In 2017, Christian Ard began to scrutinize the bills for his daughter’s regular psychotherapy appointments. He noticed that besides the roughly $400 charge for the therapy, she was also being charged over $500 for each patient visit.
Even though insurance was covering two-thirds of the cost, something didn’t seem right.
He called his daughter’s nurse practitioner, but she had no idea what the $500 charges were for. The insurance company said it meant his daughter’s sessions had run over 50 minutes—only they hadn’t. UCSF billing said the charges were for documentation but couldn’t tell him what was being documented.
“If you don’t know, why should I pay for it?” Ard recalled asking. The response? “Good health care is priceless.”
“That’s when I said, ‘OK, I’m going to go and file in court,’” he told The Standard.
That decision sent Ard on a yearslong quest to defeat UCSF Health, San Francisco’s leading medical center, in court.
Ard was not alone in his frustrations. Many patients have complained about the high cost of health care at UCSF and the University of California medical system’s opaque billing procedures.
But Ard was persistent and knew his way around small claims court. He fought the bills, and he won.
His path to victory offers a window into the long and, at times, Kafkaesque struggle that can await patients who battle what they believe to be unjustified or inexplicably large medical bills. It’s a microcosm of a larger problem plaguing American health care, experts say.
In a statement, UCSF said that the cost of care is complex and driven by many factors.
“We continuously strive to improve efficiencies to maintain and reduce the cost of the care we provide, and are judged on those efforts by organizations such as the Center for Medicare & Medicaid Services (CMS) as part of its quality assessments,” the university said. “UCSF Health currently has a 5-star rating with CMS, reflecting the highest quality of care.”
Across the United States, major medical centers are expanding, buying up private practices and sometimes becoming near-monopolies in major metropolitan areas.
UCSF itself is poised to acquire two other San Francisco hospitals, St. Mary’s Medical Center and St. Francis Memorial. That will further expand its enormous foothold in Bay Area health care.
Bigger medical bills often accompany that kind of growth. Because of these centers’ enormous negotiating power, they can charge insurers more for the same medical procedures and services.
That’s part of their motivation for purchasing smaller practices, according to Susan Null, who co-owns a medical billing and patient advocacy company, Systemedic.
“It’s just another way for them to add on another layer of expense,” she told The Standard in July.
The higher bills and extra charges—often couched as facility fees—add complexity to a medical system that to many patients feels arbitrary.
Stephanie Rosalie got a crash course in that unpredictability after she and her husband moved from Paris to San Francisco for his work.
In May, their 7-year-old daughter broke her ankle. They rushed her to the UCSF emergency room. The total bill before insurance was approximately $7,000.
Roughly three weeks later, their daughter began to suffer from severe ear pain. Because they did not yet have a pediatrician, Rosalie again took her to the emergency room.
After a quick, straightforward examination, the doctor diagnosed her with an ear infection and wrote a prescription.
Rosalie’s big surprise? The bill was almost the same as the previous time: $7,000. And it was classified as a “level four” visit, a category she found absurdly high. She contacted the family’s insurance company but was told there was nothing they could do, she told The Standard.
Rosalie knew American health care “was expensive, but I thought it was fair,” she said. “What I experienced here is that it’s not fair, it’s not logical and we don’t have a clear answer.”
After a bad batch of fast food chicken sickened Amanda Pablo, she was forced to take a 4 a.m. trip to the emergency room. Her symptoms were so severe that she had her head out the window for the entire car ride to the UCSF Parnassus Heights campus.
When Pablo arrived, she was given intravenous fluids. Three hours later, she felt better and was ready to go home. She says the doctor told her she was fine.
But he also insisted on running more tests with large intervals between them. Pablo estimates she ended up spending 10 hours in the emergency room—and being billed nearly $14,000 for the visit.
After insurance, she was responsible for more than $5,600—a heavy burden for a 23-year-old barely a year out of college.
“Imagine if I didn’t have insurance,” Pablo said. “I would have to pay $14,000 out of pocket.”
Emergency room visits are always on the pricey side. But UCSF patients have complained to The Standard about enormous bills for brief video visits and huge facility fees for in-office tests.
Ard found taking on a medical Goliath was more difficult than he expected.
Initially, it appeared UCSF was going to settle with him. When that failed, they went to court on July 29, 2019.
Ard’s case was not ironclad. His daughter had decided she didn’t want her medical records placed into the publicly visible court records.
But UCSF’s representative didn't bring her full medical records to court either. The representative simply had printouts of the visit records—the diagnosis, the date and the name of the nurse practitioner, Ard recalled.
He, on the other hand, had an email from the nurse practitioner saying she had no idea what the charges of over $500 were for. He explained that he had made multiple calls to the insurance company, the doctor and UCSF Patient Services.
Then the judge reviewed one of the bills.
“He looks at me and says, ‘The documentation [costs] more than the visit,’” Ard recalled. “I said, ‘Bingo! You got it.’”
According to Ard, the judge told UCSF that the hospital has a system for resolving issues like this, but that system didn’t work in Ard’s case. In the end, the judge awarded him nearly $3,400 in compensation.
Even after Ard submitted his demand letter to UCSF—a requirement before you can file a small claims court case—the medical center continued billing his daughter these extra $500 charges.
In December 2019, he took UCSF to court again.
But, this time, he ran into a challenge: When he filed the first case, UCSF Health ACO—the legal entity he was suing—had used a Los Angeles-based company as its agent of service (an individual or a corporation designated by a business entity to receive legal documents, such as lawsuit papers and subpoenas).
Since then, it had changed that agent to a UCSF employee, who listed only a UCSF mailbox for her address.
That distinction was important: The complaint needed to be served to a physical person. Ard believes the change was a calculated move.
In a statement, UCSF said that the entity in question was a Medicare accountable care organization and that its filings had been updated in 2019 to correct the contact information for the person overseeing that program.
Ard tried having the Sheriff’s Office serve the papers to UCSF’s Mission Bay campus, but a deputy was unable to locate the agent of service.
Finally, Ard went back to UCSF Health ACO’s registration documents with the Californian Secretary of State’s Office. Among the documents was a list of entity managers.
“I looked for one who had a unique name so I could look him up and see where he lives,” Ard said. “I sent [a deputy of the Sheriff’s Department]. He knocked on the door and served him the papers.”
That did the trick. UCSF got in touch with Ard and, this time, it settled for an additional $900.
But the experience left Ard feeling frustrated. Initially, he believed the extra $500 charges were a mistake.
“But then as I got deeper into it… I begin to think, ‘OK, maybe this isn't a mistake. Maybe this is how they do business,’” he said. “And people who are going through medical conditions are in very vulnerable positions.”
There was a small coda to Ard’s story.
He believes that UCSF’s decision to change its agent of service violated the rules of the Secretary of State’s Office, which require that person to have a physical address, not just a mailbox.
But when he reached out to the Secretary of State’s Office, an employee told him that it was a “non-regulatory filing agency” that “cannot enforce anything in California,” according to an email seen by The Standard.
So Ard sued the Secretary of State for $40. He alleged that the agency was negligent in its “duty to provide a physical address for service.”
This time, the court wasn’t on Ard’s side.
Matthew Kupfer can be reached at email@example.com