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Hospitals in Texas that sued patients over medical debt relied heavily on just two law firms: and , according to a .

From 2018 to 2020, Dallas-based DeLoney filed 81% of medical debt collection lawsuits in the state, totaling $14.8 million in judgments, according to a review of the Texas online court system by researchers from Johns Hopkins University in Baltimore and other institutions.

Patients interviewed by the researchers said they were given only last-minute notifications about their hearings -- and often these were unclear -- leading to missed court appearances. The report charges the firm has a "particularly predatory litigation strategy" as patients who fail to show up can have default judgments issued against them.

"This firm pitched their services to many hospitals," said co-author (and 乌鸦传媒 Editor-in-Chief) Marty Makary, MD, MPH, of Hopkins. "The lawyer and court costs are another example of money sieved out of the healthcare system."

DeLoney didn't respond to a request for comment.

Over the past 2 years, Lubbock-based Boerner, Dennis & Franklin filed 7.3% of medical debt lawsuits in the state and won $2.5 million in judgments and garnished over $1 million in patient assets, the report states. Half of lead attorney William Franklin's cases were filed with a writ of garnishment that would allow the hospital to seize income and assets and place liens on their homes.

All of this comes despite the , which prohibits wage garnishment. However, debt collectors can file a writ of execution or a writ of garnishment that allows them to go after any bank funds, property, or income that's not a wage, according to the report.

Franklin told 乌鸦传媒 that his firm obtained about $1.6 million in judgments and hasn't garnished any patient accounts during the study time period.

"I do not ever recall garnishing a patient's account in any case I have filed on behalf of a medical provider," Franklin said. "Although our firm has requested writs of execution be issued, no personal or real property was seized through this process for the period of January 2018 until the present."

Makary and his team have been examining ultra-aggressive debt collection by U.S. hospitals. Last year, the group published a report . For the new report, Makary and colleagues focused on the Lone Star State because "most Texas hospitals have never sued a patient, affirming what we hypothesized that most hospitals do not engage in predatory billing."

The team performed a comprehensive search of the Texas online court system for lawsuits and garnishments for patient medical debt from 2018 to 2020.

They found 28 hospitals that sued Texas patients during that time, the majority of which (22) were in the state.

About three-quarters (73%) were proprietary or for-profit hospitals, while the remainder were non-profits.

Makary and colleagues found 1,003 cases that totaled about $17.8 million in medical debt. Looking at 15 hospitals that had 2018 revenue data available -- the mean was just shy of $1 billion -- they found the average lawsuit amount accounted for only 0.15% of gross revenue.

"While these lawsuits accounted for a negligible portion of the hospital revenue, they had catastrophic consequences for hard-working families," the researchers wrote. "What justification is there in these practices that devastate patients' lives yet make minimal impact on the finances of a hospital system?"

The hospitals that filed the most lawsuits were all small, for-profit community hospitals: South Texas Regional Medical Center (109 lawsuits), Cedar Park Regional Medical Center (84), Longview Regional Medical Center (84), Detar Hospital North (78), and Woodland Heights Medical Center (72).

Of those five hospitals, four are affiliated with Community Health Systems (CHS), a Fortune 500 company based in Franklin, Tennessee. It's the largest provider of general hospital healthcare services in the U.S., with 102 acute care hospitals in 18 states, according to the report, which calls attention to the company's "fraudulent past."

That includes how one of its CEOs in 2011 was sentenced to 5 years in prison for tax evasion, bribery, and Medicare fraud, and how in 2017 it was sued in Washington state for reporting $110 million in uncompensated and discounted care to the IRS from 2008 to 2015, which it never actually provided.

"The history of unethical billing in these small hospitals may be the foundation of their continued predatory billing tactics," the report states.

Makary and colleagues conclude that unstandardized hospital billing practices "pave the way for immoral practices, such as suing patients for medical debt."

Creating a set of standardized hospital billing quality metrics would help "increase quality, encourage price transparency, eliminate surprise billing, facilitate communication about payment options and cease all lawsuits and garnishment for medical debt," they wrote. Makary and a Hopkins colleague proposed such metrics in JAMA earlier this year.

In an email to 乌鸦传媒, Makary stressed that many hospitals "engage in fair and honest billing practices" and should be rewarded. "Billing quality is a form of medical quality, and benchmarking performance around billing quality would drive improvement as we've seen with other forms of transparent data benchmarking."

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