Case Study: Credentialing Calamity

Repurposed from The Scope, Third Quarter 2025

The patient in this case was a 50-year-old married female who was employed at the medical facility where she was initially treated. She expressed an interest in excess fat removal, breast implants, a revision to her belly button, and abdominoplasty. The practice owner, a MLMIC-insured anesthesiologist, referred the patient to a plastic surgeon at the practice.

Facts of the Case

The patient presented to the medical facility where she worked and was noted to have a history of smoking two packs of cigarettes per day, five pregnancies, left-knee surgery, and a previous abdominoplasty, and to have lost 150 lbs. during the previous year.

A consent form was obtained for mastopexy with breast implants, a repeat abdominoplasty, and an umbilicoplasty. The non-MLMIC policyholders provided anesthesia and performed the surgical procedures. The pre-operative diagnosis was bilateral breast hypoplasia with ptosis and residual abdominal elastosis. Over the course of seven hours, the procedures were accomplished and saline implants inserted in both breasts with no complications.

Post-operatively, a Jackson-Pratt drain was put in place, and the patient was instructed to use a compression garment for 72 hours. She was noted to be awake, alert, and stable during recovery, with minimal pain, and was discharged home later that day with instructions on changing her dressings and taking oral antibiotics.

The plastic surgeon left for a four-week vacation the day after the surgery.

The patient did not report any open wounds when she changed her own dressings three days post-operatively. One week post operatively, however, the patient noted that her abdominal wound was completely open with fluid discharge. She sent text messages to the plastic surgeon and the anesthesiologist and was advised to see the anesthesiologist in the office.

She presented to the office and was seen that day by the anesthesiologist along with the gastroenterologist who initially performed the patient’s pre-op exam, who observed the dressing change and suggested wound irrigation. The patient was instructed in wound care and advised to see the plastic surgeon upon his return to the office.

The patient later returned for a second postoperative visit, and the anesthesiologist became alarmed at the significant discharge and progression of the wounds. He instructed the patient to discuss further wound care with the gastroenterologist, who reviewed photographs of the patient’s wounds but failed to examine the patient or refer the patient to a specialist.

Upon his return from vacation, the plastic surgeon resumed treatment of the patient, during which time he performed three surgical repairs and debridement. However, the patient continued to text the anesthesiologist and plastic surgeon, stating that the wounds were not healing.

The patient subsequently presented to the local hospital emergency room with complaints of wound dehiscence, which was noted on bilateral breasts and the patient’s abdomen, along with erythema and yellow discharge. Upon admission, she was also noted to have cellulitis and infected incision lines. She complained of pain and was placed on IV antibiotics.

A non-party plastic surgeon at the hospital performed debridement of all wounds with placement of a wound VAC and diagnosed necrotizing fasciitis of the breasts and abdomen, with pathology confirming infected necrotic tissue. The patient was hospitalized for two weeks with a course of pain management, medication, and wound treatment. She was discharged with the wound VAC and home health nurses for daily dressing changes.

Several months later, the patient was seen at the hospital for outpatient replacement of the abdominal skin graft, with her thigh as the donor site, due to a non-healing abdominal wound, which was confirmed to be necrotizing fasciitis.

Four months later, the wounds were noted to be healed by the non-party plastic surgeon. The patient kept in touch with the MLMIC-insured anesthesiologist throughout the pendency of her recovery and later returned to work at this policyholder’s medical facility.

One year later, the patient brought a lawsuit against the plastic surgeon and the anesthesiologist who had performed the surgery, along with the facility and our insured anesthesiologist, alleging improper care following breast and abdominal reconstruction, resulting in necrotizing fasciitis that required multiple surgical debridements that left severe scarring.

MLMIC’s experts in anesthesia and general surgery found this to be a case with a poor outcome, and although our insured anesthesiologist was not involved directly with the patient’s care, she received multiple text messages from the patient without offering treatment to the patient or referring her to a wound care specialist. She was also criticized for allowing the plastic surgeon, who had licensing issues, to work at the facility without insurance. In addition, following the procedure, the patient’s chart could not be found, and there was speculation that the patient or the plastic surgeon may have removed the record from the facility. The plaintiff’s counsel argued that he would request a missing records charge at trial.

The defense for the anesthesiologist, the practice’s owner, was that she had a minor role in this case. However, due to issues with the missing chart, poor credentialing, and allowing an uninsured physician to work at the facility, a decision was made to settle the case on behalf of the practice’s owner.

A Risk Management and Legal Analysis

 The facts in this case illustrate why it is crucial to ensure that all professionals in a surgical center or practice have current New York State licensure and medical professional liability (MPL) insurance with the appropriate limits of at least $1/3 million.

Was the patient in this case a suitable surgical risk? The surgeon and the anesthesiologist should have been very concerned that she was 50 years old with a history of obesity and that she smoked two packs of cigarettes a day, which can lead to poor healing. There is no indication that she was required to obtain pre-operative clearance from her medical physician, which should have occurred.

Additionally, no one at the surgery center checked the licensure, current MPL insurance status, and other credentials of the plastic surgeon to make certain that he was eligible to work at that center. The only conclusion that can be drawn is that the practice was so intent on having him work there that it did not bother to obtain these items, which is an essential aspect of every credentialing process. It was determined later that the plastic surgeon lacked MPL insurance coverage and that he had licensure issues and should therefore not have been permitted to operate on any patient at the facility.

Unfortunately, the surgery center paid dearly for its failure to ensure that the physician had essential credentials, licensure, and medical malpractice insurance, as well as the appropriate skills to properly care for this patient. In addition, it is very possible that because the patient was a long-time employee of the surgical center, many of the items that would normally be requested of patients were glossed over.

Since the plastic surgeon lacked MPL insurance, the patient’s attorney had to focus on other personnel for whatever assets or insurance the surgery center and anesthesiologist had. Although the medical record may well have shown that the patient was appropriately cared for in the center, the defense was compromised by the fact that the surgeon was not properly credentialed by the center, which did not even verify whether he was licensed in this state. An additional concerning factor was that the patient’s medical record was inexplicably missing from the surgery center.

Credentialing Overview

Complete and thorough credentialing of healthcare professionals is a crucial process to confirm qualifications and ensure competency to appropriately treat patients. Verification of a provider’s education, residency training, board certifications, and state licensure is a vital prerequisite to determine whether individuals are qualified to provide quality healthcare. A comprehensive background check will reveal the existence of any malpractice claims, disciplinary actions, and/or criminal activity. Systematic and periodic credentialing assists in assessing whether individuals are qualified professionals who meet required standards based on education, training, and experience. If executed properly, credentialing has a positive impact on malpractice risks by confirming competency to perform quality healthcare responsibilities.

MLMIC policyholders can reach out to our healthcare attorneys for questions about credentialling matters, documentation, or any other healthcare law inquiries by calling (877) 426-9555 Monday-Friday, 8 a.m.-6 p.m. or by email here.

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This document is for general purposes only and should not be construed as medical, dental or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical, dental or professional obligations, the applicable state or federal laws or other professional questions.