The IMLC is coming to North Carolina

The Interstate Medical Licensure Compact (IMLC) was signed into law in July of 2025 as part of North Carolina (NC) Session Law 2025-37/HB 67. By joining the IMLC, there will now be an additional pathway for licensure in North Carolina as well as a pathway for our licensees to obtain licenses in other compact member states.  

In this episode, we talk with Marschall Smith, Executive Director of the IMLC Commission about the compact and what it means for licensees and for patients in and out of North Carolina. 

Host: Jean Fisher Brinkley, Communications Director, North Carolina Medical Board
Guest: Marschall Smith, Executive Director of the IMLC Commission
Producer: Sylvia French-Hodges, Communications Specialist, North Carolina Medical Board

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Email your questions to: podcast@ncmedboard.org.

Transcript

Episode 47 – The IMLC is coming to North Carolina

Intro music: 0:00 

Podcast introduction: 0:09

A new state law authorizes North Carolina to become a member of the Interstate Medical Licensure Compact. The IMLC provides a streamlined method for physicians currently licensed in a Compact state to become licensed in other Compact states. Once North Carolina officially becomes a Compact state on January first, physicians in North Carolina will have the opportunity to practice in more than 40 other US states and territories, and physicians in those jurisdictions will have the chance to practice in North Carolina. This is Jean Fisher Brinkley, Communications Director for the North Carolina Medical Board, and this is MedBoard Matters. The state law that gives North Carolina the green light to join the IMLC also authorizes our state to become a charter member of the Physician Assistant Licensure Compact. This is a new organization that, when fully operational, will offer PAs the same flexibility that IMLC provides to physicians. As the PA Compact is still in its infancy, this podcast episode focuses solely on the IMLC. I recently spoke with the IMLC’s executive director, Marschall Smith. He walked me through the finer points of how the IMLC works and explained how being part of the Compact is good news both for North Carolina patients and for physicians in and out of our state.

Main Topic: 1:37
JFB: Mr. Smith. Welcome. I wondered if we could start with you just saying what is a Compact? Can you just define that term?

MS: Yeah. So Compact, while they may sound like it's a strange new thing, it’s actually a part of the US Constitution. It's the 10th article of the Constitution. It's the Compact clause, early on. So the Founding Fathers realized that states had to have the ability to interact and make agreements with each other that did not involve the federal government. So it allows states to enter into legal agreements with each other to handle issues that it should be handled at the state level, not the federal level. The most common Compact that people deal with, and I'm sure they don't even realize it's happening, but it's the driver's license Compact. There is an agreement between all of the states that if you are licensed in a state, you can drive in any other state without getting a driver's license in that state. And it's it's a legal agreement between states. And that's how that all operates. So Compacts are this complex process that allows states to deal with each other and enter into agreements without the involvement of the federal government. And that's what we are. We are a legal agreement between states.

JFB: Thank you so much for explaining that. I wondered if you could give me a little history lesson on the IMLC, when it was started and why, that sort of thing.

MS: The Interstate Medical Licensure Compact Commissioner, the IMLCC was created and we went operational in 2017, is a expedited licensure process. It's for physicians, MDS and DOs. And what it does is it creates a unique licensure pathway for physicians to be licensed expeditiously in multiple states and allows them to practice in those multiple states. The Commission, when it started, was primarily run by Commissioners and there was no staff. And basically what the Commissioners did is they created the rules and the policies and procedures and developed the system. Once the system was developed, they needed staff to start running the process. 

JFB: Yeah. How long have you worked with IMLC, and could you say just a little bit about your role? 

MS: So I started with the Commission in September of 2017. Before that, I worked for the state of Colorado as the Executive Director of the Colorado Medical Board. And I worked with the Colorado Department of Public Health and Environment doing ambulance and EMS licensure and certification. So I come from a background of regulation in health care. I was the first and I've been the only Executive Director of the IMLCC. Since then, we have grown there about 45,000 physicians that are currently using the IMCC process. 

JFB: Wow. 

MS: Yeah. And we've issued over 100,000 licenses using our process. It's had an amazing impact on the ability of physicians to be able to practice in multiple states. And it's also had an impact on people receiving care because there are more physicians available to provide that care to them. In 2017, we had about 75 transactions per month, meaning we had Letter of Qualification, LOQ requests, license requests and renewals. Last week, our Commission processed over 2000 transactions in one week. 

JFB: Wow

.

MS: Yeah, so we've grown- 

JFB: In one week? 

MS: In one week. Yes. 

JFB: Wow. Yeah. So from 75 a month to 2000. In a week?

MS: Yes. In eight years, the Commission has grown that quickly. So it really sparks is this incredible need for states to have licensed physicians to practice in their state. Covid was a horrible, horrible event that the Compact actually was positioned to be able to provide this expedited process for physicians to get licensed in multiple states. And it really became, in a sense, the testing ground for how effective that is. And contrary to most people's or to traditional thinking, you know, if North Carolina, if a physician in North Carolina gets licensed to practice in another state, North Carolina is going to be down one physician in this other state where the physician goes to, it's going to be up a physician. And the reality and, there's an independent study that was done by three economics professors at San Jose State University, and what they found and have been able to prove using their academic data research, is that a state joining the Compact will actually see an increase in the number of physicians practicing in their state, and will not see a noticeable loss of physicians practicing in their state. In other words, your state has X number of physicians that are currently practicing there. That number X will stay the same, but you will get a about a 10 to 15% increase in the number of physicians practicing in your state. There are significant number of those physicians who obtain their licenses and practice using the Compact to specifically practice in rural and underserved areas. Almost 54 or 55 % of the physicians get licenses so that they can practice in rural and underserved areas. 

JFB: Wow. That's great. So before we go any further, I feel like I should say, for the record, that this conversation that we're having, you're speaking generally from your experience in bringing these more than 40 jurisdictions into the Compact. They're all functioning, issuing licenses. You're talking about your experiences with this Compact nationally. We're not talking about North Carolina. I mentioned that just because North Carolina, we have had quite a bit of interest. We have had a lot of inquiries from physicians about the Compact in North Carolina. Some are people just wanting general information. Some are physicians saying, when can I apply? And we honestly just don't have a lot of answers at the moment. We have attorneys and licensing folks that are working out the answers to all of those questions and more right now, as well as, you know, implementing the specific application process that's going to need to be in place so that North Carolina is ready come January 2026, when IMLC will actually be in effect in our state so that we're ready to start processing applications when that time comes. So really, I've asked you on the podcast to help us kind of fill in some of the blanks so that we can share some deeper understanding of the Compact in the absence of having specific details about our own state. So thank you for your knowledge. So you started off by talking about how one of the driving forces behind the whole idea of IMLC when it first came together was essentially to issue licenses faster. And I'd like to talk a little bit more about that and dig into sort of what the process is like. I don't think it's any big secret in North Carolina, this is something that we receive complaints about is that it takes quite a while. We tell people, you know, to allow four months if they are applying for a full license here in our state. I think a lot of folks see the Compact as a potential answer to that, at least for physicians who are in Compact states and are interested in and coming here, for practice here, I should say. Is that a correct assumption? That the Compact is going to make it easier for somebody who is in another state, is in a Compact state, who wants to see patients in North Carolina? Are they going to be able to get licensed in North Carolina faster? 

MS: They will. And let me explain how we're able to do that. And I'll give you kind of a rough example. You know, most people are accustomed to, which is if you go to the airport or you're traveling and you're going to fly somewhere, everybody has to go through the X-ray machine. But there are two different ways you can get there. You can follow the traditional way where you go through the line and you line up with everyone else. You take shoes off, take your computer out, and then it goes through the X-ray machine. Or you can go through a process, TSA-pre, where you are pre-qualified and able to expedite your method or your path through the line and up to the X-ray machine so that you can get through the airport security. Our process works very similarly in that in order to practice medicine in a state, you must be licensed in that state, and you must follow that state's Medical Practice Act with that license. So that means a physician who is licensed in two states follows the practice of medicine where they are treating their patient and under that state's laws. The way that we're able to expedite this process is that a state joining the Compact has passed legislation that makes the Compact and the Compact process a part of their state law, and our process now becomes an alternative method for obtaining a license in your state. The traditional method does not go away, but where we're able to expedite that is each physician is already licensed in a state where they are currently practicing, and that state already has all of the primary source documentation about that physician and about how they were trained, where they went to medical school, what their test scores were. They have all of the relevant information already there. And so our process, the physician goes online, they complete an application, they select a State of Principal License or a Home State, either term is used. That state then becomes their verifier or the state that will verify all of the information the physician has put on their application. Where they live, you know where they went to medical school, how many attempts it took them to pass the USMLE, their Board certification, all of these requirements. There are nine specific requirements in order to get an IMLCC Compact license through our process. So once they've selected a state as their State of Principal License, that state then goes in and verifies that application. And that process takes about 20 to 30 days to complete because the State of Principal license has to verify that application from primary source, and they have to pull a background check and they have to be able to pull the NPDB report. And so they're verifying this information that the physician has put on the application is true and correct. Then where the expedited nature in this comes in is the physician goes back into their application after it's been approved, and a Letter of Qualification has been issued by their State of Principal License. That physician then goes in and they select how many of states they want to obtain a license from. They pay that state's licensing fee. And then the state, like North Carolina, will be doing this, choose a license by taking all of the information from that application or putting it into their system and issuing the license. And that's why the licenses are able to be issued in seven to 10 days, because there is no research, there is no waiting for documentation to come in for the physician. They've already supplied that information. It's been verified by another state and then the license issuing state issues that license based on that information. 

JFB: You said that there's nine criteria that they have to meet. Can you tell me what those nine criteria are? 

MS: Yes, the nine criteria, and these are the common agreed to standards that all of our member states have agreed if a physician meets these standards, they will issue a license using this expedited process. So if North Carolina or any of our other member states have additional requirements to be licensed, those are suspended and these nine are put in place. There are very high bar standards, and they are also a bright light. So there are no appeals to these standards. If a physician does not meet these standards, they may not use the IMLCC process to get a license. So they have to have graduated from an accredited medical school. They had to have no more than three attempts at their USMLE Steps. There are four steps in the USMLE and the COMLEX. They had to have passed all of the steps with no more than three attempts at each step. They have to have had obtain their graduate medical education from an accredited institution that in the United States, they have to be Board certified, they can have no prior convictions or criminal activity. They have no history of any disciplinary actions taken by a State Licensing Board. They can have no actions against their DEA registration, the Board where they have their State of Principal License cannot have an open or an active investigation occurring at that time, and they have to agree to do a fingerprint based criminal background check. Those are the nine criteria. 

JFB: Okay, great. So back to talking about the process. 20 to 30 days to hear back from that Home State Board. So that State of Principle License or Home State, once that you hear back from the Home State, yes, they meet the qualifications, they're good to go. Then they have to obtain the Letter of Qualification. What is that all about and how does somebody go about getting one? 

MS: So once they've completed the application and they hit the submit button, the application is sent to the State of Principal License. Let's use North Carolina as our State of Principal License. So you've got a physician who's licensed in North Carolina that wants to use North Carolina as their State of Principal License. They go to our web page, they fill out the application, they hit submit, and they do pay a fee. The Compact charges $700 to use our process. 400 of that goes to the Commission for our expenses and operating, and then 300 goes to the Home State so that they can process this application and covers helps to cover their costs. To do that, the Home State receives that application, and they then process that application. It can be done online, we also have an API process that allows the two systems to communicate with each other. It can be done manually, but North Carolina will then go in, look at the application and ensure that all of the information on that application is correct and the State of Principle License. So if it finds information that's not correct. So let's say the physician says they graduated May 15th of 1998 and they really graduated May 17th of 1997, the Board, the State of Principal License, can go in and change that information so that whatever comes out on that Letter of Qualification is true and correct according to the records of that State of Principal License.

JFB: So another question, is the Letter of Qualification produced automatically by the Home State Board? Once they've verified everything they does it result in a Letter of Qualification, or does the applicant have to request that? 

MS: No. As so as soon as the State of Principal License has completed their review and determined that the physician is eligible to participate, they hit approve, the information in the Letter of Qualification is generated through the IMLCC system, and notification is sent to the physician telling them where they can now request licenses from any of the other Compact Member States.

JFB: Okay, so that hypothetical applicant, they don't really have to do anything with the Letter of Qualification. That's just their sign, okay, I can go back on to the contacts website and select the licenses that I want. 

MS: That's correct. Yep. 

JFB: Okay. That's great. 

MS; The Letter of Qualification in a sense, is the legal document that says that the physician has filled out the application truthfully, that it's been verified by the State of Principal License, and that the physician meets the eligibility criteria. And so that then gives the legal authority of the license issuing states to issue those licenses based on that Letter of Qualification and the information on the application. 

JFB: So as I mentioned, we have had quite a bit of interest from physicians asking when they would be in a position to apply for a North Carolina license using the Compact. As we also discussed, you know, that, you know, we're not going to be ready to accept applications until January 2026. Could an applicant who is interested in practicing in North Carolina be working on this other stuff now? 

MS: Yes. And we so when the bill passed in North Carolina, we saw an increase in physicians obtaining Letters of Qualification. So they are interested in getting licenses in North Carolina. North Carolina physicians that want to use this process to get licensed in another state can't do that until the Board goes live with the process. Let me also say to that that kudos to the Board in North Carolina. It is an incredible heavy lift for a Board to create an entirely new licensing process. And most Boards, on average, our experience has been it takes about six to nine months after the legislation is passed and made into law, for a Board to be able to get their systems to operate and to be able to do the expedited process and be able to make it happen and be very effective. And the Board staff of our member Boards do really incredible work. I mean, it's amazing, as I said, the number of licenses they get processed in a week. And in all of those requests, the thing about it is that the licenses are requested through our process, so a physician who is our process, once they've completed the initial approval and obtained their Letter of Qualification from their State of Principal License, they get all of the licenses that they've requested in, on average, seven to 10 days. That means that people start receiving care two to three, sometimes weeks, sometimes months earlier than following the traditional process. 

JFB: So let's talk a little bit about like once somebody's practicing. I can't honestly tell you that I've followed the discussion or the debate regarding IMLCC in North Carolina that closely, but I know that it came before our state legislature a few times before it won approval this year. One of the things that I have heard people question about the Compact or raise concerns about is this all sounds great, ou know, when everything's going well, patients have better access. Physicians have the ability to expand their practice and see more patients. But what happens when something goes wrong? What if there is an irregularity with the credentials? Somebody faked something or forged something, or there's just been an error or on the other side of things, what if there's an issue with patient care? There's an allegation of substandard care or an allegation of unprofessional conduct. What happens then? 

MS: Yeah, and I will point out that actually, it's very rare where the information on the Letter of Qualification is not valid. 

JFB: Well, that's good to know that, that that's rare. 

MS: It is rare. We have over 100,000 Letters of Qualification that have been issued by our states or principal license since April of 2017. 61 of those Letters of Qualification have been found to be invalid. So they were issued by a state in error. And most of those errors are found by the State of Principal License doing a quality check at a later point and they find out, well, the physician really did take four attempts on one step in USMLE. That's the most common reason that that a Letter of Qualification is returned. The other is that they did their graduate medical education in Canada, not the United States.

JFB: So we’re talking a fraction, a tiny fraction of a percent of total Letters of Qualification. Okay, great. 

MS: Yeah. So we've had again we have about it's a little over 49,000 physicians that have signed up and are using the IMLCC process. We've had 95 of those physicians end up with some sort of discipline, either their license being suspended or some sort of this upon being issued to them that's reported to the National Practitioner Databank. As soon as discipline is issued by a member Board or by any Board that's reported to the National Practitioner Databank, the physician becomes ineligible to continue participation in the Compact. And that means that if they got a license or obtained a license through the IMLCC process, and that license, when it comes up for renewal, that physician cannot renew that license because they are now no longer eligible to participate.

JFB: Okay. 

MS: The other part to it that is unique, as I mentioned earlier, the Compact is state statute. So each one of our states that joins the Compact, this becomes a part of their state law. And that also creates an additional opportunity for investigations and investigational activities by Boards. So most states I believe it's almost all of the states where Boards are unable to communicate or cooperate with other State Medical Boards because of privacy and state laws and all of those sorts of things that protect each state's Medical Practice Act and each State's Medical Board. By joining the Compact, those states have agreed, and it becomes law that both states can now cooperate with other states in conducting investigations. It's called a joint investigation, and it is formed and allows states to share. And we've had two joint investigations that have been formed as a result of activity. 

JFB: Wow. 

MS: It is a strong, powerful tool. 

JFB: Okay.

MS: It's not used very often. It's not required because these physicians that use the Compact process are high bar, bright light physicians. They know if they're going to lose all of their licenses if they get disciplined. So they tend not to use our process if they're on the edge or on the cusp of what's really what they're doing is, is acceptable in our culture.

JFB: So that's the reason why you're looking at their criminal history, their regulatory history, etc., because you want people who have those spotless records. Yeah. 

MS: Yeah. And if I could also just kind of add on to part of the question that you ask, and it's related to why I believe that North Carolina has taken their time in adopting the Compact and doing that process, and it relates to how the Compact interacts for physicians. And so it's an important distinction between the ability to obtain a license using the expedited process and how that license, once obtained, is used, or how the what the Medical Practice Act of that state is. We have a lot of experience that recently happened with the Supreme Court decision that actually reinforced the Compact process, which says that each state has the right to regulate the practice of medicine that is appropriate for their state and they do this through the issuance of a license in that state. So using the Compact process, physicians obtain multiple licenses to practice. That doesn't mean that they just have one way in which they're going to practice. They have to alter or adapt their practice to the Medical Practice Act of the state, where the patient is receiving care. So you can have a physician who is in practice in a certain way, in a state. They can't do that same medical act in another state because it's prohibited by their Medical Practice Act. And so that's how the Compact can exist. And that's why we're very popular among physicians, is because we get them the license to be able to practice. And then they understand that once they have that license, they have to practice according to that state's Medical Practice Act. That's why a license is issued and that's why our process exists. 

JFB: Right. Yeah. Thanks for mentioning that, because I think, as you said earlier in our conversation, each state's Medical Practice Act is different, and what's allowed in one state may not be allowed in the other. So it's really important to be aware of what the laws are in the state where you practice medicine. I wanted to make sure I heard you correctly. Did you say that there have only been two joint investigations in the history of the Compact? 

MS: Yes, there have only been two joint investigations that have been formed. It doesn't mean that states haven't shared investigative information with each other as permitted by the Compact process. It's just they have formed a joint investigation to do that. We've had 95 physicians that have been disciplined out of the 49,000-

JFB: Okay. 

MS: That we created. Right. So let me run through those numbers again. So there are 49,000 physicians that are using the Compact process. Of those 49,000 physicians, and this is since 2017, 95 of those, 49,000 physicians have had some sort of discipline taken against a license and that has resulted in them no longer being allowed to participate in the Compact. But also and another part of this that is beneficial to the states is disciplinary action taken in another member state can be used by the state to take action against that physician too. So those 95 physicians have had a total of 208 actions issued against them. We have several physicians that have had two and three disciplinary actions taken because one state took an action, and then the other states are allowed to take a similar action-

JFB: Right.

MS: Based on that. So yes. 

JFB: Yeah, I'm familiar with that. We call them reciprocal actions. That's quite common in medical regulation, as I'm sure you know, as a former Executive Director. Those are all my prepared questions, is there anything that you would like to say that I have not asked about the Compact? 

MS: Well, I would say, yes. So if anyone is interested in looking at actually going through what the process is to qualify for a Letter of Qualification to, once you have your Letter of Qualification, what it looks like for a physician to request additional licenses, what the renewal process looks like. We have videos on our web page that you can actually there are five to seven minutes long, and every aspect in every process that that Compact does is available to be reviewed and our web page is imlcc.com. And when you pull up the web page, there's a big blue line in the middle of that big blue line is a tab that says Educational Videos. And if you click on that, you can watch and we walk you through the entire process. 

JFB: Great. I'm sure that's going to be of interest to a lot of people. We would be happy to link to that on our show page. 

MS: Okay. 

JFB: Well, Marshall, thank you so much for your time and for your patience with me. I know I've had a lot of questions that are probably pretty basic to you. I hope that this is going to be helpful to all of the people who are interested in the Compact being available in North Carolina.

MS: Yeah. I think it's a great thing, and it will be a benefit to the state, and it'll be a benefit to those patients in your state. It's a good thing, and I'm so glad that the North Carolina Legislature passed the legislation, and the Board is enthusiastically working towards implementation.

JFB: Well thanks again.

Episode closing: 29:33

Well, that brings us to the end of this episode of MedBoard Matters. I hope you have a better idea of how the IMLC works and how it might change the healthcare landscape in North Carolina. The North Carolina Medical Board has received a steady stream of calls and emails from individuals who are interested in applying for North Carolina licensure through the IMLC. Just as a reminder, North Carolina will not be a Compact state until January 1, 2026, and the Board is not currently able to accept license applications through this new pathway. Physicians who are currently licensed in a Compact state and interested in a North Carolina medical license can start working towards that goal now. The first step is to apply to the IMLC directly to begin the process of establishing your state of principal licensure and verifying your credentials. Physicians who are already qualified through IMLC will just have to sit tight and wait until January to submit their North Carolina application. North Carolina physicians who are interested in the Compact, well, I’m going to have to ask you to be patient as well. NCMB isn’t yet ready to issue letters of qualification or to work with IMLC to get North Carolina physicians cleared to seek licensure in other Compact states. Rest assured, we are working on that too. If you would like more information, please visit our show page at www.ncmedboard.org/podcast. NCMB has established a resource page on IMLC, which we will be updating as more information becomes available. If you have comments or questions, feel free to email us at podcast@ncmedboard.org. Thanks so much for listening. I hope you will join me again.