provide an examination by a physician and to stabilize patients before discharge or transfer, regardless of ability to pay.

        They can ASK for payment information, but medical services cannot be delayed or refused.

        1. We haven’t live under the rule of law for quite some time.  Nobody who has any authority gives a shit anymore.

          I have yet to get a monitor on for an episode of probable SVT because it takes too long for them to get my AMEX card info.  You’d think they’d have it on file by now.

        2. There is always a work-around or a loop-hole.  Many hospitals in low-income areas intentionally under-staff their ERs so that the average time in the waiting room is between 5-7 hours.  This is intended to discourage the indigent from seeking medical care that is “not worth” waiting 7 hours for.  In my father’s case it worked – he passed a kidney stone while we were waiting so we left after waiting more than 7 hours.  Some patients die waiting which also helps control ER costs.  I wonder how many people with pneumonia go back home to die peacefully in their bedrooms.

  2. Well, on the plus side, it sounds like ‘Accretive Health’ would serve as a useful organ-donor population…

    1.  Legally, they have to stop communication with you the moment you tell them to cease communicating with you. Unfortunately, many of these people can’t afford lawyers either, so it’s a difficult thing to fight.

      1. And low-income or not, a hospital patient isn’t in the sort of physical and mental condition to get into a protracted debate. I’d like to think that, were I in this position, I’d ask if the person was a hospital employee and ask to see an ID and make legal threats or call security if he continued bothering me. But chances are I’d be too debilitated by pain or pain killers or just plain fear to have the presence of mind to do so. Often, friends and family who might otherwise act as advocates for the patient are just as frightened.

        Accretive “Health” is no doubt aware of these things, and trains its bill collectors accordingly.

  3. Shouldn’t be surprised I guess. It’s a natural consequence of rejecting state-funded universal healthcare like it was some kind of evil Stalinist plot instead of something that civilized countries do as a matter of course.

  4. A for-profit system based on health insurance and designed to deliver profits rather than a health care system designed to deliver health care gets this kind of result. Until we have a health care system rather than a for-profit health insurance system, stories like this (or variations on stories like this) will be more and more the norm.

  5. I think it depends a lot on the state, the insurance provider in question, and the hospital.

    I did not see in the article (stub.. im not logging into NYT because F* them) where they specifically stated that the debt collectors were hospital employees, it just said they were indistinguishable from the employees.

    The hospital system I work for routinely writes off charges for patients who cannot pay.

    1. If a hospital is letting debt collectors (of all people) wander around the premises dressed in scrubs and harrass or con patients, it’s just as bad. Hospitals that undermine their core mission in this way, or state governments that allow it to happen are failures.

      Unless the U.S. institutes a variation on the single-payer, non-profit universal health coverage available in every other OECD country, it’s only a matter of time before the hospital system you work for starts “embedding” these grifters.

      1. While I agree that single payer is the way to go, I think even the individual mandate ought to be enough to cut down on this sort of grifter. If everyone has insurance, than the debt collectors won’t get much from the individual patients. They’ll have to deal with the insurance companies, at which point, they’ll be slapped silly if they try any grifting on their end.

        (Now excuse while I once again sigh in relief and offer a thanksgiving prayer to the FSM that I live in a country with single payer insurance.)

          1. I don’t know what you would call an individual who dresses in a misleading manner, employs a script designed to confuse, and tries to squeeze money from people when they’re at their most vulnerable and infirm and frightened. I would call him a grifter or confidence artist without any concern about character assassination.

          2. Character assassination is always the hallmark of a strong point.

            Can you assassinate character if it doesn’t exist?

          3. I would call him a grifter

            @boingboing-66331188710fdd63ee45cdf931f793ca:disqus , you’re too kind.  I would call him a piece of shit (for starters).

        1. You forget how our free market works.  As soon as everybody has the mandated insurance, the insurance companies are going to deny every single doctor visit, treatment, or procedure, as “not medically necessary”.  It has already happened to me three times in just the past year, even though the “in-network” doctor that the insurance company contracts with INSISTS that the treatments WERE medically necessary.  Hospitals will continue to pursue patients directly even if we all have insurance.  Your “in-network” doctor will all of a sudden have an “out-of-network” facility, and bill you the balance of $35k when the insurance pays $600.  Or the doctor delivering your baby will be “in-network” but nobody will tell you that the neonatalogist is out of network and charges a flat $2,000.00 fee per delivery, not negotiable.  Think it’s bad now?  It will get worse until profit is no longer the foundation for how health care is provided today.

  6. Sooner or later, these bottom feeders are going to join forces with the for-profit jail industry via that debtor’s prison scheme discussed the other day. Then they can implement Chinese-style inmate organ donation programmes and put everything in the same physical plant. That aspect of the new guard labour economy will certainly send a message to women who have the audacity to want to keep their breasts from rotting off after they get cancer.

    Well, at least there’s some comic relief provided by the jargon-monkey who writes Accretive’s copy. I mean, really: “execution of the Revenue Cycle” … “Six Sigma Process Control and Metrics Adapted for Yield.” From that, I gather the company is making so much money from its various scams that it doesn’t have to impress people who have actual business training (or candy stripers who have worked in hospitals, for that matter).

  7. They should put this situation into one of the many modern-day hospital soaps.
    Somebody should get all present in the Capitol to watch Sick Around The World and just blindly pick a system on a dartboard. It’s better than the diluted reform that’s still being contested. 

    1. Accretive: Growth or increase in size by gradual external addition, fusion, or inclusion.

      You know, gradual. Like how the frog gradually realizes he’s being boiled.

      1. The second definition of Accretion on Merriam-Webster had the kind of example I was looking for:

        “a product of accretion; especially : an extraneous addition {accretions of grime}”

        Other things that accrete might include crust or scum.

  8. Hospitals, doctors, and everyone else in the medical industry are just that — in an *industry.*  Meaning that, for them, it’s all about the dollar.  And by “them,” I mean the system under which everyone works, not specific individuals (so, nurses, please save the “But I’m not like that” comments); it doesn’t matter how you specifically are, when the system directs people to act otherwise.

    We recently went into the emergency room of a quasi-religious HMO-run hospital, because a family member couldn’t breathe.  The doctor looked at them for 2-3 minutes, shrugged and said he didn’t know why, then personally attacked me for mentioning a theory about the possible cause when it appeared he intended to do nothing. And then he quite literally forgot about us.  

    But the staff kept us there for over three hours while the collections person, repeatedly harassing us, made absolutely sure they had literally taken every last bit of money we had on us.  As in, “can I see inside your wallet?” type harassment — with my family member gasping for breath beside us.

    Luckily, the doctor happened to stumble into our curtained-off area later, to get something for another patient (the third one for the night), and since he was personally embarrassed to find us still there, and had us escorted out — still struggling for breath.   

    Now, months later, the breathing difficulties remain.  But within a few days, they’d sent letters literally threatening financial ruin until they’d been paid off in full.  

    It was a dreadful experience.  Never ever going back.  Ever.  

    1.  Unfortunately if you want real medical care today you will either have to do it yourself, or find a doctor who functions outside of the economic goldmine.

    2. I waited in an ER room in a less-than-affluent part of town for 7 hours when my elderly father was having severe abdominal and back pain.  The ER had a uniformed officer standing guard by the main door between the waiting room and the ER exam rooms.  I saw one elderly man try to walk out and the guard asked to see his discharge papers, which he didn’t have.  Then the guard pushed him back in and wouldn’t let him leave.  Fortunately my dad passed his kidney stone and started to feel much better so we left the ER without ever being seen.  We followed up with the family doctor the next morning.  My advice is that if you ever really have a medical emergency, stay where you are and call an ambulance.  Though I’m sure it will be only a matter of time before debt collectors are embedded in 911 call centers to run your debit card number over the phone as you wait for the paramedics.

  9. To the complaint(s) about doctors are only in it for the money:  I would agree to some extent if applied to plastic surgeons in Hollywood or some private practices.

    For doctors working in hospitals 12-18 hours at a stretch, doing two hours of grand rounds, leading research, teaching and then going home to answer work emails for a few hours a day does not exactly sound like in it for the money.

    I would love their pay checks if I could work 40 hours a week instead of the 80 or so that many of them put in.

    1. Doctors haven’t run hospitals for many, many decades.  They have administrators to do that.  It’s more efficient because they can work in any industry with equal lack of knowledge.

    2. To the complaint(s) about doctors are only in it for the money

      The nice thing is it’s actually pretty difficult to find an organized group of doctors who are against a single payer system.  I’ve met some far right wing doctors who are against it, but they’re basically idiots.

      Most doctors (even fiscal conservatives) are smart enough to understand the benefits of a single payer system for economic and humane reasons.

      Shoot, even try a google search for “doctors against a single payer system” just brings up a bunch of results of doctors who are for it for the most part.

      This gives me hope that the majority of the doctors aren’t just in it for the money.

  10. Welcome to a for profit medical care system. As long as hospitals and doctors have an obligation to profits, health care will always be secondary, if that.

    1. Sadly, some of the most egregious abuses come from “non-profit” “charity” hospitals.  But for every non-profit there is an executive staff that expects to be paid the same as the executive staff for a for-profit operation of equivalent size.  And these managers will defend their cash cows to the death.  Some of the aggressive collection practices of these “non-profits” have come under scrutiny recently.  In some cases debtors are pursed to the point of having them jailed for not paying.  This is very uncommon, since the US abolished debtors prisons long ago, but debtors can still face jail when they refuse to pay a judgment on the basis that they are in contempt of a court order.

  11. Sounds like I would be paying my medical bill with the lawsuit I’ll win from the obvious breech of doctor-patient privilege that was going on there, if were in that situation.

    1. It is likely there is no breach.  Most hospitals require you to sign a notice of HIPPA practices when you are admitted.  HIPPA allows hospitals to share your information with sources that need to know.  In this case, agents that they are employing (either directly or by contract) to collect medical bills will be considered “need to know”.  

      1. But you do have an excellent Fair Debt Collection Practices Act claim.  They are not supposed to bother you in the workplace or in public places, they are not supposed to threaten consequences (such as denying care) for failure to pay, and they cannot use any techniques that would reasonably be considered harrassing.  You can get money damages for their violation of all those provisions.  

  12. I recently had to stay in the hospital over night from complications from a rotavirus.  I hadn’t had any food quite some time (or at least food that stayed in my stomach), I was severely dehydrated, and I was somewhat loopy from the fact that I couldn’t keep down regular medications I take.  Into this walked a “Financial Counselor” that worked for the hospital, to talk about my bill.  This wasn’t as I was being discharged–I was still throwing up blood.  I explained that I, luckily, have insurance, and I’d deal with it later.  She offered me a slight discount on my deductible if I paid ON THE SPOT.   I didn’t even have pants, let alone a way of paying.  I asked her to go away.

    I can’t imagine what this would be like if I didn’t have insurance and was in the condition I was in, or more likely in worse shape, since I was by far not the worst case admitted that day.

  13. I’m wondering if the stress caused by debt collectors to a sick person might actually cause them to become more ill, and have physical repercussions. What kind of creep would take a job where your duty is to harass seriously ill people for money? That is right up there with puppy kicker. 

    1. What kind of creep would take a job where your duty is to harass seriously ill people for money?

      Candidates that the TSA rejected for not being sufficiently ‘people oriented’?

    2. I’m wondering if the stress caused by debt collectors to a sick person might actually cause them to become more ill

      Absolutely, YES.  I’ve seen it nearly literally kill a loved one.

  14. Fear not, the invisible hand moves in mysterious ways.  It may seem cold and uncaring, but a capitalist hospital has to turn a profit!  Not generating a profit would be cold and uncaring to the owners/shareholders…did you think about how they’d feel?  Maybe not as bad as people who forgo vital medical care because they’re bullied by debt-collectors posing as medical staff, but still quite bad!

    I can’t wait for this kind of system to be implemented for other emergency services, like fire.  Just call 911 (have your credit card ready) and firefighters will be dispatched immediately!  Well, once the charge clears, anyway.  Have to be careful of people trying to get 911 service using fake cards, after all.

    1. Please indicate on the anatomically correct doll where the invisible hand of the market touched you. (This joke ripped off from Tank Riot podcast.)

  15. There are so many jobs in the US that would make me want to kill myself.

    This joint expects low-paid workers to beg for tips from customers to subsidise their shitty wages, co-opts and brands basic courtesy into some grotesque ‘greeter’ job description, drapes sandwich boards over the desperate, and basically pisses all over fundamental human decency in the drive to disenfranchise, humiliate, and grind into the dust anyone who’s down on their luck.

    Give me your tired, your poor,
    Your huddled masses, yearning to breathe free,
    The wretched refuse of your teeming shore,
    Send these, the homeless, tempest tossed,
    Because I need someone to shit on.

  16. Hospitals have been doing this for some time now. The only new thing here is that the debt collector isn’t employed by the hospital but rather contracted for the work.

    1. The cost of a medical education in the U.S. _is_ high, relative to the costs of other fields of education. But, the cost of a medical education is only a fraction of the income of a medical professional over their lifetime of work.

      Put into numbers, you may rack up $200,000-$400,000 in student loans to become a doctor. But you make $100,000-$500,000 or more, every year, when you reach your peak earnings.

      Practically speaking, the cost of your education is only a few years of your income. It is this huge earnings potential that still draws many, many intelligent and hard-working people to the call of being a doctor (in addition to the common desire to help other people.)

      If a doctor’s education is made free, I do not see their fees dropping by a considerable amount. They will still charge what the market will bear.

      1. Practically speaking, the cost of your education is only a few years of your income.

        Four years of pre-med. Four years of med school. Four to ten years of residency. Zero to four years of fellowship. A bottom-tier GP doesn’t finish education until about age 30. A surgical specialist will be close to 40. Some of that is paid work, but you still have to figure that physicians are in apprenticeships for a very long time, and pay reflects that once they finally finish their education.

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