By Emily Witt
and Ben Protess
Huffington Post Investigative Fund
When a woman is raped, police turn to scientific evidence — semen, blood and tissue samples — to identify her attacker. The evidence is collected through a medical exam of the victim, who is not supposed to pay for this crime-solving process.
But 15 years after Congress passed a law to ensure that rape victims would never see a bill, loopholes and bureaucratic tangles still leave some victims paying for hospital expenses and exams, which can cost up to $1,200.
Congress requires state or local authorities to cover these costs, but the state legislatures that regulate the process offer piecemeal guarantees of Congress' mandate, ProPublica and the Huffington Post Investigative Fund found. Some states allow hospitals to bill the victim's insurer. Confusion in California and other states may cause police to occasionally ignore Congress' rules and require victims to cooperate with an investigation before exam costs are covered. Lax enforcement of the law, victims' advocates say, also means some hospitals in Illinois bill victims directly.
Congress created the Violence Against Women Act to protect victims and encourage them to report rapes. The law, known as VAWA, has forced many states to crack down on billing problems.
But ambiguities in the law still allow a remarkable disparity in the legal system: Some rape victims, unlike victims of other crimes, have to pay for basic evidence collection.
"We never ask a robbery victim to pay for the cost of fingerprints," said Sarah Tofte, a researcher with Human Rights Watch, which has been tracking how states comply with VAWA.
As a victim recovers from her assault, the last thing she needs is a bill for her exam, said Katherine Hull, a spokeswoman for the Rape, Abuse and Incest National Network.
After all, she said, "rape is not something you can budget for."
Despite billing concerns, Hull and other advocates encourage victims to get a forensic exam. Many emergency rooms have specially trained nurses who swab, scan and photograph victims' bodies, hunting for evidence.
Yet states vary in how proficiently they process the evidence and medical bills that follow. As we previously reported, even if the state pays for an exam, there is no guarantee the evidence will be tested. There are more than 350,000 untested DNA samples backlogged in police departments and crime labs nationwide, according to federal statistics.
Kellie Greene, a rape victim who battled collection agencies in the 1990s because she refused to pay for her exam, is disappointed that victims still find themselves saddled with hospital bills and testing delays. "It's a frightening thought," said Greene, who runs the advocacy group Speaking Out About Rape.
An opportunity to strengthen VAWA will come soon because Congress must reauthorize the law before it expires in 2011. In a statement to us, Sen. Patrick Leahy, D-Vt., the Judiciary Committee's chairman, said Congress "will need to carefully consider what can be done to improve and strengthen the Act."
Revisions to VAWA, Leahy's statement said, "should include providing every possible assistance to victims, regardless of where they live."
It's unclear whether Republicans on the Judiciary Committee would support VAWA reform. We called and e-mailed a spokesman for Sen. Jeff Sessions, the committee's ranking Republican, and never heard back.
Some states and police departments have a history of skirting their responsibility to pay for forensic exams, we found in an analysis of state statutes and from interviews with policymakers and victims' advocates.
Last year's presidential race exposed the shortcomings. During the campaign, it came to light that until 2000, police in some Alaska towns charged rape victims or their insurance companies up to $1,200 for forensic exams — including the town of Wasilla where vice-presidential candidate Sarah Palin was mayor from 1996 to 2002.
Justice Department officials also have found that, until recently, some states refused to pay for a rape victim's exam unless she agreed to file a police report, which some victims are reluctant to do immediately after the attack.
In 2005, Congress revised VAWA  to hold states more accountable. This time, Congress required state or local officials to pay for forensic exams even if a victim declined to cooperate with police. States that didn't comply would lose federal crime-fighting grants.
The new rule went into effect this January with some marked successes.
By June, only five states were still billing victims who didn't file police reports, according to the Justice Department. By early July, that number had dropped to one. Now department officials say every state is complying.
But the department still hasn't verified that all of the nation's 15,000-plus law enforcement agencies are following Congress' mandate. After hearing about complaints from victims, the department contracted an outside advocacy group to more closely track these agencies, a Justice Department official said.
One problem the agencies are facing, interviews with police officials and advocates revealed, is lingering confusion about the new VAWA changes. When we first contacted the Nebraska State Patrol, a spokeswoman said it bills rape victims or their insurance companies if victims decline to cooperate with an investigation. When we reported this to the Justice Department, it notified the Patrol and determined that the spokeswoman had been given out-of-date information and that Nebraska is following the mandate.
While California is considered in compliance with VAWA's new mandate, the state requires law enforcement agencies to authorize and pay for exams. Even a victim who doesn't want to press charges must report the assault to get her exam covered. If she doesn't call the police, or if the police don't authorize her exam because they aren't investigating her case, hospitals will charge the victim, several advocates and a forensic exam nurse told us.
A spokeswoman for the California Emergency Management Agency, which is responsible for implementing VAWA requirements, said her agency has not received any specific complaints about hospitals billing victims.
Even states that abide by VAWA can take advantage of its loopholes, leaving victims without the full protections that lawmakers intended.
Texas authorities pay for an exam only if the victim reports her attack within four days — a time limit that could exclude some victims and viable evidence, experts say. VAWA doesn't address how long victims have to get their exam, so technically Texas is complying with the law.
Illinois requires hospitals to bill forensic exams to a victim's insurance company, although the state covers exams for the poor and uninsured, as well as co-pays and deductibles for everyone else.
Maryland law leaves the billing issue open to interpretation, because it doesn't explicitly prevent hospitals from billing insurance companies. Although VAWA clearly intended that states or local authorities pay for exams, both Illinois' and Maryland's policies comply with the law.
Kellie Greene, whose forensic exam was eventually paid for by Florida's victim compensation fund, said insurance loopholes could discourage victims from getting exams. A young rape victim might not want her parents, who hold the insurance policy, to know she was attacked, Greene said. Cases are further complicated if a family member is named as the attacker.
Greene also noted that insurance companies could deny a victim coverage for future ailments seen as "preexisting conditions" resulting from her rape, including sexually transmitted infections.
VAWA also does not require states to cover non-forensic medical expenses, including ambulance rides, emergency room stays or treatment for injuries sustained during the assault.
At least one state, West Virginia, won't cover emergency birth control or emergency medication to prevent HIV and other sexually transmitted infections.
Jeffrey Kessler, chairman of West Virginia's Senate Judiciary Committee, said he doesn't recall any efforts to change this law and suspects the provision was included for budgetary reasons.
"It would seem to me to be archaic and something we would take a look at," he said, adding that a victim willing to press charges could apply for assistance from the state victims' compensation fund.
While these states are technically compliant with VAWA, they are dodging the spirit of the law, said Jennifer Pollitt-Hill, former executive director of the Maryland Coalition Against Sexual Assault, which helped implement the new VAWA requirements.
"States are settling for the letter of the law rather than doing what's best for victims," Pollitt-Hill said.
Much of the confusion over who pays for what stems from overlapping layers of bureaucracy, Pollitt-Hill said. Hospitals must navigate federal, state and local rules, causing "confusion within states about how it's done," she said.
In Illinois, victims' advocates complain that some hospital billing departments occasionally send exam bills directly to victims — a problem VAWA was supposed to prevent. At least three Chicago hospitals send repeated bills to victims who don't pay and turn over some to collection agencies, said Kris Krafka, a legal advocate at Life Span, a Chicago-based nonprofit that helps domestic violence and rape victims.
Part of the problem, Krafka said, is that billing departments often don't know which patients are rape victims because hospital paperwork might not include that information.
The billing problems don't appear to be malicious, Krafka said, but the process hurts victims nonetheless. "It's going to keep happening unless there's repercussions for hospitals when they do the wrong thing," she said.
The problem has been known for years, according to Rape Victim Advocates, a nonprofit that is contracted by 12 Chicago-area hospitals to provide crisis support for rape victims.
We asked the group to review its files from this year to determine how often it gets reports of hospital billing problems. Between January and June, it received about 20 complaints from victims who were billed for hospital services, which typically include an exam, lab tests and treatment for injuries, said the group's executive director, Sharmili Majmudar.
Once the group notifies a hospital of a billing problem, the hospital usually stops pursuing the victim, Majmudar said.
"We make every effort to ensure all [our] patients are treated in accordance with the law," said a spokeswoman for Northwestern Memorial Hospital in Chicago, one of the city's largest private hospitals. "If a rape victim has inadvertently been billed for a forensic exam or rape kit, we ask that they contact the hospital's billing department to have the charge removed and any payment refunded."
Annie Thompson, a spokeswoman for the Illinois Department of Healthcare and Family Services, which reimburses hospitals that bill the state for forensic exams, said the department has received only a "handful" of complaints about hospitals mistreating rape victims in the last 10 years, though she acknowledged that the department doesn't keep a record of all the complaints it receives.
"In the rare occasion when an eligible survivor is billed for sexual assault-related services, [the department] works to quickly resolve these errors," Thompson said.
Victims' advocates contend Congress needs to bolster VAWA to rid it of loopholes that make for unfair billing.
Policy experts also have suggested that lawmakers craft incentives for states to comply with VAWA rather than threatening financial cuts to law enforcement grants if they don't.
Meanwhile, advocates and law enforcement officials agree that rape victims must not be deterred from getting an exam no matter the cost.
"An exam gives a victim more breathing space and options," said Pollitt-Hill, the former Maryland advocate. "You might decide a week later that you don't want to have it tested, but at least you have the choice."