Peer Review Process

One of the first articles I wrote as CADS Editor described our Peer Review process.  

In the five years since, our society has welcomed hundreds of new members, so I feel it’s time for a reminder.  During this year’s TDA Meeting, I had the opportunity to go through TDA Peer Review training, which was both a good refresher for me as well as an opportunity to learn things I never new about the process.  Peer Review, although we all hope to never need it, is one of the most powerful member benefits of the Society.

Peer Review is an informal process through which a dispute between a patient and a dentist (or even a third-party and a dentist) can be resolved at the component level by mediation or panel review.  In short, if a patient has a problem with you or something you did, this is one of the options that the patient has to resolve the issue.

The Peer Review Process:

It should be noted that all disputes are best settled within the practice, but that is not always possible.  If you or the patient feel that the peer review process is needed, the first step is for the patient to contact the component society, i.e. CADS, and our staff, i.e. Nancy, will help him or her file the proper paper work. Once filed, the Peer Review Committee Chair will review the request for several factors: timeliness, appropriateness, jurisdiction, etc.  In order for a case to be eligible for peer review it must fall within one of the following categories: quality of treatment, appropriateness of care, fees, or utilization (a utilization review is a case of dispute between dentist and a third-party carrier regarding quality of treatment, appropriateness of care or fees and is only available if both parties agree to review). The case must also be submitted for review in a timely manner; generally within three years from formal complaint to time of the last treatment at issue in the complaint. There are also cases which are not eligible for peer review: any case that is in formal litigation or that is being investigated by the TSBDE is not within the scope of the peer review committee. Any issues involving dentist-to-dentist complaints or unethical behavior/fraud/violations of the Dental Practice Act cannot be resolved by Peer Review and will be referred to the component Judicial Committee. If a complaint is filed with Peer Review and the case is determined to be eligible then a Mediator will be assigned to the case.

Mediators are members of the Peer Review Committee that have undergone formal training in dispute negotiation.  Although mediators are CADS member dentists, they act as a go between, and success in the process requires absolute neutrality and creation of a positive environment. Often times the situation can be resolved in this step of the process and an agreement is reached. All parties are notified and the case is closed.  If no agreement can be reached in mediation then the case will then go before a panel appointed by the Peer Review Chairman and a more formal hearing will take place. This hearing can include a clinical examination and gathering of further information to assist the panel on making a decision. Once a decision has been reached by the panel, the decision is final, pending appeal by either party.  Appeals are usually only granted if either party believe that the proper procedure was not followed during the process, new information is available that could change the decision, or the decision is not in line with the information presented. A formal appeal must be presented to the TDA Council on Peer Review for consideration.

As noted above, peer review cannot be initiated if the patient has already filed a TSBDE complaint or began a litigation process, however the patient still maintains the right to do either AFTER peer review has concluded.  Peer Review is not a court of law or a punitive action hearing, but if all involved parties cooperate it can be an efficient means to an end.

Obviously, none of us wants to ever be in the situation to need these resources. Good communication, good records keeping, common sense, and a little courtesy and compassion generally go a long way in keeping everyone happy. Avoid the process, but remember it is available (and valuable) if you do need it.

By Jonathon R. Kimes, DDS

Editor, CADS