‘Not accountable to anyone': As insurers issue denials, some patients run out of options
Two years later, grueling rounds of chemotherapy have slowed the cancer's progress, even as it has continued to spread. But chemotherapy has also ravaged Tennant's body and his quality of life.
Recently, however, the 58-year-old had reason to hope things would improve. Last fall, his wife, Rebecca, learned of a relatively new, noninvasive procedure called histotripsy, which uses targeted ultrasound waves to destroy tumors in the liver. The treatment could extend his life and buy him more downtime between rounds of chemotherapy.
Early this year, Tennant's oncologist agreed he was a good candidate since the largest tumor in his body is in his liver. But that's when his family began fighting another adversary: their health insurer, which decided the treatment was "not medically necessary," according to insurance paperwork.
Health insurers issue millions of denials every year. And like the Tennants, many patients find themselves stuck in a convoluted appeals process marked by long wait times, frustrating customer service encounters, and decisions by medical professionals they've never met who may lack relevant training.
Recent federal and state efforts, as well as changes undertaken by insurance companies themselves, have attempted to improve a 50-year-old system that disproportionately burdens some of the sickest patients at the worst times. And yet many doctors complain that insurance denials are worse than ever as the use of prior authorization has ramped up in recent years, reporting by KFF Health News and NBC News found.
When the Tennant family was told histotripsy would cost $50,000 and insurance wouldn't cover it, they appealed the denial four times.
"It's a big mess," said Rebecca Tennant, who described feeling like a pingpong ball, bouncing between the insurer and various health care companies involved in the appeals process.
"There's literally nothing we can do to get them to change," she said in an April interview with KFF Health News. "They're, like, not accountable to anyone."
While the killing of UnitedHealthcare chief executive Brian Thompson in December incited a fresh wave of public fury about denials, there is almost no hope of meaningful change on the horizon, said Jay Pickern, an assistant professor of health services administration at Auburn University.
"You would think the murder of a major health insurance CEO on the streets of New York in broad daylight would be a major watershed moment," Pickern said. Yet, once the news cycle died down, "everything went back to the status quo."
An Unintended Consequence of Health Reform?
Prior authorization varies by plan but often requires patients or their providers to get permission (also called precertification, preauthorization, or preapproval) before filling prescriptions, scheduling imaging, surgery, or an inpatient hospital stay, among other expenses.
The practice isn't new. Insurers have used prior authorization for decades to limit fraud, prevent patient harm, and control costs. In some cases, it is used to intentionally generate profits for health insurers, according to a 2024 U.S. Senate report. By denying costly care, companies pay less for health care expenses while still collecting premiums.
"At the end of the day, they're a business and they exist to make money," said Pickern, who wrote about the negative impacts of prior authorization on patient care for The American Journal of Managed Care.
For most patients, though, the process works seamlessly. Prior authorization mostly happens behind the scenes, almost always electronically, and nearly all requests are quickly, or even instantly, approved.
But the use of prior authorization has also increased in recent years. That's partly due to the growth of enrollment in Medicare Advantage plans, which rely heavily on prior authorization compared with original Medicare. Some health policy experts also point to the passage of the Affordable Care Act in 2010, which prohibited health insurers from denying coverage to patients with preexisting conditions, prompting companies to find other ways to control costs.
"But we can't really prove this," said Kaye Pestaina, director of the Program on Patient and Consumer Protection at KFF, a health information nonprofit that includes KFF Health News. Health insurers haven't been historically transparent about which services require prior authorization, she said, making it difficult to draw comparisons before and after the passage of the Affordable Care Act.
Meanwhile, many states are looking to overhaul the prior authorization process.
In March, Virginia passed a law that will require health insurers to publicly post a list of health care services and codes for which prior authorization is required. A North Carolina bill would require doctors who review patient appeals to have practiced medicine in the same specialty as the patient's provider. The West Virginia Legislature passed bills in both 2019 and 2023 requiring insurers to respond to nonurgent authorization requests within five days and more urgent requests within two days, among other mandates.
And in 2014, the South Carolina Department of Health and Human Services temporarily lifted all prior authorization requirements for Medicaid beneficiaries seeking rehabilitative behavioral health services.
Federal rules to modify prior authorization that were introduced by the first Trump administration and finalized by the Biden administration are set to take effect next year, with the aim of streamlining the process, reducing wait times, and improving transparency.
These changes were supported by AHIP, a trade group that represents health insurers.
'Sick With Little Recourse'
But the new federal rules won't prevent insurance companies from denying payment for doctor-recommended treatment, and they apply only to some categories of health insurance, including Medicare Advantage and Medicaid. Nearly half the U.S. population is covered by employer-sponsored plans, which remain untouched by the new rules.
For some patients, the stakes couldn't be higher.
On May 12, Alexander Schrift, 35, died at home in San Antonio, Florida, less than two months after his insurance company refused to cover the cancer drug ribociclib. It's used to treat breast cancer but has shown promise in treating the same type of brain tumor Schrift was diagnosed with in 2022, according to researchers at the Dana-Farber Cancer Institute in Boston and the Institute of Cancer Research in London.
But Schrift's insurance company refused to pay. The Right to Try Act, signed by President Donald Trump in 2018, entitles patients with terminal illnesses to try experimental drugs, but it does not obligate insurance companies to pay for them.
In May, Sheldon Ekirch, 30, of Henrico, Virginia, said her parents withdrew money from their retirement savings to pay for treatment denied by her health insurance company.
Ekirch, who was diagnosed with small fiber neuropathy in 2023, was recommended by her doctor to try an expensive blood plasma treatment called intravenous immunoglobulin to ease her near-constant pain. In April, a state agency charged with reviewing insurance denials upheld her insurer's decision. Out-of-pocket, the treatment may cost her parents tens of thousands of dollars.
"Never in a million years did I think I'd end up here," Ekirch said, "sick with little recourse."
Earlier this year, New Jersey congressman Jefferson Van Drew, a Republican, introduced a bill that would eliminate prior authorization altogether. But history suggests that would create new problems.
When South Carolina Medicaid lifted prior authorization for rehabilitative behavioral health services in 2014, the department's costs for those services skyrocketed from $300,000 to $2 million per week, creating a $54 million budget shortfall after new providers flooded the market. Some providers were eventually referred to the South Carolina Attorney General's Office for Medicaid fraud investigation. The state Medicaid agency eventually reinstated prior authorization for specific services, spokesperson Jeff Leieritz said.
What happened in South Carolina illustrates a common argument made by insurers: Prior authorization prevents fraud, reduces overspending, and guards against potential harm to patients.
On the other hand, many doctors and patients claim that cost-containment strategies, including prior authorization, do more harm than good.
On Feb. 3, 2024, Jeff Hall of Estero, Florida, became paralyzed from the neck down and spent weeks in a coma after he suddenly developed Guillain-Barré Syndrome. The cause of his illness remains unknown.
Hall, now 51, argued that the Florida Blue health insurance plan he purchased on the federal marketplace hindered his recovery by capping the number of days he was allowed to remain in an acute rehabilitation hospital last year.
Hall said that after he was forced to "step down" to a lower-level nursing facility, his health deteriorated so rapidly within six days that he was sent to the emergency room, placed on a ventilator, and required a second tracheostomy. Hall believes the insurance company's coverage limits set his recovery back by months - and, ironically, cost the insurer more. His wife, Julie, estimated Jeff's medical bills have exceeded $5 million, and most of his care has been covered by his insurer.
"Getting better is not always the goal of an insurance company. It's a business," Jeff Hall said. "They don't care."
In a prepared statement, Florida Blue spokesperson Jose Cano said the company understands "it can be a challenge when a member reaches the limit of their coverage for a specific service or treatment." He encouraged members affected by coverage limits to contact their health care providers to "explore service and treatment options."
A 'Rare and Exceptional' Reversal
Back in West Virginia, Eric and Rebecca Tennant say they are realistic about Eric's prognosis.
They never expected histotripsy to cure his cancer. At best, the procedure could buy him more time and might allow him to take an extended break from chemotherapy. That makes it worth trying, they said.
As a safety instructor with the West Virginia Office of Miners' Health Safety and Training, Eric Tennant is a state employee and is insured by West Virginia's Public Employees Insurance Agency.
As the Tennants pleaded with the state insurance agency to cover histotripsy, they faced a list of other companies involved in the decision, including UMR, a UnitedHealthcare subsidiary that contracts with West Virginia to manage the public employee plans, and MES Peer Review Services, a Massachusetts company that upheld the insurer's decision in March, citing that histotripsy is "unproven in this case and is not medically necessary."
None of their appeals worked. After KFF Health News and NBC News reached out to West Virginia's Public Employees Insurance Agency with questions for this article, the agency changed its mind, explaining the insurer had consulted with medical experts to further evaluate the case.
"This decision reflects a rare and exceptional situation" and does not represent a change in the Public Employees Insurance Agency's overall coverage policies," Director Brent Wolfingbarger said in a prepared statement to KFF Health News.
In a separate prepared statement, UnitedHealthcare spokesperson Eric Hausman said the company sympathizes with "anyone navigating through life-threatening care decisions."
"Currently, there is no evidence that histotripsy is as effective as alternative treatment options available," he said in late May, after the earlier insurance denials were reversed, "and its impact on survival or cancer recurrence is unknown."
MES Peer Review Services did not respond to a request for an interview.
Meanwhile, Rebecca Tennant worries it might be too late. She said her husband was first evaluated for histotripsy in February. But his health has recently taken a turn for the worse. In late May and early June, she said, he spent five days in the hospital after developing heart and lung complications.
Eric Tennant is no longer considered a viable candidate for histotripsy, his wife said, although the Tennants are hopeful that will change if his health improves. Scans scheduled for July will determine whether his cancer has continued to progress. Rebecca Tennant blames her husband's insurance plan for wasting months of their time.
"Time is precious," she said. "They know he has stage 4 cancer, and it's almost like they don't care if he lives or dies."
____
NBC News health and medical unit producer Jason Kane and correspondent Erin McLaughlin contributed to this report.
Copyright (C) 2025, Tribune Content Agency, LLC. Portions copyrighted by the respective providers.

Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Yahoo
a day ago
- Yahoo
This test can predict how long a middle-aged person will live in just a few seconds
When it comes to longevity, it's not just about living for as many years as possible. The goal is to live healthier, and free of disease or injury, for as long as possible. Healthy aging often boils down to simple habits like exercising regularly, eating a nutritious diet rich in fiber, getting enough sleep, and connecting with others. Even if a person practices these habits, is there a way to know how long they'll live? While there's no crystal ball for lifespan, there is a simple test you can take in middle age that may help predict how many years you have left. An exercise researcher reveals why this test can be a good indicator of longevity and a wakeup call to change your lifestyle. Longevity Tip of the Day: The Sitting-to-Rising Test May Predict How Long You'll Live The sitting-to-rising test (SRT) is a measure of how easy or difficult it is to sit on the floor without using the arms, hands or knees for support or balance, and stand back up again without assistance. The SRT assesses a person's non-aerobic physical fitness, which includes muscle strength, balance, flexibility, and a healthy body composition. These are also all indicators of healthy aging, Dr. Claudio Gil Araújo, a sports medicine physician and researcher at the Exercise Medicine Clinic in Rio de Janeiro, told NBC News. New research led by Araújo shows that a person's score on this test may predict how many years they have left to live, according to a report published in the European Journal of Preventive Cardiology. Araújo's team administered the SRT to 4,282 adults aged 46–75, using a 0-5 point system. A perfect score (five points) required going from a sitting to rising position unassisted. Any time a body part was used to balance or get up, one point was subtracted. The researchers followed up 12 years later and found that the vast majority of people with perfect scores were still alive, compared to less than half of those who scored four points or less. The authors concluded that the SRT was a strong predictor of natural and cardiovascular mortality. While the test doesn't directly prove that a perfect score results in a longer lifespan, 'it is quite reasonable to expect this,' Araújo told NBC News. Why It Matters 'Aerobic fitness is important, but muscle strength, a healthy body mass index, balance and flexibility are also vital for healthy aging,' Araújo said. The SRT is not perfect, but it is a reliable indicator of longevity because it assesses these factors. However, the real value of this test may be that it can serve as a warning sign to start changing your habits. Fortunately, the score you get on the test is not final. Instead, it can give a snapshot of your fitness level and what you need to improve upon — especially if you're in your 50s, which is an ideal time to start building healthy aging habits. If your SRT score is low, you can work on these deficits by building strength and balance to score higher, Araújo said. How to Get Started Always consult with your doctor before trying the test at home, especially if you have underlying health issues or injuries. In order to do the sitting-to-rising test, all you need is another person to keep score (you can use a 10-point system). Here's how: Start from a standing position. Slowly sit on the floor crosslegged without using any other body part to balance. Stand up from this position, without any assistance. Subtract one point every time you use your hand, knee, forearm, or side of your leg to help. If are able to sit down and stand back up with no assistance, you score a perfect 10. If you couldn't get off the ground, you score a zero. A good score would be considered eight or higher. TODAY's Expert Tip of the Day series is all about simple strategies to make life a little easier. Every Monday through Friday, different qualified experts share their best advice on diet, fitness, heart health, mental wellness and more. This article was originally published on Solve the daily Crossword


CNBC
2 days ago
- CNBC
Are 2 to 3 cups of coffee a day too much? It's complicated, experts say: 'It's different for each person'
Two-thirds of Americans drink coffee every single day, according to data collected by the National Coffee Association in 2022, and the debate about how much is too much and whether or not any amount of caffeine is safe persists. But recent research shows that the answer is more complicated than you'd think. A Harvard study, that followed nearly 50,000 women over the course of 30 years and published in June, found that drinking coffee every day may lead to healthy aging in women. One to three cups a day was also linked to heart health benefits and lower mortality rates. But research also shows that high coffee consumption can increase your likelihood of dementia. And a 2022 paper published in the Journal of the American Heart Association found a link between heavy coffee consumption and an increased risk of dying from cardiovascular disease in people with hypertension. Benefits, drawbacks, and the right amount all depend on your individual lifestyle and overall health. And health experts consistently advise that, like with most things, moderation is key for your daily coffee. Deepak Chopra, author, speaker and proponent of alternative medicine, told CNBC Make It in 2023 that he drinks two to three cups of coffee each day before noon. While that may sound like too much caffeine for the average person, it's actually within a healthy range. "Drinking two to three cups before noon is safe to do," registered dietitian Roxana Ehsani said in an interview with CNBC Make It last year. "As long as they don't greatly surpass 400 milligrams of caffeine." Ehsani's suggestion follows the Food and Drug Administration's recommendation of consuming no more than 400 milligrams of caffeine a day, which can include the caffeine found in teas, energy drinks, sodas and chocolate. Certain people may benefit from consuming much less caffeine than is recommended by the FDA. Caffeine tolerance varies from person to person, with some people feeling anxious or jittery after just one or two cups of coffee. "Within those milligram or cup of coffee recommendations, if you start feeling overly tired and the caffeine is not helping, then you've got to stop [drinking it]," dietitian Jessica Sylvester told NBC News. "If your heart starts beating incredibly fast, you've got to stop. It's different for each person." Pregnant people should consider cutting back on caffeine. And people who have diabetes or cardiovascular disease should be mindful of their sugar intake when having coffee, Nikki Cota, a dietitian at the Mayo Clinic, told NBC News. Expert opinion also varies on if teens should drink coffee, but "avoiding caffeine is the best choice for all kids," according to the American Academy of Pediatrics. But for everyone else, if you're having two to three cups, or more, "be mindful of what you're experiencing," registered dietitian Maddie Pasquariello says. And make sure you're not replacing meals with caffeine. Ehsani recommends drinking water or having a meal before reaching for coffee since caffeine suppresses appetite. And if you notice your sleep is affected when you have a coffee in the afternoon, experts suggest a mornings-only rule for your daily latte or macchiato.


NBC News
2 days ago
- NBC News
Patients allege that cosmetic surgeries led to disfiguring injuries
But a joint investigation by KFF Health News and NBC News found that Sono Bello and other cosmetic surgery chains have been the target of scores of medical malpractice and negligence lawsuits alleging disfiguring injuries — including 12 wrongful death cases filed over the past seven years. Injured patients have accused the chains of hiring doctors with minimal cosmetic surgery training, of failing to recognize and treat life-threatening infections and other dangerous surgical complications, and of high-pressure sales tactics that minimized safety risks, court records show. Sono Bello and the other companies have denied the allegations in court. 'These people promise to turn you into the fairest person in the land, and the risks aren't often worth the reality,' said Sean Domnick, a Florida attorney who heads the American Association for Justice, a trial lawyers group. Sono Bello's Centeno disagrees. He said the company's mission is to 'help each and every one of our patients live their best lives now.' Sono Bello offers 'life-changing transformations' that enhance a person's 'appearance as well as their quality of life,' said Centeno, a surgeon himself at the company's Troy, Michigan, office. The doctors who perform such surgeries, court records show, are sometimes paid more for taking on patients with a high body mass, as obesity raises the risk of devastating complications. And as the chains grow, there's little regulatory oversight. While the Food and Drug Administration maintains a database of complaints about drugs or medical devices, there's nothing similar for cosmetic surgeries. Schaeffer had liposuction at Sono Bello in January 2024 and was satisfied with the results. On the morning of March 29, 2024, she went in for more liposuction and a mini-tummy tuck that Sono Bello calls AbEX. The medical staff gave her Xanax, a tranquilizer and the painkiller oxycodone in pill form, according to medical records Sono Bello turned over to Schaeffer's attorney. During the procedure, she received an infusion of lidocaine to numb the area but remained awake. Sono Bello says the local anesthesia is safer and promotes faster healing with ' minimal discomfort,' so patients may return to work or other normal activities within a week. That didn't happen for Schaeffer, who said she felt so much pain during the operation that she began to cry and 'begged' the doctor to stop near the end. 'I said, 'I don't care what I look like,'' she said in an interview. ''I can't handle the pain.'' Two days later she spiked a fever, and a day after that her pubic area swelled up 'severely,' she said. Sono Bello medical staff told her that was normal and that she was fine, she said. Two days later, however, blood and fluid spilled out of her stomach when she got up, she said. On one visit to the office, Herrera told her she required surgery at a hospital to treat her wounds. But, she recounted, Herrera said he couldn't arrange that because he was an obstetrician, not a plastic surgeon, and didn't have hospital privileges locally. Herrera has hospital privileges in the Orlando area, about 140 miles southwest of Jacksonville. 'I was just in utter shock,' Schaeffer said. Sono Bello spokesperson Mark Firmani said the company does not require its doctors to have local hospital privileges, though many do have them. Centeno said Schaeffer's painful experience is not common. 'The reality is that over 90% of our patients who have our procedures completed are extremely comfortable during the procedure and they do quite well,' he said. Patients of Sono Bello and some other clinics also have complained to the Better Business Bureau of unexpectedly painful procedures. Centeno said that Herrera still works for the company, but the doctor's name does not appear on the company's Jacksonville website. Herrera runs an OB-GYN and aesthetics practice, which includes skin care treatments, in Winter Garden, Florida, near Orlando, and is board-certified by the American Board of Obstetrics & Gynecology. Sono Bello has considered him a rising star; Herrera's work in 2023 won Sono Bello's annual ' New Talent Award,' given to a company doctor who exhibits 'exceptional technical skills, productivity, and off-the-charts brand loyalty.' Herrera completed a Sono Bello fellowship program that teaches a 'suite of aesthetic procedures' in a six- to eight-week course under the direction of a company surgeon. The company says the fellowship offers 'patient-focused training in awake total body contouring and skin excision procedures.' Sono Bello allows physicians who have completed formal residencies in more than half a dozen types of surgery to apply for its fellowship. In a post on a Sono Bello website, Herrera said that before taking the fellowship course, he 'had been a skilled surgeon for over 13 years with extensive experience in other areas but limited knowledge on body sculpting.' Herrera did not respond to calls and emails requesting comment and directed Sono Bello to respond on his behalf. Company spokesperson Firmani said Herrera is still a member of the Sono Bello team. Many established plastic surgeons who spoke with KFF Health News and NBC News worry that chain surgery groups may be inclined to spend more effort on marketing and sales than on making sure their doctors are properly credentialed and capable of handling any complications that arise. Medical practices owned by private equity or investment firms have more money to spend drawing in patients, and 'the ability to operate and provide quality patient care is now less important,' said Mark Domanski, a plastic surgeon in northern Virginia. Doctor entrepreneurs Formed in 2008 by entrepreneurial physician Tom Garrison, Sono Bello now runs more than 100 centers nationwide. Private equity investors have pumped $816 million into the company, most of it since 2023, according to PitchBook, which tracks the industry. Sono Bello advertises widely on television and online, aimed at what one major investor termed the ' everyday woman and man.' It has advertised having '150+ board-certified surgeons who have performed over 300,000 laser lipo & body contouring procedures.' Sono Bello limits its offerings to services such as liposuction and its version of tummy tucks, which it believes its surgeons have mastered. It does not perform Brazilian butt lifts, or fat transfers, though many other cosmetic surgery chains do. While Sono Bello boasts that the vast majority of its patients are satisfied, court records show that allegations of substandard medical care have trailed its rapid growth. Sono Bello and its corporate affiliates and surgeons have defended more than 60 medical malpractice cases, including four suits involving patient deaths, since April 2013, court records show. Sono Bello has settled three of four wrongful death cases filed since May 2018, while one is pending, court records show. Schaeffer's suit in Jacksonville is among at least 19 filed since the start of March 2023. Many are pending in the courts, and the company has denied the allegations. Other physicians who have extended their brands to multiple cities and relied heavily on social media and splashy websites to bring in patients have also faced lawsuits. Mia Aesthetics, formed in 2017 by Texas surgeon Sergio Alvarez, runs a dozen cosmetic surgery clinics from Miami to Las Vegas. Mia Aesthetics provides 'the highest quality plastic surgery at affordable prices proving that being beautiful and saving money are two realities that can exist simultaneously,' its website says. Alvarez is a board-certified plastic surgeon. Patients filed at least 30 medical negligence cases against Mia Aesthetics and its affiliates from November 2020 through March of this year, court records show. A dozen suits target its Miami surgery center. The company has sought, and often won, dismissal of malpractice suits because patients signed contracts agreeing to arbitration of any disputes, court dockets show. Alvarez did not respond to requests for comment. Owned by New York physician Sergey Voskin since 2016, Goals Aesthetics and Plastic Surgery has branched out from a small cosmetic surgery office in the Brooklyn borough of New York City to a network of a dozen surgery centers it manages in eight states. Goals clinics and affiliated surgeons have been named as defendants in at least 40 malpractice suits filed from October 2018 through March, court records show. The Atlanta branch accounted for more than 20 such cases in Georgia courts from September 2022 through June 2024. Most are pending. Goals defended two lawsuits brought by the families of New York patients who died shortly after having liposuction procedures, court records show. Goals denied the allegations and won dismissal of some cases by invoking arbitration agreements, according to court dockets. The company says these agreements are commonly used throughout the medical industry. Voskin declined to be interviewed. In a statement, Goals lawyer Joshua Lurie said the medical offices it manages have performed more than 10,000 procedures and have 'one of, if not the highest track records of safety among similar types of medical practices.' Lurie said the 'vast majority' of malpractice claims are 'meritless.' These 'bad faith filings create an implication of risk when none exist and when, again, there is a very negligible negative outcome from surgery compared to the total procedures performed,' he wrote. No Guarantees Malpractice suits by themselves are not proof of wrongdoing. Nobody tracks the outcome of these lawsuits, which often are settled under confidential terms that keep key details out of public view and prohibit patients from discussing their experiences. Surgeons often argue that complications are a risk of surgery and that a poor outcome doesn't mean the doctor was negligent. To prove negligence, injured patients generally must show their care fell below what a reasonably prudent doctor with similar training would have done. That can be a challenge. Typically, the surgery chains fight back by arguing that complications are a risk of any surgical procedure and that they never guarantee results. Before their procedures, patients must sign consent forms acknowledging their expectations must be 'realistic' and that complications or dissatisfaction with the result does not necessarily mean the surgeon botched the job. The American Society of Plastic Surgeons investigates ethics complaints against its members, but not allegations of incompetence or malpractice. Some presurgery contracts allow for low-cost 'revisions' for disgruntled patients. Sono Bello has offered a 'satisfaction commitment,' which states: 'If your surgeon's evaluation determines your results to be deficient, we will touch up the area at no cost to you.' Other contracts contain disclaimers, such as reminding patients that dramatic 'before and after' photos widely shown in online advertisements and other solicitations may not reflect typical results. Demonstrating the influence of social media in driving sales, Goals once required patients to sign a nondisparagement clause. The contract stated that patients who bad-mouth the company on social media without first giving the company 'an opportunity to remedy any alleged issues' agree to pay damages of $10,000 for each violation. In a civil investigation of Goals' marketing tactics, Georgia Attorney General Chris Carr alleged that policy and others violated state consumer protection laws. In September 2022, Goals agreed to stop using the nondisparagement clause and to pay the state $119,480 to settle the matter, without admitting any wrongdoing. Both Goals and Mia Aesthetics have clauses in their service contracts that require arbitration of any disputes in lieu of court action, a process many consumer advocates believe favors the industry. These agreements are becoming more common among plastic surgeons. The arbitration clauses have prevented some aggrieved patients from getting their day in court. That happened in a wrongful death case filed by the family of Angela Mendez, 57, who was found dead in her apartment a day after liposuction at a Goals office in New York City in March 2021. She died from a pulmonary thromboembolism, a blood clot in her lung, as a complication of cosmetic surgery, according to an autopsy report. Her family sued the company alleging negligence. But in June 2024 a judge ruled that Mendez had signed a form requiring that the case be heard in arbitration and dismissed the lawsuit. Attorney Gary Zucker, who represents the family, is appealing. 'It's been a one-two punch for the family,' Zucker said. Goals attorney Lurie called arbitration 'a common practice throughout the industry and many industries' that is 'intended to speed the process to come to resolutions in a more expedited fashion.' In a 2023 deposition, Lurie said patients can opt out of the arbitration agreement, which 'has happened multiple times.' 'A Hard Sell' When Erin Schaeffer first visited Sono Bello, a sales agent told her she was a 'perfect candidate' for a tummy tuck procedure, she said in an interview with KFF Health News and NBC News. Though she wanted to think about it and talk it over with her family, she says the salesperson persuaded her to go ahead. Because cosmetic surgery is elective, insurance doesn't cover it. Schaeffer made a down payment and signed up for a credit plan through outside companies to repay most of the $19,838 bill over a five-year period, according to her medical records. She said she's now paying $420 a month. 'I definitely felt like it was a hard sell,' Schaeffer said. 'She didn't want me to leave out of there without putting money down on it.' Schaeffer said she didn't meet the doctor until about a week before the procedure, and only briefly. Some patients suing other companies have argued in court filings that they didn't meet the surgeon until the day of their operations, a practice that draws sharp criticism from more traditional surgeons. Scott Hollenbeck, president of the American Society of Plastic Surgeons, said patients need time with their doctor to fully understand the pros and cons of surgery and shouldn't be pressured into quick decisions. 'It is not possible to do that when you see the doctor an hour before surgery for the first time,' he said. 'You should have time to process what they told you, think about it, and make a decision.' 'That is best done with a surgeon, not a marketer,' Hollenbeck said. Good Candidates Many plastic surgeons discourage obese people from undergoing liposuction and other cosmetic procedures because of an elevated risk of infections and other serious medical complications. Candidates are considered obese at a body mass index of 30 or above. Sono Bello patients have an average BMI of 31, according to Centeno. At the time of her surgery, Schaeffer had a BMI of 36. But there's no consensus on who should be turned away because of their size — and policies vary. Sono Bello says its AbEX tummy tuck can be done safely with a body mass index as high as 42, well beyond the body mass limits for a traditional abdominoplasty done using general anesthesia. The AbEX removes loose and sagging skin around the stomach 'to achieve a more toned and sculpted look,' according to the company. Centeno said that high BMI 'does confer additional risk, which can be managed.' But he said it would be 'discriminatory, unethical and inappropriate for Sono Bello or any other medical practice to deny care to a patient based solely on their BMI.' Yet high-BMI patients have alleged they suffered devastating complications, according to KFF Health News' review of court cases filed against Sono Bello and other companies. One patient is Marissa Edwards, then 45, a California medical receptionist with three children. At 5 feet, 3 inches tall, she weighed 237 pounds, with a body mass index of 41. She had AbEX and liposuction at a Sono Bello clinic in San Diego on Oct. 11, 2022, according to court filings. During an office visit eight days later, she complained of swelling and pain in her abdomen, but a nurse 'dismissed her complaints,' according to the suit. On Nov. 4, Edwards noticed the incision was opening, while a rash formed around her belly button. In a text to Sono Bello, she attached a photo of her wound, which, the suit alleges, should have alerted the staff that it needed 'immediate evaluation by a qualified medical professional.' On Nov. 5, she woke up 'feeling extremely hot' and 'nearly fainted,' according to her complaint. Her husband drove her to an urgent care center, which diagnosed her with sepsis and rushed her to a hospital by ambulance. When she awoke the next morning, her bedsheets were soaked with body fluid. As she stood up, 'fluid began to pour out of her stomach and hit the floor,' according to the complaint. She spent six days in the hospital. Edwards alleges in her lawsuit that Sono Bello's medical staff failed to recognize and respond to early signs of trouble. 'I have sepsis and could have died,' she texted to Sono Bello's office line, according to court documents. 'I am very upset.' In one text that was included in her lawsuit, she wrote: 'So I would appreciate some type of empathy from you!! If you only knew what I have been through and you went through this I'm sure you wouldn't be giving me this snotty attitude.' Sono Bello denies any negligence. In a court filing, the company noted that infections are a risk of surgery, and that Edwards had signed a consent form that stated in part: 'The practice of medicine and surgery is not an exact science and results are not guaranteed.' Sono Bello filed a motion for summary judgment that argued her care was not negligent and 'not a substantial factor' in causing her alleged injuries. The case was settled earlier this month under confidential terms. Value Units While patients with high BMI are riskier, they also are more lucrative for Sono Bello surgeons, court records show. The company pays its surgeons for procedures based in part on the patient's BMI, using a formula it calls a 'surgical value unit.' The compensation plan surfaced in a lawsuit filed in December 2023 by Shirley Webb, then a 79-year-old Nevada woman. Hoping to slim down for a dream cruise, she paid $14,703 for an AbEX tummy tuck and liposuction of her stomach at the Sono Bello branch in Las Vegas. Eighteen days after her operation, she was 'oozing and bleeding' from her surgical wounds and her son rushed her to a hospital, where doctors diagnosed 'severe sepsis with shock,' according to the complaint. She spent several months in hospitals and rehabilitation care, running up medical bills of more than $2.6 million, her lawyer stated during a deposition. Lloyd Krieger, a California plastic surgeon who served as a medical expert for Webb's legal team, said the operations never should have happened because she was at 'very high risk for multiple procedures given her advanced age and high BMI,' according to the suit. In a court deposition, Sono Bello surgeon Charles Kim testified that operating on Webb earned him 'surgical value units' that boosted his pay to about $2,000 for the procedure. Sono Bello and Kim denied Webb's negligence claims and the parties settled the case in early 2025 under confidential terms, court records show. Centeno said Sono Bello surgeons are paid more for higher-BMI patients because they 'require additional work and additional complexity in terms of decision-making.' He added that 'our high-BMI patients routinely undergo our procedures safely with an extremely high patient satisfaction rate.' Schaeffer said people hoping to reshape their bodies need to do a lot of research before plunging ahead with plastic surgery. She said she was hoping to get rid of excess skin and fat after dropping 100 pounds. Instead, she missed seven weeks of work recovering from her tummy tuck in Jacksonville. 'I went into this procedure to try to make myself feel better after losing the weight, and I came out with something even worse,' she said. 'I trusted. I believed in what they told me, which I think most people do,' Schaeffer said. 'Not anymore.'