Several previous articles have discussed the unprecedented opportunity the National Registry of Certified Medical Examiners represents to the chiropractic profession. More than seven years in development, the final rule for the registry was released on April 18, 2012. It has been worth the wait. In the final rule, chiropractic physicians have full authority equal to medical doctors, osteopaths, nurse practitioners and physician assistants as certified medical examiners. Commercial drivers are required to use a certified medical examiner in the national registry for their commercial driver's license (CDL) physicals beginning April 21, 2014.
Although a number of groups were opposed to chiropractic inclusion, the Federal Motor Carrier Safety Administration's response in the final rule was: "The final rule will require all ME candidates to undergo the initial training and the certification testing that objectively measures candidate qualification and ensures that all ME's have the same level of working knowledge of FMCSA regulation and guidelines … FMCSA will continue to rely on State determination."
State determination refers to each state's scope of practice. To perform the CDL physical, your state scope of practice must include performing "physical exams." There are still two states in which DCs cannot perform physical exams: Washington and Michigan.
To become certified in the national registry, all applicants must attend an accredited training course and pass a certification test. Accredited training organizations are listed on the NRCME Web site as of May 20, 2012. Training can begin as soon as the organizations are ready; however to take the certification test, practitioners will be required to register with the FMCSA. The FMCSA and the testing organizations that will administer the certification test will not be ready for practitioner registration until Aug. 20, 2012. Practitioners must complete the training and receive their certificate of completion from the training organization before registering.
Accredited training courses must be "accredited" by a nationally recognized accrediting body of continuing education credits. Providers of Approved Continuing Education (PACE), from the Federation of Chiropractic Licensing Boards, is listed as a chiropractic example of a nationally recognized accrediting body. Training is expected to be at least eight hours in length. Training will be cross-professional, allowing a mix of health care providers to attend the same training course.
The certification test will be provided at testing centers location across the United States. The certification test is composed of 120 computer questions with multiple-choice answers. Twenty of the questions are ungraded and are being evaluated for use on future tests. Practitioners who pass the certification test will be listed on the national registry.
Certified medical examiners must take refresher training every five years, and must retake the certification test every 10 years. They must also report all completed CDL physicals to the FMCSA monthly.
Although the April 2014 implementation date for commercial drivers to use a certified medical examiner for their CDL physicals is two years away, providers who get certified early will have an advantage in building their transportation client base. The FMCSA estimates that 40,000 examiners are needed within the next two years. The training requirements, however, are expected to reduce the current number of providers of the CDL physical. Thus, this represents the opening of the "door of opportunity" for DCs mentioned previously.
Medical examiners are allowed to refer out needed services for the physical exam and/or additional testing related to a driver medical condition. One wrinkle that has arisen involve the states of New York, California, Pennsylvania and Georgia. A part of the physical is to determine the specific gravity of the driver's urine and if protein, blood or glucose is present. Most physicians collect the urine in their office and use a Clinical Laboratory Improvement Amendments (CLIA)-waived UA dipstick to get these values. However, in the above-mentioned states, DCs are not allowed to use a dipstick test in their office.
This is not an issue of the FMCSA medical standards or the state chiropractic scope of practice. Federal CLIA regulations require all physicians in every state to have a CLIA Certificate of Waiver to perform a dipstick test (even CLIA-waived test devices) in their office. When you register to obtain a CLIA Certificate of Waiver, you are actually becoming a laboratory, and every laboratory, including those that are physician offices, must have a laboratory director.
The physician always puts themselves as the laboratory director, but in the states listed above, the state laboratory regulations will not allow a DC to be a laboratory director. There are three options for DCs in these states: The first option is to collect the urine and send it to a lab for testing; the second is to refer the driver to a lab or another provider; and the third is to find another physician or accredited professional to serve as your lab director.
This is the first opportunity during my career that the chiropractic profession has every advantage. Without knowing, drivers frequently let their medical certificate expire. Offices that can offer same or next-day appointments have an advantage. Price is also an important consideration, but the relative reimbursement for performing a CDL physical is usually above the reimbursement for many chiropractic procedures.
Underutilized staff can perform up to about half of the physical exam, and all of the alcohol and drug testing. Drivers usually pay at the time of service, and motor carriers who are clients can be billed. Insurance billing is a rarity.
Adding CDL physicals to your practice is not for every DC, but every DC should take time to consider adding these services. With low back pain being a common complaint of drivers, what other opportunity pays for potential patients to visit your office?
As many of the current providers decide not to become certified, that opens the door a bit wider for those who do. All DCs will not be interested in becoming certified medical examiners, but every DC should take time to consider adding DOT-related services to their practice.
For background on the NRCME, read Dr. Megehee's articles, "A Billion-Dollar Opportunity for Chiropractors" and "DOT Final Rule to Be Released: Establishes Guidelines for Certifying Providers to Perform CDL Physical Exams," in the March 12, 2010 and Sept. 23, 2011 issues, respectively.
