AHA, which representsnearly 5,000, mostly nonprofit hospitals and medical systems, hasissued few guidelines on such aggressive practices or the limitedfinancial assistance policies that often trigger them.

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The AmericanHospital Association, the biggest hospital trade group, says itpromotes "best practices" among medical systems to treat patientsmore effectively and improve community health.But thepowerful association has stayed largely silent about hospitalssuing thousands of patients for overdue bills, seizing homes orwages and even forcing families into bankruptcy.

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Atlantic Health System, whose CEO is the AHA's chairman, BrianGragnolati, has sued patients for unpaid bills thousands of timesthis year, court records show, including a family struggling to paybills for three children with cystic fibrosis.

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AHA, which represents nearly 5,000, mostly nonprofit hospitalsand medical systems, has issued few guidelines on such aggressivepractices or the limited financial assistance policies that oftentrigger them.

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In a year when multiple health systems have come under fire forsuing patients, from giants UVA Health System and VCU Health tocommunity hospitals in Oklahoma, it has made no concrete move to developan industry standard.

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"There could be a broader message coming out of hospitalleadership" about harsh collections, said Erin Fuse Brown, a lawprofessor at Georgia State University who studies hospital billing."It seems unconscionable if they are claiming to serve thecommunity and then saddling patients with these financialobligations that are ruinous."

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Nonprofit hospitals are required to provide "community benefit,"including charity care in return for billions of dollars ingovernment subsidies they get through tax exemptions. But the rulesare lax and vague, experts say, especially for bill forgiveness andcollections.

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The Affordable Care Act requires nonprofit hospitals to have afinancial assistance policy for needy patients but offers noguidance about its terms.

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"There is no requirement" for minimum hospital charity underfederal law, said Ge Bai a health policy professor at JohnsHopkins. "You design your own policy. And you can make it extremelyhard to qualify."

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Practices vary sharply, a review of hospital policies and datafrom IRS filings show. Some hospitals write off the entire bill fora patient from a family of four making up to $77,000 a year. Othersgive free care only if that family makes less than $26,000.

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The law does not substantially limit harsh collections, either.IRS regulations require only that nonprofit hospitals make"reasonable efforts" to determine if patients qualify for financialassistance before suing them, garnishing their wages and puttingliens on their homes.

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Gaping differences in both collections and financial assistanceshow up in the policies of health systems represented on AHA'sboard of trustees.

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This year, AHA board chairman Gragnolati's Atlantic HealthSystem, in northern New Jersey, sued patients for unpaid bills morethan 8,000 times, court records show.

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Atlantic Health sued Robert and Tricia Mechan of Maywood, N.J.,to recover $7,982 in unpaid bills for treatment of their sonJonathan at the system's Morristown Medical Center.

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Three of the Mechans' four children have cystic fibrosis, achronic lung disease, including Jonathan, 18. Tricia Mechan workstwo jobs — full time as a manager at Gary's Wine & Marketplaceand part time at Lowe's — to try to pay doctor and hospital billsthat pile up even with insurance.

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"I have bill collectors call me all the time," Tricia Mechansaid. "You're asking me for more, and all I'm doing is trying toget the best care for my children. I didn't ask to have sickchildren."

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She closed a savings account and borrowed money to settleJonathan's bill for $6,000. Another son with cystic fibrosis,Matthew, owes Atlantic Health $4,200 and is paying it off at $25 amonth, she said.

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Marna Borgstrom, CEO of Yale New Haven Health, also sits onAHA's board. Yale almost never sues families like the Mechans.

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"I have not signed off on a legal action since 2015" against apatient, Patrick McCabe, the system's senior vice president offinance, said in an interview. "People are coming to us when theyare at their most vulnerable, and we truly believe we need to workwith them and not create any additional stress that can beavoided."

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Yale has treated Nicholas Ruschmeyer, 30, a Vermont ski mountainmanager, for recurring cancer. He has been careful to maintaininsurance, but a few years ago the hospital performed a $12,000genetic test that wasn't covered.

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"Yale completely absorbed the cost," said his mother, SherrieRuschmeyer. Yale is "wonderful to work with, not at allaggressive," she said.

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Atlantic Health bars families from receiving financialassistance if they have more than $15,000 in savings or otherassets. Yale never asks about savings. Even families who own homeswithout a mortgage qualify if their income is low enough.

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Atlantic Health's policies including seizing patient wages andbank accounts through court orders to recoup overdue bills. Yalesays it does not do this.

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In some ways, Atlantic Health's policies are more generous thanthose of other systems.

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It forgives bills exceeding 30% of a family's income in manycases, the kind of "catastrophic" assistance some hospitals lack.It also bills many uninsured patients only slightly more thanMedicare rates. That's far less than rates charged by otherhospitals in the same situation that are substantially higher thanthe cost of treatment.

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"Atlantic Health System's billing policy complies with all stateand federal guidelines," said spokesman Luke Margolis. "While weare willing to assist patients no matter their financial situation,those who can pay should do so."

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After a reporter inquired about its practices, Atlantic Healthsaid it "is actively engaged in refining our policies to reflectour patients' realities."

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AHA also is considering changing its position on billing in thewake of recent reports on aggressive and ruinous hospitalpractices.

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Previously AHA said billing offices should "assist patients who cannot pay," without giving specifics, andtreat them with "dignity and respect." Queried this month,association CEO Rick Pollack said, "We are reevaluating theguidelines [for collections and financial assistance] to ensurethey best serve the needs of patients."

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Kaiser Health News found that the University of Virginia HealthSystem sued patients 36,000 times over six years, taking tax refunds,wages and property and billing the uninsured at rates far higherthan the cost of care. Richmond-based VCU Health's physicians groupsued patients 56,000 times over seven years, KHN alsofound.

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In Memphis, Methodist Le Bonheur Healthcare sued patients for unpaid bills more than 8,000 times over fiveyears, ProPublica reported. In South Carolina, hospitals have beentaking millions in tax refunds from patients and theirfamilies, an examination by The Post and Courier showed.

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In response, VCU pledged to stop suing all patients. UVA promised to "drastically" reduce lawsuits, increase financial assistanceand consider further steps. Methodist erased debt for 6,500patients and said it would overhaul its collections rules.

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Yale's less aggressive policies also came in response tojournalism — a 2003 WallStreet Journal report on how the system hounded one family.Yale still sends overdue bills to collections, McCabe said. But itbalks at the last, drastic step of asking a court to approveseizing income and assets.

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For patients with unpaid bills, he said, "if you're willing toplay a game of chicken, you will win."

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Hospitals say they see more and more patients who can't pay,even with insurance, as medical costs rise, family incomes plateauand out-of-pocket health expenses increase. In particular, theyblame widespread high-deductible coverage, which requires patientsto pay thousands before the insurance takes over.

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"More consumers pay far more with fewer benefits," Pollacksaid.

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Some states go beyond federal rules for charity care andcollections. In California, patients with an income of less than$90,000 for a family of four must be eligible for free ordiscounted care. New Jersey requires Atlantic Health and othersystems to give free care to patients from families of four withincome less than $51,000.

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The National Consumer Law Center, a nonprofit advocacy group,suggests all states adopt that standard for large medicalfacilities. Its model medical debt law also would require substantial discountsfor families of four with income below $103,000 and relief forpatients with even higher incomes facing catastrophic bills.

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The AHA should consider similar changes in its own guidelines,NCLC attorney Jenifer Bosco said.

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"I would be interested in seeing them taking a more active rolein creating some standard for hospitals about what's too much," shesaid. "What's going too far? Given that this is a helpingprofession, what would be some appropriate industry standards?"

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KHN senior correspondent Jordan Rau contributed to thisreport.

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Kaiser HealthNews (KHN) is a national health policy news service. It is aneditorially independent program of the Henry J. Kaiser Family Foundation whichis not affiliated with Kaiser Permanente.

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