In the complex ecosystem of modern American healthcare, the relationship between a hospital system and its medical staff is governed by a dense web of bylaws, credentialing standards, and regulatory requirements. For Dr. Nakul Karkare, an orthopedic surgeon based in Long Island, New York, this administrative framework has become the center of a high-stakes legal and professional standoff. Since 2018, Dr. Karkare has held clinical privileges at South Nassau Communities Hospital—now rebranded as Mount Sinai South Nassau following its 2018 acquisition by the Mount Sinai Health System.
What began as a standard administrative renewal process has devolved into a multi-front conflict involving allegations of discriminatory credentialing, unauthorized practice of law, and potential violations of federal regulatory standards. As Dr. Karkare prepares for the expiration of his privileges on June 30, 2026, his case has highlighted a growing tension between independent physicians and the expanding bureaucratic control of large hospital conglomerates.
The Genesis of the Dispute
Dr. Karkare’s association with the hospital began on January 30, 2018, during a physician orientation session. At the time, his credentials—which include board certification from India and ACGME-accredited fellowships in the United States—were accepted without reservation. He remained an active staff member through several credentialing cycles, even during a period of reduced clinical activity following his last surgery at the facility on March 7, 2019.
However, in 2025, the landscape shifted. Mount Sinai South Nassau implemented revised medical staff bylaws that introduced stringent new requirements for board certification. These changes effectively placed Dr. Karkare’s long-standing qualifications under a microscope. While hospital administrators cited these new bylaws as the reason for their inability to reappoint him, Dr. Karkare argues that the institution is weaponizing administrative policy to purge independent practitioners, a charge he supports with extensive documentation, audio recordings, and correspondence with state and federal oversight bodies.
Chronology of a Collapsing Relationship
The friction between Dr. Karkare and the hospital leadership is evidenced by a series of recorded conversations and contradictory notices.
- January 30, 2018: Dr. Karkare begins his tenure at South Nassau Communities Hospital with full clinician privileges.
- December 2018: Mount Sinai Health System officially acquires the hospital.
- July 28, 2023: Dr. Karkare receives a formal reappointment letter granting him privileges through July 24, 2025.
- June 16, 2025: New medical staff bylaws are adopted, significantly altering board certification requirements.
- November 10, 2025: In a Zoom call, Dr. Rajiv Datta, Chair of Surgery at Mount Sinai South Nassau, explicitly informs Dr. Karkare that his Indian board certification is the primary obstacle to his renewal.
- December 30, 2025: Dr. Karkare receives a notice extending his privileges until June 30, 2026, though his status is downgraded to "associate staff."
- January 5, 2026: A second, broader meeting takes place with top hospital leadership, including the Chief Medical Officer, where the focus shifts to clinical volume requirements and the adoption of system-wide 2021 bylaws.
- Spring 2026: Dr. Karkare files formal complaints with the New York Department of Health and the Joint Commission, alleging procedural irregularities and potential legal overreach by hospital administrators.
Analyzing the Bylaws and Regulatory Standards
The core of the dispute lies in Section 15.3.2 of the updated bylaws, which mandates that applicants be board-certified by specific recognized bodies (ABMS, AOA, etc.) or demonstrate "substantial equivalence."
In his November 2025 meeting with hospital leadership, Dr. Karkare pointed out that his ACGME-accredited fellowships should satisfy the requirement for "equivalent professional competence." However, Dr. Stelios Koutsoumbelis, Director of Orthopedic Surgery, noted that the Joint Credentials Committee had determined the qualifications were not equivalent. Furthermore, Koutsoumbelis stated that a "board waiver" could only be granted based on "clinical need"—a niche the hospital claimed did not exist for Dr. Karkare, given his lack of recent surgical volume at the facility.
This creates a paradox. While the hospital cites lack of activity as a reason for non-renewal, Dr. Karkare argues that the bylaws allow for the reduction of privileges to match activity levels rather than the termination of membership. Legal experts, such as Susan Kratz of Nilan Johnson Lewis, suggest that federal law may provide protection. Under Medicare Conditions of Participation, hospitals are prohibited from basing privileges solely on certification status. If the hospital’s refusal to reappoint hinges exclusively on the lack of a specific board certification, it may run afoul of these federal requirements.
The Specter of the National Practitioner Data Bank (NPDB)
A critical element of the intimidation Dr. Karkare alleges is the threat of an NPDB report. During their discussions, hospital officials warned that if he were to appeal the decision and lose, the result would be a "non-renewal" entry in the NPDB—a federal database of adverse actions. For a surgeon, an NPDB report can effectively end a career, acting as a permanent red flag for any future hospital or insurer.
However, legal analysis suggests this threat may be a misapplication of the rules. According to the NPDB’s own guidelines, administrative actions that are not the result of a "professional review action"—such as a failure to meet board certification requirements—should not be reported. By framing the issue as a disciplinary matter rather than an administrative non-renewal, Dr. Karkare alleges the hospital is creating an environment of fear to compel his resignation.
Official Responses and Institutional Silence
Mount Sinai Health System has maintained a consistent stance of non-engagement regarding the specifics of the case. In a written statement, a hospital spokeswoman noted:
"At Mount Sinai, all credentialing and recredentialing decisions are made through a comprehensive, objective review process that evaluates a range of factors, including clinical performance, adherence to professional standards, and alignment with institutional policies. These reviews are conducted by appropriate medical staff committees and leadership in accordance with established governance procedures."
The system declined to comment on individual personnel or employment matters, citing confidentiality. Despite multiple inquiries, senior officials—including the Chief of Surgery and the Vice President of Medical Affairs—did not provide further clarity on the inconsistencies in Dr. Karkare’s appointment letters, such as the erroneous expiration date of 2099 or the discrepancies regarding his start date.
Broader Implications: The "Employed vs. Independent" Divide
The case of Dr. Karkare serves as a microcosm of a larger trend in American medicine: the consolidation of independent practice under corporate hospital systems. Dr. Karkare posits that the "quiet" departure of 85 other physicians within the system since 2021 is part of a calculated strategy to replace independent practitioners with employees who are more easily controlled and whose revenue is entirely captured by the parent institution.
For independent physicians, the struggle to maintain privileges often feels like a "death by a thousand cuts" through administrative requirements. When hospital bylaws change, the burden of proof for "equivalence" shifts entirely to the physician, often with no clear path to appeal or a neutral body to hear grievances.
The Road Ahead
Dr. Karkare remains defiant. Having filed complaints with the New York Department of Health and the Joint Commission, he is waiting to see if these agencies find that Mount Sinai’s application of the new bylaws violates state and federal standards.
His case brings to light uncomfortable questions for healthcare regulators:
- Transparency: Are "system-level" bylaws being used to bypass state laws regarding physician due process?
- Due Process: Is the threat of NPDB reporting being used as a coercive tool to prevent physicians from challenging credentialing decisions?
- Consistency: Can a hospital claim a lack of "clinical need" while simultaneously denying the application of other physicians in the same practice who have the very qualifications the hospital claims are missing?
As June 30 approaches, the outcome of this dispute will likely be watched closely by other independent practitioners in New York. For now, Dr. Karkare continues to operate at hospitals outside the Mount Sinai network, determined to challenge what he characterizes as a systemic abuse of power. Whether the regulatory bodies will intervene to curb the reach of these institutional policies or whether Dr. Karkare’s exit is a foregone conclusion remains to be seen. What is clear is that the "administrative state" of the modern hospital has become just as critical to a physician’s survival as their clinical skills.
