texas physician licensure seminar

1. Texas Physician Licensure Seminar Donald W. Patrick, MD, JD Executive Director 4/14//2008 Welcome Introductions Evaluation Forms � Please complete Handouts: Slides Eligibility Checklist Supplemental Documentation Checklist Online application copy � not for use as app Exam attempts & eligibility License/Permit Types and Fees Web � Texas Physician Licensure Reference Material ReleasesWelcome Introductions Evaluation Forms � Please complete Handouts: Slides Eligibility Checklist Supplemental Documentation Checklist Online application copy � not for use as app Exam attempts & eligibility License/Permit Types and Fees Web � Texas Physician Licensure Reference Material Releases

3. Governance Statute Laws relating to licensure, registration, and discipline of physicians TMB Web site link � www.tmb.state.tx.us � Laws, Rules and Guidelines/Texas Statutes/Texas Occupations Code Board Rules Rules are adopted by the TMB Board cannot waive requirements in rule unless rules specifically allow it Rule change process TMB Web site link � www.tmb.state.tx.us � Laws, Rules and Guidelines/Board Rules Governance Statute Laws relating to licensure, registration, and discipline of physicians Can only be changed by the legislature; board cannot waive requirements set in statute Generally broad and give authority to Texas Medical Board (TMB) to write rules to specify how to implement the laws Statute contained in Texas Occupations Code TMB Web site link � www.tmb.state.tx.us � Laws, Rules and Guidelines/Texas Statutes/Texas Occupations Code Mainly Chapter 155, License to Practice Medicine - Texas Occupations Code � See Appendix A for current language.Governance Statute Laws relating to licensure, registration, and discipline of physicians Can only be changed by the legislature; board cannot waive requirements set in statute Generally broad and give authority to Texas Medical Board (TMB) to write rules to specify how to implement the laws Statute contained in Texas Occupations Code TMB Web site link � www.tmb.state.tx.us � Laws, Rules and Guidelines/Texas Statutes/Texas Occupations Code Mainly Chapter 155, License to Practice Medicine - Texas Occupations Code � See Appendix A for current language.

4. Physician Licensure Process Applicant Actions FCVS (optional � credentialing service) Online Application - $885 Submission of Additional Documentation

5. Physician Licensure Process New! LIST � License Inquiry System of Texas TMB Actions Screening Review for expected documentation, etc. based on application characteristics No evaluation of documents at this stage

6. Physician Licensure Process TMB Actions Screening, continued Cannot exit screen until all documents, etc., are here. Includes: Passage of JP exam Criminal history report from fingerprints (DPS and FBI) Substantial equivalence documentation Clerkship documentation

7. Physician Licensure Process TMB Actions Licensure Processing Assigned to licensure analyst Analyst evaluates documents, etc. for compliance with rules and statute LIST - available for applicants Temporary License Only available AFTER all requirements are met

8. Physician Licensure Process TMB Actions Permanent License Full Board action required Considered at next board meeting License numbers issued to approved applicants Registration and fees due immediately (no more than 90 days after license issuance)

9. Physician Licensure Process Priority and Expedited Handling Priority - Physician applicants who agree to treat Medicare/Medicaid Patients for 5 years following licensure Expedited - Physician applicants planning to practice in: A medically underserved area (MUA) A health professionals shortage area (HPSA) A rural area

10. Licensure Application and Documentation Application form � See Handout Supplemental documentation and additional licensure forms Supplemental Documentation and Important Information � See Handout Described in instructions for completing additional licensure forms See handout � App Form, Supplemental Documentation Checklist (all listed alphabetically for reference, but we�re going through them here in categories) Used to collect information from the applicant and third parties to demonstrate compliance with eligibility requirements. Application Form The application MUST be completed by the applicant who certifies at the end of the application that all answers are truthful, that changes to an applicant�s status will be provided to the TMB within 10 days, that allows the TMB to do background checks, etc. Additional Licensure Forms These forms supplement the online application. See forms on the TMB web site. See handout � App Form, Supplemental Documentation Checklist (all listed alphabetically for reference, but we�re going through them here in categories) Used to collect information from the applicant and third parties to demonstrate compliance with eligibility requirements. Application Form The application MUST be completed by the applicant who certifies at the end of the application that all answers are truthful, that changes to an applicant�s status will be provided to the TMB within 10 days, that allows the TMB to do background checks, etc. Additional Licensure Forms These forms supplement the online application. See forms on the TMB web site.

11. Eligibility Requirements and Required Documentation See Handout Medical Education Examinations Postgraduate Training Professional Character Eligibility Requirements � See handout Old Document � 3a Update Exams � still says three attempt � refer to SB 36 handout Medical Education Domestic Graduate of a medical school approved by the board (an LCME or AOA accredited school). Statute: �155.003(a)(4) Statute: �155.0031(d) Rule: �163.2(a)(4) Rule: �163.1(1) International Medical Graduate (IMG) Must be graduate of an acceptable unapproved medical school (substantially equivalent and not disapproved by another state licensing agency unless the applicant can demonstrate the determination was unfounded) or meet remedy. Rule: �163.2(b)(4) Rule: �163.1(2) All medical schools attended are substantially equivalent to a Texas medical school and meet THECB curriculum requirements. Statute: �155.0031(d) Statute: �155.004(1) Rule: �163.1(12) Schools Whose Graduates Do Not Have To Prove Substantial Equivalence Of Their Education TMB Web site link � http://www.tmb.state.tx.us/professionals/physicians/applicants/physicianapplicants.php � Schools Whose Graduates Do Not Have To Prove Substantial Equivalence Of Their Education Because the medical education provided at international medical schools changes, the schools included on this list are subject to change at any time. For the same reason, the TMB may still require graduates of schools on this list to provide additional information about their medical education. Applicants who must demonstrate substantial equivalence of their medical education undergo a more thorough review of their medical education. The current information initially requested is: Questionnaire to be completed by medical school(s) Questionnaire to be completed by applicant Information from licensing authority in country of graduation regarding medical school and authority of graduates to practice Applicants in this situation can expect their applications to take more time to complete. Eligibility Requirements � See handout Old Document � 3a Update Exams � still says three attempt � refer to SB 36 handout Medical Education Domestic Graduate of a medical school approved by the board (an LCME or AOA accredited school). Statute: �155.003(a)(4) Statute: �155.0031(d) Rule: �163.2(a)(4) Rule: �163.1(1) International Medical Graduate (IMG) Must be graduate of an acceptable unapproved medical school (substantially equivalent and not disapproved by another state licensing agency unless the applicant can demonstrate the determination was unfounded) or meet remedy. Rule: �163.2(b)(4) Rule: �163.1(2) All medical schools attended are substantially equivalent to a Texas medical school and meet THECB curriculum requirements. Statute: �155.0031(d) Statute: �155.004(1) Rule: �163.1(12)

12. Eligibility Requirements and Required Documentation: Medical Education Graduates of Approved Medical Schools US/Canadian LCME/AOA accredited schools Graduates of Acceptable Unapproved Medical Schools International medical schools medical education substantially equivalent to a Texas medical school has not been disapproved by another state licensing agency unless the applicant can provide evidence that the disapproval was unfounded. US clerkships done in accredited settings Fifth Pathway Applicants

13. Eligibility Requirements and Required Documentation: Medical Education Licensure Form D - Dean's Certification Medical School Transcript Fifth Pathway Certificate and Letter Updated: Licensure Form J - Clinical Clerkship Affidavit Demonstration of Compliance with Statute and Rule: Documentation Statute: �155.0031 � Application Procedures And Requirements Rule: �163.5 � Licensure DocumentationDemonstration of Compliance with Statute and Rule: Documentation Statute: �155.0031 � Application Procedures And Requirements Rule: �163.5 � Licensure Documentation

14. Eligibility Requirements and Required Documentation: Medical Education Licensure Form M � Educational Commission for Foreign Medical Graduates (ECFMG) Status Licensure Form N - AACRAO Credentials Evaluation (American Association of Collegiate Registrars and Admissions Officers) Review

15. Eligibility Requirements and Required Documentation: Medical Education Eligibility to Practice in Country of Graduation Licensure Forms Z1 � Z7 � Substantial Equivalence of Medical Education American University of the Caribbean, St. George�s University, and Universidad Autonoma de Guadalajara are now on the list of schools whose graduates do not need to demonstrate substantial equivalence Substantial Equivalence Determinations �155.0031(d) - An applicant must present proof satisfactory to the board that each medical school attended is substantially equivalent to a Texas medical school as determined by board rule. 163.1(12)agency procedure No rule change drafted at this time � requires additional analysis. Benefits:Less work for ED at file reviews Less work for licensure staff in processing these applicants Faster processing of applicants from these schools Consistent methodology for determinations Notes: Docs with substandard medical education will have, at the least, 3 years of postgraduate training in the US in an approved setting Review current packet and substantial equivalence definition. List only those documents are needed to show compliance with definition. Determine most efficient method for getting required information (Does it need to come directly from school? Do we need originals? Can a country�s licensing authority substitute for the need for a statement from the country�s educational minister?) Overhaul of New School Packet: Benefits: Less work for ED at file reviews Less work for licensure staff in processing these applicants Faster processing of applicants from these schools Consistent methodology for determinations Risks/Notes: Some physicians with substandard medical education may be licensed Possibility that school�s education was not equivalent to MD, but some other type of degree (dental, nursing) Docs with substandard medical education will have, at the least, 3 years of postgraduate training in the US in an approved setting Review current packet and substantial equivalence definition. List only those documents are needed to show compliance with definition. Determine most efficient method for getting required information (Does it need to come directly from school? Do we need originals? Can a country�s licensing authority substitute for the need for a statement from the country�s educational minister?)Substantial Equivalence Determinations �155.0031(d) - An applicant must present proof satisfactory to the board that each medical school attended is substantially equivalent to a Texas medical school as determined by board rule. 163.1(12)agency procedure No rule change drafted at this time � requires additional analysis. Benefits:Less work for ED at file reviews Less work for licensure staff in processing these applicants Faster processing of applicants from these schools Consistent methodology for determinations Notes: Docs with substandard medical education will have, at the least, 3 years of postgraduate training in the US in an approved setting Review current packet and substantial equivalence definition. List only those documents are needed to show compliance with definition. Determine most efficient method for getting required information (Does it need to come directly from school? Do we need originals? Can a country�s licensing authority substitute for the need for a statement from the country�s educational minister?) Overhaul of New School Packet: Benefits: Less work for ED at file reviews Less work for licensure staff in processing these applicants Faster processing of applicants from these schools Consistent methodology for determinations Risks/Notes: Some physicians with substandard medical education may be licensed Possibility that school�s education was not equivalent to MD, but some other type of degree (dental, nursing) Docs with substandard medical education will have, at the least, 3 years of postgraduate training in the US in an approved setting Review current packet and substantial equivalence definition. List only those documents are needed to show compliance with definition. Determine most efficient method for getting required information (Does it need to come directly from school? Do we need originals? Can a country�s licensing authority substitute for the need for a statement from the country�s educational minister?)

16. Eligibility Requirements and Required Documentation: Examinations Licensing Examinations Exam Attempts and Eligibility � see handout Time period within which exams must be passed Texas Medical Jurisprudence Examination

17. Eligibility Requirements and Required Documentation: Examinations Examination Transcripts � Licensing Examinations Score Reports � JP Exam Note: USMLE Steps 1 and 2 (including Clinical Skills Assessment) are part of ECFMG certification for IMGs

18. Eligibility Requirements and Required Documentation Postgraduate Training: US/Canadian Graduates 1 year ACGME or AOA accredited program in US IMGs 3 years ACGME or AOA accredited program in US Continuous and progressive training

19. Eligibility Requirements and Required Documentation: Postgraduate Training Form L � Verification of Postgraduate Training Same form used for professional evaluations Training Certificates� Licensure Form P - Post Graduate Medical Education, Closed Programs Licensure Form P - Post Graduate Medical Education, Closed Programs

20. Eligibility Requirements and Required Documentation: Professional Character Good professional character Must not be in violation of, or committed any act described in the Medical Practice Act, Tex. Occ. Code Ann. ��164.051-.053 . Examples: a felony; or a misdemeanor involving moral turpitude unable to practice medicine with reasonable skill and safety to patients because of illness; drunkenness; excessive use of drugs, narcotics, chemicals, or another substance; or a mental or physical condition

21. Eligibility Requirements and Required Documentation: Professional Character fails to practice medicine in an acceptable professional manner consistent with public health and welfare disciplinary action taken by peers repeated or recurring meritorious health care liability claims that in the board's opinion evidence professional incompetence likely to injure the public submits to the board a false or misleading statement, document, or certificate

22. Eligibility Requirements and Required Documentation: Professional Character uses alcohol or drugs in an intemperate manner that, in the board's opinion, could endanger a patient's life uses an advertising statement that is false, misleading, or deceptive commits an act that violates any state or federal law if the act is connected with the physician's practice of medicine

23. Eligibility Requirements and Required Documentation: Professional Character writes prescriptions for or dispenses to known abusers writes false or fictitious prescriptions prescribes or administers a drug or treatment that is nontherapeutic in nature or nontherapeutic in the manner the drug or treatment is administered or prescribed fails to supervise adequately the activities of those acting under the supervision of the physician

24. Eligibility Requirements and Required Documentation: Professional Character Application Form � �Yes� answers Honesty Consequences of falsification National Practitioner Data Bank and Health Integrity Data Bank Reports Licensure Form AA - Additional Licenses Licensure Form I - Medical Professional Liability Claims Report consequences of falsification WAR Cmte appearanceconsequences of falsification WAR Cmte appearance

25. Eligibility Requirements and Required Documentation: Professional Character Licensure Form L - Evaluations and Verification of Postgraduate Training Licensure Form Q - Work Experience, Closed Programs Licensure Form R - Arrest/Criminal History Licensure Form S - Disciplinary Action History Licensure Form U - Actions/Investigations Licensure Form V - Professionalism

26. Eligibility Requirements and Required Documentation: Professional Character Form W - Mental and Physical Health Criminal History Reports � DPS and FBI Criminal Background Check � conducted by TMB staff AMA profiles and FSMB Disciplinary Action Reports � conducted by TMB staff; applicants may be asked to supply additional documentation.

27. Eligibility Requirements and Required Documentation: Professional Character Active Practice of Medicine Rule 10 Year Rule

28. Other Documentation Alternate Name Documentation Birth Certificate or Passport Licensure Form B - Photo Affidavit Personal Appearances and Inspection of Original Documents

29. Other Documentation Reissuance Applicants License has been revoked by the board Must meet current statutory requirements and board rules Must demonstrate that reissuance of a license is in applicant�s best interest and the best interest of the public

30. Other Documentation Relicensure Applicants License has been canceled for non-payment or by request Must meet current statutory requirements and board rules Specialty Board Certification Documentation Copy of the most recent certificate awarded by American Board of Medical Specialties or the Bureau of Osteopathic Specialists

31. Applicants with Issues Concerning Eligibility Statutory ineligibility Non-compliance with eligibility requirements under board rule File reviews and determinations of eligibility Appearance before the TMB Licensure Committee Appeal Process Applicants with issues concerning eligibility Statutory Ineligibility Some applicants do not meet statutory requirements for licensure and this is easily demonstrated. In cases like these, the licensure analysts notify the applicant as soon as the file is processed. Reminder � staff who screen applications are not looking for eligibility. This will not be determined until the application file is seen by a licensure analyst. Examples include: Too many licensing examination attempts Not enough acceptable postgraduate training Licensing examination modules not passed within required amount of time Status of license in another state is restricted or revoked, etc. Non-compliance with Eligibility Requirements under Board Rule While not statutory, board rules have the force of law. Some rules are not spelled out in statute, yet must be met for an applicant to be eligible for licensure. In most cases, remedies are available and the licensure analyst informs the applicant of the situation. If there are remedies, and the applicant chooses not to use them, the applicant is ineligible under board rule. Examples include: More than 10 years since last licensing or monitored board certification exam (remedy is to take the SPEX exam) Out of the active practice of medicine (remedy is usually to complete a mini-residency) File Reviews and Determinations of Eligibility Whenever there are questions about an applicant�s eligibility, a review must be conducted before a license can be issued. There are different levels of review. Licensure Manager Review can approve things like single arrests, single incidents of academic probation, etc. can notify applicant of statutory ineligibility or ineligibility under board rule. Executive Director File Group Review can approve most eligibility issues can refer applicants for review by consultant for standard of care can refer applicant files for review by forensic psychiatrists can refer applicants for evaluation by forensic psychiatrists can refer applicants for medical evaluation can recommend mini-residency can notify applicant of statutory ineligibility or ineligibility under board rule (when applicant appeals Licensure Manager�s determination of ineligibility) can refer to Licensure Committee of the board for a determination can request more information be provided by analyst or applicant Applicants with issues concerning eligibility Statutory Ineligibility Some applicants do not meet statutory requirements for licensure and this is easily demonstrated. In cases like these, the licensure analysts notify the applicant as soon as the file is processed. Reminder � staff who screen applications are not looking for eligibility. This will not be determined until the application file is seen by a licensure analyst. Examples include: Too many licensing examination attempts Not enough acceptable postgraduate training Licensing examination modules not passed within required amount of time Status of license in another state is restricted or revoked, etc. Non-compliance with Eligibility Requirements under Board Rule While not statutory, board rules have the force of law. Some rules are not spelled out in statute, yet must be met for an applicant to be eligible for licensure. In most cases, remedies are available and the licensure analyst informs the applicant of the situation. If there are remedies, and the applicant chooses not to use them, the applicant is ineligible under board rule. Examples include: More than 10 years since last licensing or monitored board certification exam (remedy is to take the SPEX exam) Out of the active practice of medicine (remedy is usually to complete a mini-residency) File Reviews and Determinations of Eligibility Whenever there are questions about an applicant�s eligibility, a review must be conducted before a license can be issued. There are different levels of review. Licensure Manager Review can approve things like single arrests, single incidents of academic probation, etc. can notify applicant of statutory ineligibility or ineligibility under board rule. Executive Director File Group Review can approve most eligibility issues can refer applicants for review by consultant for standard of care can refer applicant files for review by forensic psychiatrists can refer applicants for evaluation by forensic psychiatrists can refer applicants for medical evaluation can recommend mini-residency can notify applicant of statutory ineligibility or ineligibility under board rule (when applicant appeals Licensure Manager�s determination of ineligibility) can refer to Licensure Committee of the board for a determination can request more information be provided by analyst or applicant

32. License Types Full License Distinguished Professor Temporary License Telemedicine License Public Health License Conceded Eminence License Faculty Temporary License Visiting Professor Temporary License Visiting Physician Temporary Permit

33. Current Status (3/31/2008) Over 500 applicants will be licensed at the April 2008 meeting Average days to complete is 54 Improvement since 9/1/07 FY 08 Q3 � 54 (as of 3/31/08) FY 08 Q2 - 69 days FY 08 Q1 - 100 days

34. Current Status (3/31/2008) Number of applications waiting to be screened has decreased by half from last board meeting February 2008 Report � 507 applications waiting to be screened, up to 90 days old April 2008 Report - 228 applications waiting to be screened, up to 30 days old Licensure staff redeployment was successful

35. Current Status (3/31/2008) Most applications completed in a month in FY 08 was this March � 318 Large number of physician licensure applications continues � fewer than in FY 06 year to date, but more than FY 07 year to date

38. Tips for Applicants for a Smooth Licensure Process Review your eligibility � use the TMB web site Read and follow all instructions Review your application for completeness If in doubt, answer �yes� Send supplemental documentation in one package Track your mail � use a service that delivers to TMB�s physical address, not the PO Box

39. Contact Information Jaime Garanflo Tonie Knight Director, Licensure & Customer Affairs Manager, Licensure Jaime.garanflo@tmb.state.tx.us Tonie.knight@tmb.state.tx.us Denise Meyer Nori Peterson Team Leader, Licensure Team Leader, Licensure Denise.meyer@tmb.state.tx.us Nori.peterson@tmb.state.tx.us Monique Johnston Licensure Specialist Monique.johnston@tmb.state.tx.us Customer Information Center Verifcic@tmb.state.tx.us 512-305-7030