Peer Review FAQ's
What is the criteria for acceptance?
- Appropriateness of treatment: This is defined as professional acceptability of planned or completed treatments to include the necessity of treatment and consistency with diagnosis.
- Quality of Care: This is defined as an evaluation of the treatment provided using the standards which generally prevail within the profession by those who routinely perform the treatment in question.
What matters are not usually accepted by Peer Review?
- Litigation: It is not within the authority of peer review to accept cases in which a lawsuit has been filed. An exception to this condition is the instance in which a dentist has initiated litigation for the collection of a fee.
- Cases in which the dental care provider is not a member of the Colorado Dental Association.
- Cases in which the Council on Peer Review finds that the case has been reviewed or is currently in review by the State Board of Dental Examiners, other state peer review committees, third party carriers or managed care review bodies.
- The MDDS component does not review insurance fees/policies, disputes, or usualness of fees charged by dentists within the community.
What is the process for review?
- A Request for Dental Services Review form is submitted by the patient to MDDS.
- The Request is reviewed for completeness and appropriateness and referred to the Colorado Dental Association Council on Peer Review for approval or rejection based on criteria.
- If approved, the Request is sent to the Chairman of the MDDS peer review committee for mediation. He assigns one member of the Committee to mediate the problem.
- The mediator contacts all parties and attempts to resolve the problem. A clinical examination or record collection is not conducted during the process of mediation.
- If the problem is successfully mediated, all parties sign a Resolution Agreement. Following the completion of terms by all parties, a final written report is issued and permission to close the case is submitted to the MDDS Committee Chairman and to The Colorado Dental Association.
- If mediation is not successful and further action is necessary, the Chairman is accordingly advised.
- If the patient wants to enter the next stage of review, arbitration, he/she will be required to sign a release authorizing the arbitration thereby giving up their future rights to proceed to a court of law following this review.
- A Committee of at least three (3) dentists is appointed to review the case.
- Following the collection of all relevant materials from all parties, including a possible examination of the patient, The Committee concludes its review and all parties are notified of the decision and recommendations in writing.
How much of a refund can be expected if the committee finds against me?
The maximum a patient may recover in Peer Review is the amount he/she paid the dentist. If an exchange of monies is part of the resolution, monies paid to an insurance carrier are returned to that carrier even if the patient is no longer with that provider. It is usual that a release form and satisfaction of claims be signed especially if there is an exchange of money.
How long will the review take?
Generally, once received the mediation stage can take anywhere from one to three weeks depending on the complexity of the complaint.
Arbitration, on the other hand, may take from one to three months depending on the timing of record collection, patient examination, arbitrator meetings and, of course, the complexity of the case.
Can I appeal this decision?
Yes, to the Colorado Dental Association Council on Peer Review. Any component peer review decision may be appealed if the appealing party requests the review in writing within thirty (30) days after the involved parties are notified. All decisions of the CDA Council on Peer Review are final.
What is the criteria for appeal?
Criteria for appeal must be supported by evidence of one or more of the following criteria:
- Proper procedures were not followed by the peer review committee.
- Additional information, which was not available to the reviewing committee, has become available;
- The decision of the review committee appears contrary to the information presented.
Upon receipt of a request for an appeal, the Council may:
- Request additional information and/or documents from any of the parties involved.
- Request a consultation with other organizations or specialist consultants.
The CDA Council on Peer Review will consider all the facts in the case and determine what action is necessary. The Council may:
- Deny the appeal and let the components decision stand,
- Refer the case back to the component for further review if the initial review is considered inadequate or incomplete, or if there is new information that was not available to the committee when making its original decision, or
- Agree to review the matter and make a decision. Should the Council decide to evaluate the decision, it will evaluate the case for procedural errors. If quality of care is involved, the case may require a clinical examination of the patient by at least three (3) members of the Council.
Following the review of all pertinent information, the Council will render a final decision. The decision of the CDA Council on Peer Review is final within the peer review context.
Which private and government organizations sanction dental Peer Review?
The Metropolitan Denver Dental Society (MDDS)
(303) 488-0177 fax
The Colorado Dental Association (CDA)
(303) 740-7989 fax
The American Dental Association (ADA)
(312) 440-2883 fax
The Colorado State Board of Dental Examiners (CSBDE)
(303) 894-7758 x301