The 2021 Leapfrog Hospital Survey now includes two sets of questions regarding ethical billing and disparities in care.1

“Patient safety begins with a respect for the dignity of every patient. Part of respecting dignity is to treat people with compassion and fairness in billing for care. Part of that is treating people equitably,” says Leah Binder, president and CEO of The Leapfrog Group.

From a health equity standpoint, hospitals are asked if they stratify their data to monitor potential inequities in the delivery of care; and if so, what they do if those issues are observed. “When we set standards for safety and quality, those standards apply to all patients, regardless of race, ethnicity, sociodemographic status, disability, LGBTQ status, language, or other factors known to disrupt quality,” Binder explains.

The Leapfrog Group wants to see hospitals ensuring bias is not undermining the quality of care delivered to particular patients. From a billing standpoint, fear of costs prevents some from seeking needed care. Unfair, unethical billing processes exacerbate stress and compromise decision-making. “We recommend ethicists work with CFOs and others on the ‘business’ side of hospitals,” Binder says. Ethicists can do this in a few ways:

Help finance leaders align their practices with ethical standards for patient respect and quality of care. Ethicists can look at whether hospitals alert patients to out-of-network services at in-network hospitals before the service, if the price the patient will need to pay is available in advance, if the hospital provides an itemized bill that patients can understand, and if the hospital does all it can to ensure options for charity care and discounts are clear.

“Ethicists should monitor collections practices like suing patients to assure they meet standards for ethical business practices,” Binder offers.

Review patient complaints to identify underlying ethical issues. A patient might receive a bill he or she does not understand or believe contains an error. “Or, a patient might get a bill for care that was needed because of a medication error, and the patient doesn’t want to pay the extra costs,” Binder says.

Work with hospital boards when billing and equity policies are undergoing updates. “The business of healthcare is bound to the same ethical standards as the clinical side,” Binder emphasizes. 


  1. The Leapfrog Group. The Leapfrog Group announces changes for 2021 Leapfrog surveys of hospitals and surgery centers. March 10, 2021.