ADASA Complaints and Claims Handling
At the beginning of 2006 the Australian Dental Association South Australian Branch reviewed our Claims Management Procedures and decided to take a major shift in the way we handle Professional Indemnity matters for our members.
The main change has been the way we handle patient x when they phone our office with a query/complaint about dental treatment. The basic process is as follows:
1. We firstly confirm they have sought treatment from a member dentist. If the dentist is not a member, patient x is provided with contact details for the Health & Community Service Complaints Commissioner (HCSCC) P:(08) 8226-8652, E:info@hcscc.sa.gov.au, W:www.hcscc.sa.gov.au or the Dental Board of SA P:(08) 8364-5358 E:administrationassistant@dentalboardsa.com.au, W:www.dentalboardsa.com.au to lodge their complaint. Should patient x wish to remain anonymous, we explain to them that the service we provide is only to member dentists’ patients and we cannot assist their query/complaint if they wish to remain anonymous.
2. Once step one is established, we ask patient x if they have talked to the dentist about their query/complaint. If they haven’t, we recommend they contact the dentist to try and sort the matter out. It is explained to them that the ADA SA will only look into a matter once there is evidence that the patient and the dentist can not seek resolution independently.
3. The ADA SA Claims Management Process is explained to patient x. It is highlighted to them that the ADA SA is a membership Association for dentists, however we will use our best endeavours (through a Community Relations Officer (CRO)) to assist both parties (dentist and patient) in resolving the matter to everyone’s satisfaction. We explain the role of the CRO’s and the likely timeframe on which their query/complaint will be responded to.
4. We then ask patient x for the brief details of the query/complaint, and their contact details. We also request the details of the dental surgery where patient x saw the dentist. This information is documented in a memo and recorded onto the Claims Management Database and assigned to a CRO.
5. The Community Relations Officer (CRO) assigned investigates the details of the matter. They obtain a more detailed summation of the complaint/query from patient x, as well as gaining the dentists response.
6. Depending on the severity of the matter, the CRO may need to access dental records. The CRO obtains written consent from patient x to do so.
7. From this point onwards, the matter can go in a range of directions, including:
- After review, the CRO may determine the member dentist is not at fault and has demonstrated a high level of duty of care. The CRO and the member dentist work together in providing a written response back to the patient explaining the details of the treatment, the findings of the investigation and a denial of liability.
- The matter may be reviewed by the CRO, and details from all parties received. A specialist opinion on the clinical nature of the treatment may be sought. The ADA SA has a panel of specialists who offer an independent examination of the patient, and provide a written report. The findings of this report are relayed back to patient x.
- If patient x engages solicitors or lawyers to represent them, or involves the Dental Board or HCSCC - the matter is immediately forwarded to the dentist’s Professional Indemnity Insurer. All ADA SA (including CRO) contact with patient x ceases.
- The matter may be reviewed and the blame can partly be apportioned to the dentist. The CRO may provide advice regarding a refund/foregoing of fees, or a “without prejudice” payment.