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.

In cases where the dentist has initiated the services of a collection agency against a complainant, the district Committee should exercise discretion in determining whether peer review would be beneficial. The patient's benefits inherent in peer review are not necessarily withdrawn merely because the dentist has initiated the services of a collection agency.

Appropriateness of Care Complaints
The Committee shall examine, if procurable, pre-operative and post-operative x-rays. Before these records are requested from the treating dentist, a signed Release of Records must have been received from the complainant. This is part of the Request for Mediation Form.

The complainant involved may require a clinical examination (Quality Evaluation Exam--QEE). In its Appropriateness of Care assessment, the reviewing committee shall employ the California Dental Association (CDA) Quality Evaluation for Dental Care Manual, with the exception of Periodontal Guidelines.

The committee shall determine if the services were provided as recorded. The committee shall consider "under treatment", as well as "over-treatment".

Quality of Care Complaints
The committee shall consider an evaluation of the skill with which a treatment is provided in light of the standards, which generally prevail within the profession in the dentist's geographical practice area, by those who routinely perform the treatment in question, as judged by peer practitioners.

The complainant involved may require a clinical examination (Quality Evaluation Exam--QEE). In its Quality of Care assessment, the reviewing committee shall employ the California Dental Association (CDA) Quality Evaluation for Dental Care Manual, with the exception of Periodontal Guidelines.

II. REGISTRATION OF COMPLAINTS

Either paid staff or volunteer staff of the MDA or a district society is often the first contact a member of the public makes with regard to a complaint. This provides staff an opportunity to educate the public regarding the peer review process. It is the right and responsibility of each
district society and the MDA to set the parameters for dental office staff involvement if, in handling telephoned complaints, dental office staff become involved in more than providing an explanation of how to file a written request for mediation.

Complaints and all information relative to the complaint must be submitted in writing, on the standard Request for Mediation Form developed and distributed by the MDA. The peer review process shall be defined as commencing on receipt of the signed written Request for Mediation Form by the MDA or district society Committee.

Complaints are usually first registered by telephone with a staff member at the MDA (for outstate districts) or with a staff member at the district office (in the Twin Cities metro area) where the dentist practices. Complaints received are referred to and action initiated at the district society level and addressed by the Peer Review Committee where the dentist practices and the complainant was treated.

III. MEDIATOR'S ROLE

The mediator controls the mediation and is responsible to:

Be a catalyst to create a positive atmosphere that will prevent further polarization. Give support for parties' willingness to negotiate the dispute. Provide a process whereby the parties can discuss their disagreements and differences.
Be an educator to help the parties focus on their needs. Clarify positions of both parties.
Be a translator to explain offers of solutions.
Be a creator of options to explore potential solutions and assist parties to generate alternative solutions for consideration.
Be a facilitator to do whatever is necessary to keep the process alive until a solution can be found. Help bring about a solution or agreement between the complainant and the dentist by facilitating discussions and help parties to reach their own agreement.

IV. APPEAL GUIDELINES

If not all parties accept the Arbitration Panel’s recommendation or if there is new evidence, any party has the right to appeal a recommendation of the district society committee based on the following criteria:

Procedural error which discriminates against any party.
Availability of new evidence.
Prejudice or bias.
Request of the district society chair.
Recommendation is inconsistent with the evidence.