On a late afternoon in November 2017, Witney Arch told her 1-1/2-year-old son to stop playing and come inside. Upset, he grabbed her right breast when she picked him up. She experienced a shock of pain but did not think it was anything serious. A week later, however, the ache had not subsided. After trips to several doctors, a biopsy revealed that Arch had early-stage breast cancer. Her surgeon told her that it was likely invasive and aggressive.

By the end of January, she had made two critical decisions. She would get a double mastectomy. And she wanted her operation at the Center for Restorative Breast Surgery in New Orleans, a medical facility renowned for its highly specialized approach to breast cancer care and reconstruction. The two surgeons who founded it had pioneered techniques that used a woman's own body tissue to form new breasts post mastectomy. The idea of a natural restoration appealed to Arch. "I don't judge anybody for getting implants, especially if you've had cancer," she said. "But I felt like I was taking something foreign out of my body, cancer, and I did not want to put something foreign back in."

Arch was a 42-year-old preschool teacher for her church, with four young children, living in a suburb of New Orleans. The 1-1/2-year-old had been born with Sturge-Weber syndrome, a rare neurological disorder. Caring for him consumed her life. By nature upbeat and optimistic, Arch felt blessed that her son's act of defiance had led to an early diagnosis. "We're going to pray about this and we're going to figure it out," she told her husband.

Arch asked her insurer, Blue Cross and Blue Shield of Louisiana, for approval to go to the center for her care, and the company granted it, a process known as prior authorization. Then, a week or so before her surgery, Arch was wrangling child care and meal plans when she got a call from the insurer. The representative on the line was trying to persuade her to have the surgery elsewhere. She urged Arch to seek a hospital that, unlike the center, was in network and charged less. "Do you realize how much this is going to cost?" Arch remembered the agent asking. Arch did not need more stress, but here it was — from her own health plan. "I feel very comfortable with my decision," she replied. "My doctor teaches other doctors around the world how to do this." Over the next year, Arch underwent five operations to rid herself of cancer and reconstruct her breasts.

Arch did not know it at the time, but her surgery would become evidence in a long-running legal fight between the breast center's founders, surgeons Frank DellaCroce and Scott Sullivan, and Blue Cross, Louisiana's biggest health insurance company, with an estimated two-thirds share of the market. DellaCroce and Sullivan had repeatedly sued the insurer, alleging that it granted approvals for surgery but then denied payments or paid only a fraction of patients' bills. They pointed to calls like the one Arch received as proof of the company's effort to drive away patients. The aggressive legal attack, they knew, was fraught. Litigation against the $3.4 billion company would take a long time and a lot of money. The chances of winning were slight. "You fight dragons at great peril," DellaCroce would tell friends. But this September, after 18 years and several defeats in court, jurors found Blue Cross liable for fraud. They awarded the center $421 million — one of the largest verdicts ever to a single medical practice outside of a class-action lawsuit. In a statement, Blue Cross said it "disagrees with the jury's decision, which we believe was wrong on the facts and the law. We have filed an appeal and expect to be successful."

Frustration with insurers is at an all-time high. The December fatal shooting of United Healthcare CEO Brian Thompson allegedly by Luigi Mangione serves as an extreme and tragic example. Doctors and insurers are locked into a perpetual conflict over health care costs, with patients caught in the middle. Doctors accuse insurance plans of blocking payments for health care treatments that can save the patients' lives. Insurance companies insist they shouldn't pay for procedures that they say are unnecessary or overpriced. It is easy to emerge from an examination of the American health care system with a cynicism that both sides are broken and corrupt.

However, interviews with scores of doctors, patients and insurance executives, as well as reviews of internal documents, regulatory filings and academic studies, reveal a fundamental truth: The two sides are not evenly matched. Insurance companies are players in the fight over money, and they are also the referees. Insurers produce their own guidelines to determine whether to pay claims. When a doctor appeals a denial, insurers make all the initial decisions. In legal settings, insurers are often given favorable standing in their ability to set what conditions they are required to cover. Federal and state insurance regulators lack the resources to pursue individual complaints against multibillion-dollar companies. Six major insurers, which include some of the nation's largest companies, cover half of all Americans. They are pitted against tens of thousands of doctors' practices and large hospital chains.

The Blue Cross trial provides a rare opportunity to expose in detail the ways that health insurance companies wield power over doctors and their patients. Blue Cross executives testified that the breast center charged too much money — sometimes more than $180,000 for an operation. The center, they said, deserved special attention because it had a history of questionable charges. But the insurer's defense went even further, to the very meaning of "prior authorization," which it had granted women like Arch to pursue surgery. The authorization, they said in court, recognized that a procedure was medically necessary, but it also contained a clause that it was "not a guarantee of payment." Blue Cross was not obliged to pay the center anything, top executives testified. "Let me be clear: The authorization never says we're going to pay you," said Steven Udvarhelyi, who was the CEO for the insurer from 2016 to 2024, in a deposition. "That's why there's a disclaimer.

From 2015 through 2023, the Baton Rouge-based insurer paid, on average, less than 9% of the charges billed by the breast center for more than 7,800 individual medical procedures — even though it had authorized all of them. Thousands of such claims were never paid at all, according to court records. Testimony revealed that the health plan never considered thousands of appeals filed by the center. Corporate documents showed Blue Cross executives had set up secret processes for approving operations and reimbursing the clinic and its doctors that resulted in reduced fees and payment delays. One lucrative strategy: A national-level policy allowed Blue Cross Louisiana to take a cut of any savings it achieved in paying the breast center on behalf of patients covered by out-of-state Blue Cross companies, meaning the less the insurer paid out, the more it earned.

In Sullivan's words, the insurer was hypocritical, "morally bankrupt." Blue Cross had stranded many of the center's patients with high bills, amounts that it had absorbed over the years. On several occasions, though, Blue Cross executives had signed special one-time deals with the center, known as single case agreements, to pay for their wives' cancer treatment. To Sullivan, it seemed the insurer was willing to pay the center when patients had connections but would fight when patients did not.

Blue Cross declined to comment on any individual cases but said in a statement that single case agreements were "common in the industry" and were available to all members when needed to access out-of-network providers.

Chapter 1

The Center

Nobody would take the breast center and its adjoining hospital as an ordinary medical establishment. The two facilities take up a city block along St. Charles Avenue, the thoroughfare famous for its streetcars, Mardi Gras parades and Queen Anne mansions. Patients access the complex — created by merging a former law office, funeral home, car dealership and Dunkin' Donuts — by driving around back where a porte cochere leads into a soaring atrium. Light pours in through windows set in the high ceiling. Arrangements of white orchids are scattered among comfortable couches and chairs. Here, women consult with doctors to plan their treatment. Surgeries are performed at the 39-bed hospital, which has an Icee machine in a family room. New-age music plays softly throughout the building. Rooms are designed to be as homey as possible, with medical gear hidden away and seascapes by a local artist hanging on the wall. One patient's husband referred to it as a "spa-spital."

The idea of combining the luxury feel of an upscale plastic surgery practice with the mission-driven zeal of a medical clinic came to DellaCroce and Sullivan while they were young surgeons. The two grew up in Louisiana. Sullivan spent much of his childhood in Mandeville, a suburb of New Orleans on the north side of Lake Ponchartrain, his dad employed in the oil and gas industry. His mother wanted him to be a priest or a doctor. "I definitely was not going to become a priest," he said. DellaCroce's father worked at the paper mill in West Monroe in the state's northern neck. His mother, a nurse, gave him an appreciation for medicine as a career that was "meaningful and challenging."

They became friends while working at the Louisiana State University medical center, where they earned the nickname "the Sushi Brothers" for their favorite lunch. They were drawn to microsurgery and breast reconstruction because it was an emerging field that was innovating and improving care. Both men became board-certified in plastic surgery. Sullivan, 60, is the hard-charging businessman, stocky, direct and blunt. DellaCroce, 58, with a ponytail, goatee and soft drawl, is more the diplomat, patient and cerebral. The pair have lectured around the world and written numerous medical journal articles.

They opened their first office in 2003 in a single room rented from a fellow doctor at what was then known as Memorial Medical Center, the hulking private hospital in New Orleans. They performed operations at facilities throughout the region but found that most gave little consideration to their patients' comfort. They wanted to build a different kind of hospital. "Can we give them that little bit of extra without breaking the budget to make the experience less awful? Can't make it great, but can you make it less awful?" DellaCroce explained. "Can you attend to the human side of this patient and give them the added value of peace and confidence?" Hurricane Katrina set back their construction plans, and the new edifice, named the St. Charles Surgical Hospital, did not open its doors until 2009. It boasts of being the only hospital in the country devoted solely to care for breast cancer patients who have received mastectomies. The center does not provide radiation or chemotherapy treatments. The majority of patients come from out of state.

Women seeking to have their breasts restored after a mastectomy face two paths. Some choose a relatively straightforward surgical procedure using implants filled with silicone or another gel. The center specializes in the other option, what's known as autologous tissue reconstruction, where a woman's own fat is taken from one part of the body, like the bottom or the stomach, and used to rebuild the breast. The procedure requires a longer recovery time, but the new breasts become part of the body.

The transplant surgery is lengthy and complex. Operations can last up to 12 hours with big medical teams involved. One surgeon performs the mastectomy while another creates a new breast by knitting together layers of fat and tissue. Concentration is intense. The surgeons stare through glasses with microscopes to connect new blood vessels with a needle that's thinner than an eyelash, using thread less than half the width of a human hair. DellaCroce and Sullivan invented techniques, for example, allowing tissue to be taken from multiple sites when a woman did not have enough fat in one part of her body for a full restoration.

One afternoon last fall, DellaCroce strode into a cavernous operating room to check on a patient. On the table in front of him, a woman lay covered in curtains of blue surgical cloth, only her torso exposed. Earlier in the day, a surgical oncologist had removed her right breast as part of a mastectomy to treat her cancer. Later, another surgeon had taken flaps of fat from her stomach and interlaced them with blood vessels to create a new breast to replace the lost one. Now, in the fifth hour of surgery, a physician's assistant leaned over her midsection, closing an incision along her side with some final stitches. Nurses hurried around the space, preparing to wrap up the operation. Paul Simon's "You Can Call Me Al" played in the background. The smell of burnt flesh hung in the air. A blue light signaled that the new arteries were successfully pumping blood. "Wow, that woman looks really good," DellaCroce told the physician's assistant. "Nice job."

There is no denying that the center's high-end treatment means high costs. The median charge for an operation and hospital stay is about $165,000. DellaCroce and Sullivan hired consultants to review other well-regarded practices, who advised them their prices were competitive with their peers. "We weren't asking to be paid LeBron James, best of the best, even though we feel we're in the top 1 or 2% of the country," Sullivan said. "We just wanted something fair."

Chapter 2

Blue Cross and Blue Shield

It is one of the quirks of the American health care system that insurers almost never pay the prices for procedures demanded by doctors and hospitals.

To understand why requires a tour of the grand bargain at the heart of the health insurance system. Insurance companies negotiate with hospitals and doctors to discount reimbursements on medical procedures, like office visits or MRI scans. Providers who sign these contracts are in network. Insurance companies like in-network doctors because they can budget for health expenses and set premiums accordingly. Doctors and hospitals agree to be in network because they get a steady stream of insured patients.

DellaCroce and Sullivan held contracts with insurers that resulted in average payments to the center's doctors in the $20,000 to $30,000 range. But DellaCroce and Sullivan never came to an agreement with Blue Cross. That made them an exception in Louisiana — the insurer is so dominant that 97% of local physicians and hospitals are in network. DellaCroce and Sullivan said the company was not offering them enough money — in some cases not even enough to cover the cost of the surgeries, they argued in court documents. The doctors and their hospital remained out of network, meaning they charged Blue Cross the full price for their procedures.

Such charges are controversial. Insurance companies and many health experts say they are too often inflated and untethered from actual costs. Physicians and hospitals say their fees are justified, reflecting the true price of medical care. In the end, insurers — especially in states like Louisiana, with few competitors — use their market power in negotiations to set reimbursements at what they want to pay, not what doctors charge.

At Blue Cross, Dwight Brower was charged with reviewing the bills from the breast center. He had worked as a physician at a small family practice in Baton Rouge and then at a local hospital before joining Blue Cross as a medical director. He helped oversee prior authorizations. While many patients assume that an approval means an insurer will pay for an operation, it is simply a recognition that a procedure is medically necessary. Federal law mandates that private insurers cover breast restorations for women who undergo mastectomies because of cancer or genetic risk. And patients, in general, are allowed to choose their own doctors.

However, since the center was out of network and had no contract with the insurer, Blue Cross determined how much it would pay for the treatment, and Brower believed that the breast center's bills were exorbitant. "I did not think that they were reasonable," he would later testify. Surgeons doing lung transplants or brain surgery rarely billed Blue Cross more than $50,000 for their work. Why should DellaCroce and Sullivan get so much more? "Don't get me wrong. The surgeons at the center are extremely skilled," he acknowledged. The operations were often lengthy. "But so are open-heart surgeries," he said. "Relative to some of the other extremely complicated surgeries done by other surgeons in other areas of the body, it just seemed like their fee schedule was extremely high."

Blue Cross Louisiana executives testified that they did not even consider doctors' invoices when making decisions on what to reimburse because such charges were "unregulated" and "nonstandard." Instead, they paid "an amount we establish" — unless the doctor's bill was cheaper. In the end, the insurer said it settled on reimbursing the breast center about the same as in-network doctors performing similar operations, even though DellaCroce and Sullivan did not benefit from having patients referred to them. In practice, that meant the insurer paid out a fraction of the breast center's bills. Of the 7,837 medical procedures in dispute in the lawsuit, involving 1,680 patients, Blue Cross paid about $43 million on invoices totaling $500 million. Some 60% of the claims weren't reimbursed at all. The difference between the bill and the payment could be striking. For example, in the case of Arch, Blue Cross paid $8,580 out of $102,722 for one operation. For another, it paid $3,190 out of $34,975.

Executives said the Blue Cross reimbursements were fair, designed to keep premiums low for the nearly 2 million Louisianans who depended on the insurer to cover their health care. Paying the breast center's full fees would add to its customers' burden, they said. "If we were to just agree to any rates or any prices set by physicians or any providers, it would cause cost to be exorbitantly high for both the plan and for members particularly, because we wouldn't be able to forecast or make sure those plans are actually sound," said Curtis Anders, the vice president of provider networks for Blue Cross. "Premiums would increase."

For many out-of-network doctors, payments lower than their invoices are an infuriating part of doing business. They absorb the costs, or pass them on to their patients, a practice known as balance billing that can result in medical debt. DellaCroce and Sullivan were the rare physicians with the tenacity to fight. The center collected money from both insurers and patients — but it carried the unpaid portion of invoices on its books. That amount grew every year as it battled Blue Cross.

DellaCroce and Sullivan were convinced that Blue Cross had singled them out for their obstreperousness, but they had no proof. Then, during a phone call one day, an employee for the center was talking to a Blue Cross representative to obtain a prior authorization. The representative let slip that the request required special handling. The breast center's doctors were flagged on an internal roster. It was called the targeted list.

Chapter 3

Discoveries

On Dec. 8, 2023, several dozen attorneys and paralegals from Chehardy Sherman Williams, one of New Orleans' top law firms, were celebrating their annual holiday party. They had gathered in a private dining room with gilded mirrors and shimmering chandeliers at Arnaud's restaurant, a bastion of Creole cuisine in the heart of the French Quarter. The waiters served shrimp remoulade, prime rib and turtle soup. Small talk filled the air.

Suddenly, several attorneys' cellphones buzzed as they all received the same email, a message from the lawyers for Blue Cross. It contained discovery for the case, more than 42,000 pages of internal documents, emails and policies. Matthew Sherman, one of the attorneys representing the center, turned to a colleague. "Can you believe this?" he asked. It was like something from a John Grisham novel, the kind of thing he and his friends had joked about at law school, a document dump at Christmas time. By long tradition, many of New Orleans' biggest law firms hold their holiday parties on the same Friday afternoon in December. Afterward, rival attorneys from around town gather for drinks under a flag of truce at a local bar. Sherman realized there would be no afterparty this year. Nor much of a holiday vacation.

The delivery of the documents was a Christmas gift nearly 20 years in the making. DellaCroce and Sullivan's first lawsuits against Blue Cross, involving 88 breach-of-contract claims filed in a Louisiana civil court beginning in 2006, were dismissed because of a federal court ruling regarding jurisdiction. A second lawsuit, which lasted from 2010 through 2017, resulted in limited discovery and a two-day trial in federal court. Jurors found that Blue Cross had failed to tell the center how much it would pay for procedures, but they also ruled the center had not been financially harmed. A judge dismissed the remaining claims.

DellaCroce and Sullivan launched their third lawsuit in February 2017 with a novel legal theory: They accused Blue Cross of fraud. They contended that for years the insurer had issued prior authorizations without the intention of paying the actual bills. Their lawyers had sought the targeted list during discovery to help prove the case. Blue Cross denied it existed.

But now, as Sherman and fellow attorney Patrick Follette began poring over the thousands of documents, they came upon a spreadsheet that said "Targeted Provider List." The first names on the list were DellaCroce and Sullivan. It was labeled "confidential" and dated June 2007 — about a year after the pair had filed their first lawsuit against Blue Cross alleging nonpayment. More digging turned up other documents. There was a "blocked" list that also featured the two doctors.

A corporate policy document provided what DellaCroce and Sullivan considered the most revealing explanation for Blue Cross' financial motivation. Blue Cross insurers are independent companies that operate under a common set of rules, similar to franchisees in a fast-food chain. When a person covered by Blue Cross in their home state receives treatment in another state, the Blue Cross where the treatment occurs pays the provider and then recoups the cost from the home-state plan. What the attorneys discovered was that Blue Cross Louisiana would receive a share of any savings it could generate for the home-state plan. Say, for instance, Blue Cross Alabama was facing a bill of $5,000 for a procedure. If Blue Cross Louisiana instead paid $1,000, it saved the Alabama plan $4,000. The policy allowed Blue Cross Louisiana to earn 16% of the savings — in this scenario, $640.

For DellaCroce and Sullivan, the revelations cemented their belief that Blue Cross was a bad corporate actor more interested in power and control than health care. The percentage fee incentivized the insurer to pay the doctors as little as possible. The bigger the savings, the more Blue Cross made. "It's win-win," DellaCroce said. "That's their pay day."

As the trial approached, Blue Cross attempted to settle the case. DellaCroce and Sullivan refused the offer as too low.

Chapter 4

The Trial

On the afternoon of Sept. 5, 2024, the case — St. Charles Surgical Hospital, L.L.C. and Center for Restorative Breast Surgery, L.L.C. v. Louisiana Health Service & Indemnity Company D/B/A Blue Cross/Blue Shield of Louisiana, Blue Cross & Blue Shield of Louisiana, Inc. and HMO Louisiana, Inc. — opened in Division C of the Orleans Parish Civil District Court, a high-ceilinged room with dark brown benches and tables, fake marble columns and fluorescent lights. James Williams, the chief litigator for the hospital, had already impressed the 45 potential jurors by memorizing all their names and backgrounds during jury selection. Now, he stood up and placed a football on the plaintiff's table in front of the 12 chosen to try the case, which included a third grade teacher, a movie stunt double and a hotel manager. He warned them that they would hear a lot of "insurance talk" from Blue Cross. "I'm going to ask you, ladies and gentlemen on the jury, keep your eye on the ball. Keep your eye on what this case is about," Williams told them. "If they start saying things like, ‘Well, oh, we paid them what we thought was fair, 9%,' keep your eye on the ball, right?"

Over 10 days — interrupted by a two-day break to allow a hurricane to pass across Louisiana — Williams made his case that Blue Cross had defrauded his clients by making promises to pay but failing to deliver.

Much of Blue Cross' defense had relied on the notice that a prior authorization was no guarantee of payment. The insurer had not committed fraud, it said, since it never explicitly promised the center to reimburse anything. Udvarhelyi, the former CEO, had insisted on that. But on the stand, Blue Cross witnesses provided a more nuanced explanation. They acknowledged that the disclaimer was not meant as a general excuse to free the company from paying bills. A prior authorization "usually" resulted in a payment, testified Brower, who reviewed the center's bills. He said that the notice was intended for specific situations. For instance, Blue Cross would not cover a woman who dropped out of her insurance before the operation. Nor would it pay anything if a patient had not met her deductible. But otherwise, Brower said, Blue Cross intended to compensate for a procedure that it had authorized. "It's inappropriate for us as a company to approve a code and then turn around and deny it," Brower said.

Over the years, the center had appealed thousands of reimbursements for being too low. It hired additional employees to manage the paperwork. At the trial, Blue Cross revealed that it had never considered any of the appeals — nor had it ever told the center that they were pointless. "An appeal is not available to review an underpayment," acknowledged Paula Shepherd, a Blue Cross executive vice president. The insurer simply issued an edict — the payment was correct.

This was the core of the case. The insurer set the rules. The insurer set the prices. Doctors could appeal to a state insurance regulator. But if that failed, and it often did, the only recourse was a long, costly lawsuit.

Williams summed up for the jury the center's treatment at the hands of Blue Cross: "Our payments are slow pay, low pay or no pay."

In countering those arguments, Blue Cross witnesses explained that the insurer was committed to paying for Louisianans' health care and keeping costs low. As a nonprofit, it directed any excess revenue from operations back into the business. (Udvarhelyi, the CEO, did acknowledge that his salary, over $1 million, included bonuses that depended on hitting revenue targets and increasing membership.)

Brian West, a Blue Cross executive who monitored payments, said the center had engaged in "egregious" billing practices. "They are bad actors in the billing world," he said. But company witnesses offered only a handful of examples. Sometimes the center mistakenly coded its bills in a way that appeared to charge for four separate breast reconstructions in a single operation. In other cases, the center asked for payment for two surgeons in the room at the same time. But Blue Cross, following Medicare guidelines, would pay two surgeons only 20% more than the reimbursement for a single surgeon.

Blue Cross did not accuse the center of any intentional miscoding — but the sloppy billing led to additional scrutiny, the company's witnesses said. The targeted list, a witness testified, had been created especially for the center, requiring all prior authorization requests to bypass normal routes for a special review by company doctors. The blocked list meant that each bill from the center received a manual scrub by payment specialists before reimbursement. Blue Cross acknowledged the careful checking often resulted in the need for more information from the center, which could result in slower processing of claims. But the lists, executives insisted, were not designed to reduce payments. "Basically, no harm was done," said Becky Juncker, who was involved in approving surgical procedures.

Company witnesses explained that the 16% received in saving money for out-of-state Blue Cross insurers was a fee to cover the costs of handling adjustments of the claim — though they were not able to explain why Blue Cross did not charge a flat fee for its services.

Blue Cross also defended itself against the accusation that it had paid nothing for 60% of the charges for individual procedures. Witnesses said the insurer had followed industry practice in bundling charges to make a single payment for an operation. An attorney for the center noted that it had never agreed to take bundled payments — Blue Cross had imposed them.

As to the calls to women like Arch? That was an effort to save members money. "Our medical area would reach out to our members who were utilizing out-of-network providers to help them understand the, I would say, the financial implications," said Shepherd, the Blue Cross executive vice president, in a deposition. "It could be financially catastrophic to a member to have an out-of-network claim that they are financially responsible for. It's a huge difference."

In summing up the case, Kim Boyle, the lead attorney for the company, told jurors that Blue Cross had not committed fraud. It had acted to ensure the company and its members paid a fair price for the center's services, she said. "There's no scheme. There's no plot. There's no mafia. There are no Blue Cross employees of Louisiana that are sitting in some smoke-filled room in Baton Rouge, plotting against these plaintiffs on St. Charles Avenue in New Orleans," Boyle said. "It's fiction; it's fancy; it's completely made up."

On Sept. 20, at 1:57 p.m., Judge Sidney H. Cates IV sent the jurors to deliberate. The center attorneys retreated to a nearby hotel to await the verdict. About two hours later, they were summoned back to Division C. Williams put his head down and swore. He worried that such a quick return in the legally complex case meant victory for Blue Cross.

The center's lawyers paid close attention to Cates as he reviewed the jurors' decision. It was a two-page form. If the jurors found in favor of Blue Cross, the judge would have no reason to read on. Cates flipped to the second page: The jurors had found Blue Cross liable for fraud. "Please express in dollars the total monetary compensation, if any, Blue Cross owes the hospital and the center for the damages," Cates said, reading from the verdict. "Net damages, $421,488,633." The center's lawyers stood and shook hands as the insurer's attorneys prepared to leave the courtroom.

DellaCroce was in surgery at the hospital, having expected a longer deliberation. Sullivan was in the courtroom to hear the verdict. Afterward, jurors approached and thanked him for his work. He teared up. "We would have given more if we had been asked for more. That's how egregious the fraud was," Juliet Laughlin, a 58-year-old property manager who served as forewoman, later said. "There had been wrong done." 

Blue Cross has appealed the verdict. A health insurance trade group has warned that the finding sets a dangerous precedent. If allowed to stand, insurance companies in Louisiana may find themselves forced to pay whatever price is demanded by out-of-network doctors — which in turn could raise health insurance premiums across the state, the Louisiana Association of Health Plans said in a statement.

For DellaCroce and Sullivan, the verdict was vindication. They had refused to sign contracts they thought unfair. They had rejected settlement offers they thought too low. The trial had revealed Blue Cross' domineering behavior. "Fundamentally, I think their problem was that we were doctors who had control," DellaCroce said. "That was regarded as a threat."

In the months since the judgment, Blue Cross has not changed its practices, the doctors said. It has not approached with an offer that would bring the hospital in network. It still issues prior authorizations for women's surgeries. And it still pays only a fraction of the billed fees.

How We Reported the Story

This account is based on a review of thousands of pages of trial transcripts, depositions, federal and state court records, and internal corporate documents from Blue Cross and Blue Shield of Louisiana, the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital; scores of interviews with doctors, patients and insurance executives; medical records; regulatory filings; and reports by academics, experts and the Louisiana state Senate. Some corporate documents discussed in court were placed under seal after the trial's conclusion. Blue Cross and Blue Shield of Louisiana was provided a detailed list of questions and responded with a written statement, cited in part in the story. The company declined to make any employees available for an interview. Former Blue Cross CEO Steven Udvarhelyi declined to comment, and former employee Dwight Brower did not respond to phone calls or emails. 

Then the state's first abortion ban went into effect and the rate of sepsis spiked.

"This is exactly what we predicted would happen and exactly what we were afraid would happen," said Dr. Lorie Harper, a maternal-fetal medicine specialist in Austin.

She and a dozen other maternal health experts who reviewed ProPublica's findings say they add to the evidence that the state's abortion ban is leading to dangerous delays in care. Texas law threatens up to 99 years in prison for providing an abortion. Though the ban includes an exception for a "medical emergency," the definition of what constitutes an emergency has been subject to confusion and debate.

Many said the ban is the only explanation they could see for the sudden jump in sepsis cases.

The new analysis comes as Texas legislators consider amending the abortion ban in the wake of ProPublica's previous reporting, and as doctors, federal lawmakers and the state's largest newspaper have urged Texas officials to review pregnancy-related deaths from the first full years after the ban was enacted; the state maternal mortality review committee has, thus far, opted not to examine the death data for 2022 and 2023.

The standard of care for miscarrying patients in the second trimester is to offer to empty the uterus, according to leading medical organizations, which can lower the risk of contracting an infection and developing sepsis. If a patient's water breaks or her cervix opens, that risk rises with every passing hour.

Sepsis can lead to permanent kidney failure, brain damage and dangerous blood clotting. Nationally, it is one of the leading causes of deaths in hospitals.

While some Texas doctors have told ProPublica they regularly offer to empty the uterus in these cases, others say their hospitals don't allow them to do so until the fetal heartbeat stops or they can document a life-threatening complication.

Last year, ProPublica reported on the repercussions of these kinds of delays.

Forced to wait 40 hours as her dying fetus pressed against her cervix, Josseli Barnica risked a dangerous infection. Doctors didn't induce labor until her fetus no longer had a heartbeat.

Physicians waited, too, as Nevaeh Crain's organs failed. Before rushing the pregnant teenager to the operating room, they ran an extra test to confirm her fetus had expired.

Both women had hoped to carry their pregnancies to term, both suffered miscarriages and both died.

In response to their stories, 111 doctors wrote a letter to the Legislature saying the abortion ban kept them from providing lifesaving care and demanding a change.

"It's black and white in the law, but it's very vague when you're in the moment," said Dr. Tony Ogburn, an OB-GYN in San Antonio. When the fetus has a heartbeat, doctors can't simply follow the usual evidence-based guidelines, he said. Instead, there is a legal obligation to assess whether a woman's condition is dire enough to merit an abortion under a prosecutor's interpretation of the law.

Some prominent Texas Republicans who helped write and pass Texas' strict abortion bans have recently said that the law should be changed to protect women's lives — though it's unclear if proposed amendments will receive a public hearing during the current legislative session.

ProPublica's findings indicate that the law is getting in the way of providing abortions that can protect against life-threatening infections, said Dr. Sarah Prager, a professor of obstetrics and gynecology at the University of Washington.

"We have the ability to intervene before these patients get sick," she said. "This is evidence that we aren't doing that."

A New View

Health experts, specially equipped to study maternal deaths, sit on federal agencies and state-appointed review panels. But, as ProPublica previously reported, none of these bodies have systematically assessed the consequences of abortion bans.

So ProPublica set out to do so, first by investigating preventable deaths, and now by using data to take a broader view, looking at what happened in Texas hospitals after the state banned abortion, in particular as women faced miscarriages.

"It is kind of mindblowing that even before the bans researchers barely looked into complications of pregnancy loss in hospitals," said perinatal epidemiologist Alison Gemmill, an expert on miscarriage at Johns Hopkins Bloomberg School of Public Health.

In consultation with Gemmill and more than a dozen other maternal health researchers and obstetricians, ProPublica built a framework for analyzing Texas hospital discharge data from 2017 to 2023, the most recent full year available. This billing data, kept by hospitals and collected by the state, catalogues what happens in every hospitalization. It is anonymized but remarkable in its granularity, including details such as gestational age, complications and procedures.

To study infections during pregnancy loss, ProPublica identified all hospitalizations that included miscarriages, terminations and births from the beginning of the second trimester up to 22 weeks' gestation, before fetal viability. Since first-trimester miscarriage is often managed in an outpatient setting, ProPublica did not include those cases in this analysis.

When looking at stays for second-trimester pregnancy loss, ProPublica found a relatively steady rate of sepsis before Texas made abortion a crime. In late 2021, the state made it a civil offense to end a pregnancy after a fetus developed cardiac activity, and in the summer of 2022, the state made it a felony to terminate any pregnancy, with few exceptions.

In 2021, 67 patients who lost a pregnancy in the second trimester were diagnosed with sepsis — as in the previous years, they accounted for about 3% of the hospitalizations.

In 2022, that number jumped to 90.

The following year, it climbed to 99.

ProPublica's analysis was conservative and likely missed some cases. It doesn't capture what happened to miscarrying patients who were turned away from emergency rooms or those like Barnica who were made to wait, then discharged home before they returned with sepsis.

Our analysis showed that patients who were admitted while their fetus was still believed to have a heartbeat were far more likely to develop sepsis.

"What this says to me is that once a fetal death is diagnosed, doctors can appropriately take care of someone to prevent sepsis, but if the fetus still has a heartbeat, then they aren't able to act and the risk for maternal sepsis goes way up," said Dr. Kristina Adams Waldorf, professor of obstetrics and gynecology at UW Medicine and an expert in pregnancy complications. "This is needlessly putting a woman's life in danger."

Studies indicate that waiting to evacuate the uterus increases rates of sepsis for patients whose water breaks before the fetus can survive outside the womb, a condition called previable premature rupture of membranes or PPROM. Because of the risk of infection, major medical organizations like the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists advise doctors to always offer abortions.

Researchers in Dallas and Houston examined cases of previable pregnancy complications at their local hospitals after the state ban. Both studies found that when women weren't able to end their pregnancies right away, they were significantly more likely to develop dangerous conditions than before the ban. The study of the University of Texas Health Science Center in Houston, not yet published, found that the rate of sepsis tripled after the ban.

Dr. Emily Fahl, a co-author of that study, recently urged professional societies and state medical boards to "explicitly clarify" that doctors need to recommend evacuating the uterus for patients with a PPROM diagnosis, even with no sign of infection, according to MedPage Today.

UTHealth Houston did not respond to several requests for comment.

ProPublica zoomed out beyond the second trimester to look at deaths of all women hospitalized in Texas while pregnant or up to six weeks postpartum. Deaths peaked amid the COVID-19 pandemic, and most patients who died then were diagnosed with the virus. But looking at the two years before the pandemic, 2018 and 2019, and the two most recent years of data, 2022 and 2023, there is a clear shift:

In the two earlier years, there were 79 maternal hospital deaths.

In the two most recent, there were 120.

Caitlin Myers, an economist at Middlebury College, said it's crucial to examine these deaths from different angles, as ProPublica has done. Data analyses help illuminate trends but can't reveal a patient's history or wishes, as a detailed medical chart might. Diving deep into individual cases can reveal the timeline of treatment and how doctors behave. "When you see them together, it tells a really compelling story that people are dying as a result of the abortion restrictions."

Texas has no plans to scrutinize those deaths. The chair of the maternal mortality review committee said the group is skipping data from 2022 and 2023 and picking up its analysis with 2024 to get a more "contemporary" view of deaths. She added that the decision had "absolutely no nefarious intent."

"The fact that Texas is not reviewing those years does a disservice to the 120 individuals you identified who died inpatient and were pregnant," said Dr. Jonas Swartz, an assistant professor of obstetrics and gynecology at Duke University. "And that is an underestimation of the number of people who died."

The committee is also prohibited by law from reviewing cases that include an abortion medication or procedure, which can also be used during miscarriages. In response to ProPublica's reporting, a Democratic state representative filed a bill to overturn that prohibition and order those cases to be examined.

Because not all maternal deaths take place in hospitals and the Texas hospital data did not include cause of death, ProPublica also looked at data compiled from death certificates by the Centers for Disease Control and Prevention.

It shows that the rate of maternal deaths in Texas rose 33% between 2019 and 2023 even as the national rate fell by 7.5%.

A New Imperative

Texas' abortion law is under review this legislative session. Even the party that championed it and the senator who authored it say they would consider a change.

On a local television program last month, Republican Lt. Gov. Dan Patrick said the law should be amended.

"I do think we need to clarify any language," Patrick said, "so that doctors are not in fear of being penalized if they think the life of the mother is at risk."

State Sen. Bryan Hughes, who once argued that the abortion ban he wrote was "plenty clear," has since reversed course, saying he is working to propose language to amend the ban. Texas Gov. Greg Abbott told ProPublica, through a spokesperson, that he would "look forward to seeing any clarifying language in any proposed legislation from the Legislature."

Patrick, Hughes and Attorney General Ken Paxton did not respond to ProPublica's questions about what changes they would like to see made this session and did not comment on findings ProPublica shared.

In response to ProPublica's analysis, Abbott's office said in a statement that Texas law is clear and pointed to Texas health department data that shows 135 abortions have been performed since Roe was overturned without resulting in prosecution. The vast majority of the abortions were categorized as responses to an emergency but the data did not specify what kind. Only five were solely to "preserve [the] health of [the] woman."

At least seven bills related to repealing or creating new exceptions to the abortion laws have been introduced in Texas.

Doctors told ProPublica they would most like to see the bans overturned so all patients could receive standard care, including the option to terminate pregnancies for health considerations, regardless of whether it's an emergency. No list of exceptions can encompass every situation and risk a patient might face, obstetricians said.

"A list of exceptions is always going to exclude people," said Dallas OB-GYN Dr. Allison Gilbert.

It seems unlikely a Republican-controlled Legislature would overturn the ban. Gilbert and others are advocating to at least end criminal and civil penalties for doctors. Though no doctor has been prosecuted for violating the ban, the mere threat of criminal charges continues to obstruct care, she said.

In 2023, an amendment was passed that permitted physicians to intervene when patients are diagnosed with PPROM. But it is written in such a way that still exposes physicians to prosecution; it allows them to offer an "affirmative defense," like arguing self-defense when charged with murder.

"Anything that can reduce those severe penalties that have really chilled physicians in Texas would be helpful," Gilbert said. "I think it will mean that we save patients' lives."

Rep. Mihaela Plesa, a Democrat from outside Dallas who filed a bill to create new health exceptions, said that ProPublica's latest findings were "infuriating."

She is urging Republicans to bring the bills to a hearing for debate and discussion.

Last session, there were no public hearings, even as women have sued the state after being denied treatment for their pregnancy complications. This year, though some Republicans appeared open to change, others have gone a different direction.

One recently filed a bill that would allow the state to charge women who get an abortion with homicide, for which they could face the death penalty.

United argued that three separate doctors had reviewed her case. The Dwyers sued and lost, but appealed to the 5th U.S. Circuit Court of Appeals, which reversed that decision and ruled unanimously in favor of the family. In a harshly critical opinion, the judges wrote that the denial letters issued by the three doctors were "not supported by the underlying medical evidence." In fact, the court found, they were "contradicted by the record."

Dwyer, who was pleased to learn of the agency's investigation, said she hopes it results in "substantive action."

"I never would have thought that our story would be part of that," she said. "I think it's incredible that the Department of Labor is paying attention to this issue and is investigating the insurance doctors. But I also hope they look beyond the actions of the individual doctors to deeper issues of the way insurance companies operate more systematically."