Practical Telemedicine Medical Advice

The contents of this article are based on general observations of the State Medical Board's reaction to Physicians seeking to license in the various States for the purpose of Telemedicine. We are limiting this article to Telemedicine / Telepsychiatry. We are not including Teleradiology, Telepathology, or Tele-Intraoperative Neuromonitoring because Telemedicine and Telepsychiatry can involve prescribing drugs whereas the others do not.

The largest risk associated with the practice of Telemedicine is directly connected to the prescribing of Controlled Substances Classes II, III, IV, and V. With the advent of the Internet and the endless possibilities which it opened, Internet Pharmacies sprang up as a way to avoid the micro-management of State Control and a way to reduce the cost of such Controlled Substances by importing from other States where the cost was lower or other Countries. In order to meet the Federal DEA Requirements, the online Pharmacies utilized Physicians who were willing to sell their DEA # at a price to them in order to make a quick buck. Quickly these online pharmacies became online drug dealers. The DEA aggressively pursued these online pharmacies and the physicians who had lent their DEA # and License # to them for a fee. The DEA prosecuted the various Physicians who are involved in these practice.

Because of the abuse of this medium, the State Medical Boards have taken a strong stance in monitoring Telemedicine Physicians. States like Arkansas will scrutinize the applicant and issuance is not a guarantee. South Carolina has a similar process. Each Medical Board has imposed its' own rules on this practice. There are some general guidelines, that if followed will help keep your Telemedicine License out of the Boards Microscope.

# 1 - Establish a direct patient - physician relationship. You need to be able to document this to the Medical Boards. The Boards are going to want to see that you have a personal, one on one relationship with your patients. How this is established can vary. I have clients who will use a locally, licensed Physician to provide a standard physical on the patient and then forward the report to the Telemedicine Physician. From there the Physician provides whatever type of Medical Treatment with the Patient. One visit does not constitute a Patient-Physician Relationship under most cases. Many times a patient will have to come back multiple times to a Physician's office for updated evaluations. Remember - if you do it in real life then it needs to be done in Telemedicine.

# 2 - What ever you are required to do for your patients that would physically come to your practice / office, you need to do for those who are treated online, via phone, or teleconferencing. You are required to maintain thorough records for your patients in an office setting, and as such you will need to do so for your Telemedicine Patients. If you do it in real life, then you  need to do it in Telemedicine.

# 3 - The Law applies where the Patient is located and where you are located. Just because the State where you are based allows it does not mean that it is ok in the State where the Patient is located. If State A does not have restrictions on a Drug (non Controlled) and State B does, then you have to abide by State B's rules when dealing in Telemedicine. Your license is to precious to allow it to be placed at risk for an easy dollar. You have to abide by the more Restrictive State when dealing with Telemedicine. If your home State allows it and the Patient's State does not, then you have to follow the Patient's State Medical Board Rules. If your State does not allow it and the Patient's State Medical Board does, then you have to follow your State Medical Board rules. Period.

# 4 - Do not prescribe Controlled Substances Class II Drugs unless your Attorney has cleared with the State Medical Board, Pharmacy Board, and DEA that what you are prescribing and the way you are prescribing meets their requirements. Know your State and Federal Laws concerning Class II, III, IV, and V Drugs. Some may be unlawful to prescribe in some States whereas they may be fully lawful in others. This will vary from State to State. Here is an excellent guide to Interstate Prescribing of Controlled Substances:  Telemedicine Prescribing: https://www.cchpca.org/topic/online-prescribing/

**Update to #4  (2024)  - The DEA has reinstated its' pre-Covid Rules concerning prescribing across State Lines. If you are prescribing Class 2-5 substances to a patient across State Lines, you will need:

• A physical office in the State where the patient is located
• A CSR Permit in the State where the patient is located - if the State has a CSR/CDS permit requirement
• In many/most circumstances, the patient will have to be seen by the physician in person at the beginning of the patient/physician relationship

# 5 - Talk to your Malpractice Insurance Carrier / Insurance Agent before taking on a New State. Why? Insurance is regulated by the States Dept. of Insurance. The rules vary State by State. As such there is a good possibility that your insurance company might not cover new States. Often times they will. You have to call in advance to determine this. Having to face a malpractice lawsuit filed in a State 1500 miles away is not something you want to do without Malpractice Coverage.

# 6 - Do not trust a your Employer to do the right thing. Know what you are doing and what you are getting into. Ask the right questions. Determine if the company will be directing the medical care / treatment or will you. Will you have direct access to the patient medical records? Will you have access to the billing? As a general rule, if you are not in control then walk away. I have seen multiple lawsuits filed against Telemedicine Companies because they used the Physician's license to offer services which were unlawful. The Physician paid the price with his/her license. It took you Hundred's of Thousands of Dollars and 9 to 15 years of training to get where you are. Why are you going to risk this for a easy dollar? Fully vet any offer presented to you and have your attorney review their practice plan against the Medical Board's rules. I have had a number of physicians call our offices with sob stories concerning the fact that they signed on with a telemedicine company without truly exploring the company, protocols, and background. Once signed on, they weren't given access to the patient records/billing. Then when they were contacted by the Insurance Commission of the State, Medicare, Medicaid, the State Medical Board about fraudulent billing practices ( fraudulent compounding to inflate the billing to the insurer ) by the Telemedicine Company, they lost their careers and in some cases their freedom. All because they didn't have access to the patient records and billing. What they actually  prescribed wasn't what was billed. 

I hope this information has been helpful. It is based on 22 years of experience, continual research, and the actual observation of our client's practices.

Services Included with Medical Licensing:

• Set up of the State Medical Board Application
• Set up of the required primary source confirmations
• Submission of the State Medical Board Application
• Submission of Reference Forms to References
• Submission of Required Forms to other State Medical Boards
• Requests of Transcripts from Medical Schools and Universities
• Submission of Required Forms to Hospitals and Institutions
• Submission of Temporary License Applications Completion of FCVS forms (if required or requested)

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How Licensure Affects Telemedicine:

Advances in technology have opened new doors of opportunity for many medically underserved communities in America. Because of relatively inferior rural access to specialty health care providers, citizens in these communities must often travel great distances to receive care, or forego medical treatment until it becomes urgent. Telemedicine technology increases physicians' capacity to serve these citizens and improves their access to health care. Yet, when medically underserved patients and physicians are located in separate states the issue of practitioner licensure arises. Licensure laws that regulate interstate telemedicine practice vary from state to state. Categories of telemedicine licensure Restrictive licensure Restrictive licensure laws require a practitioner to obtain a full license to deliver telemedicine care across state lines. Typically, states with restrictive licensure laws also have several exceptions (varying from state to state) that may release an out-of-state practitioner from the additional burden of obtaining such a license. A number of States require practitioners who seek compensation to frequently deliver interstate care to acquire a full license. If a practitioner serves several states, obtaining this license in each state could be an expensive and time-consuming proposition. Even if the practitioner never practices medicine face-to-face with a patient in another state, he/she still must meet a variety of other individual state requirements, including paying substantial licensure fees, passing additional oral and written examinations, and traveling for interviews.

Additional Telemedicine License Information:

Advances in technology have opened new doors of opportunity for many medically underserved communities in America. Licensure laws that regulate interstate telemedicine practice vary from state to state. Restrictive licensure laws require a practitioner to obtain a full license to deliver telemedicine care across state lines.

Most States require practitioners who seek compensation to frequently deliver interstate care to acquire a full license. If a practitioner serves several states, obtaining this license in each state could be an expensive and time-consuming proposition. MedLicense.com can reduce the burden and cost of obtaining the required licensure. Most States require the Physician to have a license where they are physically located and where the patient resides.

The Telemedicine License Renewal and CME problem:

You spent thousands of dollars and hours and hours to obtain licensure in States across the country. Now you can practice Telemedicine on a grand scale. However, what you didn't realize when you committed to this process is that now you have permanently brought upon yourself a two fold problem. 

1- you have to keep track and insure that you do not miss a State Medical Board License Renewal / Expiration Date

2- you have to make sure that you complete the required suite of CME/CE required by EACH State Medical Board within the required time frame

The more licenses you have, the more complex and problematic this process will be. MedLicense.com has partnered with a company that does just that.  MedRenewal.com     MedRenewal provides complete State Medical License and CME/CE Monitoring Services. There are no contract requirements. Signing up is easy. Set up your account, enter your license #, issue dates, expiration dates, upload your CMEs for each State and then you are done. MedRenewal will track each State Medical License for you.  It will also send you email notifications 90, 60, 30, 7, and 1 day prior to the expiration date of each Medical License to insure that you don't miss one.  On top of this, it will also do the same for your CMEs for each State. When you log in, the portal will also report where you are deficient in your CME / CE for each State. Need a link to the required CME / CE? No problem. MedRenewal.com provides the link for you.   You also can upload your CME / CE to MedRenewal to store them. When a State Medical Board notifies you that you are being audited for your CME compliance, you won't have to search for your CME certificates. You can just download them from MedRenewal.com   The price point on this service is incredibly reasonable. Only $20 a month for unlimited license and cme monitoring. This is why we whole heartidly recommend MedRenewal.com to our clients.