She was questioned, prodded and photographed over the course of six hours. Nurses collected samples of tissue and fluid from her mouth and her body. They took her urine, drew her blood and bagged her clothes. They offered her drugs to prevent pregnancy, HIV and other sexually transmitted diseases. Then, they led her to a private shower and sent her home.

Her life, she felt, was now divided into two eras: Pre-rape and post-rape. Eight days into the shock of this new reality, she received a letter she couldn't comprehend.

The cost of some of the medical services she received totaled nearly $2,000, it said. Insurance would pay $1,400. She would owe the remaining $600 — for her share of the cost of two HIV drugs and two other medications designed to stave off side-effects of those drugs.

She folded the papers, stuffed them in her purse and tried to calm down. A few days later, another bill would arrive, showing an additional $1,700 in charges for her care, including an $860 fee for her visit to the emergency room.

"You never really think, 'Is rape covered by insurance?'" the New Orleans woman said. NOLA.com | The Times-Picayune does not generally identify victims of sexual crimes.

The letter from the hospital was no aberration. In Louisiana, victims of sex crimes often face paralyzing bills for forensic medical exams and related care, even though state and federal guidelines require that many of these services be provided at no cost to the victim. And there's little continuity in how rape victims are treated from parish to parish and hospital to hospital.

While the state's Crime Victims Reparations Fund does permit victims to apply for reimbursement for some medical expenses, there are strict limitations regarding who can qualify, including a requirement that the victim file a police report. Research by the U.S. Department of Justice indicates nearly two-thirds of sex assault victims don't ever go to law enforcement.

Victim advocates worry that prohibitive costs will only increase the likelihood that rape victims will suffer quietly without seeking the medical assistance they may need.

"Sexual assault is already one of the most underreported crimes, period," said Amanda Tonkovich, a counselor at New Orleans Family Justice Center and coordinator of the New Orleans Sexual Assault Response Team. "Even if people don't want to report, we want them to come to the hospital and make sure they're OK, medically speaking."

In New Orleans, rape victims were once examined for free

Last year, a New Orleans college student awoke nude in a public place, disoriented and fearing she had been drugged and raped. Emergency officials responded to the scene and urged her to let them take her to the hospital.

She hesitated. She just wanted to go home. She also worried the hospital charges would appear on insurance statements and alarm her parents, whose health plan she was on. But, she said, the responders convinced her there would be no charge.

A year later, a letter appeared in her campus mailbox informing her that she owed $2,254.

"When I first saw it, I was confused," she said. "It was a known policy that you won't be charged. … To have it just pop right back into my life, it was hard."

At Interim LSU, where trained nurses see about 20 to 25 sexual assault patients per month, nurses until recently were instructed to reassure victims they would not be billed. Although the public hospital was not required by law to do so, it for years absorbed the costs of these exams and all the related medical expenses, area sexual assault victim advocates said.

"Now that's changed," Tonkovich said.

The hospital, Tonkovich said, began billing victims for exams after the state last year turned control of the hospital over from Louisiana State University to a private entity, Louisiana Children's Medical Center, now known as LCMC Health. Recent victims have received bills totaling more than $2,000, Tonkovich said.

Siona LaFrance, a spokeswoman for the hospital, said that Interim LSU does not charge patients for costs associated with the collection of evidence or a pelvic exam. But it does bill for related tests to learn if the victim is pregnant or has HIV, she said.

"We can't speak to the hospital's previous practices prior to the transition from LSU," LaFrance wrote in an email.

Itemized bills for the two Interim LSU patients who spoke to NOLA.com | The Times-Picayune show that in both cases the women were charged for being admitted to the emergency room and for extensive lab work. In one case, the ER charge was $860. In another, it was $421.

Tonkovich said that in order for patients to be seen by Sexual Assault Nurse Examiners at Interim LSU, they must be admitted to the ER. Victims from all over the city are referred by other hospitals to Interim LSU's rape crisis program because of the staff's specialized training.

"It just seems absolutely morally wrong that someone would be charged for this," Tonkovich said. "It's really traumatic to go through a sexual assault. And this just makes things worse."

The college student said the arrival of a bill a full year after her assault not only reopened emotional wounds, it also presented new financial difficulties. Her parents' insurance company informed them it was too late to file such an outdated claim.

"I have good insurance," she said. "It probably would have been covered."

After receiving numerous debt reminders through the mail, the woman last month sent a letter to the hospital's collection company disputing the charge. She has yet to hear back.

Practices vary by parish and hospital

Whether a patient gets charged — and how much — varies according to what hospital they go to, who the admitting staff on duty are, and whether the billing employees know the processes for charging rape victims.

In Donaldsonville, 60 miles upriver from New Orleans, a billing official at Prevost Memorial Hospital said she wasn't aware of any separate laws regarding how rape victims should be charged.

"We usually process it (the examination) as a regular patient," said Jane Arboneaux, business office manager at the 25-bed hospital in Ascension Parish.

In the Lake Charles area, hospitals bill a fund overseen by the Southwest Louisiana SANE program, built on contributions from area law enforcement, parish government and local hospitals. The fund covers the collection of evidence, but does not cover the additional medical tests.

In East Baton Rouge Parish, one woman told NOLA.com | The Times-Picayune, her daughter received two bills totaling more than $4,200 from Our Lady of the Lake Regional Medical Center after being treated there following a violent sexual assault.

"You know what really gets me? Prisoners in Angola get medical treatment for free," the woman said in a phone interview. She did not want her name to be used for fear of identifying her college-age daughter, who has reported the attack to police.

She appealed to Sexual Trauma Awareness and Response, a Baton Rouge advocacy organization for rape survivors, for help getting the bills waived. On Tuesday (Sept. 23), she said, she got word the expenses would be covered by a charitable fund at the hospital. 

What the law says

Under Louisiana law, local coroners are responsible for examining victims of rape and sexual battery. And the state's administrative rules place responsibility for covering costs of forensic medical exams squarely on the shoulders of "the parish governing authority."

But in many cases, such as in New Orleans, cash-strapped coroners outsource that responsibility to another entity, such as the Sexual Assault Nurse Examiner program at Interim LSU Hospital. 

The New Orleans hospital not only picks up most of the costs related to the forensic portion of collecting evidence, it provides the SANE program with personnel, training and a private room. It buys the evidence collection packets known as "rape kits" and, according to Tonkovich, recently purchased a new colposcope, a medical instrument used during such examinations.

The law has never required the hospital bear the burden of any of these expenses. That Interim LSU is now billing victims for rape-related medical expenses outside of the scope of the forensic evidence collection is a jolting departure from the hospital's past practices, Tonkovich said. But the hospital is still going above and beyond to help rape victims.

Not all communities can say the same.

Louisiana is one of only six states that look to local parishes and counties to pay for the exams, according to a report by AEquitas, an organization that provides training, information and technical help to prosecutors in sexual assault cases. Thirty-two other states pay through their state victim compensation funds.

The Louisiana administrative rule that mandates parishes governments pay also says that a forensic exam for a sexual assault victim is "considered an expense associated with the collection and securing of crime scene evidence."

The federal Violence Against Women Act dictates that a victim's access to free forensic exams should not be conditioned upon reporting to law enforcement. The law says forensic exams should include an examination of physical trauma, a determination of penetration or force, a patient interview and collection of evidence.

By that definition, costs for procedures that are a regular part of the SANE screening — pregnancy tests and HIV tests, among them — could be considered extra. And, in many cases throughout Louisiana and the United States, they are.

Under state law, hospitals in Louisiana are instructed to treat sexual assault victims who don't want to report to police as "regular emergency room patients."

"Tests and treatment exclusive to a rape victim shall be explained to the patient, along with the costs of the test," the law says. "The patient shall decide whether or not such tests shall be conducted."

Both of the New Orleans victims who spoke to NOLA.com | The Times-Picayune said they were told they had the right to refuse any services offered during the exam. But neither of them was informed that certain medical procedures could cost them money. In fact, one of the women said it was the first question she asked.

"The triage nurse just said, 'You just need to be seen.' I don't think I asked about the cost again," the woman said.

The Louisiana state administrative rule goes on to say other medical expenses associated with sexual assaults can be 100 percent reimbursed to victims by the Louisiana Crime Victims Reparations Board, but there's a hitch. Such reimbursements are "subject to the provisions of the Crime Victims Reparations Act and its administrative rules."

That means the victims have to file a police report. They can't have had any felonies in the past five years. They can't have behaved in a way that, in the opinion of the board, "contributed to the crime." They can't have been involved in other illegal activity at the time they were victimized. Statistically, that closes out a lot of people.

Only about a third of sex assault victims go to police. And underage drinking is a huge factor in rapes, with the National Institutes of Health reporting that among college students under 21, about 50,000 experience an alcohol-related date rape.

One of the survivors who spoke to NOLA.com | The Times-Picayune said that before she was sexually assaulted, she would have stood with those who advocate rape victims go to police. Indeed, she went to the hospital to give evidence so that she would have a strong case if she decided to press charges later.

But now, as she weighs her decision, she said her lack of confidence in local law enforcement and the criminal justice system makes her feel like there are more negatives than benefits to getting police involved.

"Now, the fear of retaliation is real to me," she said. "Now, the fear of the police not doing a good job is real to me. Now, the fear of the court system taking over my life is real to me."

As angry as she is about these financially debilitating hospital bills, she also is angry that the law as it stands would require her to report her perpetrator in order to be relieved of the debt.

"It feels like a crime happened to you," she said, "and then you're getting charged for the crime."

Something needs to change, advocates and leaders say

Since 2005, Louisiana has received $17.3 million in federal dollars predicated on the idea that victims are not paying any out-of-pocket costs for their sexual assault forensic exams.

Rutha Chatwood, the federal programs manager at the Louisiana Commission on Law Enforcement, said that for years she believed the state was in compliance with a STOP Violence Against Women grant rule that says states or other entities should be picking up the costs.

But about a year and a half ago, she started to hear complaints that victims were being billed.

"We're aware of it," she said. "We have legislation out there, but it's not being followed."

Her agency is working with advocacy groups like Louisiana Foundation Against Sexual Assault and Sexual Trauma Awareness Response to address the issue.

Ebony Tucker, executive director at the Louisiana Foundation Against Sexual Assault in Baton Rouge, said victims should not be dealing with any of these billing-related questions — not for the collection of evidence and not for the related medical care. But the most feasible correction for now is to at least make sure everyone is on the same page when it comes to the forensic exam billing.

"The by-parish system of paying for rape kits is part of the problem," she said.

State Sen. J.P. Morrell, D-New Orleans, said it's something he would like to work on in the session next year. "At the end of the day," he said, "something is going to have to happen to bring uniformity to it, because I don't think any woman who is raped in Louisiana should have to go and research whether they're going to have to pay for it."

Taking help where it comes

The survivor who faced a $600 bill for HIV meds did get good news.

The HIV Outpatient Program at Interim LSU could help cover the out-of-pocket costs of those expensive medications.

Now, she's waiting to see what happens when the hospital bills her insurance for the additional $1,700 for all those other medical services.

Last week, after making some calls, a hospital employee sent her information on how she could apply for financial assistance from the hospital. The material stated that the deadline for applying is 10 days after the ER visit or hospital discharge.

"Otherwise," it read, "you will be responsible for the bill."

She's not holding her breath. By the time she even got the form, it had been far more than 10 days since her trip to the hospital.

Rebecca Catalanello can be reached at [email protected] or 504.717.7701.

Correction: An earlier version of the "By the Numbers" graphic included a wrong figure for the proportion of sexual assault victims who report their attacks to police. Studies indicate one-third of victims go to law enforcement.