The Peer Review System

The California Dental Association and its 32 component dental societies, in keeping with their obligation of service to the public, have established a statewide peer review system. The purpose of the peer review system is to resolve disputes that may arise in the delivery of dental services to the public in particular, disputes regarding the quality and/or appropriateness of dental treatment, utilization (programs related to dental insurance benefits when treatment is questioned), and/or potentially irregular billing practices.

A peer review committee, comprised of CDA member-dentist volunteers, evaluates all available evidence pertaining to each dispute and follows specific procedures (listed below) to make a fair and impartial determination. The parties involved are then notified of a committee’s decision by a letter of resolution. If any party to a review can factually demonstrate that a procedural error may have occurred, or that the decision was not based on available facts, an appeal to the Council on Peer Review may be requested. This appeal must be mailed within 30 days of the date the letter of resolution is sent. Any decision of an appeals panel is final and binding.

PEER REVIEW PROCEDURES

All disputes that are evaluated within the peer review system must adhere to the following procedures:

• The responsibility for conducting a review will be that of the local component dental society of which the dentist is a member.
• The patient must sign a Patient Agreement Form prior to review. (The dentist, by virtue of membership in CDA, has already agreed to be bound by a peer review decision.)
• An Authorization For Use & Disclosure of Health Information Form 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), 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 must be invited to meet with the review committee if he/she chooses.
• All other involved parties (second treating dentists, insuring entities) will be contacted for whatever additional evidence is available.
• The peer review committee will evaluate all evidence available (patient examination, radiographs, statements from other treating dentists, etc.) and make a final determination. This will be communicated to all involved parties in the form of a letter of resolution.
• All involved parties will be given Appeal Criteria 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 purview of the 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 one year from the date the complainant became aware of the problem, whichever comes first.

Cases in litigation
- The peer review system is designed to resolve patient/dentist disputes. Consequently, no matter will be accepted for peer review if either party has initiated litigation concerning any aspect of the dental services which might otherwise be directed to review.

Cases petitioning for 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, communication problems, etc.) are outside the purview of the peer review system.