On July 9, 2016, Justin Zanders, 19, was walking down a San Francisco sidewalk when a pole hanging off the back of a public bus hit him in the face. A video shows the blow knocking Zanders to the ground, rendering him unconscious.

After his accident with the city bus, Zanders woke up in the city hospital: Zuckerberg San Francisco General. He received stitches and a CT scan before heading home shortly after midnight. He spent about four hours at the hospital.

Zuckerberg San Francisco General is a public hospital that is owned and operated by the city — just like the bus that hit Zanders in the face. Even though Zanders had insurance, the hospital’s unusual billing practices held him responsible for $27,660. When he didn’t pay quickly, he says that debt collectors began calling his apartment. The hospital eventually placed a lien on the entire bill.

“I went from being hit in the head by a city bus to being treated at the city hospital, and then I was stuck with the bill,” Zanders says. “It just didn’t really make sense. This was something I didn’t cause, and I feel like it could have been billed to someone else.”

Zanders sued San Francisco and spent two years in court until a jury ruled in his favor, ordering the city to pay his entire bill as well as economic damages.

Zanders is among half a dozen patients who have reached out to Vox since we began reporting on Zuckerberg San Francisco General Hospital’s surprising and aggressive billing tactics.

Patients have described an array of incidents — from bike crashes to climbing-wall falls to emergency surgeries — that have left them under a mountain of debt, despite having insurance coverage.

The hospital — named for Facebook founder Mark Zuckerberg, after his multimillion-dollar donation in 2015 — is the largest public hospital in San Francisco and the city’s only Level I trauma center. But for years, it has been out of network with all private insurance plans — a practice that experts describe as extremely unusual.

Patients frequently did not learn about these unconventional billing practices until after a visit and a bill for tens of thousands of dollars arrived. The same care would likely cost them significantly less at other hospitals.

After Vox reported on these practices, San Francisco Mayor London Breed announced on February 1 that the hospital would temporarily suspend these billing practices as the city works toward writing a new, more patient-friendly policy.

The city’s board of supervisors, who oversee the hospital, will also hold a hearing on the issue this Thursday.

Some patients who have been fighting bills for months say that since the announcement, they’ve received calls canceling their debts altogether — resolving bills that, in some cases, they spent nearly a year contesting.

In response to questions from Vox about which patients would no longer be held responsible for their bills, Zuckerberg San Francisco General Hospital spokesperson Rachael Kagan said, “There are many reasons that patient bills get adjusted. ... Our patient financial services team works with patients to help resolve bills. Most of the time, this is successful, as apparently happened in the case you are referencing.”

But for patients still facing steep bills, it’s unclear what happens next. Those interviewed by Vox say they have struggled to get answers from the city. None report receiving notices from the hospital that their bill had been placed on hold. And many are wondering: What happens next?

Hit by a city bus — and with a $27,660 hospital bill

Zanders moved to the Bay Area shortly after graduating high school in rural Louisiana. He was attending a community college, playing football for his school, and working part time for a catering company. He had aspirations of playing football at a university and even had scouts from the University of California Berkeley coming to watch him play.

On the day of the accident, Zanders had gone with a friend downtown to a shopping mall. They were walking back to the friend’s car when a passing bus had an equipment failure that caused a large metal pole that should have been pointing upward to instead jut out onto the sidewalk.

A bus camera caught the incident on video, and shows the poll hitting Zanders directly in the face. He fell to the ground, and a bystander called an ambulance that transported him to the hospital, where he regained consciousness.

“I’m a football player, so I’ve gotten hit in the head a couple of times,” says Zanders. “I know what a hard hit is. But this was nothing in comparison to any hit I’ve taken before. It was pain I had never experienced.”

Zanders received six stitches and a CT scan to check for any brain bleeding before being released home. He ended up at a different emergency room the next day for continued pain and vomiting. Zanders ultimately quit his job as well as his position on the football team, neither of which he could tolerate due to his head injury.

Then the bill came: a $27,660 charge for his emergency room visit. “I was scared,” Zanders says of receiving the bill. “I was an 19-year-old that could barely work because of a head injury, who could barely afford an apartment I was paying $1,800 for.”

Zanders did have health insurance through his father’s policy. The hospital says the insurance paid just over $2,000 for his visit — but records provided by Zanders indicate that the hospital continued to pursue the entire bill, eventually placing a lien on the entire amount.

Zanders ultimately retained a lawyer to sue San Francisco over the hospital bill, as well as for the economic damages the accident caused. The lawsuit stretched on for more than two years. On October 3, 2018, the jury ruled in his favor. The court ordered the city to pay the hospital bill and awarded Zanders a total of $266,740 to cover economic damages as well as his other doctor fees.

Still, the accident — and the ensuing legal fight — has taken a toll.

Since the accident, Zanders has given up on his football career and moved back to Louisiana with his fiancée. They have a 10-month-old daughter, and Zanders works for the state Department of Transportation doing maintenance work on highways.

“We’re engaged, and we were supposed to get married last year, but then things came up with a trial date and we had to push that back,” Zanders says.

“It was a lot of weight on my shoulders, having the bill out there,” he says. “I wasn’t really enjoying my job because I was just thinking, I need to go to pay off my bills. I can’t take any vacations because I have this bill. I was preparing for this mindset of, whatever happens will happen, and I’ll have to deal with it, even if it means getting two or three jobs to do that.”

She tried to go to an in-network emergency room. She ended up with a $28,254 bill anyway.

Nelly Liu ended up at Zuckerberg San Francisco General after falling off a gym’s climbing wall — and she didn’t want to be there.

“When I fell, I immediately knew that I had hit my spine and my head, and that I felt really bad,” she remembers. Liu took a Lyft home but began to feel dizzy and nauseated during the ride. A nurse with her health insurance plan’s triage line advised her to go to the emergency room immediately.

Liu asked if she could go to Zuckerberg General, but the nurse advised against that, noting that it was out of network. So Liu went to the emergency room at the University of California San Francisco instead.

Except the doctors wouldn’t see her there: Liu was considered a trauma patient because of her fall from a high height, and UCSF isn’t a trauma center.

Trauma centers require special certification to provide emergency care for patients suffering very serious injuries above and beyond a regular emergency department. In San Francisco, Zuckerberg SF General is the only Level I trauma center. In other words, it’s the only hospital in the city that would see a patient who’d had an accident like Liu’s.

“The doctor was like, of course you have to go there, why are you even thinking about it,” Liu says. “I argued with them, I told them it wasn’t in network, but they kept saying that I had to go.”

An ambulance ultimately transferred Liu to Zuckerberg, where she received a CT scan and drugs to control her pain.

A few weeks later, the bill came: The hospital charged $39,270.90. UnitedHealth, Liu’s insurance plan, covered $10,873, leaving Liu with a $28,254.90 bill. She has appealed that bill to her insurance plan, asking them to pay more, but that appeal was denied.

“People don’t choose to go to a trauma center,” she says. “I would really love it if the hospital thinks they can do better, if they can retrospectively fix this for other patients who have been impacted.”

The same day that Vox reached out to Zuckerberg San Francisco General about Liu’s bill, she got some good news: The hospital had resolved its payment fight with the health insurer and was dropping the bill.

Kagan, the hospital spokesperson, followed up by email to say, “This case has been in process for a while and has nothing to do with recent media coverage.”

Liu is one of two patients Vox has spoken with who have had their bills dropped entirely in the past week. The other, Griffin Knight, is a 24-year-old San Francisco resident who had an outstanding bill of more than $72,000 for an emergency appendectomy last summer. He received a call last Wednesday that his bill would be dropped, too, aside from the $200 copay he had already submitted.

Patients with outstanding bills — some as high as $10,400 — left in limbo

Officials at Zuckerberg San Francisco General Hospital have said they intend to change their longstanding policy of being out of network with all private insurance, which historically has left patients like Liu and Zanders with significant medical debt.

Previously, the hospital had defended the practice of not being in network with private insurance as necessary to serving those with public health coverage through programs like Medicare and Medicaid.

“We’re the trauma center for the whole city,” hospital spokesperson Brent Andrew told Vox last month. “Our mission is to serve people who are underserved because of their financial needs. We have to be attuned to that population.”

They are expected to roll out details of a new billing policy on February 21, when the San Francisco Board of Supervisors holds a hearing on the hospital’s billing practices.

Until then, some patients are still left in limbo — unsure what they’ll ultimately owe, or how the outstanding medical debt will affect their credit scores.

That includes Angel Scott, a 29-year-old San Francisco resident who went to Zuckerberg San Francisco General Hospital last May. She took an Uber to the hospital from an urgent care clinic, where the staff said they didn’t have the right equipment to diagnose or treat her severe stomach pain.

Scott estimates she spent just under three hours at the hospital, where she received a series of blood tests and a CT scan. She left without a diagnosis — and with a $16,089 bill.

Scott’s insurance paid the hospital about $5,694, leaving Scott with a $10,394 bill she’s been contesting ever since. “The crazy part was nobody told me they were out of network,” Scott remembers. “I was always thinking, I’ve got good insurance, I’ll just pay my copay.”

Scott has spent months now trying to appeal her bill — asking her insurer to pay more and for the hospital to charge less. She’s made multiple trips back to the emergency room, to try to find a physician who can explain her bill to her.

“I’m kind of fired up about it,” she says. “I try to call and talk to anybody I can, document anything I can, and not stop.”

Two weeks ago, she called the mayor’s office looking to find out if the new policy applied to a case like hers. A receptionist transferred her to the city’s department of collections — but they weren’t much help.

“That lady was like, ‘You’re in the wrong department,’ and she transferred me to the hospital,” Scott says. “The hospital then transferred me to their phone directory. The information is supposedly available but, in my experience, really hard to get.”

Kagan, the hospital spokesperson, was able to provide Vox with a little more clarity: She said that the new temporary stop in billing does apply to bills that have entered collection.

When told that patients had received no notice of the new policy and asked why that was, Kagan responded, “We are working individually with patients and insurance companies that have disputed bills. We have announced the temporary halt and encourage any patient with a question to call us.”

Late last week, Scott tried emailing the city debt collector handling her bill to see if she could get any insight into what would happen next — trying to figure out if the billing pause would apply to her case.

The city employee responded over email, “Sorry Angel, I don’t know, I guess we will have to wait.”