After Blake Pfeifer, a veteran plumber in Colorado Springs, Colorado, underwent emergency stomach surgery at a nearby nonprofit hospital in 2022, he struggled to understand the bills flooding in for his weeklong stay. The initial charge for the procedure at the University of Colorado Health Memorial Hospital Central was $104,000, his records show. Because Pfeifer had no insurance and would be paying out of pocket, he was quoted a discounted price of $58,124. He said he called the hospital to get clarity on the bills but got nowhere. He began paying some of them and was pursued by a collection agency on others. Then he sought the help of a patient advocacy group. "I've always paid my bills," Pfeifer, 63, said. "I wanted a little better explanation." The group he worked with,Patient Rights Advocate.org, found that some of his charges were far higher than the amounts UCHealth reported under a federal price transparencyrulethat went into effect in 2021. And that wasn't the only notable finding: Only 25% of Pfeifer's charges showed up on the hospital's required price list and therefore could not be compared at all. Pfeifer's experience is not uncommon, according to patient advocates, public interest lawyers and Medicare data. The burden of medical debt, a problem faced by 100 million Americans, has pushed many to delay medical care and even file for bankruptcy, research shows. Making these obligations even more ruinous, patient advocates say, is that many may be based on inaccurate health care bills. These discrepancies occur even as hospitals must list prices for care on their websites. The price transparency rule,initiated by the Centers for Medicare and Medicaid Services, requires facilities to "establish, update, and make public a list of all standard charges for all items and services." Implemented under the first Trump administration, it aims to help consumers shop for care and compare prices before they go to the hospital. Now, four years after the rule went into effect, hospital billing seems "intentionally complex," said Cynthia Fisher, founder ofPatient Rights Advocate.org. "Hospitals and insurance companies alike have even hired many middle-player firms to be able to maximize their margins and profits at every single patient encounter," she added. "Sometimes what we're finding is the charges like Blake's that are billed are far beyond even the highest rate that they have within their hospital pricing file." It adds up to an increasingly costly health care experience for Americans. A West Health-Gallupsurveypublished April 2 found that 35% of respondents said they could not access high-quality, affordable health care — a new high since 2021. UCHealth is a nonprofit hospital system with 14 hospitals in Colorado, southern Wyoming and western Nebraska. In its financial filings, UCHealth says its discount program for self-pay patients like Pfeifer "reduces uninsured patients' liabilities to a level more equivalent of insured patients." Some of Pfeifer's records conflict with this description. Pfeifer received 10 common blood tests, known as a metabolic panel, and was billed $104 for each. By comparison, UCHealth's public price data shows it charged insured patients between $6.52 and $52.89 for each test in 2022. In another case, Pfeifer was charged $99 for a blood culture to measure bacteria, the records show, while UCHealth's pricing data listed a range of charges for insured patients of between $8 and $61. For a phosphate level blood test, Pfeifer was billed $30, while insured patients at UCHealth were charged between $3.72 and $22.02. Under Coloradolaw, violations of hospital price transparency requirements are a deceptive trade practice. Dan Weaver, a UCHealth spokesman, said in a statement that the health system "does everything possible to share prices and estimates with our patients, encourage insurance coverage, assist patients in applying for Medicaid and other programs that may offer coverage." Regarding Pfeifer's case, Weaver said he could not comment because the hospital had received notice from a lawyer representing Pfeifer that he may file a claim against it. He said the hospital disputes what is in the lawyer's notice, but he declined to specify what exactly it disputes. Weaver pointed to thestate of Colorado's 2024 report stating that UCHealth hospitals "are fully compliant with transparency requirements." For 2022, when Pfeifer received care at UCHealth, the document showed the hospital providing his care received a "fair" transparency rating by the state, above "poor" but below "good." Weaver added that CMS, which determines hospital compliance with transparency requirements, "has not cited UCHealth or our hospitals for noncompliance." Enforcement actions are exceedingly rare. CMS' website listsmonetary penaltiesagainst only 27 hospitals in the four years since the requirements began. (There are 6,000 hospitals nationwide, according to theAmerican Hospital Association.) A December 2024reportfrom the Department of Health and Human Services Office of Inspector General found that nearly 40% of the 100 hospitals it studied were not complying with the price transparency requirements. Coloradolawallows patients to sue a hospital bringing a debt collection proceeding against them when they believe the facilities have violated price transparency requirements. Steve Woodrow, a Democratic member of the Colorado House of Representatives and a lawyer at the firm Edelson in Denver, represents Pfeifer. "What happened to Mr. Pfeifer unfortunately repeats itself and plays out across the country thousands of times every year," Woodrow told NBC News in an interview. "We now have a situation where people are afraid to get medical care because of the financial ramifications." Last November, the Justice Departmentallegedthat UCHealth had overbilled Medicare and TRICARE, the health insurer for U.S. service members and their families. Between November 2017 and March 31, 2021, the government alleged, providers at UCHealth hospitals submitted inflated Medicare and TRICARE claims for "frequent monitoring of vital signs" among patients in the emergency department. UCHealth agreed to pay $23 million to settle the allegations without an admission of liability. Weaver, the UCHealth spokesperson, said the hospital system settled to prevent a lengthy and costly legal dispute. "UCHealth firmly denies these allegations," he added, "and maintains that its billing practices align with the guidelines set forth by the American College of Emergency Physicians." While UCHealth is a nonprofit, it has generated rising revenues and earnings recently. Net patient revenues at UCHealth, itssecuritiesfilings show, totaled $8 billion in fiscal 2024, 17% higher than the previous year. Operating income was $523 million, an increase of 58% over 2023. UCHealth's charges for care are higher than most other nonprofits', Medicaredatashows. In fiscal 2022, the most recent figures available, UCHealth charged patients 6.6 times the hospital system's costs for care. That is far higher than the 4 times, on average, that U.S. nonprofit health systems charged for care that year, according to Ge Bai, a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. Weaver, of UCHealth, said the hospital system's charges are competitive with others. "Last year alone, UCHealth provided $1.3 billion in total community benefits including about $570 million in uncompensated care," his statement said. It's problem enough for patients who are overcharged or billed incorrectly for health care. But when hospitals sue to receive payment for those bills, such lawsuits often result in default judgments, legal experts say, issued to patients who don't appear in court or respond. Default judgments can have dire consequences, including wage garnishments. UCHealth has sued thousands of patients using third parties or debt collection middlemen in recent years, a practice that is examined in new research by academics at theGeorge Washington University Law School, Stanford University'sCenter for Clinical Researchand Fisher's group. The study, "Hospitals Suing Patients:The Rise of Stealth Intermediaries," found UCHealth and one debt collection firm brought 12,722 lawsuits against patients from 2019 to 2023. Legal records analyzed by the authors suggested "many of the collection efforts were based on unsubstantiated and inaccurate billing records." The use of legal middlemen is a national trend and allows hospitals to hide their involvement, avoiding the bad publicity these lawsuits can bring, the research contends. Last year, Colorado lawmakers enactedlegislationbarring hospitals from suing patients under debt collectors' names, after aninvestigationinto the practice by 9News, an NBC affiliate, and The Colorado Sun. Barak Richmanis the Alexander Hamilton professor of business law at George Washington Law School and a co-author of the study. "What this research shows is people are being pulled into court where a power imbalance takes advantage of them," he said. "There needs to be a lot of deliberative thought into what to do about courts as it relates to medical debt." In a statement about the study, UCHealth's Weaver said those suits make up a "tiny fraction of our patient care — in fact, more than 99.93% of all patient accounts are resolved without a lawsuit." He added: "This study, based on older data, does not reflect the changes put in place in recent years to minimize billing errors, ensure patients are aware of our financial assistance options, and are well informed of their medical bills." Damon Carson, a small-business owner in Longmont, Colorado, was sued by a collection company after he received an outpatient endoscopy at a UCHealth hospital in his town. The suit came while he was disputing the hospital's charges as excessive. A self-pay patient along with his wife, Traci, Carson tried to be a savvy shopper before he went in for the procedure in 2021. He asked for price estimates from several providers, and the nearby UCHealth facility provided one totaling $1,448, according to a court document. Carson paid upfront. "I had the procedure and everything was fine," Carson told NBC News. "Then the bills started rolling in." Additional charges of $4,742 drove the total cost for the procedure to around $6,200, a court document shows. Carson said that when he questioned the bills, noting the far lower original estimate, the hospital told him the add-on costs reflected the removal of growths found inside him during surgery. A UCHealth spokesman said the original estimate for Carson's care was accurate and that he was told there might be additional charges and signed an acknowledgement of that, which the hospital provided to NBC News. (Carson says he recalls no discussion of the potential for additional charges.) When Carson refused to pay, he was sued by Collection Center Inc., a debt collection firm that has often filed lawsuits against patients on behalf of the hospital, the academic study shows. In 2023, Carson and the collection firm conducted a mediation, according to court documents. Carson wound up paying only one-third of the additional charges to settle the case. "I was surprised they caved that fast," Carson told NBC News. "Traci and I could easily have paid the $4,000 and our lives gone on. But this was a principle thing." Fisher, the patient advocate, said the outcome of Carson's case is revealing. "No one should ever pay that first bill," she said. "The onus of proof needs to be on the hospital and the insurance company to prove that they have not overcharged us."
