One in five Florida plastic surgeons are uninsured, USA TODAY found. Patients suffer after botched tummy tucks, Brazilian butt lifts and more.
Nyosha Fowler awoke to a nightmare.
A month after an outpatient plastic surgery procedure, the Detroit native's eyes fluttered open. She heard machines beeping, and her mother crying out her name.
Fowler’s abdomen gaped open. And she couldn’t walk.
Fowler learned that Dr. Osakatukei Omulepu had accidentally punctured her bowels during liposuction and injected fat into her sciatic nerve during a Brazilian butt lift at Spectrum Aesthetics in Florida, according to interviews and Department of Health records. Hospital personnel trying to repair the damage had placed the 35-year-old in a medically induced coma.
Four blood transfusions and seven surgeries later, Fowler was just beginning her recovery when she regained consciousness. By then, her medical treatment costs had already soared over a million dollars.
After insurance paid a share, Fowler still owed the hospital hundreds of thousands of dollars. She lost her job and was evicted from her apartment. Bills piled up. Fowler’s mother connected her to an attorney to sue the doctor.
That attorney, Michael Grife, called Fowler’s case heartbreaking – one of the most horrible he’d seen. But there was a hitch: Omulepu was practicing without medical malpractice insurance. Grife withdrew from representing Fowler; there was little chance she could recoup money for what the doctor had done. She never sued.
Omulepu told USA TODAY he doesn’t remember why he opted out of medical malpractice insurance, although he noted it is expensive.
"Why pay it if you don’t have to?" he asked.
Nearly 6,900 doctors in Florida lack malpractice insurance or other coverage, colloquially referred to as "going bare," a USA TODAY investigation has found. When they maim and kill, there’s less recourse, leaving patients damaged physically and financially, with families struggling to pay medical bills.
Those physicians have been disciplined 44% more frequently over the past decade, and they are more likely to have committed criminal offenses – mostly for driving under the influence, according to USA TODAY’s analysis. In all, 110 of those physicians without insurance are licensed to practice in Florida after facing disciplinary action in other states.
While only a handful of states require doctors to carry malpractice insurance, lack of coverage creates a serious mismatch with Florida’s status as a national destination for discount plastic surgery procedures, including the Brazilian butt lift.
In Florida, 1 in 5 board-certified plastic surgeons elected not to carry medical malpractice insurance, based on USA TODAY’s analysis of insurance information reported by doctors to the Department of Health. That figure does not include doctors who perform plastic surgery without certification, which Florida allows. Omulepu, for one, was not certified.
This can enable doctors with repeated medical malpractice cases to stay in business without having to pay higher insurance premiums.
Despite the high level of risk involved in some plastic surgery procedures, including the fat transfer process of a Brazilian butt lift, Florida’s oversight system has few built-in checks and balances.
Detroit resident Nyosha Fowler was seriously injured in 2015 when Dr. Osakatukei Omulepu accidentally punctured her bowels during liposuction and injected fat into her sciatic nerve during a Brazilian butt lift in Florida. Fowler’s stomach remains scarred.
RYAN GARZA, USA TODAY NETWORK
The state only enacted stricter regulations after a USA TODAY and Naples Daily News investigation earlier this year revealed dangerous practices in two clinics overseen by the same doctor. Eight of the clinics' patients died after surgeries, nearly a dozen more needed to be hospitalized.
It was the fifth time since 2014 that such legislation had been proposed.
In Florida, doctors self-report whether they carry medical malpractice insurance. The Florida Department of Health does not verify whether they are telling the truth. Nor does it confirm that doctors without insurance have other funds available to pay claims that arise.
In three of the cases examined by USA TODAY, doctors told the Department of Health that they carried malpractice insurance. When a patient’s attorney asked later, those doctors said they did not have it.
Even when patients can find an attorney willing to take their case and manage to get court judgments for their injuries and financial setbacks, they may not be able to collect.
The Florida Financial Responsibility statute requires physicians to pay judgments up to $250,000, but federal bankruptcy law creates a loophole in which physicians can file for bankruptcy instead. According to a 2010 article in the University of Miami Law Review, the state medical board can’t discipline them for doing so.
In the end, Grife said, it is the patients who lose. He described it as an epidemic that affects thousands, if not tens of thousands of patients each year.
"In Florida, unfortunately, there are many plastic surgeons who do a lot of harm to patients – who either kill them or leave them on death's door," Grife said, "and then they do not have the means to compensate the patients that they've harmed."
‘An eloquent solution’
Florida lawmakers gave doctors the ability to opt out of medical malpractice insurance in 1986. The legislation was designed in part to avert a growing crisis: doctors quitting over the rising cost of insurance premiums.
A decade earlier, more than 20 insurance companies canceled malpractice coverage and withdrew from the market, citing an increase in the size of awards and settlements in Florida, according to a report from the U.S. General Accounting Office (GAO). Congress was examining what federal officials called a nationwide liability insurance crisis to determine whether the U.S. government should intervene.
The Florida case study found insurance companies that remained in the state instituted dramatic rate increases. Premiums in Miami-Dade and Broward counties – considered a separate market from the rest of the state – rose even higher.
By the 1980s, insurance premiums were so high that some doctors chose to retire early or practice elsewhere, according to the GAO report. Some neurosurgeons resigned in protest.
Daniel Sumner, then Florida’s deputy state treasurer, testified before Congress that the cost of malpractice coverage was so high it had influenced obstetricians “to get out of the business of delivering babies.”
The Tort Reform and Insurance Act of 1986, Sumner said, solved those problems and others.
"In Florida, nobody will go out of business because they can’t find insurance they have to have," he told a House subcommittee.
The legislation brought sweeping changes to the state’s insurance regulations. Tucked into it was Chapter 458, which for the first time allowed physicians to forgo medical malpractice insurance.
Spectrum Aesthetics in Miami kept Dr. Osakatukei Omulepu on staff while he was under investigation by the Florida Department of Health for critically injuring two patients at the clinic.
JUDY S. REICH FOR USA TODAY
The law required the doctors to agree to satisfy any adverse medical malpractice judgment against them, up to $250,000, and mandated they notify patients if they are not insured.
Marc Singer, a director and senior adviser for Mariner Wealth Advisors, said he advises doctors to drop coverage and, if they’re sued, offer the patient a choice: take a small settlement or get nothing when the doctor files for bankruptcy.
Singer called going bare "an eloquent solution" to the high cost of medical malpractice insurance.
"This was a way that physicians were able to solve a problem from the bottom up," he said, "one physician at a time."
"By and large, doctors do save lives," he added, "and if they continue practicing without malpractice insurance, that’s still better than them not practicing."
But by trying to fix one problem, Florida lawmakers created another: The state’s most problematic doctors had a greater incentive to stop carrying medical malpractice insurance.
"I understand why the insurance companies raised the rates on those people – and they probably should," health care lawyer Chris Nuland said. "But it creates a perverse reason for the potentially highest-risk physicians to probably be the most likely to go uninsured. Yeah. I don’t have a solution for that, but certainly, it's worthy of study."
Nuland, who also is general counsel for the Florida Society of Plastic Surgeons, said the organization believes deserving patients – those injured as a result of medical malpractice – should be made whole.
But Spencer Aronfeld, a trial lawyer in South Florida for nearly three decades, said that’s not how it plays out. Aronfeld said he's no longer focused on Florida malpractice cases because it is too hard to collect even after a judgment.
Doctors shield themselves by leasing cars, office space and equipment, he added. They may put boats or second properties in the name of a spouse, child or trust.
And if they’ve paid off their homes, they can live in luxury and "be insulated from the reach of creditors" due to Florida’s homestead exemption, Aronfeld said.
"It's a brilliant move by the doctors," he said of how doctors protect assets, "but it's a very unfortunate thing for patients and their families."
‘I feel deformed’
Janira Gonzalez wants to hold Dr. Jose Aquino accountable for what she believes was improper medical treatment.
The doctor gave her a tummy tuck last December at an outpatient surgery center in Boca Raton. Gonzalez hoped the procedure would help alleviate back pain and smooth the stomach pooch she’d acquired after giving birth to her youngest daughter seven years earlier.
At first, it seemed to be a success. A neat row of sutures spanned Gonzalez’s lower abdomen. But over time, the skin around the incision reddened and peeled apart. Just one inch. Then two. Then more.
The Homestead, Florida, woman returned to Aquino eight times for post-operative treatment, according to medical records and interviews. Her condition continued to worsen.
Gonzalez said she did everything Aquino told her to do. He disagrees. Aquino told USA TODAY that Gonzalez continued taking medication for rheumatoid arthritis after he advised her it would impede the healing process.
By February, the incision gaped in four places, the largest about three inches tall and five inches wide.
On Feb. 12, Gonzalez said, her fever spiked. It hurt to breathe. Her husband, Luis Hernandez, brought Gonzalez to the emergency room. The hospital admitted her and brought her into surgery to cut and drain the infected incision, medical records show.
Aquino’s attorney, David Di Pietro, said infection is a known complication of surgery and can happen under the best care. He said it does not, by itself, mean there was medical malpractice.
Gonzalez said she was out of work without pay for a month as her body healed. She and her husband borrowed money from her brother and his wife to pay the electricity bill. She fell behind on the cellphone and water bills. And they still are paying off the loan they took out for the tummy tuck.
Today, a lengthy concave scar on Gonzalez’s abdomen remains visible through close-fitting clothing. She said it still hurts. Twice a day, every day, Gonzalez said she rubs cocoa butter on it.
"I massage the scar tissue hoping that it will go away or that it will get smaller," she said. "But when I look at myself in the stomach, it's like... I feel deformed."
Gonzalez filed a complaint against Aquino with the Florida Department of Health, which is still pending, and contacted an attorney.
One of the first things Gonzalez’s attorney, Andres Beregovich, checked was whether Aquino carried medical malpractice insurance.
Doctors are required to submit a financial responsibility form to the Department of Health when they apply for a license. They also are expected to update the information. The Department of Health told USA TODAY that physicians who put false information on such forms could face disciplinary action up to a $10,000 fine and revocation or denial of licensure.
The agency did not respond to questions about the number of doctors who have been disciplined for submitting false information.
According to those state health department records, Aquino carried malpractice insurance at the time of Gonzalez’s surgery. That was incorrect.
Responding to a letter from Gonzalez’s attorney, Aquino wrote that at the time he submitted his Florida paperwork, the University of Nebraska Medical Center had provided malpractice insurance coverage for him because he was a resident there.
"I am no longer affiliated with this facility so the policy is no longer in effect," he wrote in a letter dated June 19.
Records show Aquino updated his information with the Department of Health the day before he sent that letter to Beregovich.
Aquino also told USA TODAY that Gonzalez knew that he did not have insurance at the time he completed her surgery. His attorney provided a copy of a consent form with her signature.
Gonzalez recalled that employees at the facility did have her sign a stack of paperwork when she came in, but she doesn’t remember that form.
Beregovich, who has initiated legal action on Gonzalez's behalf, said the inaccuracy of Aquino’s information on file with the state is part of a broader problem. He's found two other doctors whose state records indicated they had malpractice insurance when they actually did not.
"Nobody is holding their feet to the fire to force them to demonstrate their financial responsibility," Beregovich said.
‘Justice is not being done’
Even when a patient does receive a court judgment, the doctor can avoid paying it.
In his late 40s, Rick Martinez was about 50 pounds heavier than the 195 pounds he had weighed less than a decade earlier. His medication for a chronic illness had added weight. The Florida man, who is gay, sought love – but men wouldn’t even talk to him at clubs.
"In Miami, everything is about being a star or a model and if you don’t look like a model, people will reject you," said Martinez, now 56.
For months, on his way to the gym, he drove past billboards displaying stunning transformations. Fat to skinny. Flabby to toned. Martinez saw his future in those billboards: Lonely to loved.
Eventually, he called Dr. Amaryllis Pascual. Her office was close to his house.
"I needed to do something for myself," Martinez said.
On Jan. 11, 2013, Martinez underwent liposuction of his abdominal area and back.
The procedure went horribly wrong. Pascual perforated his small bowel in multiple places, alongside other errors, Florida Department of Health records show.
In January 2014, Martinez sued Pascual and her businesses for medical negligence and won a $1 million judgment. But Pascual escaped paying most of that, thanks to the bankruptcy loophole.
Martinez ended up as No. 136 of 161 creditors in Pascual’s 2015 federal filing.
"All these doctors are just worming their way through, making money and getting away with hurting their patients," Martinez said. "Justice is not being done."
Through bankruptcy proceedings, Pascual sent Martinez $15,754.18 – less than 2% of the malpractice judgment, records show.
Pascual now practices at a clinic known as Jolie Plastic Surgery, a subject of a USA TODAY investigation earlier this year that found the Miami clinic and a nearby facility overseen by the same doctor were responsible for a spate of casualties in the past six years unlike anywhere else in Florida.
In a video on Jolie’s site, Pascual joyfully executes a lip augmentation. "They’re going to look like – bam – when we get done with this," she says. "I love, love, love doing lips."
The doctor did not return messages left at Jolie, a sleek white space in a bland suburban strip mall. She did not respond to emails or attempts to reach her on social media, either.
In July 2018, Pascual bought a five-bedroom, $615,000 home in a Broward County suburb known for A-rated schools and lush parks.
Martinez, by contrast, lives alone in a manufactured home in a 55-and-older community with a turnpike view. He still owes more than $100,000 in bills from the hospital stay and surgeries that saved his life.
Along with multiple small bowel perforations, doctors found necrotizing fasciitis, a fast-moving bacterial infection that can follow surgery. As many as one-third of people with necrotizing fasciitis die from infection, according to the Centers for Disease Control and Prevention.
Recovery kept Martinez from work for more than three months, he said. The wounds left scars sprawling across his stomach. As a young man, he unabashedly donned a Speedo at the beach. Now he’s ashamed to even go shirtless in public.
The experience also affected Martinez’s psychological health, leading to panic attacks.
Before his liposuction, Martinez assumed Florida doctors had malpractice insurance. New Jersey, where Martinez moved from in 1999, is one of seven states that require doctors to carry malpractice insurance, according to the Medical Professional Liability Association.
"I was very naïve coming from another state," Martinez said. "In a million years I would have never known in the state of Florida it differs."
In the years since, Martinez has fought to make malpractice insurance mandatory. He launched a change.org petition that drew nearly 8,500 supporters. He wrote letters to Florida lawmakers.
He also sought recourse through the state. He submitted complaints against Pascual with the Florida Department of Health. And, in 2016, the agency concluded Pascual’s treatment of Martinez fell below the minimum standard of care. Because he was at high risk for complications, he should not have been a candidate for liposuction, the agency said in its filing.
In 2017, the Florida Board of Medicine fined Pascual $10,000 and banned her from liposuction procedures until her skills could be evaluated, records show. By December 2018, however, her license was back in the clear.
One of Martinez’s complaints to the Department of Health cited Pascual’s failure to satisfy his malpractice judgment. Four months later, the agency sent Martinez a letter, saying the Board of Medicine had not found probable cause to discipline Pascual under Florida law.
Department of Health spokesman Brad Dalton said complaints without a finding of probable case are confidential. However, he noted in an email that Florida law indicates, "a physician has a legal obligation to satisfy an outstanding medical malpractice judgment."
Bankruptcy, however, seems to erase that obligation.
It can wipe out debts, including medical malpractice debts, unless the patient can prove that the harm was the result of "willful and malicious injury," said Andrew Dawson, a professor at the University of Miami School of Law who teaches bankruptcy law.
The law, he said, "does a very poor job" of considering the plight of creditors like Martinez.
"This isn’t a particularly unusual scenario, just a particularly sympathetic one," Dawson said. "It does seem to violate people’s expectations as patients."
‘It felt like I could have saved her’
Fowler shuffled slowly across the hardwood floor into the living room of her Detroit home.
More than four years after Omulepu botched her surgery, the 40-year-old said her recovery is "still every day."
She has had to relearn how to eat, how to stand, how to walk.
After regaining consciousness, Fowler remained in Baptist Hospital of Miami for about two weeks until she was stable enough to be airlifted to a nursing home in Jackson, Michigan. It took a year to move from a wheelchair to a walker and leg braces. Then she switched to a cane.
"I was trying to figure out what was going on with my body," Fowler said. "I didn't know how I was going to take care of my kids and my livelihood. … My life was turned upside down in a matter of two hours."
She missed her oldest son’s high school graduation. She lost her job as a truck driver and her car was repossessed. She was evicted from her apartment in Alabama, where she’d been living before her surgery. The medical bills kept coming.
In 2017, Fowler filed for bankruptcy, federal court records show. She listed more than $283,600 in liabilities – $200,000 of which she owed to Baptist Hospital.
Unbeknownst to Fowler, Baptist Hospital of Miami filed a complaint in 2015 with the Department of Health on Fowler’s behalf.
In 2016, state officials, in turn, filed an administrative complaint against Omulepu, accusing him of “committing repeated medical malpractice” in his care of Fowler and three other patients, state records show. Fowler and one of the other patients were injured on the same day.
The medical board revoked Omulepu’s license in 2017 for violating the standard of care for Fowler and another patient. He fought the charges in a state appellate court and temporarily regained the right to practice.
He returned to work and five weeks later performed a surgery that led to a patient’s death. He lost his license again and is no longer practicing.
"You want to talk about angry?" Fowler said, describing how she felt when she learned a woman had died. "That’s when I really broke down, like I don't matter. It felt like I could have saved her. I tried. I felt defeated that day."
Omulepu’s case has been covered extensively in local and national media, including in USA TODAY. The former doctor said that having patients end up injured was devastating for everyone.
"The Board of Medicine’s decision – although I accept it and do take responsibility for what happened – doesn’t take into account the emotional toll that a severe complication takes on the surgeon," Omulepu told USA TODAY, "especially a surgeon that cared very deeply about his patients."
Fowler said she hopes Florida officials will be more transparent with the public when doctors are facing disciplinary action. Fowler did a search on Omulepu after the Department of Health’s administrative complaint was filed, and she said it didn’t show he had a case pending. She’d also like to see the state verify that doctors have the means to pay for medical malpractice.
Longtime politician Dennis Jones fought for medical malpractice requirements during his more than 30 years in the Florida House and Senate.
"If you’re in the healing arts profession then the public deserves to know they have some level of protection," said Jones, a retired chiropractor who termed out in 2012.
The Department of Health said no bills filed in the past five years would change the statute that allows physicians to opt out of malpractice insurance.
Nuland, the general counsel for the Florida Society of Plastic Surgeons, said there’s talk every year of addressing the insurance exemption as well as raising the burden of proof in medical malpractice actions, but nothing happens.
"It’s the path of least resistance for the legislature," he said.
But Nuland said that may change in the next year because he’s hearing that insurance companies may raise their rates in January. If rates go too high, he said, more doctors may drop their coverage.
"Nothing gets legislators to move more quickly than a crisis," he said.
In February, Florida Sen. Anitere Flores introduced legislation to crack down on "bad actors" in surgery centers after learning about the plight of patients.
"This was kind of a niche industry that had been popping up in my district," said Flores, who represents parts of Miami-Dade, a mecca for plastic surgery procedures.
The new law, which takes effect in January, will give the state the power to suspend or restrict a surgery center’s operations if it determines the facility poses an immediate public threat. It also mandates that the center and the doctors meet financial responsibility requirements.
The law prevents centers that have had their registrations revoked from quickly opening another office under a new name with the same owners or directors. That practice had prevented patients from discovering a center’s reputation and history, she said.
Yet Flores said she does not think all doctors should be required to carry malpractice insurance, citing the expense. Instead, she said she would like to research how the state can ensure patients are fully informed when their doctors do not have coverage.
Florida reporter Jeffrey Schweers contributed to this report.
Marisa Kwiatkowski is a reporter on the USA TODAY investigations team, focusing primarily on children and social services. Contact her at email@example.com, @IndyMarisaK or by phone, Signal or WhatsApp at (317) 207-2855. Janine Zeitlin is the South Florida reporter for the USA TODAY Network Florida. Contact her at firstname.lastname@example.org, @JanineZeitlin or by phone at (239) 910-4991. Maria Perez is a reporter on the Milwaukee Journal Sentinel investigations team, focusing primarily on immigration and social services. Contact her at email@example.com, @mariajpsl, and by phone, Signal or WhatsApp at (646) 675-1050.