A few months after Waynesboro, Virginia, resident Kanise Marshall delivered a baby boy on New Year’s Day 2023, the hospital bills rolled in.
Marshall’s insurance paid Martha Jefferson Hospital more than $24,000, and she set up a payment plan for the remaining balance.
She thought she paid the full amount billed by the Charlottesville, Virginia, hospital until a process server showed up to her home in November 2025 – nearly three years later. Martha Jefferson Hospital, owned by Sentara Health, was suing Marshall for $2,366 in unpaid bills she said she didn’t know existed.
The nonprofit Sentara Health initiated more than 96,000 lawsuits in Virginia from 2010 through 2024, routinely suing patients who’ve struggled to pay their medical bills, according to a report by researchers from Stanford University, George Washington University and Patient Rights Advocate, a nonprofit that pushes for price transparency in health care.
While Sentara filed the most lawsuits of any Virginia hospital or medical provider to collect medical debt over the 15-year period, the Virginia-based chain was by no means alone. Virginia hospitals, doctors and medical providers brought 1.15 million lawsuits to collect $1.4 billion in medical debt from consumers.
Hospital billing experts say aggressive medical debt collection tactics can soon turn to financial ruin for families.
The Virginia medical-debt lawsuits were in addition to more than 403,000 filings to take portions of patients wages or bank accounts through garnishments and more than 5,500 filings to either place liens on homes or extend court-ordered judgments up to 20 years, according to PRA.
Cynthia Fisher, founder of Patient Rights Advocate, said the report shows most people who are sued have insurance but aren’t fully protected from medical billing. Insurance plans often have cost-sharing requirements and red tape such as prior authorizations that can delay or deny coverage.
“It’s an unfortunate and unfair trend against the American worker who tries to do everything right − to pay to get access to their care,” Fisher said.
For Marshall, the episode has been harrowing and maddening.
“It’s extremely frustrating,” Marshall said. “They took their sweet time to send the bill, but they don’t want to give me the courtesy of more time to get it paid or providing an explanation.”
Sentara spokesman Mike Kafka said the chain was not contacted by Patient Rights Advocate researchers and did not see or contribute to the report. However, he said Sentara, the largest health system in Virginia with 11 hospitals and one hospital in North Carolina, is “recognized nationally for our commitment to compassionate and responsible billing practices.”
“Our goal is to support patients during difficult times – not add financial strain,” Kafka said. “This approach reflects our mission to serve communities with compassion and integrity in every aspect of care.”
‘This Is the Affordability Crisis’
While Congress has battled over the expiration of the Affordable Care Act’s enhanced subsidies that made health insurance more affordable for millions of Americans, elected officials have focused much less attention on the 100 million Americans who carry medical debt.
Patient Rights Advocate researchers said the problem is exacerbated by the combination of expensive and often undisclosed prices charged by hospitals and other medical providers.
Even patients with health insurance often face big medical bills. Insurance plans often require people pay copays, coinsurance and deductibles, the amount a consumer must pay before most coverage kicks in. The average deductible for a person with insurance through the workplace was $1,886 in 2025, according to KFF’s employer health benefits survey.
When people can’t afford to pay off balances their insurance plans don’t cover, the PRA report shows how hospitals and medical providers frequently pursued medical debt lawsuits. Costs for consumers can quickly inflate beyond the delinquent medical bills hospitals or providers seek to collect, said Barak Richman, a professor of business law at George Washington University Law School and a co-author of the PRA report.
“They get ensnared into a legal system that charges them court fees, charges them interest and makes them afraid of ever going to the hospital again,” Richman said. “This is the affordability crisis. The affordability crisis is I get unwittingly ensnared into this state-sponsored extraction system I can’t get out of.”
These Hospitals Pledged to Halt Patient Lawsuits
Several hospital chains have been scrutinized for their billing practices and willingness to sue patients for uncollected debt.
While Sentara filed the most medical-debt lawsuits in Virginia over the 15 years, other hospitals followed closely. VCU Health ranked second in the state with 92,700 lawsuits over the 15-year period, followed by Inova Health, UVA Health, and Mary Washington Healthcare.
Three of those hospital systems in Virginia − VCU Health, UVA Health and Mary Washington Healthcare – previously pledged to stop suing patients or erase liens on homes following news reports about the debt-collection lawsuits.
The PRA report said UVA Health and Mary Washington have appeared to halt patient lawsuits since 2020, but said VCU Health has filed some suits since then. The report offered one caveat: Researchers said they did not know whether any hospitals or other providers used “stealth intermediaries” to sue on their behalf. This describes use of third parties such as debt collectors to sue patients without naming the hospital or medical practice as a plaintiff.
Although PRA’s report focused on Virginia hospitals and medical practices, medical-debt lawsuits are a nationwide phenomenon, the authors said
“What we’re seeing in Virginia is happening throughout the country,” Richman said.
Nonprofit Hospitals Sue Most Often
Nonprofit hospitals pursued the most medical-debt lawsuits and wage and bank account garnishments in Virginia.
Nonprofit hospitals and hospital-owned medical practices filed more than 802,000 lawsuits or garnishments in Virginia courts over the 15-year period, the report said.
Nonprofit hospitals get a tax break that is worth billions, but they must meet community benefit standards in exchange for this favorable tax status.
Under IRS rules, nonprofit hospitals must publicly post their financial assistance policies and spell out which patients are eligible for assistance, discounts or charity care that wipes out balances.
The IRS does not tell hospitals how generous their charity care policies need to be, but they must follow those policies for eligible patients, said Erin Fuse Brown, professor of health services, policy and practice at Brown University School of Public Health.
“They shouldn’t be billing patients who are eligible for financial assistance or seeking collection actions,” said Fuse Brown.
Fuse Brown noted some patients might not be aware of the charity care standards or be invited to apply for free or reduced-cost medical care.
PRA said patients sued for medical debt were more likely to live in lower-income communities with higher rates of poverty.
Sentara’s Kafka said the hospital chain doesn’t garnish wages, seize savings or foreclose on properties. He also said patients who have less than $50,000 in assets and earn less than 300% of federal poverty level − $46,950 for an individual − are eligible for free care.
Likewise, the Virginia Hospital & Healthcare Association defended hospital’s record on providing charity care and limiting aggressive debt collection.
“Virginia hospitals have a well-documented record of making significant investments in expanding access to care and providing free and discounted care to low-income individuals across the commonwealth,” said Julian Walker, a hospital association spokesman.
Arnold Milstein, a Stanford professor of medicine and a co-author of PRA’s report, said the research team’s analysis identified companies who were under court order to garnish wages of workers to collect debt. The report said workers in retail, manufacturing, grocery stores, gas stations and food service were more likely to have their wages garnished. Among employers, Walmart had the most wage garnishments of its workers in Virginia, the report said.
Milstein said such garnishments are an indicator of how well employers’ health insurance plans protect workers from medical debt. An employee with robust health insurance might be better protected. But an insurance plan with a high deductible or other cost sharing could leave workers vulnerable to big medical bills. The report described employers as the “final boundary of the medical debt ecosystem.”
Researchers also took aim at Virginia hospitals record on properly disclosing all prices to patients under federal price transparency laws. Even consumers with negotiated discounts from health insurance plans often were clueless to what their final charges would be.
“This is not a problem of the uninsured,” Richman said. “Even if you have insurance, you’re not told how much you’re going to pay.”
‘Predatory Pricing on Average American Citizens’
Charlottesville resident Latricia Giles is among the thousands of Virginia residents who’ve been sued by Sentara.
“A nonprofit suing a member of the community is crazy when you really think about it,” Giles said. “They’re there to help people.”
Giles said she developed gastroparesis from a prescription medication she took to manage her diabetes. The condition interferes with digestion and triggers bouts of nausea and vomiting that require frequent hospital visits.
Giles was billed nearly $68,000 for multiple visits to Martha Jefferson Hospital from January to March 2023. Her insurance plan discounted the bill and paid nearly $26,000, but the hospital sought more money from Giles. She made some payments, but in 2024, the hospital sued Giles for an unpaid balance of more than $10,200.
Virginia hospitals and medical providers filed medical-debt lawsuits for unpaid bills ranging from less than $250 to more than $10,000.
Small amounts were most common. The hospitals and medical providers filed more than 253,000 cases attempting to collect $250 or less. The hospitals also went after patients such as Giles who had larger bills. Nearly 20,000 lawsuits sought $10,000 or more.
With legal assistance arranged by Patient Rights Advocate, Giles contested her bills and found inconsistencies. In a counterclaim, Giles attorney said Martha Jefferson overcharged her.
Giles said “being sued changes the way I think about care,” she said.
“There are some nights I’ve been in this house vomiting – for hours and days,” Giles said. “I don’t want to go to the hospital … I can’t afford to go to this doctor. I can’t afford to keep putting my family through this.”
She’s been back to Martha Jefferson Hospital since the lawsuit. And she knows she might face future financial repercussions.
“Call it what it is – predatory pricing on everyday, average American citizens,” Giles said.
Debt After Birth
While Giles fended off her case in court, Marshall still faces a legal battle over medical debt. She is scheduled to appear June 17 in Albemarle General District Court in Charlottesville.
After Marshall’s son was born, doctors transferred the newborn to a specialty nursery within the hospital. During birth, he had swallowed meconium – a mix of amniotic and other fluids – and needed his lungs cleaned. He spent nine days in what the hospital described as a level three specialty care unit before he could go home.
Marshall also had her own health scare during and after the cesarean birth. She had hemorrhaged during the C-section, transferred to postpartum and was released.
But she still didn’t feel well.
During a return trip to the hospital to see her son in the hospital’s specialty care unit, she was out of breath and struggled to walk from the parking garage and up a flight of stairs. A nurse noticed and guided her to the hospital’s emergency room where she was diagnosed and treated for heart failure.
Marshall doesn’t challenge the quality of care she received while hospitalized. She chose the hospital because she has such a good experience with her daughter.
But she is angered by the nonprofit hospital’s billing practices and pricing.
“I’m more than happy to pay my bills if they’re assessed fairly and I’m given transparency,” Marshall said.
Have you had a medical billing issue you’ve been unable to resolve? Reach consumer health reporter Ken Alltucker at [email protected].
This article originally appeared on USA TODAY: Hospitals in this state routinely sue patients over unpaid bills
Reporting by Ken Alltucker, USA TODAY / USA TODAY
USA TODAY Network via Reuters Connect
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