Free or discounted medical care: DollarFor and hospital bill relief

Jared Walker is the founder of DollarFor, which helps people apply for charity care in hospital bills – free or discounted care people may be eligible for, based on income and household size. The charity care policies of hospitals are based on Internal Revenue Service regulations for supplying “community benefit,” which is required to maintain nonprofit status under Section 501(r) of Schedule H of their tax return. Walker’s organization has reduced or dismissed thousands of health care bills. We talked about his work on Zoom; this conversation has been lightly edited for length and clarity.

Jeanne Pinder

What is DollarFor?

Jared Walker

We are a nonprofit organization. We help people eliminate medical debt. We do that mainly by enforcing the hospitals’ charity care policies. We’ve eliminated over $26 million in medical debt for people throughout the country by implementing this best-kept secret of the Affordable Care Act, charity care.

Exactly what is charity care?

Charity care is a federal law that went into place with the Affordable Care Act. This law requires nonprofit hospitals — about 65% of hospitals in America are nonprofit — in order for them to keep their nonprofit status, they have to provide community benefit. And the main way that they do that is by providing charity care, which is free or reduced-price care to people within a certain income range.

If you meet the income requirements, hospitals are legally required to write off your medical bills. Unfortunately, hospitals don’t do a great job telling people about these things. So we have millions and millions of people that are declaring bankruptcy or on payment plans for bills that they actually don’t have to pay.

From crowdfunding to charity care

How did you get started doing this?

I originally started in Portland, Ore., crowdfunding to help people pay medical bills. I would do these small, grassroots events, and fundraising. Every month, we would pull the money together and pay medical bills for people in our community.

I did that for several years. And then I met an attorney, who’s now our general counsel, Eli Rushbanks, and he told me what charity care was, and he thought that we could utilize it in our work. I thought it was too good to be true, and tested it out and found out that it worked. In a few months, we got over a million dollars in the medical debt to be written off.

And I thought, oh, my gosh, I’m a chump. I’ve been paying all these medical bills for people that would have qualified for these programs. So we switched the model. And here we are.

Did you have a personal experience with the healthcare system that brought you into contact with this topic?

Yeah. In 2012, my wife and I were sitting at home. She got a phone call, and her aunt passed away from cancer. And then a couple minutes later, I got a phone call. My cousin had gone into labor, seven weeks premature, and the baby needed heart surgery to live. On the same day, our families were hit with these medical emergencies.

One of the big topics and things that people were asking was, “How much is this going to cost? How are we going to pay for it?” and I was really frustrated that that was the conversation that people were having. I thought we’re not the only people that got bad news today. And I realized how many people this impacts — there’s almost $200 billion in outstanding medical debt. By some estimates, 100 million Americans have outstanding medical bills that they can’t pay. So there’s no lack of need. And that’s kind of what got me into it.

Charity care or financial assistance

I want to go into a little bit on how charity care works with DollarFor from the hospital perspective. But first, from the individual perspective, how does it work? If I’m a person wanting to know or use it, how does it work for me?

First, you would go to the hospital’s website — if you’re if you’re going to do this without using DollarFor’s services. You would try to see if your hospital has a charity care policy. You would search your hospital name plus charity care or financial assistance, so let’s say, “Legacy Health, financial assistance,” and then you would find their policy, dig through two dozen pages and see if you meet the income requirements.

Then you would download their application, complete it, and then probably mail or fax it in to the hospital. Unfortunately, it’s not very accessible. So you would submit the application — usually they want to know who you are, who you live with, where do you work, how much money do you make, and then they would like to see proof of income, so bank statements, pay stubs, tax returns.

You send all that into the hospital, and then you wait, and if you don’t hear back in a few weeks, you call and bother them and you don’t hear back after that. You do it again. There’s a lot of back and forth, a lot of hoops to jump through. Sometimes hospitals want to see more information, you send in more information. And you just kind of keep going until you get that letter from the hospital that says hey, you’ve been approved for financial assistance.

Can I do this before I go into the hospital for an operation or is it usually after I have a bill?

I would say 98% of people are doing this after they receive the bill. You can do it before, if you know that you have a surgery coming up or something like that, and you want to see if you’re eligible, you can fill it out beforehand and get approved.

You can think of financial assistance and charity care as like a status — when you’re approved, you’re usually approved for a certain timeframe, maybe it’s three months, six months, and any medically necessary treatment that happens within that time would be approved for charity care, assuming you’re eligible. And then if you have treatment afterwards, you’d have to reapply.

Hard to find, and hard to apply

This sounds fairly easy when you describe it. But as I understand it, the system goes wrong in lots of different ways — it’s hard to find the information, the application gets lost. Can you tell us a little bit about that?

This has been a federal law for over 10 years. And it requires nonprofits to have their policies listed on their website.

I challenge people all the time: go to your hospital’s website, go to the homepage, try to find the policy. It’s usually hidden in the in the policy or in the in the website. And that’s if you know about it. Most people don’t even know that this option exists.

Hospitals are supposed to make a good effort to make this information known. And a lot of times what that means is they put a poster in their emergency room – which, I don’t know if you’ve been to the E.R. lately, but you usually aren’t reading the posters on the wall. Or you’ll get the fine print on the back of the bill. So that’s kind of how they make it known.

Then if you do find out about it, you have to find the policy, you have to see if eligible, and then you have to find the application and apply. And like I said, most hospitals require you to fax or mail your applications, and applications get lost all the time.

You have to send in this packet of sometimes 30, 40, 50 pages of documents, and, proof of income and all that, and then you have to hope that they treat you fairly — because at the end of the day, the hospitals are calling all the shots.

If they deny you for some reason, you have to appeal it. These cases on a really, really good day can take two weeks, three weeks, and other times we’ve had cases take eight months, where you’re fighting and advocating and calling and waiting on hold.

It’s a pretty big burden — and imagine you are going through chemo or recovering from a surgery or you have some type of medical crisis. This is the last thing that you have bandwidth for.

After months, bill was sent to collection

Could you tell us some specific patient stories? Without, of course, revealing anybody’s identity.

I had a case at Ascension Health in Austin, Texas. Somebody was driving under the influence, reckless driving, and hit him on the sidewalk. He was hit by a car and had a huge medical bill, like $76,000. He was definitely within the income guidelines, plus he missed several months of work.

**DollarFor examples of patient experiences as described by people who used DollarFor. Source: DollarFor.**

We applied, and the hospital said, “Well, this is under review, because it’s a big bill. Call back in a month.” We called back and they said “We’re gonna review this.”

That happened eight different times — eight months of calling in, “Oh, yeah, we’re gonna review this, we’re gonna review this.” Meanwhile, they sent him to collections. During this time, you’re supposed to freeze the bill, and not do all of these collection practices, but of most of the time, the financial assistance and charity care department and the billing department are not communicating.

So you get people that are, eligible for charity care, who are applying for charity care, being told to wait. And then in the meantime, they’re being sent to collections. At the end of the day, the medical bills were waived, but it shouldn’t be that hard.

‘The hospital let us wait and wait’

I’d listen to another story like that.

We had a patient out of Arizona at Banner Health. Her husband passed away from Covid. Single mom, couple of kids and not a big income, and she got a $450,000 bill from this hospital. English was her second language, we were trying to get through to the hospital saying, “Hey, this is absurd — not only is a person experiencing extreme loss, but this medical bill is like, out of this world large.”

It was the same kind of thing. We submitted all the paperwork, we jumped through all the hoops, and the hospital just let us wait and wait and wait. And again, they sent her to collections. We had to continue calling. I did like five or six three-way calls with the patient and the hospital and waited on hold for hours. Finally, the medical bill was waived.

I tell people all the time, not everybody has an advocate. And if you don’t — that person could lose their house, and so on. There are so many things that can happen from a debt like that. I mean, that’s a life-changing amount.

There are times where hospitals ask on their application for two months of pay stubs and bank statements and the tax return, and then you’ll send all that in, and then they’ll come back and they’ll say, “Oh, well, we want to see this and this and this, too.” It wasn’t even on their application. But you jumped through the hoops. I think that it’s difficult on purpose.

‘Difficult on purpose’

So you do think it’s intentional?

I think that, yeah. I try to sometimes sugarcoat it. I think that hospitals always complain about the administrative burden of trying to vet people — who is eligible, who’s not. We have an eligibility screener that can tell someone if they’re eligible immediately.

I think that there’s a lot of outs for hospitals. Hospitals can say, “Oh, well, we send paper applications in the mail, or we have posters in our E.R. We’re doing all we can.”

But these are the most inefficient ways to get this information out there to patients. It’s fairly easy to make this information known. So I just don’t buy it when they say that they’re doing all that they can. Obviously there are hospitals that do this well, and there are hospitals that do this very poorly. On average, I would say it’s difficult on purpose.

Can you name hospitals that are doing a good job of this?

Yeah, O.H.S.U. out of Portland, Oregon. They are a hospital that if you look at their Schedule H in their 990 tax filings, they’re giving away an absurd amount of charity care.

They use something called “presumptive eligibility,” where if a patient is on SNAP benefits, or any other public service benefits, that would be an obvious indicator that they’re eligible for charity care. In that case, they won’t even ask for an application, they’ll just write the bills off.

DollarFor Applications for hospital free or discount care: Amount of bills submitted, number denied or approved, and dollars approved. Others are still in follow-up or being processed. Source: DollarFor.

I think a lot of hospitals could implement something like that — a presumptive eligibility tool, and not even pester people with the application. O.H.S.U. is doing a phenomenal job with that.

When I first started doing this, it was like 2019. We got a lot of applications from O.H.S.U. But then they implemented their new tool, for presumptive eligibility, and we might get one or two a year now from them.

It’s a completely different story for patients who go to hospitals that do this poorly. I mean, there’s an endless list. I think I mentioned Ascension – Ascension is not great. Then there’s a handful of Mayo Clinics. That is a very large hospital system. We probably get more applications from these hospitals anyway, because they’re in large populations. There’s M.D. Anderson, which is the cancer clinic. They have some absurd rules in their policy.

There are some things that hospitals do to make this extra difficult. One would be a minimum bill amount. So some hospitals say you don’t get charity care unless your medical bill is over $2,500, which is absurd. Actually we would say it’s outside of the law: 501(r) does not say that you can do that. It says if you are within the income range, you should be eligible, it doesn’t matter what the bill is. A lot of hospitals that throw that in there, and they just keep on doing it, because nobody’s stopping them.

About 50% of hospitals will require you to not have any type of insurance to get charity care. So they’ll ask you, if you have any type of commercial insurance, through your employer, whatever, you are not eligible for charity care at all, even if you have a $12,000 deductible. Again, I would say it’s a stretch outside of 501(r).

Then the last one would be residency. Some hospitals will even draw a line of like, you have to be in these zip codes, or live in this county, to get charity care at this hospital. So if you’re traveling — I live in the Pacific Northwest, I’m in San Francisco right now, if I had an emergency, and I had to go to a San Francisco hospital, I should be able to get charity care, regardless of me living somewhere else.

I understand hospitals saying that if it’s elective care, if I prefer to doctor in Boston over a doctor in Portland, Ore., and I traveled there, maybe they did not cover, and I think that’s fair. But if I if I had some type of an emergency, that should be exempt.

So yeah, we have a shit list for sure. We have a list of hospitals that that we have our eye on. And it’s a long list, unfortunately.

Particularly problematic states

Are there some particularly problematic states for medical debt? I mean, is there state regulation that, in some cases might override federal regulation, or states that just tend to be tougher on this than others?

Yeah. I would say states like Oregon, Washington, Colorado, they have great state laws that are better than the federal law. So they’ve added things in, like, you have to give patients more than 240 days to apply. The federal law would only require a hospital to give people 240 days to apply, but in Oregon, Washington, Colorado, that’s extended.

**State map of hotspots for charity care applications received by DollarFor, measured in number of applications over the last two years. Source: DollarFor.**

States that are particularly bad: The big three would be Texas, Florida, Georgia — states that have not expanded Medicaid. That’s a big indicator. There’s just no state law protecting people, so hospitals are basing their policies off the federal law, which is very vague. And that’s when you get these people throwing in extra requirements.

Another example. There was a New York Times article recently about a hospital that was denying care if you had outstanding medical debt. There’s not a whole lot of oversight with stuff like this. And hospitals have been able to just throw stuff in there because nobody’s checking them on it. We are trying to step in and do that at some level.

‘We need to add some teeth to those rules’

Do you have any choice words for legislators, regulators, people who should be minding the store on this?

It’s frustrating because there are actually laws in place that they’re supposed to follow. And if they were doing that, it would be better. But a lot of them just aren’t. Like filing a Schedule H in the 990 — hospitals should be filing a Schedule H, which is a bunch of questions about their charity care policies, like how much charity care are you giving? And how much bad debt do you have? How much do you think was eligible for charity care?

More often than not, we cannot find the Schedule H for these hospitals. It’s either not completed, or they leave all the numbers zero or blank. The I.R.S. is the entity that should be enforcing these things. And I think that more hospitals should have pressure — even just the fact that they could lose their nonprofit status. That should be a real a real thing that could happen, but it hasn’t happened.

There are rules in place, and they have not been followed. So we need to add some teeth to those rules.

Who pays for your work? You said you have donations — can you tell us from whom?

We’re completely funded through philanthropy, which is a tough gig. We are fundraising.

We have a lot of individual small donors that might sign up for $5 or $10. That’s super helpful.

We have foundations, I think it’s it’s available on their websites, like Dovetail Foundation, the Woodnext Foundation, we have support from EJF Philanthropies — so there’s a handful of foundations that give us grants.

Then we have some larger donors that believe in the work we do. We’ve gotten support from Reid Hoffman, from a handful of people that will give larger-scale gifts.

I think there’s a potential revenue model with organizations, in that the service that we provide to patients is valuable. We will never charge patients for the work we do. All of our services are completely free. But if we can provide relief to, let’s say, a credit union that has a whole bunch of members that have medical debt, our service could be a great benefit to that community, and the credit union should pay us for it. So that’s kind of like things that we’d like to test out as revenue models. But right now it is all through philanthropy.

Advice for those with burdensome bills

What do you want people to take away from this conversation?

First, if you have a medical bill, if this is a burden for you, it’s a struggle. Take a deep breath. You have time. There’s support out there.

A lot of people get very, very overwhelmed. And sometimes they’ll just throw the bills away, or put it on a credit card. Most of the time, you have more time than you think. And there are more options.

So keep that in mind and find people that are helping — obviously, DollarFor is a resource. People can go to our website, DollarFor.org. We can immediately tell you if you’re eligible, and we have patient advocates ready to help fill out the paperwork, and advocate on your behalf.

There is no lack of need. Everyone knows someone that has had a medical crisis or medical bill, or has given to a GoFundMe to help people with their medical expenses.

Our hope is that we can make charity care known, easy and fair. Right now, nobody knows about it. Even if you do know about it, it’s very difficult to find.

And then at the end of the day, the hospitals call the shots, and we’re trying to keep them accountable. So that’s our hope. And yeah, I would say get loud about it. And help spread the word.

‘Don’t assume this is not for you’

Great. What have I not asked?

People can go to DollarFor.org/help. If people want to see if they’re eligible, they can see here.

One of the biggest myths and misconceptions that we get are, “This isn’t for me. I probably don’t qualify — this is for like very, very, very poor people.”

A lot of people think, “I didn’t qualify for Medicaid or food stamps, so I’m not going to qualify for this.” I would encourage people to ask. The hospital charity care policies are usually much more generous than those programs. There’s no harm in in seeing if you’re eligible. So don’t assume that this is not for you.