This series will provide New York State Dental Association members with a new online E-Learning Article once every two months, for a total of 12 FREE MCE home-study credits per year. Each article will present the participant with a timely topic of interest and will be followed by a series of questions based on the article. This NEW online series will be entirely FREE for members of the New York State Dental Association and will be available to non-members for $50.00 per E-Learning Article (2 credits each). To begin, read the article below. Once you have finished the article, continue to step 2, the online exam. This exam can only be accessed by NYSDA members with their ADA number, non-members should return to www.nysdflearning.org to register online there.
The New York State Dental Association’s Peer Review and Quality Assurance Process
By Dr. Judith Shub
Assistant Executive Director for Health Affairs
New York State Dental Association
As part of its obligation to serve and protect the public as a professional association, the New York State Dental Association (NYSDA) conducts a peer review and quality assurance program. Peer review derives from the profession’s ethical duty to promote patient welfare and its responsibility to regulate itself.
NYSDA is a constituent of the American Dental Association (ADA). The ADA calls for its constituents to conduct a peer review program; however, each constituent dental society structures its program differently. The goal of the program is the same: to provide impartial evaluations of the quality of dental care. Unlike some other dental associations, NYSDA offers peer review as a membership benefit. NYSDA does not review complaints submitted against dentists who are not members of the professional association. NYSDA does not resolve fee disputes. And, NYSDA requires participation by its members.
NYSDA’s protocol resolves patient complaints about the appropriateness and quality of treatment. This protocol is designed to be fair, impartial and confidential. When a Peer Review Committee determines that treatment does not meet the standard of care, the dentist refunds the fees paid by the patent for that treatment. There are no arbitrary punitive awards or partial refunds, unless the dispute is resolved in mediation.
The basis of NYSDA's peer review process is a contractual agreement based on New York’s common law contractual arbitration. The contract, the Agreement to Submit to Peer Review, has been refined over the years to comply with New York state law and best protect the needs of the participants in the process. In return for the dentist’s compliance with peer review, the patient is required to deposit any outstanding funds owed to the dentist in order for the process to commence. In addition, the parties to the peer review agree that they will accept the peer review finding, will not initiate any legal action against the other party(s) (except if necessary to enforce the peer review contract) and will maintain the confidentiality of the process.
Peer review is an alternative dispute resolution program. It is available to the public at no cost. Patients are required to deposit any outstanding balance owed to the dentist for the treatment in question in an escrow account held by the dental society pending the resolution of the complaint. In some circumstances, the dentist is required to deposit the fees received from the patient in the dental society’s escrow account as well. These include cases involving practices with multiple dentists or those where the dentist is an employee of another dentist.
Dentists who are members of the association are required to participate in the process as a condition of membership. Failure to comply with peer review can result in the dentist’s expulsion from NYSDA and the ADA.
Peer review is conducted by each of NYSDA’s 13 local component dental societies using a uniform protocol, procedures and paperwork. Appeals are considered by NYSDA’s Council on Peer Review and Quality Assurance. The council consists of a representative from each of NYSDA’S 13 component dental societies. It is responsible for developing policy recommendations and general administrative oversight of the peer review process. Peer review committees are comprised of volunteers who are members of the professional association.
NYSDA does not publicize peer review proceedings or findings, nor does it provide information to any outside party or agency. The confidentiality of the process is protected by §6527 of the New York State Education Law. The privacy and confidentiality of the parties is protected further by transferring cases involving dental society component officers to other components. Any party to the peer review may request that a member of a peer review hearing committee be removed for cause. Only the parties to the peer review, committee members and chairman, lay observers and necessary clerical staff may attend a peer review hearing.
The parties are advised to consult with an attorney prior to signing the Agreement. However, other than advising a client, attorneys have no role in the process or in a peer review hearing.
Complaints about dental treatment are accepted only when the treatment was performed by a NYSDA-member dentist within 2½ years of the date the Agreement is received by the dental society. The complaint cannot be under review or have been resolved in another venue.
When a component dental society sends a patient an Agreement to Submit to Peer Review, a copy of A Guide to Peer Review is enclosed. Patients are advised to review the terms of the Agreement and read the Guide carefully. The Agreement includes an affirmation that the parties have read both the Guide and the Agreement before signing and submitting the documentation to the dental society. The patient is directed to submit additional evidence in support of the complaint including financial records and copies of dental records from any subsequent treating dentist. The Agreement includes a statement whereby the patient authorizes the treating dentist to release copies of his/her dental records to the peer review committee.
In addition to a factual record of the dates of treatment and fees charged, the Agreement requests the parties – patient and dentist(s) – provide their own statements. The patient is asked to describe the “specific problem(s) with the treatment to be reviewed”. This focuses the review on the patient’s specific complaint. The dentist is asked for his/her “experience with the treatment under review”. This provides an important opportunity for the dentist to respond to complaint specifically by providing or highlighting information that may not be included in the patient’s clinical record. The dentist’s statement may elucidate why the patient may be reporting the complaint. The dentist may point to other health or behavioral issues that result in the patient’s current problem which may be unrelated to the quality of the treatment itself. For example, “following treatment, the patient began chemotherapy”. Or “treatment was delayed because the patient failed to keep a number of scheduled appointments” Or, “when the patient presented, he indicated that he has been dissatisfied with every doctor that he has seen in the past.” Or, “The patient repeatedly was advised to see a specialist to address his complaint but the patient refused to make an appointment with a specialist.”
The Agreement only is provided to the actual parties to the peer review and the peer review committee directly involved with the specific case. Both the volunteer dentists on the peer review committee and the limited staff with access to peer review case files are diligent about protecting the confidentiality of the materials submitted and the privacy of the parties.
Once all records and financial documentation are submitted and escrow collected from the patient and dentist, peer review begins with “mediation”. Essentially mediation consists of a member of the peer review committee contacting the parties to clarify the complaint and the treatment rendered. If the dentist offers the patient a partial fee refund and the offer is acceptable to the patient, the case ends. If the dentist offers to refund the entire fee, the case ends as well. If no refund is proffered or the patient refuses a partial refund, a hearing is scheduled.
The hearing is conducted by three general dentists (peers). If treatment were provided by a specialist, the committee is comprised of three specialists. A member of the peer review committee chairs the hearing and a lay person is usually present. The members of the hearing committee review the dental records and x-rays submitted. The patient and dentist have an opportunity to present their positions and are questioned by the committee members. There is no cross examination or questioning of the parties by the parties to the peer review or, if represented by counsel, their attorneys. However, both the patient and dentist use this opportunity to better explain their positions and provide additional input to the committee. Each committee member then individually performs a clinical examination of the patient. The records review and clinical examination form the basis for the committee’s finding as to the quality of the treatment rendered. The chairman then adjourns the hearing and the committee meets to determine its findings.
Following the resolution of the complaint in mediation or a hearing, a decision letter is sent to the parties. The decision letter restates the complaint, outlines the process through which the complaint was resolved, and presents the resolution and consequences. If the hearing committee finds that the treatment is not consistent with the standards of care or was not appropriate for the patient, the patient receives a refund of the fees for that treatment. The committee also may require that the dentist complete continuing education in a particular clinical skill. Either party can appeal the committee’s finding by presenting evidence of a significant procedural irregularity or new evidence that could not have been available at the time of the hearing that could affect the outcome of the hearing.
When a case is closed, the component dental society sends the case file to NYSDA. NYSDA retains only the Agreement to Submit to Peer Review and the decision letter.
Summary of Frequently Asked Questions about Peer Review
1. What is Peer Review?
Peer Review is offered by the New York State Dental Association as an option to resolve patient complaints about dental treatment. It is provided at no cost to patients.
2. How is Peer Review Initiated?
The patient starts a Peer Review by submitting an Agreement to Submit to Peer Review to the Dental Society. On the Agreement, the patient describes the dental treatment performed, how much it cost, and the complaint. The patient encloses copies of any documentation of the charges and payments, e.g., insurance statements, bills, cancelled checks, etc. If seen by any other dentists, the patient is directed to ask those dentists to send copies of their dental records and x-rays to the Dental Society.
3. If the Patient has an Outstanding Balance for the Treatment?
If the patient has an outstanding balance for the cost of the treatment, he/she will be required to place that amount in an escrow account until the Peer Review is resolved.
4. What happens after the Patient Submits the Agreement to Submit to Peer Review?
The Agreement is sent to the dentist(s) for his/her statement. The dentist must return copies of the patient’s treatment records with the Agreement. The Peer Review Committee chairperson then will determine whether Peer Review can resolve the complaint.
If the complaint is accepted, a mediator will contact the parties. The mediator will ask the dentist if he/she wants to offer a full or partial fee refund. If the dentist offers a full refund, the case will be closed. If he/she offers a partial refund and the offer is acceptable to you, the case is closed and you will be sent your refund. If the complaint is not settled by mediation, a hearing will be held.
5. But the Patient didn’t pay for the treatment, an insurance company did!
All fee refunds are made to the patient. It is up to patients to resolve any obligation they may have with their insurance company.
6. What if the patient wants the dentist to pay for any subsequent treatment?
If Peer Review settles the complaint, either by mediation or a hearing, the most money the dentist can return to the patient is the actual amount of the fees charged.
7. Does the patient need a lawyer?
Peer Review hearings focus only on the Peer Review Committee’s evaluation of the dental treatment itself. Neither party is required to be represented by a lawyer. There is no questioning or “cross examination” by the patient or the dentist. No witnesses are questioned. If either is represented by a lawyer, that lawyer should notify the Dental Society. Peer Review will not award money to cover the lawyer’s charges.
8. What happens at the hearing?
The patient will explain the complaint and the dentist can respond. The Peer Review Committee will review all of the records and materials presented. Each Committee member individually will examine the patient. The Committee then will make a decision about the dental treatment. Was it appropriate and completed in a manner consistent with the standards for quality care?
9. Who comes to the Peer Review Hearing?
Peer Review Hearings are attended only by the patient, the dentist(s), the Peer Review Committee chairperson, three examining Committee members, clerical support staff and a non-dentist observer. A lawyer representing a party to the Peer Review may attend the hearing. In special circumstances, the chairperson may allow other persons to attend as observers, e.g., translators, aids, or committee trainees. Such attendees do not participate in the hearing.
10. What happens if the Peer Review Committee upholds the patient’s complaint?
When a Peer Review Committee finds that the dental treatment does not meet acceptable standards, the dentist must refund the entire fee for that treatment to the patient. The Peer Review Committee also can require the dentist to complete continuing education.
11. What if either party disagrees with the Peer Review Committee’s decision?
Following the Peer Review Committee’s decision, there is a 30-day appeal period. Appeals are granted only on the basis of significant procedural irregularities or the discovery of new evidence that could not reasonably have been available during the Peer Review.
12. If the patient goes through Peer Review and is unhappy with the decision,
can he/she still sue the dentist?
No. Peer Review is based on an Agreement to Submit to Peer Review signed by both the patient and the dentist. This agreement is a contract in which the patient and the dentist agree to use Peer Review to resolve the complaint, to accept the decision of the Peer Review Committee, and not to sue the other party.
13. Is Peer Review fair?
Peer Review Committees are impartial and committed to improving the quality of dental treatment.
STEP 2: Click here to complete the short quiz corresponding to the above E-Learning article.
Please note that you will need to have your ADA number and e-mail address to complete the exam. If you are not a member of the New York State Dental Association, you will need to register for this online opportunity at www.nysdflearning.org under "Online Courses."
E-mail the instructor with any questions you may have regarding this course.
The New York State Dental Foundation is an ADA-CERP approved provider of continuing education.
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