What Psychiatrists Need to Know: Telehealth Across State Lines

December 2021 

As the pandemic continues, many psychiatrists are raising questions about their options for providing out of state telehealth to their patients. One psychiatrist recently wrote us and asked: I’m not ready to see patients in-person, and have patients scattered across several states. These patients either formerly came to NC for their visits with me, moved out of state with the pandemic, or started receiving care from me while out of state during the pandemic. Many states have rescinded emergency authorization to allow telehealth by out-of-state physicians. Before I communicate that I can no longer provide care for them, I wanted to see if NCPA had some advice about other options for NC providers in this situation.

We hope to address these concerns and answer questions about out of state telehealth here.

How did COVID have an impact on out of state telehealth?

Prior to the pandemic, telehealth adoption was constrained by federal and state laws and health plan policies. To maintain access to treatment during COVID-19, federal and state agencies temporarily eased many telehealth restrictions. Every state implemented regulatory changes, and licensure requirements were loosened. However, policies for these adjustments were far from uniform. These regulatory solutions were also time limited. Many states only allowed out of state physician care for a month or so; for patients residing in those states that have rescinded those allowances, it is recommended that psychiatrists send letters out to their patients as soon as possible. The Federation of State Medical Boards has compiled a state-by-state guide to COVID-19 policies related to telemedicine and other topics.[i] A link to this guide is posted on the NCPA website.

My patient is not currently residing in North Carolina. Is it legal for me to conduct assessments via telemedicine and prescribe to them?

If the patient’s home state, or current state of residence, allows it, then yes. Most medical boards require a physician or PA to be licensed in the state in which the patient care is given. Each state has different laws and rules regarding licensure, telemedicine, and prescribing. Some of these restrictions may be lifted during a state of emergency, but you would need to contact the corresponding medical licensing authority of that state to determine its individual requirements[ii]. 

But I have a long-time relationship with a patient who has moved!

Yes, it is a conundrum. The emotions that come with a patient relocating are complicated, regardless of how matter of fact the regulations are. It is important to make clear to patients at the outset of treatment that you are bound by state regulations and licensing requirements. Moving is a part of life and as a psychiatrist you have an important role in supporting patients through that transition and change. You can provide referrals and provide good care for your patients by maintaining strong connections with your out of state psychiatry colleagues. Perhaps this is an opportunity to draft or edit your list of out of state networks and contacts. The NCPA office may be able to assist with directing you to other APA district branches.

What’s the bigger picture here?

The pandemic has highlighted the need to update medical licensing while preserving state authority and revenue.

One approach that has been suggested is that Congress could regulate telemedicine across state lines as interstate commerce and establish the “place of service” of a telehealth visit as the location of the clinician, not the location of the patient.[iii] This definition would allow physicians to provide telehealth services if licensed by the state from which they would conduct telehealth visits. Such legislative action would not override state licensure or insurance regulations but would increase access to telehealth services by removing state licensing as a barrier.

Another alternative would involve expansion of the Interstate Medical Licensure Compact (IMLC). The IMLC, established in 2014, is a legally binding agreement in which 26 states agreed to adopt uniform standards for licensure. These states also agreed to recognize each other’s vetting processes for medical licenses but not each other’s licenses.[iv] Congress could encourage more states to join the compact through incentives.

The regulations currently in place make good sense. Without them, there’s a risk of corporate telehealth pulling patients out of their therapeutic relationships with their local psychiatrists.  Whatever reforms are considered, it is important to hold firm on the value of therapeutic relationships and understand the local continuum of care.

Once the COVID-19 pandemic is resolved, will we revert to the old regulations governing licensure, malpractice, and prescription of controlled substances?

That remains to be seen. Policy makers and payers are now considering which of these flexibilities should be maintained. We are hearing from members that telehealth could be the best form of treatment for some patients, in some circumstances. The pandemic could bring about systemic changes related to telehealth and a cultural change for out-of-state care, but for the time being, a state’s medical board is your best source for determining out-of-state telehealth regulations. We also suggest reaching out to your risk management resources.