Peer Review Policy
I. TYPES OF COMPLAINTS
Fee Complaints
Consideration of fee complaints is limited to determining whether the fee charged is the dentist's usual fee*, or that the fee was a reasonable fee* due to unusual circumstances. The Committee shall not attempt to establish a fee for a particular service, nor shall it attempt to identify or establish a customary fee*.
If the fee question is whether the dentist's usual fee* was charged, the Committee shall satisfy itself by requesting that the dentist send a representative sampling of other patients’ billings with confidential complainant information obliterated which will serve to establish the dentist's usual fee*. This sampling should include at least a total of ten (10) recent insured and non-insured cases. Less common procedures may require, of necessity, fewer samplings.
The Committee may act in an advisory capacity in connection with the unusual circumstances of a particular case in determining whether the fee charged was reasonable*.
*The definitions of "usual", "customary" and "reasonable" fees as adopted by the American Dental Association are: "usual fee" - the fee that an individual dentist most frequently charges for a given dental service; "customary fee" - the fee level determined by the administrator of a dental benefit plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for the specific procedure; "reasonable fee" - the fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances, and therefore may differ from the dentist's "usual" fee or the benefit administrator's "customary" fee.