Physicians and advanced practice professionals have over a year of clinical telemedicine experience under their belts but still have questions about the maze of legal, regulatory, and reimbursement requirements. Federal and state regulators have relaxed, waived, or modified telemedicine requirements during the pandemic, especially during shut-downs. As enforcement of these regulations resumes, practices and clinicians should review their telemedicine processes to ensure compliance.
Variations on a Theme
One of the most frequent telemedicine questions has many variations but can be summarized as whether a physician or advanced health care practitioner licensed and located in one state can provide telemedical care to a patient in another state at the time of the encounter.
Illustrating Questions about the Patient’s Location
- Dr. Acton (licensed and practicing in Utah) has an established patient, Jenny, who resides in Utah and is on a 3-day business trip in New Hampshire. Jenny wants a telemedicine appointment while she is away.
- Dr. Bonet’s (licensed and practicing in Utah) long-time pediatric patient, Jimmy, resides with his mother in Utah. Jimmy is visiting his father in North Dakota for the summer. Jimmy’s mother requests a telemedicine appointment while Jimmy is in North Dakota and his mother is in Utah.
- Dr. Camara’s (licensed and practicing in Arizona) established patient, Ann, lives in Michigan but spends winters in Arizona. Ann wants Dr. Camara to continue treating her via telemedicine during the months she is in Michigan.
- Nevada-based nurse practitioner Divata has taken care of a pediatric patient for many years. The patient and her family are in California for a week-long vacation. The mom asked for a video visit to assess and treat a rash on the patient’s arm.
Location and Licensure Answers
When the patient is out of state, even temporarily, the answer is always the same. Physicians, advanced health care practitioners, and other licensed health care professionals have always had to comply with federal and state laws as well as state licensing requirements where the care is received – known as the originating site. In the examples above, the clinicians are not located or licensed in the state where the patient is located. Each state licensing agency oversees and disciplines the professionals it regulates. A physician providing care to a patient in Nebraska is subject to the rules and regulations of the Nebraska medical board. If the physician is not properly licensed in Nebraska, the physician may be practicing medicine in Nebraska without a license and subject to discipline.
A Utah-licensed and -located clinician treating a Utah resident visiting Nebraska could also be subject to other Nebraska laws and court rules. Should the patient file a medical professional liability lawsuit in Nebraska, the Utah physician may be required to defend a lawsuit there.
Risk Solutions
The patient’s location
Physicians, advanced health care practitioners, and practices should prepare now for patient requests for out-of-state medical care by considering the workflows for appointment scheduling, telephone triage, and telemedicine appointments. For telephone triage and telemedicine encounters:
- Screen for the patient’s anticipated geographic location during scheduling;
- Before a clinician begins a telemedicine appointment or a telephone triage call, confirm the patient’s physical and geographic location and document in the medical record; and
- If the patient’s physical location is inappropriate, e.g., driving or steering a car, and the patient cannot immediately relocate, e.g., pull over and park, staff should reschedule the appointment.
As part of telemedicine appointment workflows, staff should also confirm:
- The patient or representative provided their informed consent for the telemedicine appointment, and their consent is documented;
- Intake forms or questionnaires are completed;
- The practice provided instructions for connection problems; and
- If appropriate, reasonable accommodations are in place for patients with disabilities.
Interstate medical licensure
Another consideration for workflows is the Interstate Medical Licensure Compact, in which member states have agreed to streamline and expedite licensure for out-of-state physicians. Physicians must have a full, unrestricted medical license in a Compact member-state. Physicians may designate that state as their State of Principal License (SPL) if one of the following applies:
- The physician’s primary residence is in the SPL;
- At least 25% of the physician’s medical practice occurs in the SPL;
- The physician is employed to practice medicine by a person, business, or organization located in the SPL; and
- The physician uses the SPL as the state of residence for U.S. federal income taxes.
In addition to meeting the SPL requirements, physicians applying for licensure through the Compact must not have a history of licensure disciplinary actions, a criminal history, a history of controlled substance actions against their license, or a license currently under investigation.
The Compact does not issue a single interstate medical license. Instead, participating states issue individual licenses. Physicians can select multiple Compact member states where they wish to be licensed but only need to complete one application. Member states include Alabama, Arizona, Colorado, Georgia, Idaho, Iowa, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland, Michigan, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, North Dakota, South Dakota, Tennessee, Utah, Vermont, Washington, West Virginia, Wisconsin, and Wyoming.
Between April 2017 and August 2021, the Compact licensed 23,321 physicians. Details about eligibility, participating states, application, renewal, and costs (an initial non-refundable fee for the Compact and then the individual cost of a license in each state) are available on the Compact’s website. Under the Compact and state law, medical care is provided and received where the patient is physically located.
Resources
Many of the state public health emergency orders that temporarily waived telehealth licensing requirements have ended. Others are on the verge of expiring. As a result, physicians, advanced health care practitioners, and practices should consider their workflows and licenses before patients call for out-of-state care.
For state-specific telehealth and licensing information, consult these resources from the Federation of State Medical Boards and Center for Connected Health Policy:
- Telemedicine Licensure Policies – Board by Board Overview
- State-by-State-Listing of Waivers and Other Modifications of Telehealth Requirements in Response to COVID-19
- COVID-19 Cross-state Licensing Page
- Professional Requirements Cross-state Licensing Page
In addition, call your medical professional liability carrier to confirm that your policy provides coverage when you render care to patients in other states.
About MICA
MICA risk management services are exclusively available to its members at no additional cost. Contact MICA today to learn more about the benefits of joining a physician-owned and physician-directed mutual insurance company. To request a quote, visit https://info.mica-insurance.com/quote or call 800-681-1840.
