Practicing Over State Lines 1.26.24.pptx
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Practicing Over State Lines 1.26.24.pptx
- 2. Marlene M. Maheu, PhD Authored five peer-reviewed telehealth textbooks, 60+ book chapters and journal articles, and 1250+ blog posts found at blog.telehealth.org. Developed 72+ hours of evidence-based and competency-based telehealth training at Telehealth.org, trained more than 86k professionals in telehealth since 1994. • Founder & CEO of Telehealth.org • Founder & CEO of the Coalition for Technology in Behavioral Science (CTiBS) & Founder of the Journal for Technology in Behavioral Science • Chair of the first Committee for Telebehavioral Health Competencies
- 3. © 1994-2024 Telehealth.org, LLC All rights reserved. And you? Please introduce yourself to our group with: 1. Your years w/ TBHI 2. City, State 3. Specialty …
- 4. Learning Objectives • List the eight common types of state-specific regulations you must follow when working across state lines or international borders. • List at least one way your malpractice coverage can automatically be nullified despite your carrier’s claims that you are “covered” for online practice. • Outline the 2-step process for legally and ethically practicing over state lines and international borders.
- 5. Audio-Only Mode • Q&A period will be at the end of today’s training. I will stay as long as it takes after the end of the webinar to answer all your questions. (You are free to go after our scheduled time. All post-test content will have been covered.) • Telehealth.org assistants are here to help you with administrative issues (not hearing me, finding post-test, etc.)
- 6. Maximize Your Learning • Turn on your camera. • Join the conversation throughout our time together. • Ask questions in chat box as they occur to you rather than waiting. • Mute your phone. • Lock your door. • Ask family & friends to stay away.
- 7. © 1994-2024 Telehealth.org, LLC All rights reserved. Finding Your Course Completion Certificate
- 8. © 1994-2024 Telehealth.org, LLC All rights reserved. • What is your #1, most burning question about working over state lines? • Please type it into the chat box.
- 9. Dr. Jones Case #1 • Works at a community behavioral health center and sees approximately 25-30 clients/patients per week. Many of them are Medicare or Medicaid beneficiaries. • Reluctantly transitioned all clients/patients to telehealth services during COVID. • While many of the clients/patients in Dr. Jones’s care returned to seeing them in person, about 40% have chosen to continue telehealth.
- 10. Dr. Jones Case #1 • Some of them moved out of state to be with family or other strong support systems and have chosen to remain out of state. • Dr. Jones only maintains a license to practice in the original state but has continued to deliver care, feeling ill-at- ease out terminating and referring to local therapists. • Dr. Jones is not sure of the legalities involved but is taking this class to figure that out.
- 11. © 1994-2024 Telehealth.org, LLC All rights reserved. Ethical standards are built on the foundational framework established by law. • Ethics • Law How are ethics and law related?
- 13. © 1994-2024 Telehealth.org, LLC All rights reserved. • State Boards are the final decision- makers. No matter how you twist and turn, they have the final say over your meal ticket, your license. • When you ask them questions, if you use the wrong term, you may not get a useful answer. • (Garbage in = garbage out.) • Also, so many people have “opinions” that it is easy to be misled. If you know how concepts are strung together, you can easily spot who to believe. Why do the terms matter with practicing across state lines?
- 14. © 1994-2024 Telehealth.org, LLC All rights reserved. • Also, so many people have “opinions” that it is easy to be misled. • If you know how concepts are strung together, you will know who to believe. Why does terminology matter when learning about practicing across state lines?
- 15. © 1994-2024 Telehealth.org, LLC All rights reserved. • Ethics – moral vales and judgement rooted in shared values (standards) about how professionals ought to behave. Provides framework for thinking about what is right and wrong. • Law – rules and regulations to be followed. How are best practices, ethics and law related?
- 16. © 1994-2024,Telehealth.org.org, LLC All rights reserved. Ethics vs Law? Ethics – More principles at the core of making decisions, rooted in shared values that professionals agree to adopt within their groups Ethical Codes Law – Required foundational framework made of laws at the state level and regulations at the state board level.
- 17. © 1994-2024 Telehealth.org, LLC All rights reserved. • The term "best practices" refers to a set of established methods or techniques that are recognized as the most effective and efficient approaches for achieving optimal outcomes in healthcare (or any industry). • Typically based on research, empirical evidence, and expert consensus, making them the preferred methods for addressing common challenges or achieving optimal outcomes. What are “best practices?”
- 18. © 1994-2024 Telehealth.org, LLC All rights reserved. Best Practices, Ethics, Law Law Ethics Get desired outcomes Do the right thing Follow the law Best Practices
- 19. © 1994-2024 Telehealth.org, LLC All rights reserved. Best Practices, Guidelines, Ethics, Law Best Practices Guidelines provide specifics of doing the right thing. Privacy put files in locked file cabinet, in a locked room. Or if using cloud secured cloud. Law Guidelines Ethics
- 20. © 1994-2022 Telebehavioral Health Institute, LLC All rights reserved. Competencies, Best Practices, Guidelines, Ethics, Law Competencies Law Best Practices Ethics Guidelines Competencies are preferably discreet knowledge, skills & attitudes that are the building blocks (amino acids) of job performance. • Often used to teach and assess oneself or others. • Starting to show up on licensing exams.
- 21. © 1994-2024 Telehealth.org, LLC All rights reserved. CTiBS TBH 7 Competency Domains (We will look at only one of them today) An Interprofessional Framework for Telebehavioral Health Competencies https://telehealth.org/tele behavioral-health- competency-framework/ Technical Telepresence Clinical Legal & Regulatory Ethical & Evidence- Based mHealth Practice Development
- 22. © 1994-2024 Telehealth.org, LLC All rights reserved. Regulations for Practicing Over State Lines Are Made by State Licensing Boards • Not Congress • Not Governors • Not professional associations
- 23. © 1994-2024 Telehealth.org, LLC All rights reserved. When it comes to practicing across state lines for licensed professionals, state law overrides all other contributing factors, even national emergencies.
- 24. © 1994-2024 Telehealth.org, LLC All rights reserved. Which State Boards Are Involved with Practicing Over State Lines? • Licensing boards for your profession or that of your supervisee. • Several may assert jurisdiction: • The board in the professional’s state(s) of licensure • The licensing board in the patient’s or client’s location at time of contact • Boards in both geographic areas
- 25. © 1994-2024 Telehealth.org, LLC All rights reserved. Licensing Board Inconsistencies • Many Boards differ from one another within the same state. • Differences often dependent on: • Training required of different states for applicants • Enforcement cost of infractions • Tradition (Power holders who stay on Boards w/o term limits)
- 26. © 1994-2024 Telehealth.org, LLC All rights reserved. Licensing Facts Calling yourself a "coach" to practice over state lines when you are licensed can get you in more trouble than its worth. • Your licensure trumps your label for your work • Check your state codes for the definition of your profession • Write to your board and ask
- 27. End of Public Health Emergency: April, 2023 • Laws prohibiting healthcare practice across state lines did not go away for COVID, other health emergencies or natural disasters. • They have always been enforced by the states: • Innies • Outies
- 28. Overall “Best-Best” Practice Across State Lines • Best practice for providing telehealth services to a client or patient when either a) the licensed professional or b) client/patient is outside of the clinician’s state of licensure is to contact all involved boards directly, in writing. • Only the boards are updated about their laws.
- 30. © 1994-2024 Telehealth.org, LLC All rights reserved. Inter-jurisdictional Practice • More Detailed Best Practices • Provide services only where you are licensed • Require client/patient to attest to his or her location on every call. • (Required by NASW 2017Technology Standards for social workers.)
- 31. © 1994-2024 Telehealth.org, LLC All rights reserved. 1. State Licensure Requirements 2. Telehealth Practice Standards 3. Reimbursement Policies 4. Emergency Services 5. Prescribing Regulations 6. Cross-State Licensing Exceptions 7. Continuing Education and Training 8. Professional Liability Insurance 9. Jurisdictional Legal Variances 10. Documentation and Record-Keeping Best Practices That Can Differ Across States
- 32. © 1994-2024 Telehealth.org, LLC All rights reserved. 1. State Licensure Requirements Typically, healthcare providers must be licensed in the state where the client or patient is located at the time of the telehealth interaction. • Patient centered care – care follows the client or patient Some states may participate in interstate licensure compacts that facilitate the ability for providers to practice in multiple states. Best Practices That Can Differ Across States
- 33. © 1994-2024 Telehealth.org, LLC All rights reserved. • Interjurisdictional Practice (psychology & addictions) • Interstate practice (SW) • Interstate compact (counseling) • License portability (MFTs) • Multistate license (nursing) • Interstate licensure (medicine) What are professional-specific terms for referring to practicing healthcare across state lines and international borders?
- 42. © 1994-2024 Telehealth.org, LLC All rights reserved. 2. Telehealth Practice Standards Providers should adhere to the same standard of care as in-person consultations. • This includes obtaining appropriate consent for telehealth services, mandated reporting, and ensuring that patient confidentiality is maintained according to the Health Insurance Portability and Accountability Act (HIPAA) as well as any privacy and confidentiality additions made by state law. Best Practices That Can Differ Across States
- 43. © 1994-2024 Telehealth.org, LLC All rights reserved. • You most likely cannot legally or ethically practice in that state. • Consult: Your malpractice attorney Ethics office of your national professional association. What happens if you cannot meet the definition of a state’s standard of care?
- 44. © 1994-2024 Telehealth.org, LLC All rights reserved. 3. Reimbursement Policies • It is essential to your practice survival that you understand the reimbursement policies of different states as they can vary significantly. • Make sure your services are covered by Medicare, Medicaid, or private insurance in the state where the client patient receives services. • Medicare violations can land you in prison, and incur hefty financial penalties. Best Practices That Can Differ Across States
- 45. © 1994-2024 Telehealth.org, LLC All rights reserved. 4. Emergency Services You must have a protocol for emergency situations wherever your client or patient is located. • Opening protocol – where are they now and more • Informed Consent • Termination procedures Also includes always having thorough knowledge of local emergency services at your fingertips. Best Practices That Can Differ Across States
- 46. © 1994-2024 Telehealth.org, LLC All rights reserved. • Opening protocol: Ask client/patient to “attest” to location at the start of every session • Document their response • Informed consent • If not in your state(s) / province(s) of licensure, ask about whether it is an emergency • Use an emergency protocol Say more about the opening protocol and how I can establish my client’s location…
- 47. © 1994-2024 Telehealth.org, LLC All rights reserved. 5. Prescribing Regulations States have varying regulations regarding the prescription of medications via telehealth, especially controlled substances. • Providers must comply with both federal and state regulations governing telemedicine prescribing. • If you don’t prescribe medication but are seeing someone who does, and they are in a state where their prescriber is not licensed, what will you do if they run into trouble? Best Practices That Can Differ Across States
- 48. © 1994-2024 Telehealth.org, LLC All rights reserved. 6. Cross-State Licensing Exceptions • During certain public health emergencies and natural disasters, states may issue temporary waivers allowing out-of-state providers to practice without obtaining a license in that state. • However, these are exceptions and not the norm. Best Practices That Can Differ Across States
- 49. © 1994-2024 Telehealth.org, LLC All rights reserved. 7. Continuing Education and Training • Providers should pursue ongoing education and training in telehealth, as some states may require specific training to practice telehealth. • Your best defense if something goes wrong is to be able to demonstrate that you tried to get formal, documented training by an approved CME or CE training group for your profession. • “What would a reasonable professionals do in a similar circumstance?” Best Practices That Can Differ Across States
- 50. © 1994-2024 Telehealth.org, LLC All rights reserved. 8. Professional Liability Insurance • Providers should ensure that their professional liability insurance covers telehealth services across state lines. • Read the fine print in your policy. (Seriously. Read it all.) • Write a letter to your malpractice carrier asking for a written response to all your questions. Get all answers to your questions about your telehealth coverage in writing – in plain English. Best Practices That Can Differ Across States
- 51. © 1994-2024 Telehealth.org, LLC All rights reserved. Coverage can be nullified if a practitioner is practicing “criminally” • Over state lines without proper documentation • Definition of practice and all applicable laws for each state must be met (e.g., you might need to have a signed client agreement or informed consent for clinician to be considered as providing a professional service worthy of coverage) • Write to your malpractice carrier and describe your proposed service, including every state you enter to deliver care How does practicing over state lines affect your malpractice insurance?
- 52. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Providers must be aware of and comply with the specific legal and regulatory frameworks governing telehealth that can vary widely from state to state. • Texas vs Florida (Telehealth Provider Registration) • Consent - Some states require written consent, whereas others accept verbal consent. For instance, California requires written consent, while Pennsylvania does not specify the format. Best Practices That Can Differ Across States
- 53. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Establishing a Professional Relationship - Certain jurisdictions may have specific requirements for establishing a provider- patient relationship via telehealth, which could include an initial in-person examination or a specific protocol for remote examinations. • Confidentiality and Data Security - Some states may have additional protections above and beyond HIPAA. Best Practices That Can Differ Across States
- 54. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Mandatory Reporting - States may differ in their requirements for mandatory reporting of certain conditions or situations encountered through telehealth. • Several examples of this important issue are detailed next. Best Practices That Can Differ Across States
- 55. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Child Abuse and Neglect: All states require the reporting of suspected child abuse and neglect. However, the specifics of what must be reported, to whom, and within what timeframe can vary. • Elder Abuse: The reporting of elder abuse, including physical, sexual, emotional abuse, or financial exploitation, is mandatory, but the specifics can vary by state. Best Practices That Can Differ Across States
- 56. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Injury by a Weapon - Reporting requirements for injuries caused by firearms or knives can differ for medical professionals, with some states requiring all such injuries to be reported and others requiring only under certain circumstances. • Domestic Violence - Some states mandate reporting of domestic violence, while others leave it to the discretion of the provider or have specific conditions for reporting. Best Practices That Can Differ Across States
- 57. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • California: Providers are legally obligated to report to local law enforcement when it is suspected that a wound or physical injury of a patient has resulted from domestic abuse. Includes injuries believed to be caused by assaultive or abusive conduct, (i.e., inflicted by a firearm, stabbing, sexual assault, or torture.) • Some providers must make an immediate report and follow up with a written report within 48 hours. Best Practices That Can Differ Across States
- 58. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • CA continued: But, if the healthcare provider is treating for a consultation not related to a physical condition, such as a mental health consultation, then they may not be required to report unless there is physical evidence of abuse. • Practitioner Misbehavior • Sexual communications • Impairment due to illness, drugs, alcohol or physical condition • Improper billing Best Practices That Can Differ Across States
- 59. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Pennsylvania: Physicians, interns, and managers of healthcare facilities are generally required to report suspected domestic violence, but if the victim is an adult who does not consent to the reporting and is informed about the reporting requirement, the provider is not mandated to report. The victim is provided with a referral to victim services agencies. Mental health providers who do not fit these roles usually need not report. Best Practices That Can Differ Across States
- 60. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Threats of Serious Harm: Healthcare providers are typically required to report if a patient is a threat to themselves or others, but the criteria and process for reporting such threats can differ. (Tarasoff - Duty to Warn) Best Practices That Can Differ Across States
- 61. © 1994-2024 Telehealth.org, LLC All rights reserved. • Inform clients/patients of your remote safety policies in your informed consent process • National Conference of State Legislators tracks Duty to Warn (“Serious Harm”) Differences Across States • http://www.ncsl.org/research/ health/mental-health- professionals-duty-to- warn.aspx What else should I know about mandated reporting when I practice across state lines?
- 65. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Standard of Care: The expectation for the standard of care in telehealth services can vary, with some states providing detailed guidelines on what is expected of telehealth providers. • Other states say little or nothing about telehealth, leaving the practitioner to guess at how to operate. These states make it very difficult for providers to comply, and therefor are riskier – left to the whims of presiding board members. Best Practices That Can Differ Across States
- 66. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Coverage and Reimbursement: Insurance coverage and reimbursement rates for telehealth services are not uniform across states. • Some states have parity laws that require insurers to cover telehealth services similarly to in-person services. • Others do not, which allows insurers to cover or not cover, as they choose, often for unspecified reasons. Best Practices That Can Differ Across States
- 67. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Malpractice and Liability Laws: The malpractice and liability laws applicable to telehealth can differ from state to state, affecting how telehealth services are delivered. • Malpractice insurance companies, then, can be subject to differing laws about how and when they will protect you. Best Practices That Can Differ Across States
- 68. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Telehealth Modality Acceptance: Some states have specific regulations about the types of telehealth modalities that can be used (video, audio, asynchronous communication). • Telehealth Platforms: The approval of telehealth platforms and software may also be subject to state-specific regulations related to privacy, security, and interoperability. Best Practices That Can Differ Across States
- 69. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Regulatory Bodies: Different states may have different regulatory bodies overseeing telehealth practices, and their rules and regulations can impose additional compliance requirements. • Regulations can differ widely from one board to the next in the same state. Best Practices That Can Differ Across States
- 70. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Threats of Serious Harm: Healthcare providers are typically required to report if a patient is a threat to themselves or others, but the criteria and process for reporting such threats can differ. (Tarasoff - Duty to Warn) Best Practices That Can Differ Across States
- 71. © 1994-2024 Telehealth.org, LLC All rights reserved. 9. Jurisdictional Legal Variances • Threats of Serious Harm: Healthcare providers are typically required to report if a patient is a threat to themselves or others, but the criteria and process for reporting such threats can differ. (Tarasoff - Duty to Warn) Best Practices That Can Differ Across States
- 72. © 1994-2024 Telehealth.org, LLC All rights reserved. 10. Documentation and Record-Keeping • Accurate and thorough documentation of telehealth services is essential, including compliance with each state's laws regarding medical records. • Protects you. • Protects the people you serve. • If you work for a group or employer, protects them. • Protects your profession’s reputation. Best Practices That Can Differ Across States
- 73. Ethical Issues
- 74. © 1994-2022 Telebehavioral Health Institute, LLC All rights reserved. • Available as a PDF at: • https://www.socialworkers.org/includes/newIn cludes/homepage/PRA-BRO- 33617.TechStandards_FINAL_POSTING.pdf NASW, ASWB, CSWA & CSWE Technology Standards
- 75. © 1994-2022 Telebehavioral Health Institute, LLC All rights reserved. NASW, ASWB, CSWA & CSWE Technology Standards
- 76. © 1994-2024 Telehealth.org, LLC All rights reserved. • States typically have a definition of practice. That definition explains what licensees are expected to do. Who decides when healthcare professionals are engaged in a “professional relationship?”
- 81. When Practicing Telehealth, All In-Person, Local, Legal & Ethical Rules Apply
- 82. 5 Steps to Practicing Legally in Foreign States & Countries
- 83. 1. Verify your licensure in your own state (enter your license number into your state website).
- 84. 2. Comply with all foreign state laws re: • Intake/progress notes • Termination notes • Informed consent • Mandated reporting (suicide, Tarasoff, etc.) • Continuity of care • TBH training/supervision • Additional security and/or privacy laws/other
- 85. 3. Contact the local licensing boards of all states you wish to serve to review their requirements. Ask about any telehealth-specific documents that you can review. Ask if they are in, or are considering joining, a profession-specific model act of some type to facilitate practicing across state lines.
- 86. 4. Check the destination state’s licensing board website for their requirements in your profession. Compare and contrast to see what’s different. Consider: abuse reporting, duty to warn, crisis intervention and planning, state policy guidelines for involuntary hospitalization, continuing education requirements and reporting, license renewal. Decide if your practice can develop a policy to encompass each state’s rules and regulations or if your practice will need separate policies for each state of practice. Determine if you are up for the challenge in each foreign state (or country) being considered.
- 87. 5. Contact your malpractice carrier and get a written explanation of your coverage. Have an attorney interpret their response.
- 88. Questions for Your Malpractice Carrier about Practicing Over State Lines 1. Will you cover me for practicing over state lines? 2. What if I am not licensed in the foreign state or country, will you still cover me? 3. If you do cover me, will I be covered for regulatory or civil actions? 4. What are the limits of each of those types of coverage? 5. What if I do something illegal to meet the requirements of my online employer, will you cover me?
- 89. © 1994-2024 Telehealth.org, LLC All rights reserved. Other General Considerations before Offering Telehealth Across state Lines • Where is the client/patient? • Traditional setting/home? • Is the contact for intake or follow-up? • Is medication being prescribed? • Have you been trained in distance assessment, referrals, how to handle emergencies, breaks in the connection, intrusions, security breaches or lack of responsiveness? • Does the state require continuity of care? • Is your informed consent appropriate? • Are you meeting the local standard of care? • Do you need to be “credentialed” beyond licensure? Prescribing often involves Drug Enforcement Agency approval.
- 91. Cultural Sensitivity Over State Lines • Essential aspect of telehealth • Screening procedures must be well developed • Referral options must be responsibly offered • Knowing how to sensitively handle emergencies, including at first visit, must be error-proof • Complaints involving cultural bias are some of the most frequently reported by boards.
- 92. © 1994-2024 Telehealth.org, LLC All rights reserved. Multicultural Sensitivity and Diversity Issues • 7 Notable Diversity Issues: • Acceptance & respect • Accommodation of beliefs • Ethnic & cultural differences • Gender equality • Physical & mental disabilities • Generation gaps • Language & communication
- 93. Diversity Sensitivity or Training for Practicing Over State Lines & Internationally Telehealth poses unique challenges to respecting diversity: • People can often present only from “neck up” (when needed, ask people to back up so you can see them more fully). • Many speak a different form of English • If “impossible,” telehealth & diversity training is warranted.
- 94. Disparities Telehealth providers must educate themselves about telehealth and disparities, especially in rural areas. • Literacy • Local idioms • Local religious and political beliefs
- 96. © 1994-2024 Telehealth.org, LLC All rights reserved. International Practice • Where you will be and who you will serve? • In U.S. and serving another country? • In another country and serving U.S.?
- 97. © 1994-2024 Telehealth.org, LLC All rights reserved. • Ignorance is not a defense in the face of the law. • Many countries not only require local licensure, but all license applicants must sit for their local exam in their local language. • If you are investigated, choosing to leave US soil and entering a country via technology places the burden of proof on you to show that you are operating legally and ethically. Steadily accumulate that “proof.” Do other countries require that foreigners hold a local license for legal practice in their country?
- 98. © 1994-2024 Telehealth.org, LLC All rights reserved. May not be adequate for your circumstance, but this is what some providers have done: • Visit the foreign country’s website, look for translation services. • Take screen shots of the country’s website, embassy in Washington DC, and proof • Show proof of having tried to contact the foreign embassy, asking for the name of their department of health (ministries?) or similar term. • Time and date stamp on your email How do you document practicing over international borders w/o a foreign license?
- 99. © 1994-2024 Telehealth.org, LLC All rights reserved. • Seek the consult of your malpractice attorney. • We have been told that some malpractice attorneys have suggested that clinicians should explain the law as they understand it in the patient record, giving ample detail about the clinical rationale for delivering services. • Possibly mention beneficence over malfeasance. Ethical dilemma: How can you think about delivering “illegal” services, if in your clinical judgement, you are obligated to help someone due to a moral imperative?
- 100. © 1994-2024 Telehealth.org, LLC All rights reserved. Remember “Innes & Outies” • Check with your licensing board to be sure that you can go out of state. Get written approval from the foreign entity when needed. • Be aware that some states make it illegal for you to exit a state to practice elsewhere without written authority from the foreign state or country. • Check with your malpractice carrier and get their written response if possible. How do you legally & ethically practice over international borders w/o a foreign license?
- 101. © 1994-2024 Telehealth.org, LLC All rights reserved. International Practice: Case #2 • I'm moving to Portugal next year and plan to keep clients from states where I'm licensed. • I might take on new clients in my area of expertise. • I’ve worked hard to develop a reliable network of professionals and resources throughout my state to provide backup support and send me trusted referrals.
- 102. © 1994-2024 Telehealth.org, LLC All rights reserved. Q. • How can I do this without running into legal or ethical problems? • What should I do to make sure my clients are safe when I'm out of the country? • And, can I bill Medicare for working with these clients? Here are my questions:
- 103. © 1994-2024 Telehealth.org, LLC All rights reserved. Q. How can I practice in Portugal without running into legal or ethical problems? • Contact your Board & the legal body overseeing your profession in Portugal. • Do what they suggest and document it well. • Let your malpractice company attorney know about your shift and do what they tell you. • Speak with the Ethics Board of your professional association and ask for direction. Here are my questions:
- 104. © 1994-2024 Telehealth.org, LLC All rights reserved. Q. What should I do to make sure my clients are safe when I'm out of the country? • Do your research about local support systems for each of your clients/patients. • Document your research, including articles and their sources (Google Scholar, PubMed, etc.) • Develop a written, signed emergency plan from each client or patient. Here are my questions:
- 105. © 1994-2024 Telehealth.org, LLC All rights reserved. Q. What should I do to make sure my clients are safe when I'm out of the country? • Develop emergency protocols to handle all possible scenarios, run them by your local colleagues or agencies to which you would turn if on of your clients or patients would get into trouble. • Modify as suggested. • Document who, what, when where you did the above. • What else? Here are my questions:
- 106. © 1994-2024 Telehealth.org, LLC All rights reserved. Q. And, can I bill Medicare for working with these clients? • Medicare is tricky, but in most cases no, you cannot bill when your feet are on foreign soil. Here are my questions:
- 108. © 1994-2024 Telehealth.org, LLC All rights reserved. International Medicare (Part B) • Beneficiary lives in the US but the foreign hospital is closer to their home than the nearest US hospital (medical emergency or not) • Beneficiary is in the US and the foreign hospital is closer than the nearest U.S. hospital (medical emergency) • When a beneficiary is traveling through Canada from Alaska directly to another US state and the Canadian hospital is closer than the nearest US hospital in
- 109. © 1994-2024 Telehealth.org, LLC All rights reserved. International Practice • Will you try to collect other reimbursement while your feet are on foreign soil? • Allowed by some insurance companies • Ask a few months ahead of time. Do it in writing so you get a time stamp. Talk to your malpractice carrier attorney and national association ethics board.
- 110. © 1994-2024 Telehealth.org, LLC All rights reserved. International Practice • Does your profession have a licensing board in the foreign country? • Speak to your regulatory association • Contact the U.S. embassy for the intended country
- 111. Marketing
- 112. © 1994-2024 Telehealth.org, LLC All rights reserved. • Approach professional associations and ask them for local referral networks. Many associations have their own referral services. • Contact local medical offices. • Approach schools. • Any of these traditional sources can become a source of referrals for you as well. How can you systematically build a manageable resource network across states?
- 113. Supervision
- 114. © 1994-2024 Telehealth.org, LLC All rights reserved. 1. Understand the nuances of what your legal and ethical codes say about practicing over state lines. 2. Learn what your supervisee’s licensing code says about practicing over state lines. • Ask them to do the footwork. • Perhaps make a chart comparing the two. • Might be 5-6 hours of work. • Find like-minded colleagues to help you. • Certainly doable. •How to think about legal and ethical interjurisdictional issues for your supervisee's profession if different from yours.
- 115. © 1994-2024 Telehealth.org, LLC All rights reserved. 1. Always use proper procedure & modifier codes for telehealth or telephone. 2. If you are not licensed in the foreign state, you technically cannot bill for services rendered to people located in those states at the time of their appointments. 3. Your signature on the 1500 form attests to the honesty of your bill, which is a request for payment. •How to think about billing for services delivered over state lines or in multiple states for the same client or patient?
- 116. Q. Toni: I am licensed in NY and just relocated to Arizona for the year. I started working in Arizona the first week of January and did not work in New York at all this year, although all of my clients reside there. Do I file income tax in Arizona? And New York?
- 117. © 1994-2022 Telebehavioral Health Institute, LLC All rights reserved. • Not a telehealth question. • Has to do with many factors, such as state definitions and requirements for of “residency,” and the laws of the state where you reside at which point in time. • Speak with your accountant – preferably before you move. Tax laws differ dramatically from one state to another. • Example: Some states have 0% income tax – CA has almost a 10% income tax. • Inheritance tax • Sales tax • Others Important Question
- 118. © 1994-2024 Telehealth.org, LLC All rights reserved. Dr. Jones • While many of the clients/patients in Dr. Jones’s care returned to being seen in person, about 40% have chosen to continue telehealth. • Dr Jones plans to specialize in delivering telehealth services for the CBHO. • The administrative staff is in the process of identifying people who moved out-of-state. Dr. Jones plans to apply to the largest of those states for information about how to get properly documented to deliver telehealth care. • Dr. Jones has also started sending “outreach” emails to state professional associations in those areas being considered, using a spreadsheet that later will be expanded to include names, addresses, specialty areas, etc. of potential contacts in case emergency care is needed. • Dr. Jones now has enough information to ask informed questions and is confident
- 119. © 1994-2024 Telehealth.org, LLC All rights reserved. Questions? What else can I discuss about practicing over state lines?
- 120. © 1994-2022 Telebehavioral Health Institute, LLC All rights reserved. • Peg: What states currently allow for registration of out of state providers for Behavioral Health (( LCSW, LPC, LMFT) other than Florida? Where can I access an updated list? How do organizations such as Better Health deal with this issue? • Lisa: Can you pay taxes in your home state for income received from out-of-state patients, or do you need to pay taxes to each state your patients are residing in? If I take a course for CEU credit required by Illinois, could that credit be used for NY hours too? Thank you. • Ingrid: Exactly how does one figure out if one is qualified? For example, if from a non-APA school, but have a license in good standing and a high EPPP score from a specific state, say CA, and wish to treat across state lines due to a rare specialty, how can one get the information if one is allowed to do so legally and insurance- wise? Thank you • Regina: I remember from grad school that clients could receive temporary transitional therapy when relocating to another state to bridge the potential gap in clinical care. The length of time was quite limited though, and I am imagining it was up to 90 days. How long can a patient receive telehealth abroad, on vacation, or Past Questions from the Telehealth.org Discussion Forum
- 121. © 1994-2022 Telebehavioral Health Institute, LLC All rights reserved. • Gloria: I'm interested in hearing about practicing in third world countries where there are minimal formal organizations of psychologists, such as the Democratic Republic of Congo or Kenya. • Rosemary: During the pandemic some of my local clients moved out of state or country and want to continue therapy with me. I am unclear on how feasible this is. Your Questions from the Telehealth.org Discussion Forum
- 122. © 1994-2024 Telehealth.org, LLC All rights reserved. • Write your licensing board directly to voice your opinions about current legislation. • Register with your board to be on their email list to receive news. • Comment on documents they send around for comments. • Collaborate with your state-level professional organizations who lobby for you. • Boards don’t know what you need if you don’t tell them How can behavioral health professionals advocate for telehealth with their licensing boards?
- 123. © 1994-2024 Telehealth.org, LLC All rights reserved. • Write your elected state officials to voice your opinions about current legislation. • Follow legislation through the free newsletters offered by Telehealth.org • https://telehealth.org/signup • Comment on laws when comments are requested. • Legislators don’t know what you need if you don’t tell them • Profound repercussions for future of telehealth and interjurisdictional practice What else can behavioral health professionals do to advocate for telehealth?
- 124. © 1994-2024 Telehealth.org, LLC All rights reserved. How to Find Licensure Information Write to your malpractice carrier to ask about your telehealth coverage.
- 125. © 1994-2024 Telehealth.org, LLC All rights reserved. FREE Licensing Information • Look at the regulatory board website for your profession • Also write to the regulatory association for your profession: • ASPPB.org – Psychology • AASCB.org – Counseling • FSMB.org – Medical (Psychiatry) • ASWB.org – Social Workers • AMFTRB – MFTs • NCSBN - Nursing
- 126. © 1994-2024 Telehealth.org, LLC All rights reserved. FREE Licensing Information • Easy way to write to all involved state, provincial and national licensing boards to get requirements is this format (www.statename.gov) • Visit board websites; read licensure information with an eye to telehealth, even if the word is not mentioned (will take you about an hour per board) • Develop spreadsheet to track issues across states • Put all good links in spreadsheet for easy access later • Split states up with a study partner or group to get help filling in your spreadsheet with added states
- 127. © 1994-2024 Telehealth.org, LLC All rights reserved. How to Get Telehealth Licensing Information • Contact your professional association (ethical or legal office) • Join association groups or ask to form one if one doesn’t exist
- 128. © 1994-2024 Telehealth.org, LLC All rights reserved. How to Find Licensure Information Visit https://blog.telehealth.org for more than 700 free blog posts.
- 130. © 1994-2024 Telehealth.org, LLC All rights reserved. Licensing Myths If you are licensed, you are a good practitioner. Only establishes minimal competency Licensure is only about states tapping into our paychecks. Many state boards don’t have enough funding to prosecute many law-breakers Licensure is about consumer protection Laws are pretty much the same across states and countries Licensing requirements can be quite different from one state to another (diametrically opposed)
- 131. © 1994-2024 Telehealth.org, LLC All rights reserved. • Contact your malpractice carrier immediately. • Usually, they will tell you to do exactly what you are told to do. • Document your compliance in detail. Do I Need to Pay Attention to a Letter from My Licensing Board?
- 132. © 1994-2024 Telehealth.org, LLC All rights reserved. • Contact your malpractice carrier immediately. • Understand that many licensing boards share databases. • They will give you instructions. • Review their instructions carefully with your attorney. • Document your actions in ample detail. Do I Need to Pay Attention to a Letter from An Out of State Licensing Board in My Profession?
- 134. © 1994-2024 Telehealth.org, LLC All rights reserved. Suggestion Make a To-Do List • Focus on “to-dos” • Prioritize your activities • Review weekly with colleagues if you can
- 135. © 1994-2024 Telehealth.org, LLC All rights reserved. • Actively researching • Issues are complex • Many haven’t yet decided how to proceed • Many have • Legislative limitations • Budgetary limitations • Write to each board, plus any regulatory associations and/or model ac groups for your profession. Get all responses in writing. Save to your desktop. What are licensing boards doing to support telehealth now?
- 136. © 1994-2022 Telebehavioral Health Institute, LLC All rights reserved. Next Month? • Mastering Telehealth Billing Guidelines 2024: A Blueprint for Success • We’ll be discussing how to get paid for telehealth, Place of Service Codes (POS); audio-only CPT codes; what’s happening with Medicare billing rates and much, much more. • See details here: https://telehealth.org/mastering-telehealth-billing-guidelines-2024-a-blueprint-for- success/
- 138. © 1994-2024 Telehealth.org, LLC All rights reserved. Problem Solving: Do you do anything else to engage with parents or families?
- 139. Medicare In-Person Visit Requirement Starting January 1, 2025 • Line-item in Consolidations Appropriations Act of 2020. • Takes effect in 2025, will give Medicare and Congress time to review new literature • Medicare bases decisions on the evidence-base and makes recommendations to Congress for laws. https://blog.telehealth.org/new-medicare-law-requires-in- person-visit-for-telehealth-coverage/
- 140. Medicare In-Person Visit Requirement Starting January 1, 2025 • Much research has been published about telehealth since 2019. • Not seen any research to support an in-person requirement to date. • Recommend waiting for Medicare to sort this out, as it has many other laws regarding telehealth mental health. https://blog.telehealth.org/new-medicare-law-requires-in- person-visit-for-telehealth-coverage/
- 141. © 1994-2024 Telehealth.org, LLC All rights reserved. Finding Your Course Completion Certificate