Your Complete Guide to the Dental Peer Review Process

As a dentist, you have hundreds of positive interactions with your patients every year. But sometimes, disputes arise about the services or treatments you provide, and a handful of these can’t be resolved without help. This is where a dental peer review committee might come in. The American Dental Association estimates it sees about 3,000 annual dental peer review cases, nationwide.

The goal of a peer review is to provide a fair, quick, and confidential resolution to disputes, usually through mediation services, though sometimes involving a dental peer review board. Peer reviews differ from other formal approaches to handling disputes, such as malpractice suits or licensing board reviews.

This useful guide explains the dental peer review process, answers questions about how peer reviews differ from malpractice claims and licensing board reviews, shares available resources, and guides you on how to prepare for a dental peer review if you are ever involved in one. It ends by explaining how dental malpractice insurance can help protect and support you if needed. Let’s get started.

What Is Peer Review in Dentistry?

The dental peer review is a confidential way to resolve disputes about dental care and treatment. State and local dental societies manage peer reviews, but each society’s guidelines and processes vary.

Most dental peer review programs consist of about five general dentists who volunteer to serve as impartial board members. In some cases, dental specialists and even non-dental professionals (in some cases, it’s members of the community) are asked to assist.

Dental peer reviews may handle these three primary types of complaints made against dentists:

1. Quality of Care

A peer review will look closely at the treatment provided by the dentist to ensure that it meets the standards of high-quality care. Consider it a form of quality assurance. For example, they may review whether a particular procedure was done correctly.

2. Appropriateness of Care

Peer review boards may also review if the treatments and evaluations were necessary and in line with the concerns and diagnosis of the patient. In doing so, they may review the patient’s oral health, existing medical conditions, and complexity of the case.

3. Fairness of Fees

The fairness of fees, which could involve concerns about the amount charged or what the fee covered, may also be evaluated by some peer review boards, though not all. Whether a dental peer review board will review complaints about fees depends on the constituent or local dental society.

A few other things to know about peer reviews according to the ADA:

• Most boards allow for disputes between dentists and third parties, such as payers, dental service corporations, health and welfare plan administrators, and employers.
• Peer reviews do not address disputes you have with another dentist, cases already in litigation, allegations of fraud, or violations of the state dental practice act.
• The American Dental Association (ADA) provides broad recommendations for peer reviews but does not impose national requirements, act as an appeal body, or generally intervene in cases.

How Does a Dental Peer Review Differ from a Malpractice Claim or Licensing Review?

A dental peer review is an alternative dispute resolution practice that allows parties to tell their stories, potentially resolve a dispute quickly, and avoid the costs of malpractice litigation. Being named in a peer review will not go on a dentist’s public record. It’s not a court of law nor does it follow the same proceedings as one. Rather, it’s a confidential way to resolve disputes, sparing both parties time and expense, and helping ensure that they each have the opportunity to present their perspective and to preserve their integrity.

Dental Peer Review vs. Dental Malpractice Claim

While both a malpractice lawsuit and a peer review complaint may involve issues around the standard of care provided, they differ in some significant ways:

• In dental malpractice cases, a judge or jury (most likely) without dental expertise will determine the outcome of cases. In contrast, a peer review panel most often involves professionals experienced in oral health and general dentistry. But it’s not intended as a court of law and does not use the same rules and procedures.
• In a malpractice case, plaintiffs may be awarded damages to cover the cost of additional care, financial losses associated with the error, and pain and suffering. Peer review decisions may require the dental professional to reimburse a patient for the cost of the service but not to pay additional compensation.
• For a peer review, lawyers typically help prepare the dentist for the mediation phase of the peer review (see below), but do not accompany them to any formal meetings. Meanwhile, a lawyer would usually assist during all malpractice claims negotiations.
• Peer review boards do not publicly share their reports on their findings. Rather, each party is notified of the results.

Dental Peer Review vs. State Licensing Board Review

While both a peer review and a licensing board review sound similar, they also differ in important ways:

• Licensing boards deal with violations related to licensing requirements, but peer review boards do not have the authority to restrict or revoke a dentist’s ability to practice.
• The goal of a licensing board is to ensure a dentist is capable and ethical in their practice while the goal of a peer review is typically to resolve a dispute.
• Licensing board actions will be made public, while peer review decisions are kept confidential.

In cases involving ethical issues or a pattern of problematic treatment, a peer review board may refer the matter to the state board of dentistry or the dental society’s ethics committee. And it works both ways: state licensing boards also may refer cases to peer review boards when an issue doesn’t involve a licensing violation.

What Types of Actions Are Recommended by the Peer Review Board?

The peer review board may make several different decisions after its review.

If it decides in the patient’s favor, the dentist may be asked to:

• Adjust, refund, or waive a portion of the fees charged
• Redo the dental work
• Improve their training or knowledge

If it decides in the dentist’s favor, the patient may be asked to:

• Pay for services provided
• Return an oral health device, such as a denture or dental appliance

What Happens if You’re Part of a Peer Review Committee Case?

• The peer review process typically begins when a patient or third party contacts their local dental society with a complaint.
• The dental society staff screens the complaint to determine whether it’s appropriate for peer review. If so, the patient must submit a written summary of the issue.
• The committee notifies both parties of the complaint, asks the patient to sign a release allowing access to their records, and requests that the dentist submit treatment records for review.

There are two phases to the process – mediation and committee review.

Phase 1: Mediation

The mediation phase is used in nearly every state and does not involve the peer review board. In this phase, the board chair appoints a mediator, either a fellow board member or a volunteer dentist, who works with both parties to try to resolve the dispute.

According to the ADA, in most cases, mediation results in an agreement, after which the peer review board notifies both parties formally. If it involves money, the agreement letter notes those details and includes a release form that indicates all claims have been satisfied.

If no agreement can be made, the case goes on to the next phase, along with the notes from the mediator.

Phase 2: Peer Review Board

The peer review phase is a lot like an arbitration, where each party presents its side, and the board assesses the facts and usually:

• Reviews the mediator’s notes
• Evaluates clinical treatment records
• Interviews the dentist and the patient
• Clinically examines the patient (each committee member does so separately)

Each board member then submits a report of their findings of the patient exam to the chair, and the board meets in closed session to evaluate and discuss the case. The board’s report is an internal document that’s not shared with either party.

When a Peer Review Decision Is Rendered

The ADA outlines what should happen after the committee comes to a decision:

• The outcome is based on a majority vote or consensus.
• The board notifies the dentist and the patient in writing of the decision and recommendations. Boards do not share individual members’ recommendations, only the committee’s findings.
• The entire process, including mediation, typically takes 60-90 days. The board sends all case documentation to the dental society. State law dictates how long the dental society retains records.
• Both parties must abide by the board’s decisions and sign release forms that reflect their agreement. If a party does not agree, they may appeal to the dental society, usually within 30 days, if they can show cause. Issues that may support a successful appeal include failure to follow proper procedures, additional materials becoming available, and evidence of bias or discrimination.
• Dental societies generally do not have the authority to enforce compliance with a board’s decision. However, either party may seek to enforce their signed agreement in a court of law, since noncompliance with that agreement may be considered a breach of contract.
• If payments are required, the dentist, dental society, or malpractice carrier may need to report them to the National Practitioner Data Bank.

How Can You Prepare for a Peer Review Committee?

If you find yourself involved in a peer review, preparation is key. Here are five useful tips to help you:

1. Do Your Homework

Familiarize yourself with the peer review process as well as the guidelines and requirements of the dental society, and the peer review board process. There are a range of resources that can help you understand the process.

2. Gather Treatment Records & Other Documentation

Peer review committees will seek records of any treatment provided to a patient. These records, which could include radiographs and dental incident reports, are key in providing case details, such as the diagnosis, care provided, and context.

3. Notify Your Dental Malpractice Insurance Company – Promptly

If you have dental malpractice insurance, notify your insurer as soon as you learn about the complaint. As long as you have peer review extended coverage, the insurance company can promptly assist you and find you an attorney who can help you compile your documentation and prepare for mediation. If you don’t have peer review coverage, you will need to decide if you want to pay for your own legal assistance.

4. Consult an Attorney

Whether it’s an attorney provided by your dental malpractice insurer or from your own pocket, you may benefit from consulting with an attorney on the situation. Your attorney should help you better understand the process, review documents, and evaluate final agreements before you sign. But they don’t typically represent you at the peer review, per ADA guidelines. Note that most state peer review committees do not award money to cover attorneys’ fees. This means if you’re paying for your lawyer yourself, you will most likely not be reimbursed.

5. Get Familiar With the Board Members

If you believe there are any conflicts of interest with members of the peer review board (for example, a board member has a previous professional relationship with the person who filed the complaint), notify the dental society or committee chair immediately.

How Can Your Insurance Company Help You?

Malpractice insurance that offers peer review coverage can get you the legal help and support you need if facing a peer review.

At Berxi, for example, our dental malpractice plans include automatic peer review committee coverage, providing an additional $25,000 in limits per policy period.

A good insurance provider should also offer another benefit: emotional support and helpful guidance. “We contact our customers within 24 hours to let them know what they can expect,” explains Lauren Maloney, Complex Claims Director, who assists Berxi customers with malpractice claims, licensing board actions, and peer review committees. “Once we determine that coverage is available, we will connect the dentist with a qualified attorney to help them throughout the entire process, and remain available for guidance along the way,” she says. This is one reason why we feel you won’t regret the coverage or personal service and attention that a Berxi dental malpractice policy offers.

Final Thoughts

When you’re in a health care profession that cares for others, the last thing you may want to think about is disputes with your patients. But there are a few things to keep in mind if you are notified of a peer review.

First, a peer review can provide a cost-effective, expeditious, and confidential way for you to resolve those issues, and preserve your reputation and integrity (usually within 90 days).

Second, having a trusted dental malpractice insurer can help you increase your chance of success (remember to check that your insurer covers peer reviews!).

And third, by keeping detail-oriented patient notes, informed consent paperwork, and your dental records consistent with best practice standards, you will help yourself tremendously in case of any future disputes.

 

Image courtesy of istock.com/Martin Barraud

 

Last updated on Aug 05, 2024.
Originally published on Aug 17, 2023.

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The views expressed in this article are those of the author and do not necessarily reflect those of Berxi™ or Berkshire Hathaway Specialty Insurance Company. This article (subject to change without notice) is for informational purposes only, and does not constitute professional advice. Click here to read our full disclaimer