Telemedicine compliance is not one-size-fits-all—it requires understanding both federal and state-specific regulations that dictate licensure, prescribing, reimbursement, standard of care, and data security.

• Your state’s laws (and the state where your patient is located)
• Your scope of practice (physician, NP, PA, etc.)
• The type of care you’re providing (prescribing, diagnosing, consulting, etc.)
• The payer (Medicare, Medicaid, or commercial insurance)

This section breaks down the most critical areas for compliance, explaining what to assess, how to evaluate compliance, common pitfalls, and where to find key regulations.

Learning Objectives

By the end of this course, participants will be able to:

Understand State & Federal Licensure Requirements

• Differentiate between state-specific licensure mandates and interstate practice rules.
• Evaluate telemedicine licensure compacts (IMLC, Nursing Compact, etc.).

Comprehend Prescribing Regulations by Scope & State

• Identify federal and state prescribing regulations.
• Implement compliant prescribing of controlled substances (Ryan Haight Act, DEA).

Apply Medicare & Medicaid Compliance Standards

• Navigate Medicare, Medicaid, and commercial payer telehealth policies.
• Avoid fraud, waste, and abuse (FWA) violations in billing and documentation.

Ensure Data Privacy & Security

• Implement HIPAA-compliant security measures for telemedicine.
• Develop data protection strategies to prevent breaches.

Meet Standard of Care & Informed Consent Requirements

• Adhere to state-specific standard of care requirements for telemedicine.
• Document informed consent and patient communication properly.

Develop a Compliance & Documentation Framework

• Build internal policies and risk management protocols.
• Conduct self-audits and compliance monitoring.

Key Compliance Areas to Assess and Evaluate

A successful telemedicine practice requires ongoing oversight of your licensure, compliance with multi-state regulations, and tracking Continuing Medical Education (CME) requirements to maintain active practice eligibility.

Licensing & Multi-State Practice Requirements

Assess Your Licensing Status

• Are you licensed in the state where your patient is located?
• Does your state offer a special telemedicine license?
• Are you eligible for an expedited multi-state license through the IMLC?

Key Licensing Considerations

State-Specific Licensing:

• You must hold a valid medical license in the state where your patient is located at the time of the visit.
• Some states offer telemedicine-specific licenses for out-of-state providers.

Interstate Medical Licensure Compact (IMLC):

• The IMLC provides an expedited process for obtaining multiple state licenses.
• Not all states participate, and some require additional steps (e.g., fingerprints, background checks).
  🔗 Check IMLC Participation

Reciprocity & Temporary Licenses:

• Some states offer reciprocity or allow temporary registration for telehealth providers.
• Licensing rules for NPs and PAs may differ from those for physicians.

Maintaining Active Licensure & Renewals

Licensing is not a one-time process—ongoing oversight is required to prevent lapses.

Essential Oversight Tasks

• Track renewal deadlines – Each state has different renewal periods (1–3 years).
• Monitor CME requirements – Each state sets specific CME credit requirements.
• Maintain DEA registration – If prescribing controlled substances, keep federal and state-level DEA registration current.
• Check specialty board certification – Some boards require periodic exams or CME credits.

Tip: Set automated reminders for renewal deadlines and documentation submissions.

Continuing Medical Education (CME) Tracking

Most states require ongoing CME credits for licensure renewal.

CME Requirements & Best Practices

• Know your state’s CME requirements – Some require telemedicine-specific courses.
• Leverage accredited CME providers – Look for AMA PRA Category 1™ Credits.
• Track CME completion – Keep certificates organized for licensure audits.

Recommended CME Resources:

• Federation of State Medical Boards (FSMB) CME Portal
• AMA Ed Hub (Accredited online CME courses)
• Telemedicine-Focused CME:
  • American Telemedicine Association (ATA)
  • American College of Physicians (ACP) Telehealth Courses

Tip: Some states allow carryover CME credits from previous cycles—check state-specific rules.

Avoiding Licensing & Compliance Pitfalls

Common Mistakes That Can Jeopardize Your Telemedicine Practice

• Assuming a license in one state allows practice in all states
• Missing renewal deadlines, leading to inactive status
• Overlooking state-specific CME or DEA renewal requirements
• Ignoring special licensing rules for NPs, PAs, or allied health professionals

Resources to Check Licensing & CME Requirements:

• Federation of State Medical Boards (FSMB)
• Interstate Medical Licensure Compact (IMLC)
• Nursing Licensure Compact (NLC) (For NPs & RNs)

Final Checklist & Next Steps

• Review your current licensure status and ensure compliance in every state where you see patients.
• Set up a tracking system for renewals, CME completion, and DEA registrations.
• Complete any required CME courses before your next renewal deadline.
• Check for new telemedicine licensing rules—state regulations change frequently.

By proactively managing your licensing, renewals, and CME tracking, you’ll ensure uninterrupted practice and compliance across all states you serve.

Prescribing Rules and Managing Controlled Substances

Prescribing in telemedicine requires understanding federal and state laws, ensuring a valid patient-provider relationship, and following prescription drug monitoring regulations where applicable. Some states and situations allow greater flexibility, while others impose strict in-person evaluation requirements—nuance is key.

Establishing a Patient-Provider Relationship for Prescribing

Before prescribing any medication—controlled or non-controlled—you must establish a valid patient-provider relationship, but how this is done depends on state laws and the type of medication being prescribed.

Key Questions to Assess:

• Does your state allow remote prescribing?
• Does an in-person visit or a synchronous video evaluation need to occur before prescribing?
• Are there specific restrictions for prescribing controlled substances via telehealth?

Methods of Establishing a Relationship (Varies by State & Drug Type)

• Synchronous Video Evaluation: Many states allow prescribing after a live, interactive video consultation.
• Asynchronous Store-and-Forward Evaluation: Some states allow prescriptions based on medical questionnaires or pre-recorded videos, but this often excludes controlled substances.
• In-Person Exam Requirement: Certain states require an in-person visit before any prescription is issued, while others only require it for controlled substances.
• Ongoing Provider-Patient Relationship: If the patient is already under your care, some states waive additional requirements for renewals or refills.

Tip: Some states allow greater flexibility for certain medications but tighten regulations for controlled substances. Always check the latest state rules.

Federal Law: Ryan Haight Act & DEA Telemedicine Prescribing Rules

The Ryan Haight Act generally requires an in-person medical evaluation before prescribing controlled substances, but there are important exceptions.

When Can Controlled Substances Be Prescribed via Telemedicine?

• A DEA-registered provider conducts an in-person medical evaluation.
• The prescribing provider is part of a DEA-registered hospital, clinic, or telemedicine provider.
• The provider qualifies for an exception (e.g., addiction treatment programs, temporary COVID-19 flexibilities).

🔗 DEA Telemedicine Prescribing Rules

Upcoming Rule Changes: The DEA is expected to revise telehealth prescribing rules as pandemic flexibilities phase out—stay updated to remain compliant.

State-Specific Prescribing Rules

Each state sets its own prescription and controlled substance laws for telemedicine.

Key Variations by State

• Some states require in-person visits before any prescription is issued.
• Others allow prescriptions after a video evaluation (synchronous telemedicine).
• Some states permit asynchronous prescribing (e.g., questionnaires, recorded videos).
• Controlled substance rules differ—some states ban telemedicine-controlled prescribing entirely, while others allow it under strict conditions.

Tip: If prescribing in multiple states, create a state-by-state prescribing policy to ensure compliance and avoid costly mistakes.

🔗 State-Specific Prescribing Laws – NABP Lookup

Prescription Drug Monitoring Programs (PDMPs)

Many states require prescribers to check the PDMP before issuing controlled substance prescriptions.

PDMP Compliance Steps

• Check your state’s PDMP before prescribing controlled substances.
• Verify patient prescription history to detect potential misuse.
• Document the PDMP check in the patient’s medical record.

Tip: While some states mandate PDMP checks, others recommend but do not require it for certain medications. Be aware of your state’s specific regulations.

🔗 National Association of Boards of Pharmacy (NABP) PDMP Lookup

Compliant vs. Non-Compliant Prescribing Scenarios

Below are real-world examples of compliant and non-compliant prescribing operations in telemedicine.

Compliant Prescribing Scenario #1: Synchronous Video Consultation (Non-Controlled Medication)

• Dr. Lee conducts a video consultation with a new patient experiencing mild anxiety.
• The patient describes their medical history, symptoms, and past medications.
• The state does not require an in-person visit for this type of prescription.
• Dr. Lee documents the evaluation and prescribes an SSRI (non-controlled medication).

• A live video visit established the patient-provider relationship.
• No in-person requirement exists for this type of medication.
• Proper documentation supports medical necessity.

Compliant Prescribing Scenario #2: Controlled Substance with PDMP Check

• Dr. Patel sees a returning patient for chronic pain management via telemedicine.
• The patient was previously evaluated in-person and has an established diagnosis.
• Dr. Patel checks the state PDMP, ensuring no recent opioid prescriptions from other providers.
• Dr. Patel documents the patient’s condition and ongoing treatment plan before issuing a controlled substance refill.

• The patient already had an in-person medical evaluation for this condition.
• The state permits refills via telemedicine under an established relationship.
• The PDMP was checked, and no red flags were found.

Non-Compliant Prescribing Scenario #1: Controlled Substance Without Proper Evaluation

• Dr. Smith receives an online request from a new patient seeking Adderall for ADHD.
• The patient has never been seen by Dr. Smith and provides no medical history.
• Dr. Smith issues the prescription without conducting an evaluation.
• No PDMP check or documentation is recorded.

• No video consultation or in-person visit established a valid patient-provider relationship.
• The provider never verified the patient’s medical history.
• No PDMP check was performed, increasing the risk of overprescription.

How to Fix It: Dr. Smith should require a video consultation or an in-person evaluation, verify patient history, and check the PDMP before prescribing.

Non-Compliant Prescribing Scenario #2: Asynchronous Evaluation When Not Allowed

• Dr. Adams works with an online telehealth platform that allows asynchronous patient assessments.
• A patient submits a medical questionnaire requesting Ambien (a controlled substance for sleep disorders).
• Without a live consultation, Dr. Adams issues the prescription.

• Many states require synchronous (live) visits for prescribing controlled substances.
• Dr. Adams did not check if the patient’s state allows asynchronous prescribing.

How to Fix It: If prescribing controlled substances, Dr. Adams must ensure the state allows asynchronous assessments or conduct a video visit before issuing the prescription.

Standard of Care & Informed Consent in Telemedicine

Providing telemedicine services requires adherence to the same standard of care as in-person visits while also meeting state-specific informed consent laws. Failing to follow proper documentation and care standards can result in licensure issues, malpractice claims, and reimbursement denials.

What You Need to Assess

• State laws on informed consent for telemedicine.
• Documentation requirements for consent and treatment.
• Standard of care expectations to avoid legal risks.

Informed Consent for Telemedicine

Informed consent ensures that patients understand the nature, risks, and limitations of telemedicine services before receiving care. 

🔗 CCHP State Telehealth Consent Laws

Tip: If practicing in multiple states, create a standardized telehealth consent form that meets the strictest requirements.

State-Specific Consent Requirements

• Some states mandate specific informed consent for telemedicine (e.g., written, verbal, or electronic documentation).
• Other states do not have explicit telehealth consent laws, but standard informed consent still applies.
• Medicaid and private payers may require additional consent documentation for reimbursement.

What to Include in Telemedicine Informed Consent

• Nature of the telehealth visit – Explain that care is being provided remotely.
• Potential limitations – Clarify that telemedicine may not be a substitute for in-person care in certain situations.
• Confidentiality & HIPAA compliance – Inform the patient about data security measures and any risks.
• Emergency care protocols – Outline what happens if a medical emergency occurs during a telehealth session.
• Right to decline telehealth – Patients should know they can request in-person care if preferred.
• Patient & provider location – Some states require documentation of both patient and provider locations during the visit.

Tip: If a state allows verbal consent, always document the conversation in the medical record, noting the date, time, and content of the consent discussion.

Standard of Care in Telemedicine

The standard of care for telemedicine must match in-person care—providers cannot deliver subpar or incomplete medical evaluations simply because the visit is virtual.

Standard of Care Parity

• Follow clinical guidelines – Diagnosis, treatment plans, and follow-up care should align with in-person care standards.
• Conduct a thorough evaluation – If a physical exam is necessary for an accurate diagnosis, the patient should be referred for in-person care.
• Use appropriate technology – Ensure that video/audio quality allows for a meaningful clinical assessment.
• Recognize limitations – If telehealth is not appropriate for a condition, refer the patient to an in-person provider.

Tip: Document why telemedicine was appropriate for the patient’s condition and any clinical limitations that may have influenced decision-making.

Common Pitfalls & Compliance Risks

• Not documenting telehealth consent in the patient’s record – If audited, failure to document consent could result in claim denials or regulatory penalties.
• Providing care that does not meet in-person care standards – If a lack of physical examination leads to a misdiagnosis, it could result in malpractice claims.
• Failing to verify patient identity – Some states require proof of identity before a telemedicine visit.
• Ignoring state-specific consent rules – Some states mandate signed telehealth consent forms, and failure to obtain them can result in licensing issues.

Tip: Use EHR templates or consent forms to standardize documentation and avoid missing key elements.

How to Implement a Compliant Standard of Care & Consent Process

Before the Visit

• Verify state-specific telehealth consent requirements.
• Confirm that telemedicine is appropriate for the patient’s condition.
• Obtain and document patient consent (verbal or written, depending on state law).

During the Visit

• Deliver care at the same standard as an in-person visit.
• Assess whether a referral for in-person evaluation is needed.
• Document clinical findings, decision-making, and follow-up instructions.

After the Visit

Ensure documentation is complete and includes:

• Consent verification
• Patient identity confirmation
• Medical decision-making

Final Checklist: Ensuring Compliance with Standard of Care & Informed Consent

• Confirm state-specific consent requirements before each telehealth visit.
• Document verbal or written consent in the patient’s medical record.
• Ensure telehealth visits meet the same standard of care as in-person encounters.
• Use proper documentation templates to track compliance.
• Refer patients to in-person care when necessary to avoid liability risks.

By adhering to informed consent laws and maintaining a high standard of care, providers can ensure compliance, minimize liability, and deliver high-quality telemedicine services.

Tip: Some states allow verbal consent, while others require written or electronic consent before providing care.

Medicare, Medicaid, & Private Payer Compliance in Telemedicine

Reimbursement for telemedicine services depends on the payer type (Medicare, Medicaid, or private insurer), the type of service provided, and federal and state regulations. Providers must navigate strict compliance rules to ensure they receive reimbursement while avoiding legal and audit risks.

• Medicare & Medicaid Telehealth Coverage (Eligibility, Services, Billing)
• Private Insurance & Commercial Payer Variations
• Key Documentation, Coding, & Compliance Requirements

Why This Matters: Telehealth coverage is not standardized, and payer policies change frequently. Failing to meet compliance standards can lead to denied claims, audits, and potential penalties.

Medicare & Medicaid Telehealth Coverage

Medicare and Medicaid are two major government-run health insurance programs in the United States, but they serve different populations and have distinct eligibility, funding, and coverage rules.

Medicare: Federal Health Insurance for Seniors & Certain Individuals with Disabilities

What is Medicare?

Medicare is a federal health insurance program primarily for:

• People aged 65 and older
• Younger individuals with certain disabilities
• People with End-Stage Renal Disease (ESRD) or ALS

Medicare is administered by the federal government through the Centers for Medicare & Medicaid Services (CMS) and is available nationwide.

Medicare Coverage Parts

Medicare is divided into four parts, each covering different types of medical services:

Medicare Part A (Hospital Insurance)

• Covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health services.
• Most beneficiaries do not pay a premium for Part A if they or their spouse paid Medicare taxes while working.

Medicare Part B (Medical Insurance)

• Covers outpatient services, including doctor visits, preventive care, lab tests, durable medical equipment, and certain telehealth services.
• Beneficiaries pay a monthly premium and are responsible for deductibles and coinsurance.

Medicare Part C (Medicare Advantage)

• Private insurance plans that provide Medicare benefits (an alternative to Original Medicare).
• Covers Parts A & B benefits, often includes Part D (prescription drugs), and sometimes extra benefits like vision & dental.

Medicare Part D (Prescription Drug Coverage)

• Helps cover the cost of prescription medications.
• Offered by private insurance companies approved by Medicare.

🔗 Learn More: Medicare Official Website

Key Facts About Medicare & Telemedicine:

• Traditional Medicare (Parts A & B) has strict telehealth reimbursement rules, limiting where and how services can be provided.
• Medicare Advantage (Part C) plans have more flexibility, often covering more telehealth services.

Medicaid: State-Federal Health Insurance for Low-Income Individuals

What is Medicaid?

Medicaid is a joint federal and state program that provides health coverage for low-income individuals and families.

• Covers children, pregnant women, low-income adults, elderly individuals, and people with disabilities.
• Eligibility & benefits vary by state, but federal guidelines set minimum coverage standards.
• Funded jointly by federal and state governments but managed at the state level.

Medicaid Coverage Basics

• Essential benefits covered in all states include:
  • Doctor visits, hospital stays, preventive care, lab tests, mental health services, prescription drugs, and maternity care.
• Some states offer expanded Medicaid programs under the Affordable Care Act (ACA), covering more low-income adults.

🔗 Learn More: Medicaid Official Website

Key Facts About Medicaid & Telemedicine:

• Each state sets its own Medicaid telehealth policies, including reimbursement rates, covered services, and provider requirements.
• Some states allow more flexibility in telehealth than Medicare does (e.g., covering phone visits, remote patient monitoring, or store-and-forward telemedicine)..

Medicare Telehealth Coverage: Federal Guidelines

Medicare has strict rules on what telehealth services are covered, where they can be provided, and which providers are eligible to bill.

1. Covered Services: Medicare reimburses for a limited set of telehealth services, including:

• Evaluation & Management (E/M) visits
• Mental health services
• Chronic care management (CCM) & remote patient monitoring (RPM)
• Opioid & substance use disorder treatments

2. Eligible Providers:

• Physicians (MD/DO)
• Nurse Practitioners (NPs), Physician Assistants (PAs)
• Clinical Psychologists, Licensed Clinical Social Workers
• Physical, Occupational, & Speech Therapists (for some services)

3. Geographic & Location Restrictions:

• Historically, Medicare required the patient to be in a rural area to qualify for telehealth reimbursement.
• Post-pandemic rule changes allow broader virtual care access.
• Some services can now be provided at home, while others still require a Medicare-approved originating site (e.g., hospital, clinic).

4. Reimbursement Rates:

• Medicare reimburses telehealth services at the same rate as in-person visits under the Physician Fee Schedule (PFS).
• However, only approved services qualify for reimbursement.

🔗 CMS Medicare Telehealth Guide

Tip: Medicare Advantage (Part C) plans often have more flexible telehealth policies than traditional Medicare—always check with each plan for coverage specifics.

Medicaid Telehealth Coverage: State-Specific Rules

Medicaid telehealth policies vary significantly by state—some states expand access, while others impose strict limitations on reimbursement.

1. State-Specific Rules:

• Each state determines which services and provider types are covered.
• Some states allow telehealth for all Medicaid enrollees, while others restrict access to specific populations.

2. Payment Parity:

• Some states reimburse telehealth visits at the same rate as in-person visits.
• Others pay a lower rate for virtual care.

3. Coverage Flexibility:

• Many states now cover:
  • Asynchronous (store-and-forward) services
  • Remote patient monitoring (RPM)
  • Audio-only (phone) visits

🔗 CCHP State Medicaid Telehealth Policies

Tip: State Medicaid policies are changing rapidly—regularly check updates to avoid billing errors.

Private Insurance & Commercial Payers

Key Compliance Considerations for Private Insurers

1. Coverage Differences:

• Some private insurers only cover synchronous (live video) visits.
• Others allow asynchronous services (store-and-forward), phone calls, and RPM.

2. Network Restrictions:

• Many require providers to be in-network to receive reimbursement.
• Out-of-network telehealth services may not be covered at all.

3. Prior Authorization:

• Some plans require pre-approval for telehealth services, especially for:
  • Specialist care (e.g., dermatology, cardiology)
  • Mental health therapy
  • High-cost diagnostics

Tip: Always verify benefits before the visit—private payer telehealth coverage is not standardized like Medicare.

🔗 Check private payer policies with:

• National Telehealth Policy Resource Center
• State insurance departments & major commercial payers (e.g., BCBS, Aetna, UnitedHealthcare)

Documentation, Coding, & Compliance Requirements

Key Documentation Requirements

1. Provider-Patient Relationship:

• Confirm that an eligible provider conducted the visit and that the patient’s location meets payer requirements.

2. Visit Modality:

• Specify whether the visit was:
  • Synchronous (live video)
  • Asynchronous (store-and-forward)
  • Telephone-only

3. Patient Location:

• Some payers require documentation of the patient’s physical location at the time of the visit.
• Certain states restrict telehealth based on where the patient is located.

4. Medical Necessity:

• Clearly document:
  • Reason for the visit
  • Why telehealth was appropriate for the condition

Tip: Some payers require time-based documentation (e.g., total minutes spent on the visit).

Telehealth CPT Codes & Modifiers

Using the correct CPT codes and modifiers ensures proper reimbursement for telehealth visits.

1. Evaluation & Management (E/M) Codes:

• 99212–99215 (Established Patients)
• 99202–99205 (New Patients)

2. Telehealth-Specific Codes:

• 99441–99443 (Phone Visits)
• G2010 (Asynchronous Store-and-Forward)

3. Modifiers for Telehealth Claims:

• GT Modifier → Telehealth services via live video
• 95 Modifier → Telehealth service performed via real-time interactive audio and video
• POS 02 → Telehealth Provided Outside of Patient’s Home
• POS 10 → Telehealth Provided in Patient’s Home

Tip: Check payer-specific policies, as not all payers accept the same modifiers.

CMS List of Telehealth Services & CPT Codes: https://telehealth.hhs.gov/providers/billing-and-reimbursement

Common Fraud Issues in Telemedicine Billing & Compliance

Telemedicine has transformed healthcare access, but billing errors, intentional fraud, and compliance violations can lead to severe penalties, audits, fines, and exclusion from Medicare, Medicaid, and private insurance networks. Providers must stay vigilant to avoid unintentional mistakes and ensure compliance with federal and state regulations.

Upcoding & Misrepresentation of Services

Common Fraudulent Practice:

• Billing for a higher-level E/M service than was actually provided (e.g., billing a 99215 for a brief check-in that should have been a 99212).
• Misrepresenting a phone call, text exchange, or brief check-in as a full telehealth consultation.
• Billing extra time that was not spent with the patient during a telehealth visit.

Compliance Tip: Ensure that time-based and complexity-based documentation matches the CPT code selected. If the visit was brief, do not bill for a full-length encounter.

Billing for Non-Covered or Non-Eligible Telehealth Services

Common Fraudulent Practice:

• Billing for services not covered under Medicare, Medicaid, or private insurance telehealth policies.
• Submitting claims for services that require in-person visits but were performed via telehealth.
• Billing for telehealth visits in states where the provider is not licensed to practice.

Compliance Tip: Verify payer rules before providing telehealth services. Check state licensure laws to ensure compliance with patient location requirements.

False Claims & Phantom Billing

Common Fraudulent Practice:

• Billing for telehealth visits that never occurred (phantom visits).
• Submitting claims for non-existent patients or services that were not actually performed.
• Using stolen patient information to generate fraudulent claims.

Compliance Tip: Implement internal audits to ensure that all claims align with documented patient encounters. Require proper patient verification before submitting claims.

Kickbacks & Referral Fraud

Common Fraudulent Practice:

• Accepting or offering illegal payments for patient referrals to telehealth companies, pharmacies, labs, or DME suppliers.
• Participating in fraudulent marketing schemes where providers are paid per patient consultation, regardless of medical necessity.
• Working with third-party billing services that submit false claims in exchange for a percentage of reimbursement.

Compliance Tip: Ensure all financial and referral arrangements follow the Anti-Kickback Statute (AKS) and Stark Law regulations. Be cautious of telehealth companies promising guaranteed high reimbursements with minimal patient interaction.

Telehealth Prescribing Violations

Common Fraudulent Practice:

• Issuing prescriptions without a valid patient-provider relationship or medical evaluation.
• Prescribing controlled substances without complying with the Ryan Haight Act or state laws.
• Prescribing medications for non-medically necessary reasons based on online forms with no real patient assessment.

Compliance Tip: Follow federal and state prescribing rules for controlled and non-controlled medications. If prescribing controlled substances, ensure compliance with the Ryan Haight Act and Prescription Drug Monitoring Programs (PDMPs).

Unlicensed & Out-of-State Telemedicine Practice

Common Fraudulent Practice:

• Providing telehealth visits for patients in states where the provider is not licensed.
• Misrepresenting licensure status to insurers or patients.
• Using another provider’s credentials to bill for services in a restricted state.

Compliance Tip: Verify state licensure laws before treating out-of-state patients. The patient’s location at the time of the telehealth visit determines licensure requirements.

Identity Theft & Fraudulent Enrollment

Common Fraudulent Practice:

• Using stolen or fake provider credentials to enroll in Medicare, Medicaid, or private payer networks.
• Submitting fraudulent provider applications to bill for services under someone else’s NPI.
• Using patient identities to bill for unnecessary or fake telehealth visits.

Compliance Tip: Conduct regular audits of provider credentials, verify National Provider Identifier (NPI) use, and implement patient identity verification measures.

Improper Supervision & Incident-to Billing Fraud

Common Fraudulent Practice:

• Billing under a supervising provider’s NPI when the service was performed by an unqualified or unauthorized person.
• Claiming services as "incident-to" without meeting supervision requirements (e.g., billing under a physician when a nurse or PA performed the visit independently).
• Billing for services outside of the provider’s scope of practice.

Compliance Tip: Ensure all billing follows Medicare and Medicaid supervision rules and that services are performed by licensed providers within their scope of practice.

Duplicate Billing & Double Dipping

Common Fraudulent Practice:

• Billing for the same service multiple times under different codes or payers.
• Submitting claims for telehealth and in-person visits for the same patient on the same day when only one service was provided.
• Billing for overlapping services that are already included in bundled payments (e.g., RPM bundled codes).

Compliance Tip: Use claim scrubbing tools to prevent duplicate submissions and verify that all services are distinct and medically necessary.

Misuse of Remote Patient Monitoring (RPM) & Chronic Care Management (CCM) Services

Common Fraudulent Practice:

• Billing for RPM services when devices were never used or patient data was never reviewed.
• Auto-enrolling patients into CCM programs without their knowledge or consent.
• Billing for non-qualified staff performing CCM services without proper supervision.

Compliance Tip: Ensure RPM and CCM services are properly documented, patient participation is voluntary, and billing rules align with payer guidelines.

Telemedicine Prescribing Complexity: Understanding Scope by Specialty

Prescribing in telemedicine is not one-size-fits-all—different specialties have different prescribing rules based on state laws, drug classifications, and medical necessity. Some states allow full telemedicine prescribing, while others restrict certain medications, particularly controlled substances.

• Key prescribing considerations for different specialties
• State and federal rules for controlled substances
• Complexities of prescribing in telehealth based on drug type
• Common compliance pitfalls and best practices

Why This Matters: If you're prescribing for weight loss, mental health, or pain management, your telemedicine prescribing requirements may be drastically different.

Each specialty has unique prescribing limitations and compliance challenges. Below, we break down what to watch for, common restrictions, and best practices.

Weight Loss Medications (GLP-1s, Phentermine, etc.)

What You Need to Assess:

• Does your state allow prescribing weight loss drugs via telemedicine?
• Is the medication a controlled substance?
• Are there specific patient evaluation or lab requirements?

Key Restrictions & Considerations:

GLP-1 Medications (e.g., Wegovy, Ozempic, Mounjaro):

• Not controlled substances, but many insurers require documented failed weight loss attempts before coverage.
• Some states require in-person visits or lab work before prescribing.

Phentermine (Controlled Substance - Schedule IV):

• Some states prohibit prescribing via telemedicine without an in-person visit.
• Often requires BMI documentation, patient agreement, and periodic follow-ups.

Common Pitfalls:

• Prescribing phentermine without checking state laws on controlled substances.
• Not documenting failed weight loss attempts for insurance approvals.
• Issuing prescriptions without discussing diet, exercise, and medical history.

Check Your State’s Weight Loss Medication Rules:

• DEA Controlled Substance Schedules
• State Medical Boards (FSMB)

Mental Health & Psychiatric Medications (SSRIs, Benzodiazepines, Stimulants)

What You Need to Assess:

• Can you prescribe psychiatric medications via telemedicine in your state?
• Is an in-person evaluation required?
• Are there special telehealth prescribing rules for controlled substances?

Key Restrictions & Considerations:

SSRIs & Non-Controlled Medications (e.g., Prozac, Zoloft, Wellbutrin):

• Some states require ongoing psychiatric monitoring for prescribing.

Stimulants (e.g., Adderall, Ritalin, Vyvanse - Schedule II):

• Heavily restricted via telemedicine due to DEA rules.
• Some states require an in-person evaluation before initial prescribing.
• Certain insurance companies require ADHD-specific screening or psychological testing.

Benzodiazepines (e.g., Xanax, Klonopin - Schedule IV):

• Tightly regulated for long-term use—often requires an in-person visit and routine follow-ups.
• Some states prohibit prescribing benzos via telemedicine for anxiety.

Common Pitfalls:

• Prescribing stimulants without an in-person evaluation in restricted states.
• Issuing long-term benzodiazepine prescriptions without ongoing assessments.
• Not documenting patient history for psychiatric medication safety.

Check Your State’s Mental Health Medication Rules:

• National Association of State Mental Health Program Directors
• State Board of Pharmacy Regulations

Pain Management & Opioids (Oxycodone, Hydrocodone, Suboxone, etc.)

What You Need to Assess:

• Does your state allow opioid prescribing via telemedicine?
• Does the patient need an in-person visit before starting pain management?
• Are you meeting Prescription Drug Monitoring Program (PDMP) requirements?

Key Restrictions & Considerations:

Opioids (Schedule II - Oxycodone, Hydrocodone, Morphine):

• Most states prohibit first-time opioid prescriptions via telemedicine.
• DEA requires an in-person exam for chronic pain management.
• Some states allow follow-up opioid management via telemedicine.

Buprenorphine/Suboxone (MAT for Opioid Use Disorder):

• Some states allow first-time prescribing via telemedicine.

Common Pitfalls:

• Prescribing opioids without checking state PDMP databases.
• Failing to document risk assessment and opioid treatment plans.

Check Pain Management Prescribing Rules:

• State PDMP Lookups

Dermatology, Primary Care, and General Prescribing (Antibiotics, Acne Medications, Hormones)

What You Need to Assess:

• Are there any state restrictions on telehealth prescribing for non-controlled medications?
• Are follow-up visits or lab testing required?
• Is the medication subject to insurance prior authorization?

Key Considerations:

Acne Medications (e.g., Accutane, Retinoids):

• Requires iPLEDGE enrollment for isotretinoin.
• Some states require monthly pregnancy testing for female patients.

Antibiotics (e.g., Amoxicillin, Azithromycin):

• Generally allowed via telemedicine with proper documentation.
• Some insurers require in-person confirmation for complicated infections.

Hormone Therapy (e.g., Testosterone, Estrogen, Thyroid Medications):

• Testosterone is a controlled substance (Schedule III), requiring special rules for prescribing.
• Some states require in-person hormone level testing before starting therapy.

Common Pitfalls:

• Prescribing isotretinoin without ensuring iPLEDGE compliance.
• Not confirming antibiotic appropriateness for virtual diagnoses.
• Failing to monitor hormone levels before prescribing testosterone.

Check General Telemedicine Prescribing Rules:

• iPLEDGE Program for Isotretinoin
• Endocrine Society Guidelines for Hormone Therapy

State-Specific Telemedicine Case Studies

Telemedicine regulations vary significantly from state to state, particularly regarding licensure, prescribing, and reimbursement. Below are real-world scenarios illustrating common compliance challenges and strategies to address them.

Case Study 1: Interstate Telemedicine Consultation – California to Texas

Scenario

Dr. Smith, a physician licensed in California, has been treating a long-time patient who recently relocated to Texas. The patient requests a virtual consultation for a chronic condition. Dr. Smith is familiar with California’s telemedicine regulations but is unsure whether Texas law allows him to continue care without obtaining a Texas medical license.

Questions for Participants

1. Does Dr. Smith need a Texas medical license to treat this patient?
2. What are Texas’s telemedicine licensing requirements for out-of-state providers?
3. Are there specific patient consent, prescribing, or documentation rules Dr. Smith should follow?
4. What are the risks if Dr. Smith proceeds without verifying Texas regulations?

Texas-Specific Considerations

• Texas requires physicians treating patients located in the state to have a full Texas medical license. (Texas Medical Board: tmb.state.tx.us)
• Texas mandates an in-person visit before prescribing Schedule II controlled substances, except in limited cases. (Texas Administrative Code, Title 22, Part 9)
• Written or verbal informed consent must be obtained and documented before a telehealth visit.

Actionable Strategies

1. Verify licensure requirements and consider obtaining a Texas medical license or working with a Texas-licensed provider.
2. Understand Texas prescribing laws, particularly for controlled substances.
3. Document informed consent in the patient’s record.
4. Consider joining the Interstate Medical Licensure Compact (IMLC) for streamlined licensing in participating states, though Texas is not a member.

Consequences of Non-Compliance

• Regulatory action from the Texas Medical Board.
• Denied insurance claims due to licensing violations.
• Legal liability for practicing without proper licensure.

Case Study 2: Prescribing Weight Loss Medication via Telemedicine – Florida

Scenario

Dr. Patel, a physician based in Illinois, wants to expand his telemedicine practice to provide weight loss consultations for patients in Florida. A patient requests a virtual consultation for GLP-1 medications such as Ozempic and Wegovy. Dr. Patel is not licensed in Florida but is aware that Florida offers a telehealth provider registration option. He is unsure whether telehealth prescribing is allowed under Florida law.

Questions for Participants

1. Does Florida allow out-of-state providers to offer telemedicine services?
2. Can Dr. Patel prescribe weight loss medications remotely?
3. Are there patient evaluation requirements before prescribing?
4. What steps should Dr. Patel take to ensure compliance?

Florida-Specific Considerations

• Florida allows out-of-state physicians to register as telehealth providers. (Florida Department of Health)
• Florida prohibits prescribing Schedule II controlled substances via telemedicine except in limited cases. (Florida Statutes, Section 456.47)
• GLP-1 medications are not controlled substances, but phentermine, a common weight loss medication, is Schedule IV and may require an in-person visit.

Actionable Strategies

1. Complete Florida’s telehealth provider registration before offering services.
2. Prescribe only non-controlled weight loss medications remotely.
3. Ensure BMI and medical history are documented before prescribing.
4. Obtain telehealth-specific informed consent.

Consequences of Non-Compliance

• Out-of-state providers cannot practice telemedicine in Florida without registration.
• Prescribing phentermine without an in-person visit may violate Florida law.
• Insurance companies may deny claims if telemedicine prescribing does not meet state regulations.

Case Study 3: Medicaid & Medicare Compliance in Telemedicine – New York

Scenario

Dr. Lee, a New York-licensed telemedicine physician, provides mental health services through virtual visits. A Medicaid patient without internet access requests a phone-only consultation due to poor broadband connectivity. Dr. Lee is unsure whether audio-only telehealth is reimbursable under New York Medicaid and Medicare rules.

Questions for Participants

1. Does New York Medicaid reimburse for audio-only telemedicine services?
2. What are Medicare’s telehealth reimbursement rules?
3. What CPT codes and modifiers should Dr. Lee use?
4. What documentation should Dr. Lee maintain for Medicaid and Medicare audits?

New York-Specific Considerations

• New York Medicaid covers audio-only telehealth for certain services when medically necessary. (New York State Medicaid Telehealth Policies)
• Medicare reimburses audio-only telehealth for mental health conditions if video access is not feasible. (CMS Medicare Telehealth Guidelines)
• Proper coding requires Modifier 95 for video visits and Modifier FQ for audio-only visits.

Actionable Strategies

1. Verify Medicaid and Medicare policies for audio-only visits before billing.
2. Use appropriate CPT codes and modifiers to ensure proper reimbursement.
3. Document why the patient could not use video and obtain consent for the telehealth visit.
4. Stay updated on telehealth reimbursement changes, as policies are frequently revised.

Consequences of Non-Compliance

• Improper billing may trigger Medicaid audits and result in claim denials.
• Medicare rules for audio-only visits may vary by specialty and must be followed closely.
• Failing to document patient consent and technology limitations may lead to compliance violations.

Key Takeaways

• Telemedicine regulations differ by state, requiring providers to verify licensure, prescribing, and reimbursement policies before offering services.
• Prescribing laws, particularly for controlled substances, often require in-person evaluations.
• Medicaid, Medicare, and private payers have specific billing and documentation rules for telehealth visits.

Providers should always check state medical boards, payer policies, and telehealth regulations before expanding their telemedicine practice across state lines.

Quick Guide to State-Specifics Laws

The Quick Guide to State-Specific Laws provides a concise overview of key legal regulations that vary by state, covering topics such as employment, taxation, business compliance, and consumer rights. Designed for quick reference, this guide helps individuals and businesses navigate legal differences efficiently.

Telemedicine Informed Consent Checklist

A Telemedicine Informed Consent Checklist ensures that patients understand the risks, benefits, and limitations of virtual healthcare services before receiving remote medical care. It typically includes key elements such as patient consent, data privacy, technology requirements, and emergency protocols to promote transparency and legal compliance.

Quick Guide to List of States with Unique Telemedicine Laws

The Quick Guide to List of States with Unique Telemedicine Laws provides a concise summary of state-specific regulations governing telemedicine practices across the U.S. It highlights key differences in licensure, patient-provider relationships, and reimbursement policies to help healthcare professionals navigate compliance requirements efficiently.

HIPAA Compliance & Data Security Best Practice

HIPAA compliance ensures the protection of sensitive patient health information by enforcing strict privacy, security, and breach notification rules. Data security best practices, such as encryption, access controls, and regular audits, help safeguard healthcare data from unauthorized access and cyber threats.

Compliance Risk Mitigation and Best Practices

Compliance risk mitigation involves identifying, assessing, and addressing potential regulatory, legal, and ethical risks to ensure an organization operates within established guidelines. Best practices include implementing strong internal controls, regular audits, employee training, and staying updated with evolving regulations to prevent violations and maintain business integrity.

Research and Evidence-Based Sources

These sources provide regulatory, legal, ethical, and security considerations for telemedicine, helping providers stay informed about compliance challenges and best practices.

• Fields BG. Regulatory, legal, and ethical considerations of telemedicine. Sleep Medicine Clinics. 2020;15(3):409-416. doi:10.1016/j.jsmc.2020.06.004

  • Discusses the evolving legal and regulatory landscape of telemedicine, including liability concerns, patient privacy, and cross-state licensure requirements.

• Houser SH, Flite CA, Foster SL. Privacy and security risk factors related to telehealth services – A systematic review. Journal of Medical Internet Research. Published January 10, 2023.

  • Examines cybersecurity threats in telehealth, including data breaches, HIPAA violations, and risk mitigation strategies for telemedicine providers.

• Nittari G, Khuman R, Baldoni S, et al. Telemedicine practice: Review of the current ethical and legal challenges. Telemedicine Journal and e-Health. 2020;26(12):1427-1437. doi:10.1089/tmj.2019.0158

  • Explores ethical dilemmas in telemedicine, such as patient autonomy, equity in access to care, and consent issues in remote consultations.

• Pandya A, Waller M, Portnoy J. The regulatory environment of telemedicine after COVID-19. The Journal of Allergy and Clinical Immunology. 2022;10(10):2500-2505.

  • Analyzes post-pandemic telehealth regulations, policy changes, and reimbursement updates that affect virtual care delivery.

• U.S. Department of Health and Human Services (HHS). Telehealth Accreditation and Best Practices.

  • Provides official guidance on telehealth accreditation, quality assurance, and regulatory compliance for providers implementing virtual care.

These sources offer valuable insights for telemedicine providers navigating legal risks, security requirements, and evolving telehealth policies.