For some sex assault victims, ordeal carries price tag

A week before Christmas 2013 Christine, a sexual assault forensic nurse from suburban Chicago, went out for a night of dinner and drinks with friends. It was a night that forever changed her life.

"I don't remember anything after leaving the dinner portion," Christine told CBS News. "I woke up naked and I don't remember anything else after that."

She says she was a victim of sexual assault, and would feel victimized again by the hospital where she received a forensic medical exam, commonly known as a rape kit. At her request, CBS News is withholding Christine's last name because she was the victim of a violent crime.

"The next day I got my first bill for my copay," Christine said through tears. "The bills just kept coming after that."

The bills should have never come. Illinois has a voucher system that pays for medical expenses not covered by insurance incurred up to 90 days following a sexual assault.

Since 2005, the federal Violence Against Women Act has prohibited sexual assault survivors from being billed for the forensic collection of evidence, including copays. VAWA requires that the exam, at a minimum, include assessing physical trauma, determination of penetration or force, a patient interview and the collection of evidence. But, sexual assault victim advocates say, the medical guidelines for the rape exam goes beyond what the law provides for. Who pays for that treatment varies by state and at times, county by county.

We contacted Victim Advocates in all 50 states. Thirteen reported survivors getting billed for medical services related to a sexual assault forensic exam in their state. Stretching coast to coast, those advocates described a hodgepodge of laws that for some victims means a rape kit and the associated medical treatment come at a price.

"When you keep getting revictimized once a month you get a reminder in the mail, hey you were raped, hey this happened, you know, it's hard to move on," said Christine.

For Christine, the horror of her assault was made worse by the medical bills that kept coming. She was unable to get out of bed for months. The hospital threatening to send her to collections if she didn't pay was the very same hospital where she'd worked on crafting a sexual assault response protocol.

"It becomes extremely devastating for them and oftentimes triggers reliving the assault itself or the forensic-medical exam," said Sarah Layden, Director of Advocacy Services at Rape Victim Advocates in Chicago.

RVA says it receives as many as six calls a month from survivors of sexual assault who wrongly receive bills. The organization says the errant billing happens at hospitals across the state and at some with regularity.

"It is very common for a survivor to get a bill," Layden said during an interview with CBS News Correspondent Kris Van Cleave. "We have a full time staff advocate who spends the bulk of their time helping clients resolve bills."

The Illinois Department of Public Health it infrequently receives complaints regarding billing. In a statement to CBS News IDPH investigates complaints of patient billing. It requires hospitals found to be out of compliance to provide "evidence of its billing policy and how the hospital will make its system better moving forward."

Earlier this year, reports surfaced of rape victims in Louisiana receiving large medical bills after seeking a rape kit at state-owned LSU Hospitals. Operations of those hospitals had recently been turned over to a private company that ended the state's practice of writing off those related charges.

"For two nights in a row, I was raped and sexually assaulted, most of which I don't remember," a college student, whose name was withheld, told a Louisiana Senate committee during the legislature's first hearing on the billing issue. "It was around $2,000 of which my insurance covered none of it at all."

Hours after her testimony, Governor Bobby Jindal issued an executive order calling for changes to medical billing practices in the state and pledging to work with legislators to change the law.

"I believe that the victim should never be charged," said Louisiana Department of Health and Hospitals Secretary Kathy Kliebert. "The next part of this is that we would work with legislators for next session to make sure providers could bill directly to fund to assure that victims were not billed and that there are statutes in place to make sure the victims are not billed."

The Louisiana Hospital Association acknowledged to state lawmakers during the Oct. 20 hearing that there are a number of inconsistencies across the state and that reimbursement policies vary by hospital.

"We are committed to working through this and try to figure out how to make this as painless for the victim as possible," Sean Prados, Executive Vice President of the Louisiana Hospital Association, told the state Senate Select Committee on Women and Children.

Advocates in Arizona, California, Illinois, Kansas, Louisiana, Maryland, Minnesota, Nebraska, Nevada, Ohio, South Dakota, Texas, and Wisconsin all expressed concern about victims receiving bills in their states. The laws are different and the reasons for the charges vary.

Quantifying the scope of the billing issue is challenging. The Department of Justice estimates more than 237,000 sexual assaults occur annually in the United States, but only 40 percent are reported--and other studies put that number even lower. In at least 34 states, a survivor who reports the attack and cooperates with law enforcement may be eligible to have medical bills reimbursed by state run crime victim compensation funds, according to a 2014 Urban Institute case study. Survivors who choose not to report their attack, such as Christine and the college student who testified in Louisiana, are blocked from accessing that money.

A 2012 AEquitas study found 33 states cover specific 'collateral' services to victim care, 15 states will pay for tests for sexually transmitted infections, 15 states cover medications prescribed during the forensic exam, 10 states pay for emergency room and hospital fees, 13 states cover the cost of a pregnancy test, six will pay for emergency contraception and at least two will pay for victims' counseling related to the sexual assault. According to the study, only five states will pay for treatment of injuries caused by the attack, another four states provide payment for reasonable medical care related to the assault. Several states allow the victim's insurance to be billed for uncovered medical expenses.

Delaware does not allow a survivor to be billed. And just last summer Colorado passed a law creating a state fund to pay the entire bill for the forensic medical exam and related charges regardless of reporting after survivors received medical bills for thousands of dollars.

In the majority of cases victims are not billed says Janine Zweig, the lead researcher on the Urban Institute study, "but that left a substantial minority" who, in some fashion were billed.

Her report finds, while victims typically are not billed for the costs associated directly with the forensic collection of evidence, "they might be billed for other services that are not covered by the public payer in state statutes. This distinction may be lost on victims--a bill is a bill."

In six states the payment is left up to the individual counties. Advocates in all six--Minnesota, Kansas, Arizona, South Dakota, Nevada and Louisiana--told CBS News about reports of survivors receiving bills for medical care. In Minnesota that means 87 counties with their own individual policies about what gets paid for and by whom.

The Minnesota Coalition Against Sexual Assault Executive Director Donna Dunn says the system results in inconsistency across the state and "a lot of confusion."

The Urban Institute report concludes "victims in some portions of the states may have more services paid for...than do victims in other portions of the states."

"We have heard anecdotally that this is a significant issue," says Allie Bones, the CEO of Arizona Coalition to End Sexual and Domestic Violence. Her office just hired someone to study the hospital billing practices in the state.

"The choice to go to the hospital to get the exam is not theirs to make. It's the only place to get it," she said.

Advocates in Nebraska cited several examples of victims receiving bills in the last six months alone. Similar story in South Dakota and Kansas where some survivors may be billed for medical treatment associated with the forensic exam and can languish in a system advocates say can be hard for survivors to navigate. In Nevada, the county is required to pay for all medical care in the first 72 hours, but in rural counties there have been reports of victims being billed anyway. While the numbers are likely small, so is the population in smaller Nevada counties and advocates admit a small number of people could still be a big problem.

In essence, while the medical treatment a sexual assault survivor receives during a forensic medical exam is similar nationwide, who pays for that care varies widely. The end result is a patient may end up being billed for a service that a patient in another state may not.

For victims in California, the bill for the exam goes to law enforcement, but the state law does not require medical care beyond the scope of the federal requirements to be paid by that agency. Those who choose not to report to law enforcement may ultimately find they themselves, or their insurance, billed for those costs.

"It's not something that people expect at all," says Sandra Henriquez, the Executive Director of the California Coalition Against Sexual Assault. She believes the state's victim compensation fund should cover rape kit related medical costs for all survivors, "it's a matter of prioritization, I think they should have to pay for it and not have survivors revicitimized by getting a bill."

Maryland hospitals are not supposed to bill for related medical costs, but there remains confusion over what's covered, says Lisae Jordan, Executive Director of the Maryland Coalition Against Sexual Assault. She's received complaints from victims who were hit with costs like ambulance fees, and follow up testing.

"There is not consistent application of the law," said Jordan. The state has formed a panel to study access to forensic exams. The panel's first meeting is Thursday.

Katie Hanna, the Executive Director of Ohio Alliance to end Sexual Violence would like to see changes in her state as well. In Ohio the state pays $532 dollars for an exam, the excess can be passed on to the survivor.

"It varies county to county and hospital to hospital, and needs to change," said Hanna. "The level of care and the amount of charges a survivor incurs should not depend on the zip code in which they live or the hospital that just so happens to be nearest to them after being raped."

The Texas coalition against sexual assault hears about survivors surprised by medical bills "with frequency."

"Wisconsin Coalition Against Sexual Assault is receiving fewer reports of victims receiving bills associated with the forensic exam," Executive Director Pennie Meyers told CBS News in an email, "However, there is more work to be done."

Officials from the Wisconsin Department of Justice acknowledged receiving complaints, but say the agency is working on preventing similar problems in the future. State officials in Minnesota, Texas, Nevada, Kansas, Ohio, and Maryland said they have not received billing complaints. In South Dakota complaints would be handled at the county level. Government agencies in Arizona, California and Nebraska have not offered comment.

"Across the United States, victims are being victimized by the very system that is set up to help and protect them after they've been a victim of this crime," said Kellie Greene, the Founder and Director of Speak Out Against Rape, or SOAR.

For Greene, the billing issue is a very personal one. On January 18th, 1994 Greene was brutally raped by a stranger who broke into her Florida home. After being taken to the hospital for the forensic exam and medical treatment, she began receiving bills for the entire procedure, from the rape kit to the towel used on her bleeding head in the ambulance.

"It's like being punched in the gut when you open that mailbox and you see that bill."

Greene refused to pay and the hospital sent her bills to collections. She worked with the state attorney general to change Florida's law a year later.

Now through her Washington, D.C. non-profit she tries to help other survivors by speaking about her experiences. In the last few months she says SOAR has been contacted by at least a half dozen survivors across the country looking for help with medical bills. Her group pays some of the bills itself.

Greene believes the change needs to come on a national level. Senator Al Franken introduced legislation in 2009 and 2011 to address the issue, but both bills died in committee.

In response to our investigation, Senator Franken told CBS News, "I'm committed to making sure that survivors of sexual assault never see the bill for their rape kit exam, and we made significant progress with my provision in the Violence Against Women Act. But I'm very troubled that some women are still being charged for services related to their rape kits. That's unacceptable, and I'll be looking into options to fix this problem."

In a statement the American Hospital Association says "it is every hospitals' goal to treat and care for sexual assault victims in a safe and compassionate manner. While fees related to their care vary by state, we encourage all hospitals to review their policies on charges related to sexual assault victims."

"Would we like to see a standardized best practice response across the country? Of course," says Dr. Kimberly Lonsway, Ph.D., the Research Director for End Violence against Women International, "we are working very hard to get there but we aren't there yet."

In Christine's case, her bills were due to hospital error, she had been marked as self-pay; a simple coding error that took more than 10 agonizing months to resolve.

"We regret that this happened," Highland Park Hospital officials said in a statement. "We have implemented a new series of protocols and procedures in our billing system to ensure this does not happen again."

Later this year, Christine will complete her master's program to become a nurse practitioner. She and her husband are considering a move west and away from the memories of her attack.

CBS News Producers Polly Leider and Laura Strickler and researcher Bianca Brosh contributed to this report