Virginia hospitals and medical providers filed more than 1.15 million lawsuits between 2010 and 2024, seeking to collect $1.4 billion in medical debt from patients, a report co-authored by a GW Law professor found.
Professor of Business Law Barak Richman, three Stanford University researchers and two from the nonprofit organization Patient Rights Advocate analyzed Virginia court records and found medical debt collection cases generated more than 800,000 judgments in favor of providers and more than 403,000 garnishment filings, or the court-ordered seizure of wages or assets, with lower-income communities facing a disproportionate share of the collection actions. Researchers said hospitals and health care providers sued many patients for medical debts tied to hidden prices and bills they could not easily verify, sometimes without clear upfront cost information when receiving their service.
The report found that medical debt collection and garnishment actions disproportionately affected patients in lower-income, higher-poverty communities because they’re less prepared to shoulder those costs when they come up unexpectedly. Patients in the lowest income bracket had the most cases against them at 30.4 percent of the total number of lawsuits, according to the report.
Richman said that pattern may reflect what he described as a broader correlation between health and wealth, with lower-income patients accruing more medical debt as they are often more likely to need care and less able to afford medical bills.
“What surprised me most is just how punitive these measures are,” Richman said. “This is what people call the cycle of poverty. If you owe money or get sick, you get trapped in this vortex.”
A 2024 KFF analysis found that nearly 20 million people, or one in 12 adults, owed medical debt in 2024, with approximately 14 million owing over $1,000. The analysis also found that those in lower income brackets were more likely to have medical debt, with 11 percent of low-income adults having medical debt as compared to 8 percent of all adults, and 22 percent of low-income adults with poor health having medical debt.
The report found that many medical debt cases went uncontested, with 72.5 percent of cases larger than $25,000 ending in default judgments where the defendant does not contest the case made against them. Richman said patients may not contest their cases because they are balancing work and childcare, struggling to understand their bills or lacking adequate notice, and many low-income defendants cannot afford legal help.
The results indicate that medical debt is not a result of irresponsible overspending by patients but of healthcare providers and hospitals not being upfront about the cost of their services, according to the report. The findings state that at Sentara Health, a nonprofit health care system listed in the report, identical procedures can vary in cost by as much as 77 times.
Richman said lawyers representing hospitals have various mechanisms to collect debt, and the severity of each mechanism depends on the state. He said the report builds on his ongoing research into how hospitals use courts to collect medical debt, work he began at Duke University and has continued at GW in collaboration with Stanford and Patient Rights Advocate.
“People are having to choose between going to the hospital and staying home and dying,” one patient in the report said. “Because at least my family won’t be burdened with a lawsuit if I die at home.”
The report states nonprofit medical providers were responsible for 52.7 percent of lawsuits against patients. Sentara Health, which has 12 hospitals in Virginia and North Carolina, was the most litigious hospital system by its average share of hospital beds in Virginia, with 96,900 cases for 16 percent of the bed share.
The report found that 20 law firms — many of them small firms with fewer than 10 attorneys — were responsible for more than half of Virginia’s medical debt collection lawsuits from 2010 to 2024. It identified the Richmond, Virginia-based Parrish & Lebar as the top filer, saying the firm initiated 98,844 debt cases and 27,680 garnishment orders over that period, or more than 18 actions per day.
Arnold Milstein said the researchers hope the findings push hospitals and health systems to reform collection practices they may see as inconsistent with their mission or reputation, and raise awareness among state and federal policymakers so they can strengthen protections against those practices in Virginia.
“The purpose of science is to generate evidence that advances either human or planetary benefit,” Milstein said.
The researchers analyzed Virginia state court databases for all 50 states to understand the experiences of patients and identify the main actors in the medical debt collection. Milstein said Virginia’s court database was more detailed than the datasets the team used in North Carolina and Colorado because it let researchers see whether patients showed up for hearings and whether their wages and bank accounts were later garnished.
“That was uniquely granular about the data and therefore useful in understanding the whole chain of agony that was being visited upon disproportionately lower-income people,” Milstein said.
Milstein said structural barriers exist that make patients less likely to win their cases, like how they would need specialized legal help to scrutinize hospital billing policies, negotiated insurance rates and required cost disclosures. He said most patients cannot afford that kind of attorney or the time away from work to fight a case in court.
Julia Havlak, the manager of research and communications of Patients Rights Advocate, said patients usually don’t get an itemized bill, making it difficult to determine whether the charges were fair. She said many patients are afraid to go to hospital as they fear getting sued.
“One woman even reported that she was too scared to go back to the hospital after getting sued,” Havlak said. “That is when they told her she might have stomach cancer, and because she had no idea what a scan would cost, she just took out life insurance.”
Representatives for hospital systems and law firms named in the report pushed back on the findings, saying the study did not fully reflect their billing practices or noting they have changed their collection policies in recent years.
Michael Kafka, the director of corporate communications and public relations at Sentara Health, said the report has failed to accurately reflect Sentara’s billing practices. Kafka said Sentara Health does not charge interest on payment plans, garnish wages, seizing savings, use collection agencies or foreclose on property.
Sentara Health’s financial assistance policy states the hospital may place unpaid patient bills in their collections department or an outside collection agency if they are not paid by the patient within 120 days. It also states that the hospital may file a lawsuit or dock liens on a patient’s property.
Eric Swensen, the public information officer at UVA Health, which is named in the report, said UVA Health developed new billing policies and practices from 2019 to 2021, which provide “significantly larger” discounts for low-income and uninsured patients and release liens and judgements for patients at or below 400 percent of the federal poverty level. He said they have not filed any lawsuits against patients since 2019.
George Parrish and Robert Lebar declined to comment on the report.
