Washington hospitals appear to be falling short in their charity-care duties, according to state Attorney General Bob Ferguson and a legal-rights group. Spanish-speaking patients may face particular challenges.

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After going to the emergency room for stress and stomach pains, Enedina Andres-Juan returned to the Highline Medical Center with a completed application for charity care.

But staff at the Burien hospital, who didn’t speak Spanish, refused to take her request for financial assistance, said Andres-Juan, a hotel housekeeper who then made a little more than $8 an hour.

“I thought it was because I was a Latina and they didn’t want to help us,” said Andres-Juan, 37, through an interpreter.

The hospital handed her case to a collection agency, which said in March 2015 she owed $12,165 for two visits, interest and fees. The agency began garnishing her wages.

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In July, a King County District Court judge halted the collection and ordered a refund of the $1,112 taken from her paychecks. Andres-Juan indeed qualified for charity care, but the hospital did not screen her for eligibility as state law requires.

Hospitals around Washington appear to be falling short in their charity-care duties, according to a report by Columbia Legal Services (CLS), which helped Andres-Juan get her pay back, and Attorney General Bob Ferguson, who announced last week a lawsuit against St. Joseph Medical Center in Tacoma.

St. Joseph has withheld charity care from tens of thousands of low-income patients since 2012, Ferguson alleged. Senior managers at the hospital, part of the CHI Franciscan chain along with Highline Medical Center, knew about the problems but did nothing, he said.

CHI Franciscan provided $20 million in charity care in the last year, a company executive said in a statement responding to the lawsuit. “We are disappointed by (the) lawsuit and, as always, we’ll continue to provide care to absolutely everyone who needs it,” said Cary Evans, vice president for communications and government affairs.

Evans did not respond to a request for an interview about the lawsuit or Andres-Juan’s case.

The hospital was founded by the Sisters of St. Francis to help all people, Ferguson noted, but failed to screen patients for charity care.

“I want to be clear,” he said at a news conference, “St. Joseph’s has lost their way.”

The CLS report reinforces Ferguson’s claims about faulty charity care. Hospitals make it hard for some patients to get assistance by not following the law’s eligibility requirements. And they’re billing patients, sometimes aggressively, for care that should be free or discounted, according to the report.

“I hope the industry is paying attention to this,” Ferguson said of his lawsuit.

The industry definitely is, and has been for a while, said Cassie Sauer, president of the Washington State Hospital Association (WSHA).

It’s evident in a new one-page application, available in multiple languages, that 91 of the state’s 99 hospitals have agreed to use for charity care, she said.

The hospital association has also convened focus groups to better understand what obstacles patients see. “It’s certainly ongoing work,” Sauer said.

She said she appreciated issues highlighted in the CLS report, particularly around language barriers for some patients. The new application forms should alleviate some problems, she said.

CLS research included test calls to 20 hospitals by English and Spanish speakers. Sixteen of the 20 hospitals hung up on at least one of the calls from a Spanish-speaking tester, according to the legal-advocacy group.

“If what they found is correct, it’s an area we really need to focus on,” Sauer said.

State law is clear

Hospitals must provide free care to people below the federal poverty level, which is $12,060 for an individual and $28,780 for a family of five, such as Andres-Juan’s. Patients need to provide only one document, such as a tax return or pay stub, to verify their income.

It doesn’t matter what language they speak or if they are undocumented immigrants.

“We would not want people not to seek care because of immigration issues,” Sauer said.

Under state law, hospitals must provide discounted care to patients whose income is less than twice the federal poverty level.

Some hospitals, including CHI Franciscan facilities, say they offer discounts to people earning less than three times the poverty level.

In 2015, hospitals statewide reported spending $999 million on uncompensated care, which combines charity care and bad debt they absorbed.

But that figure is kind of like a manufacturer’s suggested retail price for a car. It’s not what insurers would actually pay for services.

Instead, the state Office of the Insurance Commissioner (OIC) considers the discounted rates insurers get as the true cost of uncompensated care. According to the OIC, in 2015 that spending by hospitals totaled $245 million.

The Affordable Care Act (ACA), which took effect in 2014, greatly reduced hospitals’ uncompensated care.

Also known as Obama­care, the ACA expanded government-subsidized Medicaid coverage to more than 600,000 low-income Washingtonians.

But the need for charity care persists for some of the 500,000 Washingtonians who remain without health insurance.

Some are uninsured because undocumented immigrants don’t qualify under the ACA. Others earn a bit too much for Obamacare, which limits Medicaid coverage to individuals with incomes under $16,643, but they still qualify for discounted care, falling under its $24,120 ceiling for individuals.

And there are people, according to Sauer, who don’t enroll in Obamacare for political reasons.

The WSHA focus groups revealed that some people don’t apply for help even when hospitals encourage it because “charity” connotes they are homeless or destitute, according to Sauer.

That’s one reason hospitals should use the term “financial assistance” for charity care, she said.

Language barrier

Language barriers may also be an obstacle to charity care.

CLS testers called 20 hospitals of different sizes across the state. Each hospital got two calls from a Spanish-speaking tester and two calls from an English-speaking tester. Testers used identical scripts about poor family members needing care.

In addition to the hang-ups on Spanish-speaking testers, CLS found that just 11 of 40 Spanish-speaking callers were told about financial assistance when they reached the hospital’s main number, while 36 of 40 English-speaking callers were informed about assistance.

The tests were done over two weeks, said Ann LoGerfo, a CLS attorney. They did not attempt to verify chronic problems at any particular hospitals. But what testers encountered “replicated the experiences people keep reporting to us,” LoGerfo said.

The overarching issue, according to LoGerfo and CLS, is that hospitals have a duty to determine if a patient is eligible for charity — and must do so before attempting to collect payment. And they must translate information about financial assistance.

Sauer noted that many hospitals do have Spanish-speaking staff and offer interpreter services.

Ferguson’s lawsuit alleges that employees of St. Joseph’s billing vendor were told to “never volunteer information about St. Joseph’s charity care program to patients, even if they were obviously low-income or homeless.”

Instead, the hospital’s vendor pressured low-income patients to pay upfront for treatment, according to the lawsuit — even when a patient requested a charity-care application.

Ferguson also said the hospital provided charity care at below the regional average between 2012 and 2015. If it met the average, he said, it would have given out $70 million more in care to needy patients.

The attorney general said he is seeking restitution and civil penalties, noting that each violation could carry up to a $2,000 penalty.

“I have a special interest when the population that’s being impacted is especially vulnerable for whatever reasons,” he said.

Andres-Juan said she would advise other patients to seek help from lawyers so they don’t have to go through what she did.

“I was very happy,” she said about her refunded wages. “I was waiting for that check.”