Resolve a Complaint or a Dispute with a Dentist Through the LDA’s Peer Review Process
Even in the best dentist-patient relationship, a problem may occur. First, discuss any concerns you have with your dentist. Many times this will help clear up the matter. If you are still not pleased, the LDA has an established dispute resolution system called Peer Review to help resolve the occasional disagreement about dental treatment.
The purpose of the peer review system is to resolve disputes that may arise in the delivery of dental services to the public. Unbiased, objective and timely reviews are conducted using the Louisiana Dental Association's format for addressing disputes between patients, dental care providers and third-party carriers.
Peer review is not a court and has no disciplinary function. It merely provides an alternative dispute resolution mechanism, at no cost to either party. Peer Review is a process by which the dental profession reviews and attempts to resolve dental treatment problems and misunderstandings through mediation.
Participation in the peer review process is purely voluntary for all concerned, and the decisions of peer review bodies, whether originally or on appeal, are advisory only. The decisions of peer review bodies and the information gathered in the course of peer review investigations are confidential to the extent allowed by law and are not disclosed to the general membership of the Louisiana Dental Association, its component associations, or the general public.
(Cases over one year from today’s date do not qualify for peer review.)
DISPUTES WITHIN THE SCOPE OF REVIEW
The following types of disputes may be reviewed by a Peer Review Committee:
A. Disputes concerning pre-determination of dental services to
be provided under insurance contracts or other prepayment
B. Disputes concerning whether services for which a fee was
charged were rendered.
C. Disputes concerning whether a fee charged was customary
D. Disputes concerning utilization of services or appropriateness
E. Disputes concerning the quality of services rendered.
The Peer Review Committee may not consider any dispute on which a lawsuit has been filed, and if suit is filed after peer review has been initiated, the review shall immediately terminate.
The Peer Review Committee shall have no disciplinary powers over the participants in peer review. However, when a Peer Review Committee determines that the health and welfare of a patient has been adversely affected by the professional conduct of a dentist, it may include in its decision a request that the executive director of the Louisiana Dental Association forward a copy of the peer review file in issue to the Louisiana State Board of Dentistry for review.
1. To institute a review one must file with the executive director of the Louisiana Dental Association at its office in Baton Rouge, a detailed written complaint and a filing fee of $10. (Cases over one year from today’s date do not qualify for peer review.)
2. Upon receipt of a complaint the executive director will immediately refer the complaint to the Component Association in the area where the dental services were rendered or to be rendered.
3. The Board of Governors of the Component Association shall immediately refer the complaint to a Review Committee.
4. The Committee shall immediately mail a copy of the complaint to the party or parties about whom the complaint is made. The committee shall advise all concerned in writing that participation in peer review is voluntary and that if they participate, they have a right to appeal the decision of the Peer Review Committee to the LDA Council on Dental Benefits Programs. The Committee shall ascertain whether the parties involved wish to participate in the peer review process. If all parties wish to participate, the Committee shall advise the party against whom the complaint is filed that an investigation will be conducted by the Committee.
5. The Committee shall notify all parties to the dispute of the names of the persons appointed to the Review Committee. Any party to a dispute may challenge any member of the Review Committee upon a showing of good cause. Challenges shall be determined by the Review Committee. The member challenged shall not vote. In case of a tie vote, the member challenged shall not serve. Members so displaced from the committee shall be replaced by new appointment made by the Board of Governors of the Component Association.
6. The committee shall appoint one of its members to conduct a preliminary investigation. This member shall thoroughly review the complaint to determine if a bona fide dispute exists. When necessary, he shall contact all parties to the dispute and determine their positions. Under no circumstances will the preliminary investigation include a clinical examination of the patient. When the preliminary investigation is completed, the investigating member shall report to the committee in writing and shall attach to the report all documents and other pertinent materials gathered by him.
7. Upon receipt of the written report from the investigating member, the committee shall determine if a formal hearing is necessary. If it determines that a formal hearing is necessary, all parties to the dispute will be notified by certified mail at least 10 days in advance of the hearing.
8. If a hearing is called, the committee shall determine that all necessary parties are present. Each party may submit such information and testimony that it wishes to have considered in support of its position.
9. If the committee decides that an examination of the patient is necessary, it shall notify all parties to the dispute of the date, time and place of the examination. Only when absolutely necessary, should post-operative radiographs be taken during the examinations. The patient's consent to the radiographs must be obtained.
10. If the committee desires or deems necessary the opinion of a specialist, a specialist Peer Review Board, or other dental consultants, in its investigation, it may call upon such specialist, specialist review board, or other dental consultant to investigate and receive their opinion. If a party to the dispute desired that the committee receive the opinion of a specialist, specialist review board, or other dental consultant, designated by the party, the committee shall also receive that opinion before rendering its judgment.
11. The Review Committee shall consider its decision in closed session. The members of the Committee shall base their decisions on the facts and circumstances of the particular case, using their own individual experience, training and judgment. In disputes concerning fees, the Committee shall not use fee schedules or relative value guides established by the LDA or any Component Association in arriving at its decision. A majority vote shall constitute the decision of the Committee. Upon reaching a decision, the committee shall render a written opinion. If the decision is not unanimous, a written minority opinion may be rendered by the dissenting member.
The decision of the committee should be specific and concise and should state the reasons and evidence on which it is based. Each decision shall state that it is purely advisory. If the committee determines that the patient's condition is or may be detrimental to his general health, it should promptly notify him of such belief.
13. The Review Committee shall forward its decision and the peer review file to the executive director of the Louisiana Dental Association immediately upon completion of its review. The Review Committee shall complete its review and render its decision with reasonable promptness.
14. The executive director shall immediately send a copy of the Review Committee's decision to all parties to the dispute. He shall further notify the parties of their right to appeal the Review Committee's decision to the Louisiana Dental Association's Council on Dental Benefits Programs.
After the Review Committee makes their decision, any party to the dispute may appeal the Review Committee's decision to the Louisiana Dental Association's Council on Dental Benefits Programs on any of the following grounds:
l) proper procedure was not followed by the Review Committee,
2) information not available at the time of the Review Committee's decision has since been developed, or
3) the Review Committee's decision on its face is contrary to the evidence presented.
Appeals must be in writing to the executive director of the Louisiana Dental Association, and they must be mailed or delivered within 30 days of the party's receipt of the Review Committee's decision. The executive director shall transmit the written appeal and the peer review file to the Council on Dental Benefits Programs.
Decisions of the Peer Review Committees and of the Appeal Committee of the Louisiana Dental Association's Council on Dental Benefits Programs, as well as all information and communications developed in the course of their investigations or deliberations, are confidential to the extent allowed by law. Peer review decisions and related information shall not be disseminated among the general membership of the Louisiana Dental Association, its component associations or the general public. Disclosure of peer review decisions and related information within the Louisiana Dental Association shall be limited to the extent necessary to permit appeals and administration of the peer review system.
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