COLUMBUS, Ohio (WCMH) — NBC4 Investigates is following allegations of systemic problems inside a central Ohio hospital.

In recent months, NBC4 exposed claims of sexual misconduct against two doctors at Adena Medical Center and how hospital administrators reacted to those claims.

Now, NBC4 has learned from sources inside the Chillicothe hospital with direct knowledge of its inner workings that, on as many as three patients, a cardiac surgery was performed by a doctor who was not properly credentialed.

The Transcatheter Aortic Valve Replacement (TAVR) procedure is a relatively new surgery to replace a damaged heart valve without cutting open the patient’s chest.

“[It is] highly specialized and complex,” said one source with direct knowledge who spoke to NBC4 on the condition of anonymity, saying they have, “a general concern about safety of the patients at the hospital.”

TAVR is one of many medical procedures that requires the proper credentials. Credentialing is an essential part of the healthcare system because it allows insurers to know that they’re paying for the right providers to serve their customers. Without credentialing, a claim would be denied.

As the largest payer for health care in the United States, the federal government via Centers for Medicare and Medicaid services sets the most universally-adopted standards. CMS has guidelines for TAVR procedures requiring two credentialed doctors, each with a specific set of requirements, to complete the surgery in order for a hospital to bill for it.

The source told NBC4 that one of the two TAVR doctors at Adena was not credentialed when they started performing the procedure in March 2022, but obtained the credential shortly after. A second person with direct knowledge confirmed this information to NBC4 but declined to speak on the record.

Even though both of Adena’s doctors are currently credentialed, the on-the-record source said, the fact that one doctor was not before performing up to three TAVR procedures on March 1, 2022, raises concerns.

“My concern is not one of one specific case, but more of a process that needs to be in place to ensure the safety of all patients for all types of procedures,” they said. “And if we skip parts of the process, we can put people at risk.”

Rev. Dr. Jason Link voiced similar concerns directly in an email to Adena’s executives and board members, then spoke to NBC4 after he said he was not satisfied with the answer.

“There just seems to be holes in what Adena is saying,” Link said.

Link is the pastor at First Presbyterian Church Chillicothe, one of eight remaining “corporate member” churches that founded Adena Health in 1895.

“If I know something and I don’t say something, then I’m complicit in anything that happens beyond that,” Link said.

The eight churches still play a role at the hospital: each nominates one member to the 15-seat board, and the pastors must sign off on any mergers or changes to hospital regulations.

“I talk about it as, we can almost be the voice for the greater community. Where the board members — they can look at what’s best for Adena Hospital — the pastors have this opportunity to take a broader look at what’s best for the whole community.”

A response from an “Adena Communications” email address to Link’s email said, of the three TAVR procedures performed on March 1, 2022, “medical staff leadership determined that the [surgical] privileges for TAVR should be called out as ‘additional privileges’ to better outline the distinction from ‘core privileges.’”

“We believe this change may have caused some confusion,” the response said, also stating that Adena did not bill for the procedures in order to ensure compliance.

The source confirmed everything in the response is true. They do not believe any patients were harmed, and said they still feel that patients are safe going to Adena Medical Center for surgery. The source said they are only aware of this issue occurring with TAVR.

“I have not seen it outside of this particular specialty and this particular procedure,” they said.

Adena’s leadership denied the allegations, writing to NBC4, “The team of cardiovascular physicians who performed Adena Health’s first TAVR procedures in March 2022 were appropriately credentialed to do so per all regulatory requirements and were accordingly privileged by the organization to perform the respective disciplines essential to the procedure. Claims to the contrary are patently false.”

A spokesperson for the hospital there is internal documentation to debunk the claims of an uncredentialed surgeon performing TAVRs, but the hospital cannot legally provide those documents.

It’s important to point out that privileges are different from credentials. By all accounts, the doctors have the appropriate privileges.