
The Medical Bill “Negotiation Lab”
It’s often possible to negotiate medical bills. It sounds hard, and it can be, but what if we got it down to a science? Mapped out all the moves ahead of time? Jared Walker and his team at the nonprofit Dollar For are running a big experiment to see if they can do just that. And we got to visit the lab.
The folks at Dollar For caught our attention, and lots of other people’s, when they went super-viral on TikTok with a 60-second recipe for crushing medical debt by accessing charity care, financial assistance that most US hospitals are legally required to offer. That was early 2021.
Next, a group of whip-smart volunteers helped Dollar For develop a user-friendly system to help folks apply for that assistance. Dollar For also started holding open trainings on Zoom, teaching people the ins and outs of applying for charity care, and helping others to do so. They say their work to date has helped erase more than $18 million in medical debt.
But lots of people who can’t afford their medical bills don’t qualify for charity care. So Dollar For is trying something new: what they’re calling a “negotiation lab” for gaming out the best way to negotiate with hospitals and debt collectors.
We listen in on one of Dollar For’s real-life negotiations with a debt collector and take notes.
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Dan: Hey there. If you’ve listened to the show for a while, you may remember our pal Jared Walker. And if not, you should meet him. He’s the guy who went super-viral on TikTok, with a 60-second recipe for crushing medical debts, starting with the fact that non-profit hospitals— most U.S. hospitals — are required to have financial assistance, or charity care, policies
Jared Walker: This is going to sound weird But what that means is that if you make under a certain amount of money, the hospital legally has to forgive your medical bills.
Dan: The video got seen about ten million times in its first few days, and a lot more after that. At the end of it Jared offered to help folks apply, and two things happened: He got a TON of requests for help… and he got a bunch of super-smart, super-committed volunteers to help him provide that help.
That was last year. Those volunteers helped Jared build a whole system for getting people help quickly. And Jared started holding open trainings on Zoom, teaching people how to help other people apply for financial assistance. It was really impressive to watch.
All of that would be a lot. But this year, he’s launched into something potentially bigger. A grant let him hire a couple people for yet another project ‚Äì to help people they hadn’t been able to help before.
And honestly, so far, this new project has been harder than they thought. But they’re learning a ton along the way. And some of what they’re learning is immediately useful for us.
So let’s go.
This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge, so our job on this show is to take one of the most enraging, terrifying, depressing parts of American life and bring you something entertaining, empowering and useful.
Here’s Jared’s new project. He figures about a third of people in the U.S. could qualify for the type of financial assistance from hospitals that he’d been focusing on so far — there are income cutoffs. And a third is a lot of people. But a lot *more* people than that could easily get stuck with a medical bill they can’t pay, even if their income isn’t low enough to qualify for that assistance.
Jared: these are the people that, you know, they get the $5,000 medical bill, it’s like a game changer.
Dan: This is a lot of us: We have deductibles in the thousands of dollars, and we don’t have thousands of dollars just lying around.
And here’s the other thing: A lot of the time, if you can reach the right person, whoever is sending you that bill may be willing to settle for less. To make a deal.
Jared wanted to pair patients with skilled advocates who could help get that deal made. Which sounded great to me: I’d love to have someone experienced on my side. Someone who knows how this stuff works. Someone who isn’t ME, shaking in my boots.
Jared: that’s what we hear from patients. It’s like you know, I have anxiety about this. I’m, I’m terrified.
Dan: Jared had been testing out taking on these cases himself, and he liked how it was going.
Jared: I was on a call and, and we got to know, you know, it was just like a flat-out no, there’s nothing we can do. And, uh, you know, we, we hang up and I call the patient back and patient’s super down and it’s like, oh, like, thanks for trying.
And I was like, Like, no, we’re calling again. I’m just going to ask for somebody else. Like, I don’t, I don’t give a shit that they said that, you know, it’s like, because I know that something can be done. I, you just got to get to the right person or, you know, whatever.
Dan: I got to observe the program in action.
Oh, and I got to meet Jared in person when my family was on the West Coast this summer.! We met up in Vancouver, Washington, where Jared lives and works, and I saw the office where he shot that original TikTok video,
Before we went in, he let me know: He hadn’t been there himself for months. He and his wife used to live just a three minute walk away, in a tiny apartment, but last winter they moved. Their new place is farther away, and he’s got some space to work there.
So he wasn’t sure exactly what we’d find when he opened the door.
Jared Walker: I’m nervous about this. Oh yeah. It’s a shit show. Here it is. Wow. all my plants have died. Oh, it’s a ghost town.
Dan: Jared collected his mail, and we walked over to a park to talk. One big update: The system that Jared and his team have built for their original hospital charity-care project has continued to get more sophisticated.
These days, You go to his group’s website— dollar for, dot org — and plug in your information to see if you qualify for financial assistance according to your hospital’s policies.
Jared Walker: now, if you’re found eligible on our website, you have two choices. Do you want us to do this for you? Or there’s a self-advocacy track where they can just take the info and run and we give ’em all the, you know, tips, tricks, tools to do it.
Dan: The resources are cool. And if you get stuck, you can get help from a volunteer by text, or on the phone— and you can always say, “This is too tough. Can you guys take over?”
If you want Dollar For to file your application, that’s handled by someone on staff: you’re handing that person your bank statements and stuff like that.
Jared says they’ve cleared more than 18 million dollars in medical bills this way— closer to 19 million.
And I should mention: Patients never get charged a dime for this assistance. Dollar For’s doing it for free.
But now there’s a new issue: Finding more people to help. Jared says they can now can serve hundreds of people a week. And most weeks, they don’t get nearly that many requests.
Jared Walker: So, uh, like priority number one right now, other than just, you know, getting the money to make sure we can continue the work is how do we get more patients?
Dan: It’s so interesting cuz a year ago, right? You’re the question was like, how will we ever clear the backlog?
Jared Walker: yeah, yeah.
Dan: And now you’re like, how can we get, how can we build the pipeline?
Jared Walker: Yeah. I mean, it’s weird too, cuz like at that point I was thinking, how do we ever build capacity to, to meet this need? And if that were to happen today, I don’t think we would miss a single patient.
Dan: I mean, this is a GREAT problem for him to have. He’s looking at collaborations with groups that have relationships with lots of patients — like associations for specific conditions — who could use Dollar For’s help.
And he’s thinking about PR, and other ways to get people’s attention, beyond TikTok.
Jared Walker: Like, who’s on TikTok, young people, like who has medical bills, a lot of old people have medical bills. Like how do we reach out to them?
Dan: Meanwhile, he and his colleagues have spent the last couple months negotiating with bill collectors for people who don’t qualify for help through the charity-care side of things.
And after I got back home, I got to sit in while Jared’s colleague Eli Rushbanks did a little negotiating.
That’s right after this.
This episode of an arm and a leg is produced in partnership with Kaiser health news. That’s a nonprofit newsroom covering healthcare in America. Kaiser health news is not affiliated with the healthcare giant. Kaiser Permanente will have more information about K H N at the end of this episode.
So, here’s where I listen in on what Jared and Dollar For are calling the Negotiation Lab, with Jared’s colleague Eli.
There were limits to what I could tape: It can be a crime to record somebody without their OK— laws are different in every state — and we didn’t know what state the person on the other side of the call would be in. So Eli made his calls by phone, and I listened to his side on Zoom.
For this Negotiation Lab, this experiment, dollar for has been pulling the records of people who filled out the form at dollar for dot org and didn’t qualify for financial assistance— and getting in touch with them. When Eli gets this patient on the phone, he explains the setup: they’re gonna try and help her, by negotiation. Another bite at the apple, he says.
Then, it’s down to business.
Eli: So I wanted to get an update from you as to where you are at with your bills. So I wanted to get an update from you as to where you are at with your bills.
Patient: so I have two bills. One that is in collection,
Dan: Both of her bills are connected with the birth of her son about four years ago. Both for around 17 hundred dollars. Parts her insurance didn’t pay. Eli lays out his strategy.
Eli: Usually the leverage that we have for a debt that’s this old is to offer the debt collector, sort of like one in the hand is better than two in the Bush type of type of argument.
Dan: In other words, offer an upfront lump sum that’s lower than the full amount. He asks: Is there an amount that if the collector offered, she’d just say yes to? She’s not sure.
Patient: Um, we’re just kind of, um, living paycheck to paycheck
Dan: Actually, she says her family is paying credit cards with credit cards right now.
Eli says sometimes he can get the debt sent back to a hospital, try and get a deal from them— but this hospital— he’s looking at their financial assistance policy. They’re stingy. That’s probably not going to work. (It’s also probably why she didn’t qualify for financial assistance there in the first place.) So Eli’s thinking: Let’s just call the debt collectors and see what they might do.
Eli: , so does that sound good for you? Yeah. Okay. I can do all the talking with the debt collector. Once you give them permission to talk with me.
Dan: Well, not so fast. In the lab, there’s always something new to learn— new little hurdles that can come up. All the extra steps, the time-sucks. This time, after Eli’s colleague Abby dials the number for the collector, Eli and I sit on hold for a few minutes. Then…
Eli: So the debt collector is saying that they are, uh, not allowed to do threeway calls.
The patient has to tell them to expect Eli’s call, get off the phone, then Eli is supposed to dial in directly. Ten minutes later, Eli gets a text:They’re expecting his call. Or they should be.
Hi there. Uh, my name’s Eli rush banks. I’m a patient advocate at dollar four and I’m calling on behalf of one of our patients who just called in and gave permission for you to talk to me. I’m supposed to speak to an Angela.
There’s a couple minutes of Eli of explaining why he’s calling, on whose behalf, and then another eight minutes on hold. Then Eli’s back to his spiel.
Hi, my name’s banks. I’m calling from dollar four. I believe that you just spoke to a patient. I’m trying to help out,
He gives the name, says he’s looking for information, and then listens…
And is there an expiration date on that offer?
Later, Eli tells me what the other person said next: They were expecting him to be coming to the phone with cash in hand. He clears that up— says he’s just trying to negotiate. Stars asking questions.
Is there interest accruing on this account and when did it, uh, end up in your office
Dan: More questions: Is there an expiration date, when this moves to some other collector? And:
Eli: Do you guys have a policy to, or not to Sue on accounts?
From what Eli says next, it sounds like he’s getting some pushback.
uh, I’m just getting information about, about where we’re, where we’re at. Uh,
Dan: It takes another minute and a half for Eli to squeeze in one last question
Eli: did you guys purchase this from the hospital or was it, was it just referred for collection?
Dan: He confirms: They bought it.
Eli: Okay. Um, alright. That is helpful information for me to have, and I appreciate your time. okay. Bye. So she tried to hang up on me.
This was after Eli’s first couple of questions.
She said my understanding was you were calling to make a payment. You were just asking a bunch of questions about her company.
Dan: oh, wow.
Eli: But we learned a lot
Dan: Eli gets his patient back on the line and explains what he learned:
Eli: I, I talked to the, um, collector and I learned some things that are useful.
Dan: The headline is: They said they’d accept 784 dollars and 48 cents, cash upfront, which is a lot less than the 1700 they’ve been chasing her for.
Eli: Um, so that’s good to know, but I think it’s possible that you, or we could do better than that because we learned that they purchased the step from the hospital
Dan: and that’s good news. It means means they’re not collecting FOR the hospital— not under a contract with the hospital that might limit how much of a discount they can give.
Eli: . So we could offer them anything under the sun and they don’t have to take it, but at least they could take it.
Mm-hmm . Um, we also learned that interest is not accruing and that they, uh, don’t Sue for debts.
Dan: This is also good news. It means that this is a problem that isn’t likely to get worse.
Eli: with the one big exception is that they could always then sell this to another debt buyer down the road who may, may decide that they’re gonna be more aggressive, may accrue interest, and may, may try to Sue for it.
Dan: Eli’s like, what do you think about this 784.48? She’s like— that is a lot better. Maybe I could put it on a credit card.
Eli says he’d hate to see her do that. Then she’d be accruing interest, which isn’t happening now.
Also, if she fell behind on the credit card, she’d get a fresh ding on her credit. This one has already hit her credit report. Eli hopes— best case— maybe he could get it taken off if she settles it with this collector.
He asks her: Is there an amount you might be able to save up— say, if you had a month — that we could try offering them?
She says she could probably get a hundred dollars a week. That’s what they try to put away for an emergency fund.
Eli proposes a strategy, based on what he’s learned from the woman at the collector’s office— and what he knows about how these folks operate.
Eli: So she technically, she didn’t, she wouldn’t gimme an expiration date for the offer of 7 84, 48.
She claims that that had been extended before, which I don’t know if that’s true or not. And so she said, quote, unquote, technically it had already expired, but she would accept it today.
Dan: So, Eli thinks it’s likely that this offer will still be there in a month or two.
And he thinks, if they come back in a month with, say, 400 in cash, there might be a conversation to have. Because if these folks bought this debt? They bought it cheap.
Eli: we don’t know what they purchased this for, but sometimes it’s pennies on the dollar.
So they might have bought this debt from the hospital for, they, they might have only spent a couple hundred bucks on it, if that,
Dan: And right now, they’re spending money: Calling her, sending her letters. Four hundred bucks might sound OK to them. He proposes putting a date on the calendar: He’ll call her again, and if she’s got some cash together, he’ll help pitch it to the collection folks.
Eli: without having any cash to work with today.
I, I think it’s gonna be tough to do much, but we might, we might be close enough to, to get it there then. Okay. Yeah. Sounds good.
Dan: They set a date in late September.
Eli: that gives you about six weeks and we’ll give ’em a call and see if we can, if we can knock it out then. Okay. Sounds good. Okay, perfect. Uh, we’ll talk to you then. Yeah. Have a good one.
You too, right? Okay.
Dan: Eli and I debrief for a minute
Eli: So that’s how, that’s how a lot of those go. a lot of these calls end with that where I, we try to help people kind of coach to a, to a dollar figure they’re aiming for. And we put a, a timeline. We haven’t been doing it long enough to know if those are, if those are gonna work or not, if we’re gonna follow up in a month and if they’re gonna have saved any money,
Dan: He says there are easier cases: Situations where someone’s being chased for seven thousand bucks, say, and they can offer two or three.
Eli: those, those are the ones where it’s more likely, um, these ones where people have no extra money are, are tough.
Dan: It was tough to listen to— tough to hear somebody say they’re putting credit card bills on credit cards. And being chased for medical bills on top of that. I ask how he’s feeling, having been doing this for a couple of months.
Eli: Um, I am, I’m feeling like I have to learn every lesson the hard way. And that’s just how it’s always been. Um
Dan: He says he and Jared — they’ve worked together for years — have always wanted to focus on immediate, boots-on-the-ground ways to help individual people. Access to charity care turned out to be something they could scale up. This is looking different.
Eli: we definitely have successes, but there are definitely things that we run into where I see exactly why all of these like big, successful organizations do policy work because you you’re just, you just can’t , can’t get there, um, for some of these boots on the ground cases and, and if you can, it takes so much time effort, persistence that it, it can’t scale
Dan: This is more or less what Jared told me when we sat on that park bench in July.
When he was getting ready to start the Negotiation Lab, Jared was thinking they’d develop a flowchart, a set of scripts— even videos where they’d use recordings from their own phone calls, to show how negotiation works. A curriculum for self-help, and to train volunteers. Maybe even for an automated system.
But now? He’s not so sure they’ll ever be able to boil it down to a system.
They’ve been working on the flowchart— adding to it every time they run into a new angle— and it’s incredibly hairy. New angles all the time. He pulls out his phone
Jared Walker: I’m trying to log into this flow chart. I wanna show you. Oh, okay. Yeah. Yeah. Uh, what is my password?
Dan: He pulls it up. We look a bubble for the “hospital phase” — where you’re negotiating directly with a hospital, not an outside debt collector.
Jared Walker: , um, draft and send to hospital settlement offer, uh, if they say, yes, we win. Yeah. They say, yes, we went, uh, they say, no, you know, next steps, blah, blah, blah, call the person who denied the negotiation, blah, blah.
And then like, but the reason I say, like, we’re not ever gonna be able to, to systematize this, uh, and automate it is because every single one of these little blocks. is time. And it’s not a little amount of time. It’s like write a letter, wait on, hold, talk to this person, get to the supervisor, like, you know, call the debt collector,
there’s so much time on the phone, they wear you down.
Dan: I mean, not everybody can be worn down. Jared tells me about Steve, who he describes as a volunteer who does not F around.
Jared Walker: He will run a case until he gets the desired outcome. And , they think we’ll just wear him down. And they do, they do it all the time. Uh, but not with Steve now with, you know, if you have, if you have dedicated patient advocates like that, you can usually make a big enough fus, make enough calls, ask for enough exceptions, get to enough supervisors, blah, blah, blah, where it’s like, you know, you, you have a decent shot of some good outcome, but.
But we don’t have time to do that for everybody. And there’s way too many people that need that exact intervention like that, that, and we just, we’re not gonna be able to offer that through a program. Um, so what the hell do we do with it? Um, it’s really hard.
Dan: There’s not enough Steves
Jared Walker: Not enough Steves
Dan: I mean, I’d like to find Jared some MORE Steves. More people who could use this kind of outlet. I think there’s people out there. Somebody I stayed with in Portland—I described this to her, and she was like, “My mom should do this.” Come to think of it, I still need to connect her to Jared.
And Jared, and Eli, and their colleagues, and Steve, and a LOT of other volunteers are every day piling up wins, big and small.
I can see it on their twitter feed: nine hundred and ten dollars and thirty four cents. Twenty-one thousand, six hundred and eighty dollars.
But I get Jared’s point. This is freaking hard.
And: This is why I think it’s smart that Jared and his colleagues are calling this a negotiation lab. They’re experimenting.
And they’re keeping track of what happens. So they can both learn how to be effective and learn where NOBODY can be effective. They’re piling up a big stack of receipts.
Jared Walker: At the end of the lab, I wanna be able to come out with a report, said we had four experts that were working on this X amount of patients to, you know, and this was the impact, but this is how many times our calls were transferred.
This is how many times we were promised to call back and didn’t get one. This is how many times we, this is how much time we waited on hold. This is how, you know, every data point that we could possibly put together and then come out and say, this is why this is bullshit. Cuz then we can , use that data to, to drive some, some real change.
Dan: I am for it. I mean, the big picture with this stuff can be really discouraging. It’s hard to see how to get out ahead of things, beat the system.
But piling up wins is good.
And piling up data can work. You might remember — we covered it on the show— last year, in Maryland, advocates got the state to pass a law saying hospitals couldn’t sue people over medical debts if those people qualified for financial assistance.
Which, I mean, duh. Of COURSE that should be illegal. But they had to fight to MAKE it illegal. And data was ammunition. They pulled a hundred and forty-five thousand lawsuits that hospitals had filed over ten years. And they were able to show who got hit with those lawsuits: Often, people who qualified for financial assistance.
That was in 2021. Since then, Maryland passed another law: Patients who overpaid — who were entitled to financial assistance but didn’t get it— are supposed to get refunds.
These kinds of fights are way too hard. And there are too many of them. But I love to see these victories. We’re stuck living with this terrible system, but we don’t have to accept it.
And we can pass around the lessons we learn in the fight — like: listening to Eli with the debt collector on that call, was basically a lesson. What questions do we need to ask, and what do the answers tell us? We’ll pull together some of those takeaways in a future First Aid Kit newsletter, so look for that in your inbox later this fall. (You can sign up for those at arm and a leg show dot com, slash: newsletter.)
And next time on An Arm and a Leg: Another victory.
Congress actually took action this summer that will, yes, help people on Medicare pay less for prescription drugs. One scholar who has been piling up data, fighting for changes like this, for years, tweeted while the Senate was voting:”Haven’t cried this much watching CSpan in a while.”
We’ll have her with us in three weeks.
Till then, take care of yourself.

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