Cinthya Arenas’ mind started racing after she opened her mail last month. 

Just under the “In the District Court of Kay County” header, there was her name in all caps followed by the words “petition for money due on account.”

As she continued reading, the 24-year-old Ponca City resident began to suffer something she could only describe as “a panic attack” when it became clear what was happening: AllianceHealth Ponca City was suing her for $3,483.25 — plus $217 in interest — for treatment at the hospital in April 2019. 

Arenas said she was sent to the hospital’s emergency room after being referred there by her urgent care provider when she was having trouble breathing and was concerned about an unusual growth on her uvula. 

Arenas lacked insurance at the time and was under the impression that she was taking care of the bill through a payment plan. She would later find out that arrangement was for a separate bill she was charged during the visit. 

The timing could not be worse for Arenas, who works at a Lowe’s in northern Ponca City. 

“Because of the COVID pandemic and working retail, my mental health has deteriorated,” she said. “My anxiety is at an all-time high, and being sued is the last thing I needed.”

Arenas’ experience isn’t unusual in Oklahoma. 

A first-of-its-kind review of court records by Oklahoma Watch revealed last year that an average of 520 Oklahomans were sued by a hospital over unpaid medical bills each month from Jan. 1, 2016 to July 31, 2019.

Hospitals’ use of the legal system to compel patients to pay their unpaid bills, which has resulted in many low-income workers seeing their wages or bank accounts garnished, has drawn criticism from patient advocates and health officials as the practice has increased across the nation

And now, as the country faces unprecedented dual economic and health crises due to the COVID-19 pandemic, many of these lawsuits are continuing in Oklahoma. 

A new review of court records by Oklahoma Watch shows that although some hospitals in the state have suspended or pulled back on filing lawsuits against their former patients, others are continuing with business as usual. 

Who Is Filing the Lawsuits

Since July 1, 2019, Oklahoma Watch identified 5,841 lawsuits filed by Oklahoma hospitals against patients in an effort to collect unpaid medical bills. 

The lawsuits were being filed at a fairly constant clip until they largely paused when a rise in COVID-19 cases caused Oklahoma officials to temporarily shut down the courts near the start of April. 

But weeks later, many of the lawsuits resumed. 

At least 1,178 lawsuits were filed since Gov. Kevin Stitt declared a statewide health emergency on April 2 in response to the state’s COVID-19 spread, which has now killed 496 and infected at least 37,000 Oklahomans. 

In the bulk of those cases, the hospitals have demanded the collection of anywhere from a few hundred dollars to more than $10,000. The vast majority of the bills, even those filed in recent weeks, stem from hospital visits that occurred in 2019 or earlier. 

The majority of post-April 2 lawsuits identified by Oklahoma Watch came from five hospital systems: AllianceHealth’s seven Oklahoma hospitals (841 lawsuits), Saint Francis Health System (158 lawsuits), Integris (80 lawsuits), and Hillcrest Health Care System (48) Norman Regional Health System (47).

Representatives of these hospitals and others that frequently sue patients argue that they use the courts as a measure of last resort and often offer uncompensated care for those who can’t afford it. 

But Caitlin Donovan, spokeswoman for the National Patient Advocate Foundation, a Washington D.C.-based group that lobbies for patients’ rights and access to affordable health care, said she was dismayed to learn that the COVID-19 crisis hasn’t caused some of Oklahoma’s hospitals to rethink their practices. 

“It surprised me to see that hospitals are willing to contribute to a global health crisis because that’s what they are doing,” she said. “It tells me that they’re putting profits before patients.”

COVID Prompts Some Changes, As Others Resume Lawsuits

AllianceHealth, which has more than 500 staffed beds spread out across its hospitals in Clinton, Durant, Madill, Midwest City, Ponca City, Seminole and Woodward, has been one of the state’s most litigious hospital systems both before and after the pandemic occurred. 

Its hospitals filed at least 2,540  lawsuits since July 1, 2019, amounting to 44% of all lawsuits identified in Oklahoma Watch’s review of the court records during this time. 

Except for a brief pause during much of April, including the time when courts across the state were shut down due to the virus, the hospital system hasn’t seen much of an interruption in taking legal action. 

The seven AllianceHealth hospitals have filed nearly 800 lawsuits since April 2. 

AllianceHealth Oklahoma spokeswoman Emily Kezbers said bank garnishments across the hospitals have been suspended during the pandemic, regardless of when they received the care. But she said wage garnishments, which are much more common, will continue as before. 

Kezbers added the hospital provides “robust” financial assistance and they do not pursue collection suits against “anyone without the means to pay” their bills. 

“Legal action is always the last resort, and it is only considered after evaluating a patient’s ability to pay,” she said. “Unfortunately, sometimes legal action is the only avenue through which patients will engage in a conversation about the amount they owe for healthcare services that already have been provided.”

Of the hospitals with a large number of lawsuits identified by Oklahoma Watch, only one reported a major reversal in its billing policies because of the COVID pandemic. 

“I thought it was wrong that they didn’t see if I wanted to get on a payment plan or something. But I guess they just took it in their own hands and decided to sue.”

Billy Nosler, Woodward

Saint Francis Health System, a Catholic nonprofit group with eight hospitals, including Tulsa’s 1,112-bed Saint Francis Hospital, has been one of the state’s most litigious health groups over the past few years. 

The hospital has filed more than 6,200 lawsuits against Oklahomans since the start of 2016. This includes more than 150 lawsuits that were filed since late May. 

In a move that was not previously announced to the press until Oklahoma Watch questioned the hospital, the health system said it is ceasing litigation “until further notice” and is working with its debt-collection firm to rollback any cases filed after March 15. 

“Once it was clear that COVID-19 was going to have significant and long-term economic impacts, we started working on a plan to suspend seeking legal intervention to debt resolution,” said Lauren Landwerlin, who heads corporate communication for the health system.

SSM Health, which includes Oklahoma City’s 600-bed Saint Anthony Hospital and is one of the state’s other major health systems, also announced in response to Oklahoma Watch’s questions that it also is “wholly” suspending lawsuits during the COVID-19 crisis. 

But hospital spokesman Patrick Kampert said the practice is “rare” to begin with. Oklahoma Watch also did not identify a significant number of lawsuits from the health system.

Norman Regional Medical Center and its affiliated hospitals, meanwhile only “paused” its litigation process, said hospital spokeswoman Melissa Herron. The hospital and the debt collection firm it works with stopped filing lawsuits in early April, but it resumed filing them again in June. 

Herron said the hospital is continuing its policy of trying to work with patients and using the courts as a “last resort.” 

She said unpaid bills for patients who don’t respond to any of the hospital’s attempts to contact are sent to a collection agency after about four months. Litigation is used only after the debt collectors also fail to contact the patient or work out an agreement on a payment plan.

“We make every effort to work with patients to find a successful solution,” Herron said. 

She added patients can file a claim for a wage garnishment exemption or set up a payment plan even after litigation has started. 

Integris, another of the state’s major health systems, did not respond for comment on whether its billing practices have changed. 

But Integris spokeswoman Brooke Cayot told Oklahoma Watch last year that the hospital system doesn’t track the number of lawsuits because they are filed through outside collection attorneys.

AllianceHealth, which includes a hospital in Woodward, accounts for 44% of all hospital lawsuits filed against former patiences identified in Oklahoma Watch’s review of court records since July 1, 2019. (

Impact of the Lawsuits

Jermiah Duddleston, an Oklahoma City chef, was on furlough when he found out this May that he was being sued for thousands of dollars by AllianceHealth Midwest. 

In 2019, he was treated at the hospital. After what he said was a five-hour stay where he got two bags of saline and chest X-rays, he was left with thousands in out-of-pocket expenses.

Duddleston said he received a call from the hospital and a letter from a collection agency but put off paying after feeling that his bill was “inflated.”

Since being sued, he has requested an itemized bill to further investigate the charges, but he says it wasn’t much help since “it is not a transparent process” and the descriptions left him with more questions.

Duddleston said he will continue to fight the lawsuit, but he concedes the hospital “most likely will win.”

If he loses, Duddleston isn’t sure what he’ll do. 

“I will likely have my wages garnished in a market where it is almost impossible for me to find a job,” he said. “With the second wave of corona coming, I will have to choose between the health of my fiancé and (nine-year-old son) Gavin and my ability to provide for our needs. It’s scary.”

Woodward resident Billy Nosler is also hoping to fight a lawsuit he received in mid May. 

Nosler, who doesn’t have insurance, was sued over nearly $4,000 in unpaid bills stemming from a series of visits to AllianceHealth Woodward Hospital in 2019. 

Nosler said he expected to receive more communication from the hospital or its debt collector before legal action was taken. 

“I thought it was wrong that they didn’t see if I wanted to get on a payment plan or something,” he said. “But I guess they just took it in their own hands and decided to sue.”

Nosler said he is looking into hiring a lawyer or seeing if there is legal assistance that can help him navigate the complicated legal and medical systems. But although he is unsure if he can afford one. 

“Especially during COVID, it’s been hard with all these bills,” he said. 

Saint Francis Health System, a Catholic nonprofit group with eight hospitals, including Tulsa’s 1,112-bed Saint Francis Hospital, has been one of the state’s most litigious health groups over the past few years.  The health system recently said it is ceasing litigation “until further notice” and is working with its debt-collection firm to rollback any cases filed after March 15. (Courtesy Stephen Pingry/Tulsa World)

Debate Over Who Should Bear the Costs

These billing practices highlight a heated debate in the medical community across the country.  When do hospitals have a financial responsibility to aggressively pursue debt collections? When  should they be more willing to write  off unpaid bills for low-income patients who struggle just to get by?

Hospital officials say they offer millions of dollars in charity or unpaid care for those who meet certain income standards.

The latest federal reports, from 2014, show that hospitals statewide spent an average of 2.7% of net patient revenue on charity care and had 6.5% in total uncompensated care. The Oklahoma Hospital Association, meanwhile, reports that hospitals in the state provide more than $500 million annually in uncompensated. 

Cynthia Fisher, founder and chairman of the Massachusetts-based Patient Rights Advocate Inc. nonprofit group, said although those efforts are commendable, hospitals should not be suing during a time when there is so little transparency when it comes to medical prices. 

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Because of the prevalence of surprise medical bills — something that disproportionately has hit Oklahomans hard — and the inability for most to compare prices, she said it’s unfair to compare someone not paying a medically necessary hospital bill they weren’t able to negotiate upfront with someone not paying their mortgage, credit card payments or other bills.

“You have to look at the cause for all of this and it’s the opaque of this entire system,” she said. “And that is capitalizing on the misfortune of all Americans and their healthcare.”

Fisher said her worries about the hospitals’ billing practices have only increased during the COVID-19 crisis. 

Even before the pandemic, she said she’s heard plenty of stories of patients refusing to go to the hospital largely because of fears they will be forced to pay bills they can’t afford. And now, she said those fears could prevent COVID-19 patients from getting the critical care they need. 

Following his lawsuit, Duddleston, the Oklahoma City chef, said he is now among those who will think twice now before heading to a hospital. 

“After all of this I’m not going to be pretty cavalier about when I see a doctor,” he said. “It seems like the safety net has failed us.”

Trevor Brown has been an Oklahoma Watch reporter since 2016. He covers politics, elections, health policies and government accountability issues. Call or text him at (630) 301-0589. Email him at tbrown@oklahomawatch.org. Follow him on Twitter at @tbrownokc

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Trevor Brown

Trevor Brown has been an Oklahoma Watch reporter since 2016. He covers politics, elections, health policies and government accountability issues. Call or text him at (630) 301-0589 or email at tbrown@oklahomawatch.org....