Scott Burch doesn't remember much from the day he got hit by a snowplow in January 2012.

It was a snowy day, and police say he was walking on Reed Market Road in Bend near the white line that guides traffic. Burch said he was trying to avoid puddles.

The rest is kind of a blur. The impact cracked Burch's mastoid, a bone inside the ear that helps maintain balance.

Even after spending a night in St. Charles Bend's emergency room, he said he kept getting confused and had a hard time paying attention. He also had behavioral problems, all of which required follow-up visits to St. Charles doctors .

Meanwhile, more confusion ensued. And the bills piled up.

“I guess I kind of slept through all the deadlines before going in,” he said. “By the time I was more with it to do anything about it, it was too late.”

The now-20-year-old uninsured Bend resident is $20,000 in medical debt and has no idea how he's going to pay it off. He said Deschutes County paid him $3,000 after the accident, but it didn't make a substantial dent in his bills.

For some, like Burch, medical debt stems from a catastrophic and unexpected health issue.

For others, it's a multitude of smaller bills that get lost in the complicated shuffle of paying for medical treatment.

And it's not just the uninsured, either. Rising deductibles and co-insurance rates have launched even those who have health insurance into debt.

One in 10 Americans said they or a family member had a medical bill they couldn't pay in 2011, according to the Centers for Disease Control and Prevention.

The Consumer Financial Protection Bureau recently began investigating medical debt — both how it's collected and how it affects peoples' credit scores.

Some consumer advocacy groups also believe rules in the Affordable Care Act that require hospitals to establish financial assistance policies and make them visible will cut down on Americans' medical debt.

A major cause of medical debt, they say, is that patients don't know help is available and they don't ask about it before seeing a doctor.

“They just figure whatever it is, they take it,” said Yolanda Vanderpool, homeownership coordinator at NeighborImpact in Bend, “They don't question anything, either.”

'They do what they can do'

Many of the Deschutes County residents who struggle with medical debt wind up at social service agencies, where experts help them sort through their bills and dissect their credit scores.

Mosaic Medical, for example, has a team of community health workers, said Mosaic CEO Megan Haase. Oftentimes, though, the workers have little choice but to refer patients back to the place they got their care to sort through payment options, she said.

Debtors looking to buy a house or car end up sitting across from people like Vanderpool or DeeDee Johnson, family services manager for the Bend Area Habitat for Humanity.

Sometimes, Vanderpool and Johnson said, they help people dispute medical bills that appeared on their credit reports in error, either because their private insurance or Oregon Health Plan coverage was supposed to pay the bills.

Some clients are surprised to learn they have medical debt at all.

“Sadly enough, we see a lot of people that have a lot of small medical collections that they were not even aware of,” Vanderpool said.

Nearly half of Americans who have medical debt owe less than $2,000, according to an April report by the Commonwealth Fund.

It's not uncommon for medical debt, sometimes in combination with other debt, to prevent people from buying a home, a car or get a credit card.

“If it's more than $500, it will keep them from getting a house,” Johnson said. “That can be a judgment and held as a lien against your home.”

Health care providers, agencies and patients paint differing pictures of providers' flexibility in terms of paying bills on time. While hospitals say they're open about their financial help and willing to allow more time, others describe rigid billing officers that don't hesitate to send bills to collection agencies.

Families commonly tell Johnson, for example, that when they try to set up payment plans with providers or ask to pay a smaller amount, they're met with rigidity. Providers also tend not to extend deadlines before bills are turned to collection agencies, she said.

“I think people just get frustrated,” Johnson said. “They do what they can do, but it's all they can do.”

Denise Montee, director of revenue cycle operations at St. Charles Health System, said St. Charles patients can apply for financial assistance even after they've already received care. St. Charles also will extend to its hospital patients in January its zero-percent interest payment program, she said. The program already is offered to patients in St. Charles' clinics.

“Part of the overall patient experience is the financial help of the patient as well,” Montee said. “When they leave our hospital, they're taking care of their physical health, not their financial health.”

In addition to financial assistance, some advocates encourage patients to simply ask ahead of time what a procedure is going to cost. And providers are increasingly getting better at calculating answers.

St. Charles can provide “patient estimates,” a combination of the cost of the procedure a patient is getting and the portion his or her insurance covers, Montee said. That doesn't include specifics about the patient, however, and can change depending on physical conditions or unanticipated costs from the procedure, she said.

“Patients will ask us 'What is this going to cost me?'” Montee said. “It's very common. They want to know. They're smart consumers.”

Oregon Health&Science University in Portland is piloting a program that works similarly to the St. Charles program to provide patients an estimate of their bills, said Matt Navigato, OHSU's enterprise revenue cycle director.

The push to provide prices at OHSU was driven by insurance plans that increasingly require people to pay more money, he said.

“The patients no longer have those plush health care coverages of 90/10 coverages or 80/20 coverages,” Navigato said, “and I think the patient is becoming a much more informed consumer and wants to know how much they're going to pay out of pocket.”

'Be willing to push'

As the director of the Boston-based Community Catalyst's Hospital Accountability Project, Jessica Curtis is working to help hospitals prepare for Affordable Care Act rules that will force them to be transparent about the financial help they can provide.

The Internal Revenue Service has yet to issue final guidelines on the rules, which means some hospitals likely are holding off on making changes to their policies.

Generally, the rules, which apply only to non profit hospitals like St. Charles, require the hospitals to let patients know about financial assistance policies. That could look like a notice on peoples' bills or a large icon on the providers' websites.

Ideally, billing officers would inform patients when they're standing in front of them, but that might not be a requirement, Curtis said.

Curtis led a two-year project that ended in 2010 for which her team called hospitals across the country — Oregon not included — posing as uninsured people asking about their financial assistance programs. The results weren't encouraging.

“It's very difficult to find that information in a way that you can actually do something with it,” she said. “Between looking on the website and calling the hotline, in most cases, if you requested an application or wanted to know eligibility guidelines, it was, at that time, very hard to find that information.”

At St. Charles, Montee said, uninsured patients are told right away what assistance programs they might be eligible for. That often includes state or federal programs like disability or OHP, she said.

The hospital's financial assistance policy, which can be found on its website, is based on a sliding income scale, Montee said.

The No. 1 piece of advice Curtis gives people for staying out of medical debt is just to be informed.

“People should be aware of what the ACA says about this,” she said, “and be willing to ask questions and be willing to push.”

The IRS also will solidify rules that require hospitals to take reasonable efforts to ensure people are eligible for assistance before selling their debt to collection agencies.

Patients also will have up to 120 days after a bill has been issued before it goes to collections, and up to 240 days if they apply for financial assistance after receiving the bill. There is currently no federal law that gives patients a certain number of days to pay their medical bills before they're sent to collections.

Oregon Sen. Jeff Merkley for years has been trying to pass a law that would remove paid medical debt from credit scores. He praised the CFPB for its attention to the issue in an Oct. 18 letter to CFPB Director Richard Cordray.

“Medical debt is different from other types of debt as it is an unplanned expense, often resulting from an unforeseen illness or emergency,” he said. “Additionally, due to the medical billing process in which billing disputes and errors can spur the incurrence of medical debt, consumers often do not even know that they are responsible for a medical debt before it has been reported to collections.”

And once people are in debt, the process of trying to get out is made even harder by how complex navigating medical care can be, Haase, of Mosaic, said. People don't get one bill or one place to go for help.

“It's like, 'Here are your 10 bills,'” she said. “'Here are the 10 places you need to go to navigate getting discounted services.' With families that are already struggling to get basic life needs and maybe some pretty complex medical conditions, adding that into your day-to-day life management is very difficult.”

As for Burch, he said his future includes lots of night shifts at the local memory care facility where he works as a caretaker.

He needs to find a new apartment but said he was recently denied for one because of his credit score, which his debt has pushed into the low 500s.

Still, Burch is working toward a music degree at Central Oregon Community College in Bend. His student loans have not been affected by the accident, he said.

“That's the debt I want,” he said. “I want it; I picked it. I don't want the $20,000 in debt that I didn't pick that I don't feel like I have any control over.”

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