41% of Texas Nonprofit Hospitals Bill Patients Before Charity Care Screening

Nearly half of nonprofit hospitals in Texas bill patients for care before determining if they qualify for free financial assistance, according to a new analysis. The review examined the financial assistance policies of all 166 nonprofit general hospitals and children's hospitals in the state.

The analysis found that 41% of these facilities state they screen patients for charity care only after unpaid bills are sent to debt collectors or other aggressive actions begin. Only 8% of the hospitals have policies that require screening patients before sending an initial bill.

Aimee Carlock, a self-employed house cleaner, is one patient affected by this timing gap. In August 2025, Texas Health Resources told her she must pay $5,500 up front to schedule surgery for severe pain and bleeding from her uterus. Carlock said the system would not proceed until payment was made. She borrowed money from family members to cover the cost.

Carlock learned after the surgery that she qualified for hospital financial aid. Her care should have been free, but the hospital system does not issue full refunds. The $5,500 she paid is gone. She has since taken out loans for groceries and utilities and applied for food stamps.

Hospitals possess a tool called presumptive eligibility that allows them to automatically screen patients for aid and grant relief. However, there are few state or federal requirements dictating when or how hospitals must deploy this tool. Neale Mahoney, a health economist at Stanford University, described the current system as broken. He compared the application process for aid to a tax audit, noting it requires patients to provide bank statements, car notes, pay stubs, and divorce records.

Tom Oliverson, a physician and Texas lawmaker, proposed legislation to require hospitals to screen patients before sending a bill. He stated that the industry is not policing itself effectively. In contrast, Anna Stelter, vice president of policy at the Texas Hospital Association, argued that charity care is a relief of last resort. She said hospitals must first pursue other payment options, such as insurance, before granting aid.

Research indicates that the timing of financial aid affects patient health outcomes. A study found that people were more likely to receive diagnoses and make follow-up appointments when aid was provided within weeks of care. A separate study found no health benefit when debts were wiped out after months or years. Ray Kluender, an associate professor at Harvard University who worked on both studies, emphasized that the timing of assistance is extraordinarily important.

About 40% of Texas nonprofit hospitals said they will not inform patients if their balance is cleared after a bill has already been sent. Only 8% require notification. CommonSpirit Health, which owns Southeastern Texas hospitals, declined an interview request. Its policy states that patients will not be notified when their balance is cleared.