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Licensure & Practicing Over State Lines in Telepractice for Telemental Health and Online Therapy

TelepracticeLicensing rules are antiquated, differ and often, can be contradictory from state to state. It is not safe to assume that if we are abiding by the laws in our home state of practice (the distant site) we are also abiding by the laws where we client/patient is (the originating site). Generally, we will need a full license wherever we client/patient is located. Basically, this boils down to two things:

  1. Find out what our state says about where we can practice with our license 
  2. Find out what the state licensing board for our discipline in the client/patient’s state says about our ability to practice in that foreign state

In other words, unless otherwise stipulated, the same law that rules our geographic area of practice offline also rules our geographic area of practice online. For instance, if we only hold a California license, we only have the right to practice in California with that particular license. (Some states differ with respect to physicians and telemedicine.) Simply having an Internet connection or a webcam doesn’t change that license or the law enforcing it.  Similarly, ignorance is not a defense against the law. There are exceptions to traditional licensure requirements for health care professionals to practice across state lines:

  1. Health care professional to professional consultation
  2. Residents in training
  3. Border states
  4. U.S. Military/VA health care practitioners
  5. Medical emergencies/natural disasters
  6. Medical residents in training

Since these exceptions don’t cover the way most of us plan to engage in telepractice, we are best served by understanding and following state laws about licensure rather than trying to circumvent them. it might be helpful for some practitioners to know that many states relieve some of the administrative burden by allowing an out-of-state practitioner to work with their citizens for 30 or 60 days per year. Such activity often requires advanced registration with the foreign state through formal documentation, so getting the paperwork started early is a good idea. What If a State Doesn’t Have Specific Telepractice Laws? When state licensing statutes don’t specifically address telemental health for an allied discipline such as counseling, social work or psychology, the law often defaults to the existing medical statutes for that state. It therefore is essential for practitioners to familiarize themselves with both the mental health and medical codes pertaining to telehealth for the state(s) in which they practice. Telehealth law and technology are rapidly evolving so it’s also necessary to continuously monitor pertinent laws and regulations for updates and changes.  It is therefore prudent and suggested that we hire an experienced telehealth attorney to review our practices and supporting documents, as well as keep us apprised of changes in such law. It may also be wise to not rely solely on a malpractice attorney for understanding telehealth practice issues. Reading one’s legal code need not be overly complicated or time consuming. A solid hour or two of reading one’s own licensing law from any state’s website will answer many questions without needing to pay an attorney for the basics. Other Issues Regulations in most states also indicate that anonymous care is not acceptable for professionals to deliver, documentation standards must be met, appropriate follow-up care is necessary and mandated reporting guidelines must be followed. Depending on the discipline, in-person assessment may also be required. Providers must also be cognizant of standard of care issues as they pertain to telepractice.  Our current standard of care is office-based in-person assessment and treatment. Therefore, deviation from that standard is likely to be very closely examined if anything goes wrong. If we plan to deviate from “brick-and-mortar” practice, we must also have empirical data to support the shift in location. If we deliver services to pregnant teens, what is the date supporting the delivery of care to pregnant teens online with video? How does it differ from delivering care to pregnant teens in email, or offline? Why? What’s different? What special problems occur with video or email vs. offline? How can we legitimately overcome them? Does race or culture or language make a difference in this population? How can we reliably offer emergency services to this population online? If we can’t find studies supporting our work in the modality of our choice online, we may want to think twice about being the first one to “innovate” without scientific basis for our professional services online (or offline). Fortunately, there are many models of telehealth service delivery supported by research. To practice ethically, clinicians wanting to practice online need to be aware of them. Training for such practice is available. See our upcoming FREE webinar on January 21, 2013 for “12 Facts You Probably Won’t Learn from Your Licensing Board about Practicing Over State Lines (Licensure Portability).”

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