Peer Review

The first and most important phase in the resolution of a dispute is mediation.

• Mediation is an informal process in which a CDA staff mediator facilitates communication between the parties to assist them in identifying a mutually acceptable agreement.
• The mediator does not decide the solution to the dispute; each party voluntarily participates in and agrees to the solution. This process is conducted via phone.

If the dispute is not resolved through mediation, a committee of member-dentist volunteers follows specific procedures to conduct a review of the treatment to help reach a fair agreement. In evaluative peer review:

• Cases will be reviewed by the Peer Review Committee located as closely as possible to where the treatment was rendered.
• The patient will be given an opportunity to meet with the committee to have the treatment examined.
• The dentist also has the opportunity to meet with the committee (separately from the patient).
• All other involved parties (subsequent consulting/treating dentists, insuring entities) will be contacted for additional evidence.
• The Peer Review Committee will evaluate all available evidence (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.
• Parties have the option to appeal the decision to the Council on Peer Review Appeals Panel.

The following are potential outcomes of cases resolved via the evaluative 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.

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.

• 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), has initiated or has 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 majority of peer review cases are initiated by patients. However, there are some instances when a dentist may initiate a peer review case:

• To determine whether a carrier has properly interpreted its contract and to obtain benefits for a patient
• To appeal a carrier’s decision about the quality or appropriateness of treatment

If you are interested in initiating a peer review, please contact the California Dental Association at 800.232.7645 to speak with a coordinator. Once a request for review is received, CDA will contact the patient to obtain authorization to perform the review. The patient must consent to the review for the case to proceed.