AAO orthodontic review committee guidelines

AA0 Orthodontic Review Corrnrnittee Guidelines* Introduction

T

he functions of a review committee are to determine the adequacy of the treatment performed under the prevailing circumstances, relative to the cooperation of the patient and the treatment procedures followed, and to aid in determining the relevance of fees. The committee should provide advice and guidance, but not discipline. Review should include a determination that the services were performed, that the treatment was reasonable and appropriate, and that it was rendered in an adequate and satisfactory manner. Review procedures must be effective, efficient, objective, and routine; they must be fair to the patient, the dentist, the third party agency, and the dental profession. The component (state) orthodontic society should provide : 1. A review committee to function as such, or 2. Consultants to cooperate with the review committee of the component dental society or association. In both cases, the purpose is for communication with third party agencies, e.g., dental service corporations ; private insurance carriers ; administrators of health, welfare, and social services; other governmental agencies; other fiscal agents. Orthodontists and/or third party agencies should submit all disputed cases initially to the component orthodontic review committee, either for action or for possible referral to component dental association commi.ttees. Differences between patient and dentist which might require disciplinary action should be referred to the appropriate committee of the component dental society. They do not fall within the province of a review committee. Committee

membership

1. The component orthodontic association shall elect six members to serve three years with staggered terms (two new committee members to be elected *As adopted Orthodontists,

at the seventy-third May 15, 1973.

annual

session

of

the

American Association of 417

418

American

Association

of Qrthodontists

Am. J. Orthod. October1973

each year to replace the two whose terms have expired; the first committee to be set up with two members each for one year, two years, three years). 2. Nominees for the orthodontic review committee should be recognized for their breadth of diagnostic and treatment abilities and for mature judgment. Factors of age, training, and geographic distribution should be considered. 3. Review committee members should be willing to devote regular time from their office hours in order to serve effectively. Criteria

for

acceptance

of cases

for

review

1. Cases initiated by the review committee of the state dental association must meet all the criteria specified by that committee. 2. All other orthodontic cases not coming under the jurisdiction of the state dental association review committee (1 above) should meet the following criteria : A. Provisions for review must be included in the prepayment program in question. B. All requests for review must be submitted in writing documenting (1) the existing problem and (2) that efforts have been made to solve the problem by the parties involved before referring the problem to the review committeee. C. Cases will not be considered if litigation or disciplinary action is in process. 3. ‘The dentist involved should be informed that the orthodontic review committee will review his case. Review

procedure

1. All cases involving orthodontics considered by review committees of component dental associations should be evaluated in consultat,ion with the review committee of the component orthodontic society. 2. Those cases for review should follow the procedure outlined below: A. Upon receipt of a qualified request for review services, the chairman of the orthodontic review committee should assign the case to one or more committee members for investigation. B. The submitting prepayment organization, if involved, (I) must provide the orthodontic review committee with copies of all claim forms and/or other records in the case and should be made aware that (2) all matters concerning the case must be kept confidential. C. The dentist and the patient should be advised by the review committee to submit their cases, each agreeing to provide full information. They should also be informed by the investigation member(s) of the review committee that they have the option of presenting their views to the full orthodontic review committee. D. After all material is received, reviewed, and a judgment is made by the committee, the chairman should submit the findings to the patient, the orthodontist, and the prepayment organization simultaneously.

Volume

Number

Appeal

64 4

Orthodontic

Review Committee

Guidelines

419

procedure

1. Any decision of the orthodontic review committee may be appealed by requesting a hearing in writing to the review committee of the state dental association. A thirty-day notice to all parties of a special hearing is required. Publicity

1. The committee should treat all cases reviewed with strict confidence. 2. There should be no publicity to the general public. 3. The functions of the orthodontic review committee should be publicized to all state orthodontists, the state dental care committee, the state dental review committee, and the state service corporation in order to foster understanding of prepayment procedures. 4. Third party fiscal agents sponsoring programs involving or contemplating orthodontic services should be aware of the formation and function of the orthodontic review committee.

As a specialty it [orthodontics] grew out of dentistry, but it is a part of dentistry and must always remain so. . . It is a study of the development of the human organism and of the functioning of the various tissues which go to make up the oral cavity; bone, muscles, circulation, the nervous system, as well as the teeth themselves. (IMershon, John V.: Orthodontia and Its Relation to Dentistry, Dental Cosmos 72: 1292-l 298, 1930.)