ROCHESTER, Minn. – Something about the voice on the other end wasn’t right.
He had called to say he needed to give her something in person, that afternoon, and that he had been unable to reach her at home.
It all made her wary.
She agreed to meet him in a public location after work. For safety, she asked her boyfriend to meet up there as well.
"He had kind of a junky old car," says the Minnesota resident of the driver that awaited her. "So that was kind of scary."
He was a process server, as it turned out, a courier paid to deliver the paperwork of bad news.
Although you could call it unusually bad news. He handed her a letter saying she was being sued for unpaid charges, by a famous hospital, during a pandemic.
The woman, contacted by Forum News Service because her name appeared on public records detailing collection judgments sought by hospitals during the pandemic, has requested anonymity to protect her employer’s contracts.
She says she knew about the balance due, but not that they would ask for it like this. A few thousand dollars her insurance would not cover, she had accrued it prior to the pandemic from the use of routine health care for her kids and herself, then fallen behind on her bills during a stretch of hard times.
"I obviously don't have money to hire an attorney," she says of the paperwork the process server handed to her. She had been downsized a few years earlier and, thanks to the pandemic, her roommate was no longer working.
She recalls that when she told the server she was "a little scared because this just didn't seem like it was terribly professional," he thanked her for meeting him so late in the day, as he had driven a long way and still had a back seat full of papers to serve on behalf of the same client.
"Then I knew," she says, "that Mayo was suing a whole bunch of people."
Court filings tallied by Forum News Service show she was indeed part of a small flurry of such lawsuits undertaken by Mayo Clinic during the early months of the pandemic.
Public records show Mayo filed 55 such lawsuits that summer, part of 179 legal collections in total between March of 2020 and March of 2021.
Google searches of addresses served show homes that sometimes were comfortable but were often rural and mostly humble, including aging starter homes, modest pre-war structures in small town main streets, small farm houses and at least one trailer park.
The machinery of this legal activity ground on during some of the hardest months of the pandemic, with 23 cases filed each in October, November and December.
A Rochester resident was served two days before Thanksgiving.
A central Minnesota couple was served three days before Christmas.
That family owed $15,000, but the claims fell primarily in a range between $1,000 and $4,000, sums that might have seemed collectible in the eyes of a creditor, if not necessarily by those being served.
Research suggests these sub-$5,000 filings reflect a new norm -- one in which even insured patients with good jobs now enter a routine medical need responsible for deductibles capable of capsizing household finances for months, with out-of-pocket charges that now average $2,300 for individual Minnesotans, $3,700 for families.
For its part, Mayo says it initiates only a small number of legal collection actions given the volume of patients it serves. It says it gives out tens of millions in charity care annually, offered and continues to offer pandemic-specific assistance, and that court papers are filed only after repeat attempts at debtor engagement have failed.
The health system adds that filing a suit does not stop its efforts at trying to resolve unpaid accounts through assistance or payment plans, and that since May 1 of last year, it has yet to collect on any judgments against patients.
And when compared to the court activity of other large providers in the state, Mayo’s use of the courts to chase debtors can be described as modest -- and not interested in the smallest bills. With one exception, the state's largest health providers all posted more lawsuits for the period reviewed.
But the sharp optics of suing patients during a pandemic has only turned a spotlight on issues that have always accompanied the calculation by providers to pursue unpaid bills with the full weight of the law.
In wielding the blunt instruments of the court to collect modest sums from people requiring care, nonprofit hospitals are dunning what are generally unplanned expenses, absorbed without knowledge of prices, funnelled through the complex cost shifting protocols of payers.
It's a practice that falls within especially uneasy territory for the image long-cultivated by Mayo, a standard-bearer in healthcare for its patient-first philosophy and stated dedication to the personal touch at every turn.
For hospitals, suing patients increases leverage
Before they become patient lawsuits, medical bills usually go through collections. Last year, collection agencies held an unprecedented $140 billion in unpaid medical bills within the U.S., almost a doubling of the $81 billion recorded in 2016.
Medical charges are now the largest portion of debt held in collections today, according to "Medical Debt in the U.S., 2009-2020," research recently published in the Journal of the American Medical Association.
That analysis found roughly 18% of Americans were in collections last summer for medical services, debts averaging $2,400, and a crisis widely seen as tied to deductibles.
"Medical debt," as an accompanying editorial explained, "is incurred due to rising health care prices and increased cost sharing ... leading to high out of pocket costs for individual patients."
A recent study by the Commonwealth Fund estimated that one-third of insured adults struggled to pay medical debt last year, with 35% having "used up all or most of their savings," and 23% having delayed education or career plans.
- RELATED: Report: Mayo Clinic sued over 900 patients between 2018 and mid-2020 for unpaid medical bills
"It's within their rights," says Rochester bankruptcy attorney Karl Kruger of hospitals venturing beyond collections to enlist the courts. "If you're owed money, you have a right to collect the money for the services that you were providing."
Kruger says suing out bills effectively extends the clock during which a creditor can recover funds. While most bills turned over to collections are good for six years, a judgment is good for a decade.
Medical bills, however, are part of every bankruptcy he sees.
"I've been practicing bankruptcy for 15 years," Kruger says. "In Rochester especially, everybody has debt with Mayo. … I think every case I have down here in Rochester, they owe either Olmsted (Medical Center) or Mayo money."
In taking a balance into the courts, health care providers will tell you they hope a date with the system might trigger an unresponsive debtor to engage with them – long enough to agree to a repayment plan, financial assistance or even charity care.
Court records show this often happens. Hospitals frequently move to withdraw cases after filing suit, with the court issuing a ruling that the case has been dismissed without prejudice.
Over a third of the cases filed against patients by Mayo during the early months of the pandemic were subsequently settled and withdrawn via this process.
But records also show many if not most patients being sued will skip their hearings, inducing an automatic court judgment.
In those cases, a provider's rationale for suing has been pared down to just two: placing an extra four years of obligation onto persons who already needed six, or reserving the option to take funds owed by force.
Judgments have teeth, after all, allowing creditors to garnish up to 25% of take-home wages, and to freeze bank assets as well.
Given their ability to induce stress and presumably stress-related illness, both rationales for suing seem detrimental to the wellbeing of the patients being sued, making their use that much more notable for organizations dedicated to health.
"Medical debt and associated financial hardship," as the JAMA editorial noted, "are likely to be associated with substantial adverse health effects."
It cast medical debt as a "social determinant of health," citing its ability to cause delayed care and poor mental health, prolonging cycles of poverty and contributing to household instability.
As such, suing patients is a right not every hospital will exercise. A recent report by researchers at Johns Hopkins found that just 25% of the nation's largest hospitals sue patients.
Mayo has questioned the report that produced that finding, citing its lack of publication in a peer-reviewed journal at this time. But not all large providers in Minnesota appear to use the courts.
A Forum News Service review of court records during the pandemic found no legal cases against patients linked to Twin Cities-based HealthPartners under its corporate name.
According to spokesman James Bellamy, just "a handful" of cases were referred for legal action in Minnesota during the time period in question, "out of about 1 million patients in our care."
Bellamy said that "legal action is only taken with a very small subset of patients who likely can pay or have unique circumstances," citing a motor vehicle accident or workers’ compensation cases.
The company says it absorbs remaining unpaid balances "as the cost of care delivered to patients who are willing, but unable, to pay for the care."
Mayo pause in suing was shorter than thought
Although Mayo recently stated it had suspended all new lawsuits from March of 2020 until the end of June, public records and a clinic spokesperson confirm the provider's Edina-based legal firm restarted the activity in the days approaching Memorial Day. "On March 16, 2020, Mayo Clinic directed its outside law firm not to begin any new collection actions," explains Mayo Clinic spokesperson Jay Furst.
"Some complaints that were sent prior to that date were served and were filed as required by the Attorney General's Agreement. A small number of new collection actions were sent beginning in late May, though they were not filed until June. In nearly all new cases, Mayo Clinic reached out through its law firm to offer COVID-specific financial assistance since March and April of 2020."
Records show that Mayo lawyers put their signatures to a dozen new Summons & Complaint filings in late May of last year, then signed another dozen lawsuits the following month. Mayo patients were served these papers throughout June, 30 days in which 30 lawsuits were filed by the provider, and its law firm's busiest month for the healthcare giant during the pandemic.
"Mayo Clinic has taken many additional steps to work with and assist patients who face financial difficulties due to the COVID-19 pandemic," Furst said in a statement. "Mayo Clinic treats more than 1.3 million patients per year and in 2020 we provided $89 million in charity care for patients in need," adding that "collection action is a last resort used in rare situations only after other measures to assist patients have failed."
"Mayo Clinic has extensive financial assistance programs in place for patients who do not have the ability to pay for care," the statement offered. "We work with patients to create reasonable and extended payment plans when needed, and we often provide financial assistance if a patient is unable to pay their bill. "
Of 46 lawsuits identified by Forum News Service as either initiated, served or filed between March and June of last year, he concluded, "17 were resolved by patient payment or with full or partial financial assistance from Mayo Clinic." Of the rest: "Mayo Clinic has taken no action to execute court judgments received after May 1, 2020," Furst stated, "and continues to work with these patients, offering financial assistance and extended payment plans when needed."
"Mayo Clinic has taken many additional steps to work with and assist patients who face financial difficulties due to the COVID-19 pandemic. Mayo Clinic treats more than 1.3 million patients per year and in 2020 we provided $89 million in charity care for patients in need."
- Jay Furst in a Mayo Clinic statement
Until July 1 of this year, the clinic's decision to take "no action to execute court judgments received after May 1, 2020," was largely involuntary.
As a requirement of Minnesota Emergency Executive Order 20-50 signed by Gov. Tim Walz in May of 2020, "provisions in Minnesota Statutes … which permit service of a garnishment summons" were suspended.
The same order suspended provisions permitting creditors to obtain information about a debtor’s assets, liabilities, and personal earnings. That protection was lifted in January, permitting creditors to seek out job and banking information, but Mayo says it has not undertaken that activity.
All the above protections were given an expiration date, however, as of May 6 of this year, when Walz's executive order 20-21 assigned July 1 for the unshackling of creditors who have waited over a year to seek garnishments.
Though Mayo is not executing judgments at this time, as a result of this post-pandemic development, hundreds if not thousands of lawsuits imposed on behalf of Minnesota providers can be utilized for payroll interruption and bank levies, events likely to drive households into hard choices.
The hospital-on-patient lawsuits now clogging state courts appear to suggest a disconnect unacknowledged by providers between the predictable need of patients to seek out care and the less-predictable likelihood of their disparate users initiating aid that is available.
Financial assistance plans and opportunities for charity care regularly touted by providers are either generally required or endorsed by the terms of the Affordable Care Act, a special Attorney General's Agreement unique to Minnesota, and an industry guide to Best Practices for Resolution of Medical Accounts.
'We live paycheck to paycheck'
"It wasn't too bad," says Roger Baker, a factory worker living in Zumbrota who was served papers in May for roughly $2,700 he owed Mayo due to an emergency room visit.
Baker says he agreed to let Mayo draw a weekly sum from his bank account, and that his bill is now settled. That said, he too had a problem with getting served.
"My husband wasn't working, it was the start of COVID, we were in a pandemic, and I was getting sued. I called up my mom bawling."
- Mayo debtor
"I don't feel they should be suing patients," he says.
Others aren't as nonchalant.
"I was devastated," says a Mayo debtor and young mother who asked not to be identified.
"My husband wasn't working, it was the start of COVID, we were in a pandemic, and I was getting sued," she says. "I called up my mom bawling."
The young mother takes little consolation in the hospital's decision to suspend its execution of court judgments.
"If you're not going to follow through, then don't waste my time," she says. "I was an emotional wreck."
"We live paycheck to paycheck," she adds. "We literally have $100 in our account for groceries every two weeks, plus we have to get gas. I have no bills besides my house and Mayo Clinic."
An added complexity to these stories is that Mayo is willing, Rochester bankruptcy attorney Karl Kruger says, to forgive bills far more often than those being sued may realize.
"I have had quite a few clients who were being collected upon either by the collection companies Mayo uses, or its law firm," he says. "They applied for financial assistance from Mayo, and Mayo's been fairly forgiving. ... I've seen clients with medical bills in the tens of thousands of dollars forgiven by the clinic."
"They are not just going to willingly do that," he adds. "You have to apply for the assistance. You have to go to the business office, and the information is there on the website, and they will review it. They will get back to you, in my experience, usually within a month."
If so, debt relief is a process that was either unknown, a bridge too far, or not applicable for at least 179 Minnesotans who received papers from Mayo during the pandemic in 2020.
Asked whether Mayo offered her financial help, the voice of the young mother trails off in exasperation and fatigue.
"They said I could go in and do the paperwork all there," she replies.
Asked about her deductible, she returns with her own noteworthy question.
"What's a deductible?"