The North Carolina General Assembly meets in the State Legislative Building in Raleigh, seen here in Feb. 2018. Frank Taylor / Carolina Public Press

North Carolina hospitals could be fined $25,000 if they bill sexual assault victims for the cost of forensic exams under a bill filed Tuesday.

While state law already requires hospitals and providers to accept the payments from the state “as payment in full,” sometimes hospitals bill victims or their insurance anyway. Rape victim advocates have said billing victims or insurance can be risky because victims may not tell their parents or loved ones they have been assaulted and sought medical care.

“When they come in for billing, it’s not to be billed to their insurance,” said Sondra Phelps, a sexual assault outreach specialist with Family Services of the Piedmont in Greensboro. “In some situations, it can be dangerous.” 

As a hypothetical example, what if “a father raped his daughter and they bill his insurance,” she said. “He’s going to know they went to the hospital. It will say on the explanation of benefits a sexual assault exam.”

House Bill 626 closes what some have called a loophole in current language. It says, “A medical facility or medical professional that performs a forensic medical examination shall not bill the victim, the victim’s personal insurance, Medicaid, Medicare or any other collateral source for the examination and other eligible expenses.”

Reps. Edward Goodwin, R-Chowan, and Billy Richardson, D-Cumberland, are sponsoring the bill.

While Phelps said she doesn’t often see billing problems for sexual assault exams, “when I do have someone who comes to me for help with billing, it is an ongoing process that can take months of interactions with long breaks in between.”

Victims may receive negative marks on their credit if they don’t pay the bills, which were never supposed to be issued in the first place under current state and federal policies and laws.

Reports from WRAL last year show that Fayetteville-based Cape Fear Valley Medical Center billed more than a dozen patients for their sexual assault exams, for thousands of dollars in some cases.

Deanne Gerdes, executive director of Rape Crisis of Cumberland County, said the hospital continues to bill victims.

“As of now, we are telling victims that if they go to the hospital to get a rape kit done, they will be receiving a bill,” Gerdes said. 

“We tell victims that so they are not surprised or retraumatized when that comes in, and we tell them to bring that bill to us and we will help them through victims compensation through the state of North Carolina.”

In a statement sent to Carolina Public Press, a hospital spokeswoman said the hospital doesn’t bill patients for forensic examinations or rape kits, and the state reimburses the hospital for the forensic exam. But it does bill for other services during the visit.

“If a rape victim requires other medical services in addition to the forensic exam, we treat those needs and bill for those services, as we would for other patients needing care,” said Cape Fear Valley Medical Center spokeswoman Chaka Jordan. “Rape victims are eligible to apply for state assistance for charges involving other medical needs.” 

Hospitals can receive up to $800 for each rape kit performed from the state’s Rape Victim Assistance Program if they send in an itemized receipt. Not every hospital takes consistent advantage of the program, including Cape Fear Valley Medical Center, state records show.

CPP filed a records request earlier this year for how much each hospital system was reimbursed from the Rape Victim Assistance Program by year.

In 2016, the hospital was reimbursed $3,514. The year after that, it was $6,126. In 2018, the hospital received $2,383 in reimbursements. Then, in 2019, Cape Fear Valley Medical Center received just $625 from the state. By 2020, that amount climbed to $25,075. This amounts to roughly 68 kits reimbursed over a five-year period based on the average of $552 reimbursed per kit for eligible expenses.

Though they can receive up to $800 for expenses, hospitals have said that amount doesn’t come close to reimbursing the hospital for the hours a nurse may spend poring over a victim’s body for evidence or medicine needed to prevent pregnancy or sexually transmitted infections.

Senate Bill 561, filed earlier this month, increases the amount paid for services to $1,400 from $800. The bill, sponsored entirely by Democrats, provides $1.1 million for the Rape Victim Assistance Program.

The Department of Public Safety, which oversees the Rape Victim Assistance Program, rarely receives complaints about billing issues, said spokesman Matthew Jenkins. Right now, there’s no formal way to complain when a survivor receives a bill from a hospital.

“If a victim has received a bill from a medical provider, the victim should submit the itemized bill to the Office of Victim Services for review,” Jenkins said.

While a mandate for billing shouldn’t be necessary, Gerdes said, she praised the legislation.

“To me this was all about just doing the right thing,” Gerdes said. 

The N.C. Healthcare Association, which represents hospitals all over the state, said it has not taken a position on the bill. 

Protecting state workers

State Treasurer Dale Folwell met with Richardson about rape kit charges earlier this year.  After that meeting, as the administrator of the state’s health plan for 740,000 state workers and their family members, he wanted to know if anyone had been billed for a forensic exam.

“I had, since that meeting, tried to query our data at the state health plan to see how many times this may have occurred and have come to the conclusion that either it’s infrequent or it’s being coded in a way that we can’t see it,” Folwell said. Data for the two most recent years shows no state plan participant was billed, he said. A subsequent review of the data for the last two years shows no state plan participant was billed, he said.

“Even if it happens once out of 740,000 participants … that’s one too many.”

Folwell said he plans to ask the board of trustees for the state health plan to waive all copays and deductibles related to rape kit examinations.

“When you think about the trauma of being raped, and you think about the courage it takes to go to a hospital to determine that, the last thing I want is for women in the state health plan, as infrequently as this may happen, to be second-guessing what the financial implications will be,” Folwell said.

Any state plan member who receives a bill for a sexual assault exam should notify the state treasurer’s office immediately, he said.

Hospitals oppose SANE nurse mandate

Richardson said he intends to amend the bill to also require at least one trained Sexual Assault Nurse Examiner in every county in the state. But the N.C. Healthcare Association is pushing back against that notion.

Hospitals statewide have had “significant nursing shortages,” especially during the pandemic, NCHA spokeswoman Cynthia Charles said, when asked for the association’s position on a requirement for a certified SANE nurse in every county.

“NCHA supports holistic approaches to expand our health care workforce and to provide the support they need to provide excellent care for all North Carolinians,” she wrote. 

“The SANE certification is voluntary and time consuming for nurses to pursue. Simply legislating additional SANE nurses won’t create more SANE nurses.”

Earlier this year, a CPP investigation looked into where Sexual Assault Nurse Examiners work. These nurses have trained and practiced for dozens of hours on what to do when presented with a sexual assault victim. They have also passed an exam that grants them a credential as a SANE nurse.

Not only are SANE nurses experts in collecting the forensic evidence needed for criminal trials, but they also provide crucial moral support for victims who have been through such a traumatic event. They also help victims with medical needs including treatment for sexually transmitted infections and medicine to prevent pregnancy.

Not every hospital has one, and most that do are in urban areas, according to a survey of 130 hospitals and community programs throughout North Carolina. No state agency tracks where these nurses are located, and often, the only way victims find out whether a SANE nurse is at the hospital is upon arrival.

Prosecutors have said they’d like to see higher levels of prosecution for sexual assault. Attorney General Josh Stein told CPP that victims should not have to wait for hours or drive to several hospitals after they’ve been assaulted.

He said victims, no matter where they are in North Carolina, need equitable access to these highly trained nurses. Conviction rates are higher when exams are performed by a SANE nurse, Stein said earlier this year.

“There is a higher conviction rate,” he said, “which makes all of us, the people in the public, safer.”

Cape Fear Valley Medical Center, which serves the fifth-largest county in the state, has several nurses with some training with SANE techniques and one who is certified, according to Jordan.

While there is a grant-funded program to help nurses complete their training and test prep to get certification, all of it can take dozens of hours. Hospitals have said the time-intensive training stretches their nursing staffs when there are already staffing shortages.

“To go to a hospital and not have a competent, trained nurse to treat them and not have the resources to treat them and not take adequate and competent care of the evidence that is needed to prosecute is wrong,” Richardson said.

Kate Martin

Kate Martin is lead investigative reporter for Carolina Public Press. Email her at kmartin@carolinapublicpress.org.

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