Fact check: Contrary to Trump’s claim, no law required Roger Marshall to sue his patients

No law required Sen. Roger Marshall to file lawsuits against patients who had unpaid medical bills.

Marshall, a Republican obstetrician-gynecologist who is in a competitive race for re-election in Kansas, has faced criticism over a New York Times report that he launched hundreds of lawsuits against patients who had outstanding bills and charged patients an 18 percent annual interest rate. The Times reported that dozens of Marshall’s patients were arrested after missing court dates in collections cases.

President Donald Trump has claimed that Marshall was required by law to take aggressive action to collect from patients – though Marshall has also said that he wrote off many patients’ bills. Trump has even asserted that Marshall could have been arrested if he didn’t do what he did.

“He was given a bum rap because he was mandated by law to request, strongly, money owed from patients. You’re not allowed not to do it. You have to, by law, go after those people. And they made it like, oh, he was some kind of a Shylock-type guy,” Trump said at a Kansas rally on Monday, invoking an antisemitic trope . “And if he didn’t make these requests, he would be breaking the law, he would have been breaking a very strong criminal law, and he would be subject to criminal arrest and liability.”

But state and federal laws give doctors and hospitals wide latitude to choose to forgive patients’ debts over financial hardships or to pursue unpaid bills using methods gentler than litigation. Marshall himself claimed to CNN’s Manu Raju last week that “each year, our hospital gave away millions of dollars of charity care” and that “we wrote off hundreds of people’s bills every month.”

Similarly, there is no law that would subject a doctor to potential arrest for choosing to forgive the bills of patients who had difficulty paying. And there is no law requiring 18 percent interest on unpaid bills. The Kansas City Star, which has also debunked Trump’s claim, found that the 18 percent rate was unusually high in the state even among the Kansas medical practices that chose to sue patients.

Marshall’s campaign did not respond to repeated CNN requests to identify the law that supposedly mandated his actions. The White House, in an unsigned email, mentioned two connected federal laws, one criminal and one civil, that require healthcare providers who serve patients enrolled in federal benefit programs to make a reasonable effort to collect payments from most patients – but the White House didn’t mention that those laws allow providers to forgive the money owed by people who can’t afford to pay.

In fact, one of the very articles the White House sent as supposed evidence explicitly says that the federal inspector general overseeing health services “has confirmed that it will not enforce the (two laws) against providers who waive copays or deductibles due to genuine financial hardship.” We’ll discuss that further in the next section of this article.

“I’m not aware of any federal or Kansas law that requires doctors to collect money owed by patients and holds them criminally liable if they do not,” Christopher Garmon , an associate professor of health administration at the University of Missouri-Kansas City, said in an email. “Doctors, and other health care providers, are given broad discretion to decide how to bill patients (e.g. how much to set as billed charges) and how much to collect in certain situations. It is common for health care providers to provide charity care to low-income uninsured patients and to write off unpaid bills as ‘bad debt.’”

Garmon noted that “there are requirements that health care providers must make good faith efforts to collect patient cost-sharing to participate in certain health plans or programs (e.g., Medicare).” But he added, “I’ve never heard of a doctor going to jail for failure to collect money owed by patients.”

Barak Richman , a professor and co-director of the health law program at The George Washington University, said in an email: “Unless Kansas is remarkably different from the states that I’ve studied, I can say with confidence that the decision to sue a patient on an unpaid debt is up to the provider’s discretion, and it’s an action that most providers decide not to take.”

Trump suggested in his Monday speech that the law he is referring to “has to do with the collection of money for the federal government.” Marshall told Raju last week that “when and if it happened – like every other hospital, nonprofits alike and other doctors’ offices – some of those people by law have to go to collections. There has to be some effort to go to collections. Or otherwise, CMS (the Centers for Medicare & Medicaid Services), Medicaid, we’d be in violation of that as well.”

The White House’s unsigned email mentioned a criminal law called the Anti-Kickback Statute, under which doctors can face prison time, and a civil law called the Civil Monetary Penalties Law, under which doctors who violate the anti-kickback law or other statutes can face additional penalties.

But the website of the federal health department’s inspector general makes clear that no legislation requires doctors or hospitals to sue patients.

In undated guidance to physicians, the website says, “Where the Medicare and Medicaid programs require patients to pay copays for services, you are generally required to collect that money from your patients. Routinely waiving these copays could implicate the (Anti-Kickback Statute) and you may not advertise that you will forgive copayments.”

But here’s the key: The advice immediately continues by saying, “However, you are free to waive a copayment if you make an individual determination that the patient cannot afford to pay or if your reasonable collection efforts fail. It is also legal to provide free or discounted services to uninsured people.”

Separately, the inspector general’s office explained in 2022 that to meet the “reasonable” standard, a healthcare provider’s collection effort must include issuing a bill and then taking actions “such as subsequent billings, collection letters, telephone calls, or personal contacts with the responsible party.” Lawsuits are not on the list of required actions. In addition, the office said that in cases where a healthcare provider has determined that a patient is “indigent,” they don’t have to make the usual reasonable collection efforts.

Marshall is running against Democratic candidate Adam Hamilton, a pastor. Hamilton campaign spokesperson Tyson Brody said in an email, “Roger Marshall chose to sue his patients. He chose to charge them 18% interest, and he and his personal lawyers chose to file warrants for their arrest. These were not normal business practices – they were extreme and predatory.”

没有任何法律要求参议员罗杰·马歇尔对拖欠医疗费的患者提起诉讼。

马歇尔是一位共和党籍妇产科医生，目前正面临堪萨斯州激烈的连任竞选。此前，《纽约时报》报道称，他曾对数百名拖欠医疗费的患者提起诉讼，并向患者收取高达18%的年利率，因此饱受批评。《纽约时报》还报道称，数十名马歇尔的患者因缺席催收案件的庭审而被捕。

唐纳德·特朗普总统声称，马歇尔依法必须采取强硬措施向患者追讨欠款——尽管马歇尔也表示他免除了许多患者的账单。特朗普甚至断言，如果马歇尔不采取这些措施，他可能会被逮捕。

“他被冤枉了，因为法律规定他必须强烈要求病人支付欠款。你不能不这么做。法律规定你必须追讨这些人的欠款。但他们却把他描绘成夏洛克那样的人，”特朗普周一在堪萨斯州的一次集会上说道，并引用了一个反犹太主义的比喻。“如果他不提出这些要求，他就违法了，他触犯了非常严厉的刑法，他将面临刑事逮捕和法律责任。”

但州和联邦法律赋予医生和医院很大的自由裁量权，可以选择在患者面临经济困难时免除其债务，或者采用比诉讼更温和的方式追讨未付账单。马歇尔本人上周向CNN的马努·拉朱声称，“我们医院每年提供数百万美元的慈善医疗服务”，并且“我们每个月都会免除数百人的账单”。

同样，没有任何法律规定医生如果选择免除支付困难患者的账单，就会面临被捕的风险。也没有任何法律规定未付账单必须支付18%的利息。《堪萨斯城星报》也驳斥了特朗普的说法，该报发现，即使在那些选择起诉患者的堪萨斯州医疗机构中，18%的利率也异常高。

马歇尔的竞选团队没有回应CNN多次要求其说明据称是哪条法律强制他采取这些行动的请求。白宫在一封未署名的电子邮件中提到了两项相关的联邦法律，一项是刑事法律，一项是民事法律，这两项法律都要求为参加联邦福利计划的患者提供服务的医疗机构尽合理努力向大多数患者收取费用——但白宫没有提及，这些法律允许医疗机构免除无力支付患者的欠款。

事实上，白宫提供的所谓证据之一明确指出，负责监督医疗服务的联邦监察长“已确认，对于因真正经济困难而免除患者自付额或免赔额的医疗服务提供者，不会强制执行（这两项法律）。”我们将在本文的下一节中对此进行更深入的探讨。

“据我所知，联邦法律或堪萨斯州法律均未规定医生必须收取患者欠款，也未规定医生若不收取则需承担刑事责任，”密苏里大学堪萨斯城分校卫生管理学副教授克里斯托弗·加蒙在电子邮件中表示。“医生和其他医疗保健提供者拥有很大的自由裁量权，可以决定如何向患者收费（例如，设定多少费用作为账单）以及在某些情况下收取多少费用。医疗保健提供者向低收入无保险患者提供慈善医疗服务，并将未付账单作为‘坏账’注销，这种情况很常见。”

加蒙指出，“医疗服务提供者必须尽力收取患者应支付的费用，才能参与某些医疗计划或项目（例如联邦医疗保险）。”但他补充说，“我从未听说过有医生因为未能收取患者所欠费用而被判入狱。”

乔治·华盛顿大学健康法律项目教授兼联合主任巴拉克·里奇曼在一封电子邮件中表示：“除非堪萨斯州与我研究过的其他州有显著不同，否则我可以自信地说，是否起诉未偿债务患者取决于医疗服务提供者的自由裁量权，而且大多数医疗服务提供者决定不采取这种行动。”

特朗普在周一的演讲中暗示，他所指的法律“与联邦政府的资金征收有关”。马歇尔上周告诉拉朱，“如果这种情况发生——就像其他医院、非营利组织和其他医生诊所一样——根据法律，其中一些人必须进入催收程序。必须采取一些措施进行催收。否则，医疗保险和医疗补助服务中心（CMS）以及医疗补助计划，我们也将违反该法律。”

白宫这封未署名的电子邮件提到了一项名为《反回扣法》的刑事法律，根据该法律，医生可能面临监禁；以及一项名为《民事罚款法》的民事法律，根据该法律，违反反回扣法或其他法规的医生可能面临额外处罚。

但联邦卫生部监察长的网站明确指出，没有任何法律规定医生或医院必须起诉病人。

该网站在一份未注明日期的医生指南中指出：“如果联邦医疗保险和医疗补助计划要求患者支付服务共付额，您通常需要向患者收取这笔费用。例行免除这些共付额可能会触犯《反回扣法》，您不得宣传您会免除共付额。”

但关键在于：该建议紧接着指出，“但是，如果您个别认定患者无力支付，或者您合理的催收措施无效，您可以免除其共同支付费用。此外，向无保险人士提供免费或折扣服务也是合法的。”

此外，监察长办公室在2022年解释说，要达到“合理”标准，医疗机构的催收工作必须包括开具账单，然后采取“例如后续账单、催款信、电话催收或与责任方进行个人联系”等措施。诉讼不在强制措施之列。此外，该办公室还表示，如果医疗机构认定患者“贫困”，则无需采取通常的合理催收措施。

马歇尔的竞选对手是民主党候选人亚当·汉密尔顿，他是一名牧师。汉密尔顿竞选发言人泰森·布罗迪在一封电子邮件中表示：“罗杰·马歇尔选择起诉他的病人。他选择向他们收取18%的利息，而且他和他的私人律师还选择申请逮捕令。这些并非正常的商业行为——而是极端且掠夺性的。”