When a problem or misunderstanding cannot be resolved between a dentist and a patient, CDA can help. Our council of dentist-member volunteers follows specific procedures to conduct peer reviews of disputes to help all parties involved reach a fair agreement.
All disputes that are evaluated within the peer review system include the following procedures:
- The responsibility for conducting a review will be that of the local component dental society where the treatment was rendered.
- The patient must sign a Patient Agreement Form prior to review. (The dentist, by virtue of his/her membership in CDA, has already agreed to abide by a peer review decision.)
- An Authorization for use and Disclosure of Health Information must be signed by the patient so that a review committee may legally obtain a patient’s records.
- Unless the treatment in question cannot be evaluated (i.e., treatment has been redone and/or altered), the patient will be examined by a panel of at least three dentists.
- The patient will be given an opportunity to present any additional comments, usually at the time of the patient examination.
- The dentist is allowed to meet with the review committee if he/she chooses.
- All other involved parties (subsequent consulting/treating dentists, insuring entities) will be contacted for additional evidence if available.
- The peer review committee will evaluate all evidence available (patient examination results, radiographs, information from subsequent consulting/treating dentists, etc.), and make a final determination. This will be communicated to all involved parties in the form of a letter of resolution.
- Involved parties will be provided an Appeal Criteria, if applicable, at the time the letter of resolution is provided.
Although the peer review system can satisfactorily resolve the majority of complaints received, there are limitations which may make a complaint inappropriate for the system.
The following types of complaints are NOT within the scope of peer review system:
Cases which do not meet "time" criteria
Excessive passage of time alters clinical conditions. Therefore, a complaint will not be reviewed if it is received more than three years from the date treatment was completed, or more than one year from the date the complainant became aware of the problem, whichever occurs first.
Cases in litigation
The peer review system is designed to resolve patient/dentist disputes. Consequently, no inquiry will be accepted for peer review if either party has initiated litigation (including small claims court or sending a 90-day notice of intent to sue); have initiated or have gone through a formal arbitration process and/or both parties have signed an arbitration agreement concerning any aspect of the dental services which might otherwise be reviewable.
Cases petitioning for non-treatment monetary awards
Requests for reimbursement for time lost from work, pain and suffering, mileage and medical expenses cannot be accepted in the peer review system as it is not a punitive system, but rather an evaluative one.
Cases about fees
A peer review committee may not comment on a dentist’s fees. To do so may be construed as price fixing.
Cases not related to treatment
Questions concerning matters other than dental treatment (e.g., a dentist’s attitude, communications problems, etc.) are outside the purview of the peer review system.
The following are potential outcomes of cases resolved via the peer review system:
- Treatment is acceptable/appropriate. If the committee determines the treatment is acceptable and appropriate, no refund will be awarded.
- Treatment is unacceptable/inappropriate. If the committee determines the treatment is unacceptable or inappropriate, the committee will award a refund to the patient and/or insurance carrier for the amount paid toward unacceptable or inappropriate treatment.
- Corrective Treatment. If the committee determines that further harm was caused, necessitating additional treatment, the committee will award the amount estimated to correct the problem.
- Acceptable but incomplete. If the committee determines that the treatment provided is acceptable, but the treatment is incomplete, the committee will award a refund of the amount of the treatment that is incomplete.
- No determination. If there is insufficient evidence to render a decision, the committee will not make a determination about the case.