By 1968, ECF costs were up to $500 million, and HEW decided drastic action was required to scale the program back. They distributed "Intermediary Letter 371," which listed a number of "required" services which had never before been required and warned the insurance companies that administered the program (the intermediaries) that they should err on the side of denying, rather than approving, Medicare claims. Since Medicare claims are not reviewed until some time after the services have been delivered, thousands of elderly people and their families suddenly found out that Medicare was not going to pay for services they had already received, and which they had believed Medicare would pay. Nursing homes had to issue bills to the families asking for payment long after the fact, and thousands of residents and families had to scramble to find the money to pay for it. Estates of deceased residents had liens or garnishments placed on them, and some residents were discharged for nonpayment. Many never did pay, and the nursing homes ended up with uncollectible accounts that had to be written off. To illustrate the drastic change that took place, Medicare denial rates shot up more than 600% between early 1968 and early 1970.