March 2020, Volume XXXIII, No 12

Cover story two

Improving access to care

Expediting the licensure process

he Interstate Medical Licensure Compact went live in 2015 after the law was passed by seven states (Alabama, Idaho, Montana, South Dakota, Utah, West Virginia, and Wyoming). That same year, Minnesota became the eighth member state when the Minnesota Legislature unanimously passed the law, and 29 states, the District of Columbia, and the Territory of Guam have now joined the agreement. In October 2015, member states met for the first time as the Interstate Medical Licensure Compact Commission. Their task was to develop the expedited licensure process, codified in statute for eligible physicians, that improves license portability and increases patient access to care.

In April 2017, about a year and a half after that first meeting, the first license was issued through the Compact. Minnesota has issued hundreds of expedited licenses through the process. Until recently, though, the Minnesota Board of Medical Practice (Board) was not a full participant in the Compact. It did not have approval by the Federal Bureau of Investigation (FBI) to perform criminal background checks, a necessary requirement for full participation in the Compact. Prior to the FBI’s approval of recent state legislation, the Board could issue expedited licenses for providers in other states that had issued Letters of Qualification, but could not issue Letters of Qualification for applicants within the state. Minnesota licensees now have the opportunity to fully participate in the Compact process.

Individual physicians and large systems will both benefit from this development. For example, Mayo Clinic Health System is now able to license its physicians and export its expertise in multiple states. Minnesota physicians practicing in regional health care systems or who primarily practice telemedicine will also benefit from portability.

The Board found itself within the crosshairs of the FBI.

Letters of Qualification

The Compact law sets forth the qualifications for participation pursuant to a Letter of Qualification and outlines the process for physicians to apply for and receive expedited licenses in member states. The Letter of Qualification serves as the ticket to expedited licensure in other states. Qualification requires an applicant to meet the following statutory requirements in order to receive a Letter of Qualification. Applicants must:

  1. Be a graduate of a medical school accredited by the Liaison Committee on Medical Education, the Commission on Osteopathic College Accreditation, or a medical school listed in the International Medical Education Directory or its equivalent;
  2. Have passed each component of the United States Medical Licensing Examination (USMLE) or the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) within three attempts, or any of its predecessor examinations accepted by a state medical board as an equivalent examination for licensure purposes;
  3. Have successfully completed graduate medical education approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association;
  4. Hold specialty certification or a time-unlimited specialty certificate recognized by the American Board of Medical Specialties or the American Osteopathic Association’s Bureau of Osteopathic Specialists;
  5. Possess a full and unrestricted license to engage in the practice of medicine issued by a member board;
  6. Never have been convicted, received adjudication, deferred adjudication, received community supervision, or deferred disposition for any offense by a court of appropriate jurisdiction;
  7. Never have held a license authorizing the practice of medicine subjected to discipline by a licensing agency in any state, federal, or foreign jurisdiction, excluding any action related to nonpayment of fees related to a license;
  8. Never have had a controlled substance license or permit suspended or revoked by a state or the United States Drug Enforcement Administration; and
  9. Not be under active investigation by a licensing agency or law enforcement authority in any state, federal, or foreign jurisdiction.

The problem

An additional statutory requirement of the Compact law is for performance of an FBI criminal background check of an applicant that “includ[es] the use of the results of fingerprint or other biometric data checks compliant with the requirements of the Federal Bureau of Investigation, with the exception of federal employees who have suitability determination in accordance with Code of Federal Regulations, section 731.202.”

Although Minnesota was an early adopter of the Compact, the Minnesota Board of Medical Practice was unable to perform the criminal background check required in order to issue a Letter of Qualification. In the process of implementation of the Compact law, the Board found itself within the crosshairs of the FBI. The FBI raised concerns that Minnesota law enabled sharing of criminal history record information (CHRI). The Board had never intended to share such information with anyone outside of government, but the state was still unsuccessful in obtaining approval from the FBI to conduct criminal background checks for current licensees seeking to participate in the Compact process. The criminal background check was mandatory for processing a Letter of Qualification. The FBI explained that changes to Minnesota law—as well as laws in three other states—were necessary to specifically address their concerns.

The Board committed itself to addressing the concerns raised by the FBI. Unfortunately, the FBI was not able to provide statutory language that would be acceptable. They would only agree to review language after it had been presented to the Legislature. Over the course of three legislative sessions in 2017, 2018, and 2019, the Board worked with the Minnesota Bureau of Criminal Apprehension, Minnesota’s liaison to the FBI, representatives from the Minnesota Medical Association, and state legislators to amend statutory language responsive to the FBI’s concerns.

In 2017, the Minnesota Legislature passed an amendment to the Medical Practice Act intended to address the FBI’s concerns. The FBI reviewed the language in July 2017 and communicated its conclusion that the amending language did not satisfy the parameters of Pub. L. 92-544, the federal criteria for performance of criminal background checks, as outlined below:

  • The statute must exist as a result of a legislative enactment;
  • It must require the fingerprinting of applicants who are to be subjected to a national criminal history background check;
  • It must expressly or by implication authorize the use of FBI records for the screening of applicants;
  • It must identify the specific category of applicants/licensees falling within its purview, thereby avoiding overbreadth;
  • It must not be against public policy; and
  • It must not authorize receipt of the CHRI by a private entity.

The FBI found that Minnesota’s statutory authority to perform criminal background checks for health care professionals seeking licensure was limited to new applicants for licensure and did not include authority to perform criminal background checks for current licensees. As a result, the Board continued to pursue legislation to address the FBI’s ongoing concerns. Additional amendments were passed by the Minnesota Legislature in May 2019.

The solution

In January 2020, three years after implementation of the Compact and following several modifications to state laws, Minnesota received the FBI’s approval to obtain criminal background check information for the purpose of full participation in the Interstate Medical Licensure Compact.

The criminal background check was mandatory.

Prior to the FBI’s approval, the Minnesota Board was limited to issuing expedited licenses to incoming applicants from other member states but was unable to issue Letters of Qualification to current Minnesota licensees. As a full participant in the Compact process, Minnesota physicians will now have access to the Compact process of expedited licensure. This will allow Minnesota physicians to be better positioned to serve patients by removing barriers and enabling access to qualified medical care.

This process should also facilitate the deployment of telemedicine. Minnesota has a telemedicine registration that allows physicians in other states to practice via telemedicine, provided they don’t set up shop in this state. Each state has varied requirements for telemedicine practice.

Concerns and clarifications

Critics of the Compact process have expressed concern that the expedited licensing process would compromise state sovereignty. However, the Compact only impacts the administrative process of issuing licenses and does not impact states’ authority to regulate and enforce medical practice standards and state laws. The process maintains a state’s sovereignty.

Critics also expressed concern that the Compact would compromise patient safety by preventing regulation across state lines. They argued that under current state laws a problem physician could continue to practice in another state until the complaint was adjudicated and made public. They also argued that complaint and investigatory information isn’t shared freely among the states. Under the Compact, the opposite is true. In fact, the Compact requires establishment of a coordinated information system that requires member states to report and share complaint, investigation, and disciplinary information with other member states. The Compact law also enables expedited disciplinary action by member states, based on another state’s action.

Lastly, there has been confusion regarding the type of license that is issued under the expedited process. The license obtained via the Compact process is the same license that is obtained via the traditional process. Think of it as similar to TSA PreCheck or CLEAR at airport security checkpoints. Once you are properly vetted, you have access to the expedited process. And like TSA PreCheck or CLEAR, access to the expedited process expires after one year.

With the FBI’s approval of recent legislative changes, Minnesota immediately began issuing Letters of Qualification to its licensees. The Board is delighted that Minnesota physicians finally have the opportunity to fully participate in the Compact process.

Visit the Interstate Medical Licensure Compact Commission website for additional information:

Minnesota is grateful to its legislative authors, particularly Sen. Carla Nelson and Rep. Tina Liebling, and to the Minnesota Medical Association for their continuous support of and advocacy for the Interstate Medical Licensure Compact.

Jon Thomas, MD, served on the Minnesota Board of Medical Practice for 16 years. He was appointed by Independent, Republican, and Democratic Governors. As Chair of the Federation of State Medical Boards (FSMB), he led the effort to develop the Interstate Medical Licensure Compact. His tenure with the Minnesota Board of Medical Practice culminated with a gubernatorial appointment to the newly formed Interstate Medical Licensure Compact Commission. He was elected Chair of the Commission and oversaw the development of the IT platform and presided over the start of the multistate licensure process.

Ruth M. Martinez, MA, is Executive Director of the Minnesota Board of Medical Practice. She has been actively involved with development and implementation of collaborative initiatives, programs and policies, and technological advancements that expand portability for licensees and expand access to quality health care for consumers. Ms. Martinez is serving her third term as an appointee to the Interstate Medical Licensure Compact Commission IMLCC). She currently serves on the Executive Committee as chair of the IMLCC Rules and Administrative Procedures Committee. 


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