Bull’s experience is hardly unique. Hospitals owned by Community Health Systems, Inc., one of America’s largest hospital chains, have filed at least 19,000 lawsuits against their patients over allegedly unpaid medical bills since March 2020, even as other hospitals around the country have moved to curtail similar lawsuits during the coronavirus pandemic, a CNN investigation found.

CNN’s review of court filings across 16 states the company operates in found that most of the patients sued by CHS — like Bull — didn’t hire a lawyer or fight the lawsuits, and judges often ruled in the company’s favor by default. In some states, defendants’ debts piled on with attorney’s fees and interest. Elsewhere, the hospital chain’s subsidiaries quickly moved to garnish defendants’ paychecks after a judgment.

Advocates say those hardball collection tactics can leave low-income patients in financial ruin — especially considering the lawsuits were filed in the middle of the Covid-fueled economic collapse.

“I can’t think of a worse thing a hospital system can be doing than suing patients for medical bills during a pandemic and a recession,” said Caitlin Donovan, the spokeswoman for the National Patient Advocate Foundation, a patients’ rights group.

In a statement to CNN, CHS said its hospitals only sue a “small fraction” of the patients they treat every year, and that they work to provide assistance for those who can’t afford their bills.

“Legal action is always the last resort,” the company said. CHS hospitals only file lawsuits, it said, “after it is determined the patient appears to have some ability to pay based on credit record and employment status or if the patient has been non-responsive” following repeated attempts to discuss their bill.

The company said its hospitals do not “initiate litigation against any patient we know lost his or her job because of the pandemic,” and that under a new policy it adopted earlier this year, it would withdraw lawsuits against anyone making less than 200% of the federal poverty level — $25,760 for an individual. But many patients failed to fill out a form outlining their finances that could make them eligible for those reprieves or other aid, it said.

Patients being sued and lawyers who work on the cases say that the company’s rhetoric doesn’t always hold up. CNN interviewed more than a dozen people sued by CHS hospitals. Most said they had tried to communicate with the company’s lawyers, collections agents or the hospitals directly and found them unresponsive or unwilling to agree to a settlement they could afford.

Dr. Marty Makary, a Johns Hopkins University professor who has studied hospital lawsuits around the country, said CHS was far more litigious than most hospital groups, and that the company’s financial aid policy didn’t go nearly far enough.

“It’s like Marie Antoinette saying, ‘if somebody came to me begging for food, I would give them cake,'” Makary said. “It’s completely blind to the relentless, aggressive, predatory nature of debt collection on the ground.”

A huge caseload

The company’s practice of suing patients isn’t a new development: Many of its hospitals have brought large numbers of patients to court for years. The total number of lawsuits filed dipped in the spring of 2020, as many courthouses shut down in the early days of the pandemic, but then picked up again in the summer and fall. While the lawsuits were filed during the pandemic, they are typically over years-old medical bills.

To identify cases, CNN searched court records for lawsuits brought by a list of about 100 CHS subsidiaries, including those operating the company’s 84 current hospitals and others that ran more than a dozen facilities that CHS sold or closed during 2020 and early 2021.

CNN found about 24,000 lawsuits filed by the company’s hospitals, including more than 19,000 filed on or after March 13, 2020, when the federal government declared a national emergency over Covid-19. The review only included cases in which the hospitals sued individual people, as opposed to insurance companies. In states where information about cases was available online, CNN limited its review to lawsuits marked as related to debt, collections or monetary claims.

The company’s six Alabama hospitals filed at least 4,900 lawsuits during all of 2020 and the first four months of 2021, but the state’s court case search system does not make it possible to identify how many were filed after the pandemic gripped the U.S. or how many were debt-related.

The other top states CHS hospitals filed lawsuits in were Florida, Indiana, Missouri, Mississippi and Texas. Nationwide, roughly three-fourths of the company’s hospitals have filed at least a dozen lawsuits against patients since March 2020.

CNN was able to obtain court records from most but not all counties where CHS operates a hospital, so the findings are likely an undercount.

CHS is hardly the only hospital group that has sued patients, but experts say its aggressive legal strategy stands out. Makary, the Johns Hopkins professor, said his research had found “a pattern across the U.S.” that CHS hospitals are among the most litigious.

Spokespeople for three other of the largest national hospital chains — HCA Healthcare, LifePoint Health and CommonSpirit Health — said their hospitals do not sue patients over unpaid bills. Trinity Health, another large chain, suspended collections activity in March 2020 due to the pandemic and has “significantly limited any pursuit of legal action involving past due accounts,” a spokesperson said, although she declined to provide more details.

CHS said that its hospitals don’t sell medical debt to third-party companies that then file lawsuits against patients, while some other hospitals do — a decision it said “skews any attempt to compare” its legal practices to other hospital groups.

‘Doing my best not to drown’

Most of the patients being sued by CHS who spoke to CNN said that they couldn’t afford to pay what the hospital was asking for. And letters to courts in cases around the country also raise questions about the company’s claims that it only tries to collect from patients who can afford to pay.

After being sued by Lake Granbury Medical Center, a CHS hospital outside of Fort Worth, Texas, Richard Piper wrote to a judge in August asking for relief from the $34,894 in medical debt the hospital was demanding.

“I am [writing] this response to inform you of my inability to [pay] this outstanding medical debt,” wrote Piper, who works at a salvage yard. “I only bring home a check of 525 dollars a week and have [been] helping two daughters with my grandkids… my prayer to you is please relieve some of this debt and help out the average person.”

Instead, the judge entered a default judgment against him, ordering him to pay the full amount as well as nearly $3,500 in attorney’s fees for the hospital’s lawyers — bills from a 2018 hospital stay. Piper said in an interview that his bill came after the hospital kept him longer than he had wanted, and that he was supporting his daughter’s family after she lost her job as a teacher due to Covid-19.

“I don’t think it’s fair,” Piper said. “I can’t afford $35,000 — I don’t even make that in a year.”

In another letter to an Oklahoma court in October, a former patient being sued by CHS hospital AllianceHealth Clinton wrote that her partner had been laid off because of pandemic shutdowns, she was working part-time at a job that offered no health insurance, and she was struggling to pay each month’s rent.

“I am currently doing my best not to drown,” the woman wrote. “I do not have anything left to give. If you take my check from me, I would have no place to live.”

The hospital continued with the lawsuit. Two months after she wrote the letter, the court entered a judgment against her — ordering her to pay the hospital her $781 debt and nearly doubling it by tacking on $400 in attorney’s fees and $304 in court costs.

CHS said it could not comment on specific cases due to privacy regulations but that after reviewing the accounts of several patients who spoke to CNN, it is “satisfied that our hospitals followed their regular processes.”

Many defendants were either uninsured or owed large co-pays or deductibles. Jennifer Alegria, a chef and manager at a cafe in North Carolina, didn’t have health insurance when she found a lump in her breast several years ago. She was diagnosed with breast cancer and received a double mastectomy at the CHS-owned Lake Norman Regional Medical Center in Mooresville — and then a sheriff’s deputy showed up on her doorstep last June to serve her with a $146,000 lawsuit from the hospital.

Alegria relied on funds from a GoFundMe fundraiser started by her daughter to settle the case, agreeing to pay about $20,000, she said — still a huge sum for a single mother of three making less than $40,000 a year. She said she also fell behind on medical bills from other health providers during her cancer “nightmare,” but the CHS hospital was by the far the most aggressive in trying to collect, and the only one to sue her.

“It felt like extortion,” Alegria said. “I was scared, and I just scrambled and tried to get some money together to pay it off.”

Once a court rules against a defendant, the hospital can move to put a lien on property they own, such as a house, or garnish part of their wages, depending on regulations that vary from state to state. In Missouri, for example, CHS’s three hospitals moved to garnish defendants’ wages in more than half of the pandemic-era cases that resulted in a judgment. Many garnishments were for people working at relatively low-wage employers — the most common was Walmart.

In its annual report, CHS acknowledged — in legal speak — that the pandemic is taking a toll on patients’ ability to pay their hospital bills. “We have observed deterioration in the collectability of patient accounts receivable for uninsured patients in comparison to pre-pandemic levels as the result of adverse economic conditions arising from the COVID-19 pandemic,” the company wrote.

Christi Walsh, another Johns Hopkins researcher who has studied hospital lawsuits, said that it was typical for hospitals that sue patients to only make a tiny fraction of their revenue from those lawsuits.

“It’s not keeping the lights on for the hospitals — they don’t need to be doing this,” Walsh said. “But for the patients, some of them go bankrupt, some of them have money taken directly out of their paychecks … They’re choosing between medical care and food.”

In its statement to CNN, CHS defended its collections practices. In 2020, the company’s hospitals provided patients about $1 billion worth of “charity care,” which is not paid for, it said. Every patient is “given the option” to complete an application for financial assistance that could entitle them to free or discounted care — but many patients don’t fill out the form, the company said.

“The challenge often is that patients do not respond to the hospital’s attempts to talk to them about their bills, so we do not know what impact, if any, the pandemic has had on a patients’ ability to pay for medical care,” CHS said. It urged defendants in lawsuits who have lost income during the pandemic or fallen below the poverty threshold to contact its collections office.

“Sometimes, legal action is the only path through which patients will engage in a conversation about the amount they owe for healthcare services that have already been received,” it added.

But Daniel Moore, a lawyer in Poplar Bluff, Missouri, who has defended dozens of low-income defendants sued by the CHS-owned Poplar Bluff Medical Center, laughed out loud when a reporter read him the company’s claim that it doesn’t try to collect from people who can’t afford to pay.

“That’s total horseshit,” Moore declared. “Most of the people being sued are exactly those people… it just rains economic havoc down on them.”

No legal defense

In most states, the lawsuits by the healthcare giant are a well-oiled machine. Local lawyers file claims for bills, including an affidavit from a hospital custodian of records. In many cases, the defendants never respond to the complaint or hire a lawyer, and CHS files for a default judgment against the defendant, which they are typically granted. Other cases see the hospital dismiss the lawsuit in exchange for defendants agreeing to a payment plan.

On a Monday morning last month in Okaloosa County, a rural swath of the Florida panhandle, a judge held status conferences for 26 collections lawsuits brought by a CHS hospital, North Okaloosa Medical Center, in a hearing conducted over Zoom. Four of the defendants called in, smartphone videos showing them sitting in their cars or living rooms, and listened as Judge Jim Ward patiently explained what a judgment would mean: the potential for garnished wages, a lien on their property, and debts collecting interest. A lawyer for the hospital told them how much they owed.

“I’m real behind on a lot of things,” Christine McCullough, one of the defendants, told Ward. According to the hospital, she owed $1,642 for an X-ray she received after a car accident. She told CNN in a later interview that that was the portion her insurance hadn’t covered — and as a hairstylist, she had seen her income drop during the pandemic, making her unable to afford the charge.

Two defendants ended up agreeing to payment plans with the hospital, preventing a judgment from being filed against them unless they missed a bill. McCullough and another defendant had trial dates set. The rest of the cases were postponed, giving the hospital an opportunity to file for default judgment, or dismissed because the hospital had been unable to find the defendants to serve them with the lawsuit.

None of the more than two dozen defendants whose cases were being heard that day had a lawyer. But around the country, some of the handful of defendants who hire lawyers found that they won their cases fairly easily.

After Lake Norman Regional Medical Center sued Marianne Jurgens and her husband Robert for a $2,943 bill from Robert’s 2018 stay at the Mooresville, North Carolina, hospital, a court entered a default judgment against the couple. Jurgens said she told the hospital’s lawyers that the charges should have been covered by Medicare, but that they wouldn’t agree to drop the case. So she hired a lawyer who filed a motion to overturn the default.

Several months later, the hospital admitted it had made a mistake. “After conducting an investigation into Defendant’s claims, Plaintiff believes there was an error in coding at the time of the procedure such that the Defendant should not be liable” for the payment, a lawyer for the hospital wrote in a filing in November, asking the court to throw the case out.

L. Ragan Dudley, the lawyer who represented the Jurgens, said he wondered whether the hospital would have discovered other billing errors in the dozens of other lawsuits it filed last year if more of the patients being sued had lawyers.

But in the U.S. defendants only have a right to legal representation in criminal cases, not civil lawsuits. Some of the other former patients sued by Lake Norman said they had no way to afford a lawyer.

In September, the hospital sued Jeffery Turgeon for $20,784, costs that his fiancée Jennifer Matheson said stemmed from a four-day stay in 2019 as he suffered from stomach pain. Instead of a legal motion questioning the charges, Turgeon sent the court a handwritten letter on a sheet of notebook paper asking the hospital to settle the case.

In February, Turgeon ended up agreeing to a judgment for the entire bill, plus $180 in court costs. The couple asked the hospital to let them pay $50 a month, but Matheson said they were told the minimum payment was $100 a month.

Matheson says she lost her hospice care job due to the pandemic, and that the couple is barely able to make ends meet with the new expense. “Even something as simple as taking our kids to eat at McDonald’s, we can’t do that anymore,” she said.

At the rate they’re paying now, it would take the couple 17 years to pay off the court judgment — and that doesn’t include the annual 8% interest that will continue to accrue.

By the time the debt is repaid, “he’s going to be old,” Matheson said of her fiancé. “It feels like it’s never going to go away.”

The hospital closed, but the lawsuits continued

The company’s lawsuits against patients spiked after it sold: It sued more than 400 patients in October, by far the highest number of lawsuits it had filed in any month since at least January 2017. Overall, Bayfront was among the most litigious hospital companies in the CHS network, filing more than 800 debt-related lawsuits since mid-March 2020.

Orlando Health, the new owner, said in a statement that it has not sued any Bayfront patients over unpaid bills. But the flow of lawsuits from the CHS subsidiary — which still describes itself in court documents as “doing business as Bayfront Health St. Petersburg” — has continued, with new lawsuits filed as recently as last week.

Other CHS subsidiaries in Florida, New Mexico, Pennsylvania, Tennessee and Texas also continued to sue former patients after the hospitals they ran were sold to other companies over the last year. The new owners of eight of those hospitals told CNN that CHS had held onto the billing rights for past cases under the terms of their sales.

One CHS hospital closed completely last year. Shands Lake Shore Regional Medical Center, which has served the small northern Florida community of Lake City since 1911, shut its doors as the number of patients declined over the years — and as the pandemic put a financial strain on many small and rural hospitals.

The only part of the hospital that seems to have continued operating: its collections operation. The CHS subsidiary has sued 86 patients since mid-March 2020, including more than a dozen after the hospital ceased operations on August 31.

Some of the defendants in cases brought by hospitals sold off by CHS told CNN that they hadn’t realized they were being sued by a company that no longer operated the hospital that treated them.

Rashad Huntley, a maintenance worker and father of four young children in St. Petersburg, was sued by the CHS subsidiary that ran Bayfront hospital last month for $777.50 plus court costs — the amount his insurance didn’t cover after he received a half dozen stitches to a cut on his hand, Huntley said.

Huntley said he and his wife make less than $71,000 a year and have four kids, which would appear to qualify them for CHS’ policy not to sue patients whose incomes are less than two times the poverty rate. But no one from the hospital had mentioned the policy to him until CNN told him about it last week, he said.

“They don’t try to work it out or anything, they just demand the money,” Huntley, 30, said of the collections workers who had called him. “We’ve got car payments and rent and daycare fees, and still got to pay the lights and water.”

“I understand it’s a business,” he added, “but I wish, during this time, they’d be more understanding.”