Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called , a data analysis by Ñî¹óåú´«Ã½Ò•îl Health News has found. 

The “” group does not reveal its funders or much else — other than to say it is “dedicated to protecting and strengthening Medicare Advantage” and is “powered by hundreds of thousands of local advocates nationwide.” 

“Our campaign provides information and offers tools for concerned Americans to use to reach decision makers,” spokesperson Darren Grubb said in an email. The group has spent more than $3.1 million on hundreds of Facebook ads since September 2024, according to , a database of the social media company’s online ads. 

There’s no doubt health insurers are unhappy with a from the Centers for Medicare & Medicaid Services, or CMS, to keep Medicare Advantage reimbursement rates essentially flat in 2027 — far less than they expected from the Trump administration. 

Medicare Advantage plans offer seniors a private alternative to original Medicare. The insurance plans enroll about members, more than half the people eligible for Medicare. 

CMS is set to announce a final rate decision by early next month. The agency solicited on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views. As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online. 

Medicare Advantage Majority, which says the rate proposal amounts to a “cut” in services and warns of dire consequences for seniors should it go through, accounted for at least 13,522 of the 16,422 published comments as of March 12. 

Critics warn that these sorts of campaigns may create a misleading impression of grassroots support, especially when it’s not clear who is financing them. 

“It puts a different spin on a massive groundswell of comments to know all are being driven by one specific organization,” said Michael Beckel, director of money in politics reform for Issue One, a group that seeks to limit the influence of money on government policy and legislation.

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Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called Medicare Advantage Majority, a data analysis by Ñî¹óåú´«Ã½Ò•îl Health News has found.

The “” group does not reveal its funders or much else — other than to say it is “dedicated to protecting and strengthening Medicare Advantage” and is “powered by hundreds of thousands of local advocates nationwide.”

“Our campaign provides information and offers tools for concerned Americans to use to reach decision makers,” spokesperson Darren Grubb said in an email. The group has spent more than $3.1 million on hundreds of Facebook ads since September 2024, according to , a database of the social media company’s online ads.

There’s no doubt health insurers are unhappy with a from the Centers for Medicare & Medicaid Services, or CMS, to keep Medicare Advantage reimbursement rates essentially flat in 2027 — far less than they expected from the Trump administration.

Medicare Advantage plans differ from traditional Medicare because private insurance companies administer them. The insurance plans enroll about members, more than half the people eligible for Medicare. The plans offer things like vision and drug coverage, but Medicare Advantage insurers restrict the hospitals and doctors that patients can use and require prior approval for various procedures.

CMS is set to announce a final decision by early next month on the rate proposal. The agency solicited on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views.

Medicare Advantage Majority, which says the rate proposal amounts to a “cut” in services and warns of dire consequences for seniors should it go through, accounted for at least 13,522 of the 16,422 comments published as of March 12.

The proposed rate plan “puts my access to care at risk,” the group’s template letter to policymakers reads in part. “If the investment made by Washington in the Medicare Advantage program is nearly flat year-over-year, I could lose benefits I rely on every day, including affordable prescriptions, capped out of pocket costs, and access to trusted doctors and specialists.”

“Medicare Advantage is not optional for me. The cost protections alone have saved me thousands of dollars and made my health care manageable. Without this program, I would face higher costs, fewer providers, and fewer benefits at a time when I can least afford it,” the letter states.

Critics warn that these sorts of campaigns may create a misleading impression of grassroots support, especially when it’s not clear who is financing them.

“It puts a different spin on a massive groundswell of comments to know all are being driven by one specific organization,” said Michael Beckel, director of money in politics reform for Issue One, a group that seeks to limit the influence of money on government policy and legislation.

“There’s no way for the public to know what wealthy donors or special interests are funding dark money groups like this,” he said. “That means there’s no scrutiny of who’s really calling the shots.”

Some health care policy experts, who have long argued that the government overpays Medicare Advantage plans by tens of billions of dollars every year, believe industry groups or their surrogates routinely overstate possible negative impacts of rate decisions they don’t like.

“The plans always say that the sky is falling,” said Matthew Fiedler, a health care policy expert with the Brookings Institution. “The industry has a lot of money at stake here. They try to exert pressure on policymakers any way they can.”

At the same time, even critics concede that some of the millions of people enrolled in Medicare Advantage plans could face service cuts if insurance companies are not satisfied with government payments.

“It is legitimate for people to be worried,” said Julie Carter, counsel for federal policy at the Medicare Rights Center, a group that advocates for older adults and people with disabilities.

Her group argues that Medicare Advantage plans have never attained expected cost savings and instead have been overpaid for years at least partly due to “actions to maximize profits.” She said the health plans “are supposed to be saving money, not taking extra.”

People struggling to pay health care bills may have little use for the policy debate in Washington.

“If it wasn’t for being able to have this program, I really wouldn’t be able to afford any kind of medical services, to be honest,” said EsterAlicia Rose, 75, who works at the front desk of a hotel in Pagosa Springs, Colorado. She said she signed the Medicare Advantage Majority form letter to reach policymakers.

Kathy Lovely-Marshall, 66, a retired nurse who lives in Brookville, Ohio, did too. She said she receives “a lot of perks” from her plan, such as dental care, eyeglasses, and prescriptions.

“All those things are a big plus as far as I am concerned,” she said. “I’m very happy with the plan I have.”

But Corenia Branham, 90, a widow and cancer survivor who lives in Alum Creek, West Virginia, said she wants nothing to do with Medicare Advantage plans run by private health insurance companies. She said she didn’t turn in any of the four form letters under her name, which were posted online by CMS on Feb. 23 and signed, “Miss Corenia Branham Branham.” It’s not clear why her last name is signed twice.

Branham said she’s not on Medicare Advantage and doubts she could count on it for needed care.

“I wouldn’t recommend it to nobody,” she said. “I sure don’t want anything to do with it.”

Grubb, the Medicare Advantage Majority spokesperson, disputed that account. He said Branham responded to an ad on Facebook. On Feb. 6, she “completed the form with her information and chose to send her comment to CMS as well as to her representatives in Congress and the White House,” he said.

Other Medicare Advantage advocacy groups have stepped up ad campaigns as the rate decision looms.

The Better Medicare Alliance, whose “allies” include a range of health insurers, health care providers, and consumers, is urging seniors to “Tell Washington to Stand Up for Medicare Advantage.”

“We’ve mobilized beneficiaries to write letters and make phone calls, and we’ve run digital ads on streaming platforms,” spokesperson Susan Reilly said.

Reilly said that this year roughly 3 million seniors “were forced to find new coverage” because plans either shuttered operations or left some areas.

She also said Medicare Advantage plans have “scaled back” benefits such as offering transportation to medical appointments, nutrition support, and dental and vision coverage, while over the past two years beneficiaries have faced an average $900 increase in out-of-pocket maximums.

“We do view this as especially serious,” Reilly said. “This isn’t a single bad year; it’s the cumulative effect of years of underfunding and policy disruption from the previous administration that has left the program increasingly vulnerable.”

As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online.

CMS spokesperson Catherine Howden said the agency would make more comments public “as soon as practicable.”

“The agency focuses on reviewing the substance of timely submissions and does not speculate on volume, sentiment, or potential impact of comments while the comment period is open/under review,” she said in a statement.

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The American Society of Plastic Surgeons, which represents 12,000 doctors, is now warning patients to “do their homework” before getting liposuction, a Brazilian butt lift, a “Mommy Makeover,” or other cosmetic procedures.

“Plastic surgery is real surgery with real risks, and the risk of complications is never zero,” said Scott Hollenbeck, immediate past president of the plastic surgeons group.

And in an exclusive interview, TJ Watkins, a member of California’s medical licensing board, called for greater transparency in the secretive process for disciplining physicians, saying the board should alert the public about doctors under investigation for alleged misconduct.

Hollenback and Watkins were reacting to the “Body Shops” series, which examined allegations of disfiguring injuries or even deaths tied to cosmetic surgeries.

One story revealed that California plastic surgeon Heidi Regenass had three patients die within a few months after liposuction and fat transfer operations, according to medical malpractice lawsuits filed in California courts.

A complaint to the medical board from a patient’s daughter triggered an internal board review of the surgeon, but the public will hear nothing until the investigation is concluded, which can take years.

“If you were really protecting the patients, there would be a notice right now that says this doctor is being investigated,” said Watkins, one of seven nonphysicians appointed to the medical board to represent consumers.

Regenass, a board-certified plastic surgeon, did not respond to numerous requests for comment on the patient deaths. In response to medical malpractice lawsuits filed by families of the three women, she has denied any negligence or that her actions caused any deaths. One case was settled in 2024, while the two others are pending in California courts.

On Feb. 9, the California medical board filed an against Regenass unrelated to the three patient deaths. The complaint accuses Regenass of “repeated negligent acts” in caring for a 49-year-old woman who had liposuction on her abdomen and arms with a fat transfer to her buttocks in July 2022. The board alleged that the surgeon “failed to document an appropriate physical examination prior to surgery” and did not keep “adequate and accurate records” of the woman’s care. The board requested an administrative hearing on the accusations, though no date has been set. Lawyers for Regenass didn’t respond to a request for comment on the new complaint.

Some patient lawsuits have accused cosmetic surgery companies of hiring doctors who lacked adequate training or had troubled pasts, and of using high-pressure sales tactics and misleading advertising pitches that downplay safety risks, federal and state court records show. The companies dispute these allegations and have won dismissal of some suits. Other cases have been settled under confidential terms, although a Georgia judge late last year to the family of a woman who died after liposuction and a Brazilian butt lift.

Christopher Nuland, an attorney and lobbyist for the Florida Society of Plastic Surgeons, said that the “Body Shops” investigation “underscores the need for vigilance from all parties.”

“There is an opportunity for better legislation, such as regulating post-surgical recovery centers and better enforcement of existing laws,” he said in an email. “But patients need to take an active part by ensuring that they are seeing a board-certified plastic surgeon in an accredited facility and that neither has a history of bad outcomes.”

Nuland said his group supports pending in the Florida Legislature that would require licenses and set quality standards for recovery houses where patients often stay to recuperate for a few days after cosmetic surgery. Florida officials for years to regulate unlicensed facilities that often charge patients hundreds of dollars per night, though they may lack adequate medical staffing.

Cosmetic surgery companies, some financed by , are competing in a growing U.S. body-contouring market in which patients are charged up to $20,000 out-of-pocket, or on credit, for these procedures. Ads promise life-changing body reshaping techniques with minimal risk and .

As the cosmetic surgery companies have grown, there’s been little regulatory oversight. There’s no federal public database to assist patients in tracking these companies’ safety records, their staffing standards, or how commonly patients suffer severe complications. And complaints to medical boards about surgeons or other doctors can remain under wraps for years.

Ste’Aira Ballard, whose mother, Tamala Smith, died in 2023 after Regenass operated on her, filed a complaint with the California Medical Board in early 2025.

In March 2025, the board notified Ballard it had forwarded her complaint to the state Department of Consumer Affairs Health Quality Investigation Unit’s Santa Ana field office “for further investigation.” Ballard said a state investigator interviewed her in June, but neither the existence of the review nor its status has been made public. Ballard provided copies of her correspondence with the state to Ñî¹óåú´«Ã½Ò•îl Health News and NBC News. 

Asked for comment, California Medical Board spokesperson Alexandria Schembra said the board “is not authorized to post complaint information about a physician” unless it obtains an emergency suspension of the doctor’s license or files a formal administrative complaint.

“The public reporting of a patient death prior to the Board having sufficient evidence to prove that the licensee violated the Medical Practice Act would require the Legislature and Governor to enact a law change,” she wrote in an email.

But the board’s Watkins said he believes that the disciplinary process is rigged in favor of doctors, mostly because of the power of medical groups in the state lobbying to thwart change.

“Nobody is protecting the patient,” he said.

NBC News producer Jason Kane and correspondent Erin McLaughlin contributed to this report.

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But some health policy experts say the plan could help reduce billions of dollars in overcharges that have been common in the program for more than a decade.

On Jan. 26, Centers for Medicare & Medicaid Services officials announced they planned to raise rates paid to health plans by for 2027, far less than the industry expected. Some of the largest, publicly traded insurers, such as UnitedHealth Group and Humana, saw their as a result, while industry groups threatened that people 65 and older could see service cuts if the government didn’t kick in more money.

The practice has been criticized for more than a decade by government auditors who say it has triggered billions of dollars in overpayments to the health plans. Earlier this month, the Justice Department announced a record $556 million settlement with the nonprofit health system Kaiser Permanente over allegations the company added about half a million diagnoses to its Advantage patients’ charts from 2009 to 2018, generating about $1 billion in improper payments.

KP did not admit any wrongdoing as part of the settlement.

“I do think the administration is serious about cracking down on overpayments,” said Spencer Perlman, a health care policy analyst in Bethesda, Maryland.

Perlman said that while the Trump administration strongly supports Medicare Advantage, officials are “troubled” by plans that rake in undue profits by using chart reviews to bill the government for medical conditions even when no treatment was provided.

In a , CMS Administrator Mehmet Oz said curbing this practice would ensure more accurate payments to the plans while “protecting taxpayers from unnecessary spending that is not oriented towards addressing real health needs.”

“These proposed payment policies are about making sure Medicare Advantage works better for the people it serves,” Oz said.

Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, called the proposal “at least a mildly encouraging sign,” though he said he suspected health plans might eventually find a way around it.

Kronick has argued that switching seniors to Medicare Advantage plans has cost taxpayers tens of billions of dollars more than keeping them in the government-run Medicare program, because of unbridled medical coding excesses. The insurance plans have grown dramatically in recent years and now enroll , or more than half of people eligible for Medicare.

David Meyers, an associate professor at the Brown University School of Public Health, called the proposed restriction on chart reviews “a step in the right direction.”

“I think the administration has been signaling pretty strongly they want to cut back on inefficiencies,” he said.

The outcry from industry, mostly directed at the proposal to essentially hold Medicare Advantage payment rates flat, was quick and sharp.

“If finalized, this proposal could result in benefit cuts and higher costs for 35 million seniors and people with disabilities when they renew their Medicare Advantage coverage in October 2026,” said Chris Bond, a spokesperson for AHIP, formerly known as America’s Health Insurance Plans.

CMS is accepting public comments on the proposal and says it will issue a final decision on the payment rates and other provisions by early April.

Meyers said health plans often claim they will be forced to slash benefits when they aren’t satisfied with CMS payments. But that rarely happens, he said.

“The plans can still make money,” he said. “They mostly are very profitable, just not as profitable as shareholders expected.”

The government pays Medicare Advantage plans higher rates to cover sicker patients. But over the past decade, dozens of whistleblower lawsuits, government audits, and have alleged that health plans exaggerate how sick their customers are to pocket payments they don’t deserve, a tactic known in the industry as “upcoding.”

Many Medicare Advantage health plans have hired medical coding and analytics consultants to review patients’ medical charts to find new diagnoses that they then bill to the government. Medicare rules require that health plans document — and treat — all medical conditions they bill.

Yet federal audits have shown for years that many health plans’ billing practices don’t hold up to scrutiny.

A by the Department of Health and Human Services inspector general found that the health plans “almost always” used chart reviews to add, rather than delete, diagnoses. “Over 99 percent of chart reviews in our review added diagnoses,” investigators said.

The report found that diagnoses reported only on chart reviews — and not on any service records — resulted in an estimated $6.7 billion in payments for 2017.

This week’s proposal is not the first time CMS has tried to crack down on chart reviews.

In January 2014, federal officials drafted a plan to restrict the practice, only to abruptly back off a few months later amid what one agency official described as an “uproar” from the industry.

The health insurance industry has for years relied on aggressive lobbying and public relations campaigns to fight efforts to rein in overpayments or otherwise reduce taxpayers’ costs for Medicare Advantage.

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The settlement, , resolves whistleblower lawsuits that accused the giant health insurer of mounting a years-long scheme in which it overstated how sick patients were to illegally boost revenues.

“Medicare Advantage is a vital program that must serve patients’ needs, not corporate profits,” said U.S. Attorney Craig Missakian for the Northern District of California, in announcing the settlement.

“Fraud on Medicare costs the public billions annually, so when a health plan knowingly submits false information to obtain higher payments, everyone — from beneficiaries to taxpayers — loses,” he said.

Medicare Advantage plans offer seniors a private alternative to original Medicare. The insurance plans have grown dramatically in recent years and now , more than half of the people eligible for Medicare. About 2 million Medicare members are enrolled in KP plans.

Attorney Max Voldman, who represents whistleblower , said the case shows the need for a “continued effort to fight fraud in health care.”

“It’s important to send a signal to the industry, and this number hopefully does that,” he said.

Taylor, a longtime Kaiser Permanente physician, filed his suit against the company in October 2014.

“It was a long, hard-fought case,” Voldman said.

The Justice Department bundled with others, in July 2021. In court filings, the government in Colorado and California to add diagnoses “regardless of whether these conditions were actually considered or addressed by the physician during the patient visits,” policies that violated Medicare requirements.

From 2009 through 2018, KP added roughly half a million diagnoses that generated about $1 billion in improper payments to the health plan, according to the complaint.

The government pays Medicare Advantage plans higher rates to cover sicker patients. But over the past decade, dozens of whistleblower lawsuits, government audits, and other investigations have alleged that health plans exaggerate how sick patients are to pocket payments they don’t deserve, a tactic known in the industry as “upcoding.”

The Justice Department alleged that Kaiser Permanente officials knew its practices were “widespread and unlawful” but that the company “ignored numerous red flags and internal warnings that it was violating” Medicare rules. In settling the case, KP did not admit any wrongdoing.

In a on its website, the company said it settled the case “to avoid the delay, uncertainty, and cost of prolonged litigation.”

The company noted that other health plans had “faced similar government scrutiny” over Medicare Advantage billing practices. It said the whistleblower cases “involved a dispute about how to interpret” Medicare’s billing requirements.

The civil suits were filed under the False Claims Act, a federal law that permits private citizens to sue on behalf of the government and share any money collected as a result.

In all, six whistleblowers filed cases against Kaiser Permanente. In June 2021, the District Court for the Northern District of California consolidated the cases into two, one brought by Taylor and the other by Ronda Osinek, also a former KP employee.

Osinek, who trained physicians on medical coding guidelines, filed her case in August 2013. In her suit, she alleged that Kaiser Permanente inflated claims submitted to Medicare by having doctors amend medical files, often months after a patient’s visit, to slap on diagnoses that were not treated at the time or didn’t exist.

Under the settlement, the whistleblowers, known as “relators,” are set to receive a combined $95 million, according to the Justice Department.

The KP settlement comes on the heels of a this month that accused UnitedHealth Group of “gaming” the Medicare Advantage payment system, which is called “risk adjustment.”

“My investigation has shown UnitedHealth Group appears to be gaming the system and abusing the risk adjustment process to turn a steep profit,” Sen. Chuck Grassley (R-Iowa) said in a statement accompanying the report’s release.

Grassley, who chairs the Senate Judiciary Committee, said his findings were based on a review of more than 50,000 pages of internal company documents. UnitedHealth Group disputed the findings and has long denied that its coding practice triggers improper payments.

The report cited several medical conditions that have repeatedly been linked to overbilling by Medicare Advantage plans, such as coding for opioid dependence disorder in patients who are taking their medications as directed for pain.

The Senate report also alleged that Medicare Advantage plans have improperly diagnosed dementia.

The report said that Medicare removed dementia from its list of codes in 2014 partly due to concerns over upcoding. After the Centers for Medicare & Medicaid Services reintroduced the code in 2020, researchers found that “annual incident dementia diagnosis rates in MA increased by 11.5%” relative to traditional Medicare, the report said.

“Medicare Advantage is an important option for America’s seniors, but as the program adds more patients and spends billions in taxpayer dollars, Congress has a responsibility to conduct aggressive oversight,” Grassley said. “Bloated federal spending to UnitedHealth Group is not only hurting the Medicare Advantage program, it’s harming the American taxpayer.”

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Instead, she died three days after a liposuction-like procedure called AirSculpt at the San Diego office of Elite Body Sculpture, a cosmetic surgery chain with more than 30 offices across the U.S. and Canada, court records show.

Cosmetic surgery chains setting up shop in multiple states depend heavily on advertising to attract customers: television, print, social media influencers, even texts hawking discounted holiday rates. The pitches typically promise patients life-changing body shaping with minimal pain and a quick recovery.

Yet there’s no federal requirement that surgery companies post evidence supporting the truth and accuracy of these marketing claims. No agency tracks how frequently patients persuaded by sales pitches sustain painful complications such as infections, how effectively surgeons and nursing staff follow up and treat injuries, or whether companies selling new aesthetic devices and methods have adequately trained surgeons to use them safely.

In 2023, Watson-Burton’s husband and six children and stepchildren sued Elite Body Sculpture and plastic surgeon Heidi Regenass for medical malpractice, alleging that the thin cannula the surgeon used to remove fat perforated Watson-Burton’s bowel, causing her death.

The suit also accused Elite Body Sculpture of posting false or misleading advertising on its website, such as describing the clinic’s branded procedure AirSculpt as “gentle on the body” and stating: “Our patients take the fewest possible risks and get back to their regular routine as soon as 24-48 hours post-operation.”

Watson-Burton was one of three patients who died after having liposuction and fat transfer operations performed by Regenass from October 2022 to February 2023, court records state. Families of all three women sued the surgeon, who denied wrongdoing in legal filings. The parties settled the Watson-Burton family case in 2024. Two other wrongful death cases are pending, including a suit by an Ohio woman who alleges her mother relied on promises on Regenass’ website that the operation in California would be safe with a quick recovery.

Neither Regenass nor her attorneys responded to repeated requests for comment. Emails and phone calls to Elite Body Sculpture’s Miami headquarters were not returned.

State and federal authorities do have the power to prohibit false or misleading medical advertising of all types, though enforcement is spotty, particularly when promotions pop up online. That means patients must do their own homework in evaluating cosmetic surgery marketing pitches.

“While consumers should be able to trust that ad claims are substantiated because the law requires them to be, the reality is that it pays for consumers to bring a skeptical eye,” said Mary Engle, an executive vice president at BBB National Programs.

‘Up a Cup’

Founded by cosmetic surgeon Aaron Rollins, Elite Body Sculpture says in Securities and Exchange Commission filings that it offers a “premium patient experience and luxurious, spa-like atmosphere” at its growing network of centers. The , based in Miami Beach and backed by , markets AirSculpt as than traditional liposuction” and providing “faster healing with superior results.” The ads say that AirSculpt “requires no scalpel, or stitches, and only leaves behind a freckle-sized scar!” and that patients “remain awake the whole time and can walk right out of their procedure, enjoying dramatic results!” Some risks are disclosed.

Rollins, who recently for putting his Indian Creek mansion on the market for $200 million, did not respond to repeated requests for comment. A lawyer for Rollins, Robert Peal, responded to an email but didn’t comment. On Nov. 4, the that Rollins had resigned as executive chairman of the board of directors of AirSculpt Technologies and as a member of the board.

Many AirSculpt patients opt to have fat that is removed from their stomachs or other places injected into their buttocks, often called a Brazilian butt lift. Others use the fat to enhance their breasts, a procedure the company brands as “Up a Cup.” Since March 2023, at least seven patients have filed lawsuits accusing Elite Body Sculpture of running misleading advertising or misrepresenting results, arguing, among other things, that they felt more pain or healed much more slowly than the ads led them to believe they would, court records show. One of the lawsuits has been dismissed, and the company has denied the allegations in others.

The Watson-Burton family argued in their lawsuit that some marketing claims about AirSculpt were simply not true.

For instance, Elite Body Sculpture’s website stated that AirSculpt has “automated technology” set to “turn off” before the cannula penetrates the body too deeply and possibly causes serious injury, according to the suit. That feature didn’t protect Watson-Burton, who paid $12,000 for the operation, hoping for a “quick and timely recovery” before a scheduled U.S. Navy deployment, according to the lawsuit.

Rather than being gentle on the body, AirSculpt was “extremely painful, highly invasive, unsafe, required more than a short 24-hour recovery period and could and did damage internal organs,” according to the suit.

Watson-Burton called the San Diego center on Oct. 27, 2022, a day after the operation, to report “severe pain” in her upper abdomen, but staffers took no action to evaluate her, according to the suit. The next morning, an ambulance rushed her to a hospital, where emergency surgery confirmed the gravity of her injuries. Surgeons noted her injuries included three perforations of the small bowel and sepsis.

Watson-Burton died on Oct. 29, 2022. An autopsy report cited complications of the cosmetic surgery, ruling she died after becoming “septic following intraoperative small bowel perforation.” Her death certificate lists the cause as “complications of abdominoplasty.”

In court filings, Elite Body Sculpture said Watson-Burton had “experienced an uncommon surgical complication.” The company denied that it made any “specific guarantee or representation that injury to organs could not occur.” It denied any liability or that its ads made misrepresentations.

The dispute never played out fully in court. The parties settled the case in August 2024, when Elite Body Sculpture agreed to pay Watson-Burton’s family $2 million, the maximum under its insurance policy. Regenass, the surgeon, who did not carry liability insurance, agreed to pay $100,000 more, according to the settlement agreement.

Promises Not Kept

Social media pitches and web advertising also led Tamala Smith, 55, of Toledo, Ohio, to Regenass for liposuction and a fat transfer, court records state.

Smith was dead less than two weeks later, one of two other women who died following elective operations Regenass performed from December 2022 to February 2023, court records show. The surgeon operated on the two women at which runs three surgery centers in Southern California, court records state.

The families of both women are suing Regenass, a board-certified plastic surgeon, and the surgery center. In both cases, which are pending in California courts, Regenass and the surgery center have denied the allegations and filed dismissal motions that deny responsibility for the deaths.

Smith was a traveling registered nurse working the overnight shift at a hospital in Los Angeles. She chose Regenass after viewing the doctor’s , according to a lawsuit filed by Smith’s daughter, Ste’Aira Ballard, who lives in Toledo.

The ads described the surgeon as an “awake liposuction and fat transfer specialist,” while her website assured patients they would feel minimal pain and be “back to work in 24-48 hours,” according to the suit.

During the three-hour operation on Feb. 8, 2023, at Pacific Liposculpture’s Newport Beach office, Regenass removed fat from Smith’s abdomen and flanks and redistributed it to her buttocks, according to the suit. Smith called the office at least twice in subsequent days to report pain and swelling, but a staffer told her that was normal, according to the suit. Smith never spoke to the surgeon, according to the suit.

When Ballard couldn’t reach her mother, she called the hospital only to learn Smith hadn’t turned up for her overnight shift for two days. The hospital called police and asked for a welfare check at the extended-stay hotel in Glendale, California, where Smith had been living.

An officer discovered her body on the bed “surrounded by towels and sheets that are stained with brown and green fluids,” according to a coroner’s report in the court file. A countertop in the room was “covered in medical paperwork detailing post-operative instructions from a liposuction clinic,” according to the report. Ballard said she learned of her mother’s death when she called Smith’s cellphone; a police officer answered and delivered the devastating news.

“Oh, my God, I fell to the floor,” Ballard said in an interview with Ñî¹óåú´«Ã½Ò•îl Health News and NBC News. Ballard said she still has not gotten over the shock and grief. “It bothers me because how does someone that dedicated their life to save other people’s lives end up deceased in a hotel, as if her life didn’t matter?” she asked.

Ballard said her mother trusted Regenass based on her . She believes her mother, a registered nurse, would not have gone to the surgeon had she known someone had died after an operation Regenass performed at the Pacific Liposculpture San Diego office. Terri Bishop, 55, a truck driving instructor who lived in Temecula, California, died on Dec. 24, 2022, about three weeks after undergoing liposuction and fat transfer at Pacific Liposculpture, a company with a history of run-ins with state regulators.

Pacific Liposculpture did not respond to requests for comment. In court filings, the company has denied that the operations played a role in either patient’s death and moved to dismiss the cases. The company also argued that Ballard waited too long to file suit.

Bishop, who had a history of smoking, diabetes, and high blood pressure, died from “arteriosclerotic cardiovascular disease aggravated by viral pneumonia (Influenza A H1 2009),” according to a Riverside County medical examiner’s report made part of the court record. The family disagrees and is arguing that Bishop died from blood clots, a known complication of surgery. A trial is set for June 2026.

In Smith’s case, the Los Angeles County medical examiner ruled the nurse died of “renal failure of unknown cause.” The autopsy report noted: “This is a natural death since an injury directly from the surgery cannot be identified.”

Ballard is demanding further investigation to get to the bottom of what happened to her mother.

“I don’t think they were straightforward with the risk and complications that could occur,” Ballard said. “I think they are promising people stuff they can’t deliver.”

Ballard filed a complaint against Regenass with the California Medical Board, which the board is investigating, according to documents she provided to Ñî¹óåú´«Ã½Ò•îl Health News and NBC News. She believes regulators need to be more transparent about the backgrounds of surgeons who offer services to the public. She also hopes the investigation will shake loose more details of what happened to her mother.

“I just don’t understand how she came back to me in a body bag,” she said.

“I think they are promising people stuff they can’t deliver.”

Ste’Aira Ballard

‘Buyer Beware’

Concerns about sales pitches for cosmetic surgery date back decades.

Witnesses testifying at a held by a subcommittee of the House Small Business Committee in Washington heard a litany of horror stories of patients maimed by surgeons with dubious training and credentials. Subcommittee Chairman Ron Wyden (D-Ore.) said patients were victimized by deceptive and false ads that promised a “quick, easy and painless way to change your life — all through the cosmetic surgery miracle.”

Calling for reform, Wyden added: “So, cosmetic surgery consumers are largely on their own. It’s back to a buyer beware market, and it smacks more of used car sales than medicine.” Wyden now represents Oregon in the U.S. Senate.

All these years later, there’s far more territory to police: an onslaught of web advertising, such as splashy “before and after” photos, online posts, and podcasts by social media influencers and others courted by surgery companies in a costly effort to attract business. Elite Body Sculpture, for instance, spent $43.9 million in “selling expenses” in 2024. That came to $3,130 per “customer acquisition,” according to the company’s SEC filings.

Under , medical advertising must be “truthful, not deceptive, and backed up by competent and reliable scientific evidence,” according to Janice Kopec of the agency’s Bureau of Consumer Protection.

Any claims that are “suggested or reasonably implied” by ads also must be accurate. That includes the “net impression” conveyed by text and any charts, graphs, and other images, according to the FTC. The agency declined to elaborate.

Medical businesses are free to decide what documentation, if any, to share with the public. Most cosmetic surgery sites offer little or no such support for specific claims — such as recovery times or pain levels — on their websites.

“There is no requirement that the substantiation be made available to consumers, either on a website or upon demand,” Engle, who is also a former FTC official, said in an email.

The law permits “puffery,” or boastful statements that no person would likely take at face value, or that can’t be proved, such as, “‘You’ve tried all the rest, now try the best,’” Engle said.

Where to draw the line between acceptable boasts and unverified claims can be contentious.

a private equity-backed cosmetic surgery chain with locations in six cities, defended its use of terms such as “safer” and “better results” as puffery in response to a false advertising lawsuit filed against the company by Orange County District Attorney Todd Spitzer in California in August 2022.

Spitzer argued that AthÄ“nix touted its “micro-body-contouring” technique as “safer” than traditional liposuction and offered “outstanding results with less pain and downtime” without backing that up, according to the suit.

“There is no study or evidence to support these statements and no scientific consensus about the use of these new techniques,” Spitzer argued.

The parties settled the case in July 2023 when AthÄ“nix agreed to pay $25,000 without admitting wrongdoing, court records show. Before the settlement, AthÄ“nix argued that its use of terms such as “safer” and “better results” was “subjective” and “puffery” — and not false advertising.

While there’s little indication that local or state authorities are stepping up scrutiny of cosmetic surgery advertising, federal authorities have signaled they intend to crack down on dubious advertising claims made by drug manufacturers.

In a in September, FDA Commissioner Marty Makary wrote that “deceptive advertising is sadly the current norm” on social media platforms and that the agency would no longer tolerate these violations.

‘Bad Advice’

To prove medical negligence, injured patients generally must show that their care fell below what a “ would have provided. In their defense, surgeons may argue that complications are a risk of any operation and that a poor outcome doesn’t mean the doctor was negligent.

Some lawsuits filed by injured patients add allegations that advertisements by surgery chains misled them, or that surgeons failed to fully explain possible risks of injuries, a requirement known in medical circles as .

Caitlin Meehan had such a case. She underwent a $15,000 AirSculpt procedure at Elite Body Sculpture’s clinic in Wayne, Pennsylvania, outside Philadelphia. She agreed to the surgery in March 2023, she said, because the company’s website described it as “Lunch Time Lipo,” according to a lawsuit she filed in late August. The suit alleges that the doctor she discussed the procedure with “maintained that there are no serious, life-threatening, lasting and/or permanent complications,” according to the suit.

During the procedure, however, gases became trapped beneath her skin, causing a widespread swelling called subcutaneous emphysema, according to the suit. Meehan was shocked to see her face, neck, and upper body severely swollen, causing her shortness of breath.

A friend who drove her to the appointment asked the staff to call an ambulance, but staff members said that wasn’t necessary, according to the suit. After an hour’s drive home, Meehan said her skin felt like it was burning and she called 911. She spent four days in the hospital recovering and remains scarred, according to the suit. The suit is pending, and the company has yet to file an answer in court.

Scott Hollenbeck, immediate past president of the American Society of Plastic Surgeons, said recovering from liposuction in a day “seems unrealistic” given the bruising and swelling that can occur.

“The idea that you could return to work 24 hours after effective liposuction seems like extremely bad advice,” Hollenbeck said.

‘I Felt Horrible’

Ads that promised patients minimal discomfort also have come under attack in patient lawsuits.

More than 20 other medical malpractice cases reviewed by Ñî¹óåú´«Ã½Ò•îl Health News made similar allegations of unexpected pain during operations at cosmetic surgery chains using lidocaine for pain relief in “awake liposuction.”

One patient suing Elite Body Sculpture in Cook County, Illinois, alleged she “was crying due to [the] severe pain” of an operation in September 2023. She alleged the doctor said he couldn’t give her any more local anesthetic and pressed on with the procedure. The defendants have not filed an answer in court. The practice didn’t respond to a request for comment.

Engle, the former FTC official, said that while claims of discomfort are somewhat subjective, they still must be “truthful and substantiated,” such as supported by a “valid, reliable clinical study of patients’ experience.”

NBC News producer Jason Kane contributed to this report.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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