In the early morning on Dec. 13, 2018, a Duke student was sitting in her apartment’s common room in the university’s Central Campus. She was cramming for her organic chemistry final when a man she didn’t know opened the door. She said the stranger entered, threatened her with a knife, and raped her.
The student, then a sophomore, immediately went to the Duke Hospital emergency room. She wanted a sexual assault nurse examiner to collect a rape kit, an invasive evidence collection process that often takes hours and requires victims to describe the details of their assault. But that kit could provide crucial evidence for police to catch her assailant.
Police have not announced any arrests in the case. But six months after the assault, the student received a call from a number she didn’t recognize.
“This is a call from a debt collection agency for Duke Health,” the person said, according to the student. The caller informed her that she owed hundreds of dollars for her emergency room visit for the rape examination.
“Before that, I had no idea I owed any money,” the student, who asked not to be identified, told The 9th Street Journal in an interview. “I asked them to talk to my mom because it was really traumatic and hard, but they didn’t do that. They kept calling me over and over again.”
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Rape victims are not supposed to be charged for sexual assault exams, but the rules have loopholes.
The federal Violence Against Women Act requires that all states cover the cost of the exams. But beyond the exams themselves, each state can decide what additional hospital services they’ll cover.
North Carolina’s interpretation is called the Rape Victims Assistance Program. The program offers hospitals up to $800 for a sexual assault exam: $350 for the sexual assault nurse examiner, $250 for the hospital facility fees, and $200 for “other expenses,” including sexually transmitted disease antibiotics or pregnancy tests for the victim. Victims should never be directly billed by a hospital for the examination, according to the North Carolina Department of Public Safety.
But Molly Chadbourne, a former sexual assault nurse examiner in Durham, said victims still get charged for other services.
“There are still fees for checking into the hospital, for getting an X-ray, or for needing other care,” she explained. “All that other stuff, patients can get charged for. Sexual assault patients definitely get bills.”
Chadbourne said some states cover all of a sexual assault victim’s other hospital bills, while others cap their payments at a certain amount. She noted the $800 cap in North Carolina and said, “$800 is nothing at a hospital.”
Though the Violence Against Women Act is supposed to protect victims from being billed after a sexual assault, many women have reported experiences like the student’s, according to accounts in news articles and websites. The practice is caused by a combination of state policy, billing mistakes, and poor communication between debt collectors and hospitals.
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When the student went to Duke Hospital last December after being assaulted, she didn’t bring her insurance card.
“They said that was fine at the time,” she said. She was told that she wouldn’t have to pay for her sexual assault exam and that she didn’t have to worry about billing.
A few hours after the assault, police sent a Duke Alert, the university’s warning system for crime and severe weather. “A student reported that between 1 a.m. and 3 a.m. this morning… she was awakened by a white male with short brown hair and a perfume smell about him,” read the alert emailed to students, faculty, and staff. “He threatened her with a knife, put on a condom, and forced her to have sex.”
The student was embarrassed by the detailed university-wide alert. “Reading the email was really hard,” she said. “They never asked me if it was okay to send out that email, or if I even wanted to talk to the police. They just said, ‘You need to talk to this officer,’ and I did it because it felt like I had to.”
Months after the assault, she was beginning to heal. She was put in contact with the Duke Women’s Center and started seeing a psychiatrist.
Duke Hospital has an online billing system. But the student said she didn’t think she would have bills, so she never checked it. After four months, Duke Health sends all unpaid medical bills to debt collection agencies.
Then, she got the first call from a debt collector. The calls kept coming.
“We are (a) debt collector,” a voicemail message from the agency said. “This call is an attempt to collect a debt and any information obtained will be used for that purpose.”
“They’re always from a random number, and never the same number twice,” the student said. “I told them my insurance card information, and I got confirmation that everything was worked out over the summer. But they continue to call and say we owe them even more.”
When she called Duke Health to report what was happening, the billing office told her that she had an outstanding charge. She asked that the debt collectors contact her mom instead so she wouldn’t have to explain her situation to strangers. She and her mom are still working through the bill.
Her bill from her emergency room visit on Dec. 13 is labeled “Accounts with Collections Agency” in Duke’s online billing system. But she said she has difficulty determining how much she owes because the collectors have a separate billing system.
The collectors keep calling, every few months.
The student authorized Duke Health to discuss her bills with The 9th Street Journal, but a Duke Health spokeswoman declined to comment on the student’s situation.
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Across the country, victims have reported getting billed by hospitals after a sexual assault.
“We definitely hear about this,” said Grace Frances, the director of community parternships at End Violence Against Women International, a nonprofit that educates professionals about sexual assault. “It is definitely still a problem.”
In 2017, a study published in the American Journal of Public Health found that the average hospital bill after a rape was $6,737. After billing insurance, sexual assault victims were left with an average of $948 to pay out of pocket. And 88% of medical records indicated that victims were charged on the day they visited the hospital.
“Oftentimes, the charges that they’re seeing aren’t the cost of the rape kit,” said Ashley Tennessee, the lead researcher on the study and an assistant professor at the Medical University of South Carolina. “Most people who are sexually assaulted have additional costs. They might want tests completed, or treatments for physical abuse.”
Tennessee sees the problem as twofold: Victims are sometimes mistakenly charged for their rape kit exam. But more often, they’re billed for treatment related to their sexual assault.
If victims check into the emergency room, they can also be charged a facility fee. Duke itself acknowledges that going to its emergency room will cost patients “at least $1,000.”
Asked if Duke Health has a policy about charging for sexual assault exams, a spokeswoman declined to comment.
Tennessee recommends that states broaden their policies to reimburse hospitals for more than just the sexual assault exam. She also hopes that hospitals will charge sexual assault victims through a separate billing process to ensure that no mistakes are made.
“Someone has to pay for it,” she said. “At this point, it’s the victim.”
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For sexual assault survivors who have been billed by hospitals in North Carolina, there is another option: the crime victim compensation fund. Victims of violent crime can apply for medical compensation up to $30,000, including physical treatment and future counseling.
But there are bureaucratic hurdles that can be challenging for survivors of sexual assault. To submit a claim, a victim must provide a police report. That means they have to report their rape to police before they’re eligible for the compensation.
“I think you should be able to come into the emergency room and say, ‘I was sexually assaulted, I want to get medical care,’ and get that for free,” Chadbourne said. “But that’s not how it works.”
Even for victims who are eligible to apply to the compensation fund, there are still barriers. They have to collect documents and get them notarized before submitting their application, and will likely wait months to receive compensation. And in the meantime, they’ll still be billed for their sexual assault exam visit.
“It’s unacceptable,” Frances said. “You’re telling victims that you don’t care what it means to them when they get a bill in the mail, and their family sees it.”
“It’s putting the responsibility on the victim to get themselves reimbursed,” Chadbourne said. “And that’s hard.”
For the Duke student, it is also confusing.
“We’re unsure about what the bill is for at this point, because we’ve already paid so much,” she said.
She also feels betrayed by the institution that failed to protect her while on campus.
“I hated their whole response,” she said. “They just sent us to a collection agency.”
9th Street Journal reporter Cameron Beach can be reached at firstname.lastname@example.org.