I get this question a lot, and I reply to it a lot. It’s not a straightforward answer, just like “Am I having a heart attack?” doesn’t often have a straightforward answer. Can US physicians practice telemedicine while abroad? Yes. As long as you’re not breaking specific rules.
You can do almost whatever you want if you are taking cash-pay patients, and it’s your own practice. It’s 100% legal to reside abroad as long as you have a US state medical license. And as long as your state allows you to be abroad while performing telehealth visits. I don’t know of any states which have gone so far as to forbid this. More on this later.
A great website with many helpful articles is Hippocratic Adventures. Just remember that information on such topics get quickly outdated – check out the comment sections for the most up-to-date information—or joint physician groups on FB or Linkedin.
Working for Teladoc
The classic example is that you work as an independent contractor or employee for a telemedicine company. Say, Teladoc or Doctor on Demand. Their rules are clear – you cannot be abroad while doing telemedicine for them.
At least, that’s what my contract stated verbatim when I worked with them. My friend now works for Teladoc, and they are okay with her doing telemedicine abroad. I read her contract – it had nothing about where the physician should be physically located.
(1/2023 update: Teladoc now forbids performing telemedicine while residing abroad. She received a letter stating that no work can be performed while located abroad.)
But, if your employer allows it, you can practice telemedicine abroad.
There are plenty of telemedicine or telehealth companies that hire physicians and allow them to work from abroad. The tough part is finding them, and that’s best done by getting word out and reaching out to such companies on Linkedin.
Most insurance companies don’t have any clause forbidding you to reside abroad while doing telemedicine. At least from the disgustingly long contracts I have read.
If you are billing your own online telehealth practice, you can reach out to your insurance liaison and ask them to clarify it for you.
However, because CMS has created a clause about physicians residing in the US, it’s possible that insurance companies will follow suit.
CMS, which is Medicare and Medicaid, and a few other public programs have passed regulations that require physicians to reside in the US when billing CMS.
I present to you an oversight report from April 2018. The report number is A-05-16-00058. Here, they report on a psychiatrist physician who billed for a patient visit while residing in Pakistan.
I have no idea what happened to that poor bastard, but I’m sure he got a denial letter, and knowing the CMS, they probably charged him with something fraudulent.
Social Security Says…
Following the breadcrumbs, section 1862(a)(4) of the Social Security Act and 42 CFR § 411.9(a) states the following mess:
Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services which are not provided within the United States (except for inpatient hospital services furnished outside the United States under the conditions described in section 1814(f) and, subject to such conditions, limitations, and requirements as are provided under or pursuant to this title, physicians’ services and ambulance services furnished an individual in conjunction with such inpatient hospital services but only for the period during which such inpatient hospital services were furnished).
Code of Federal Regulations Says…
And from 42 CFR § 411.9(a) from the code of federal regulation:
Except as specified in paragraph (b) of this section, Medicare does not pay for services furnished outside the United States. For purposes of this paragraph (a), the following rules apply:
(1) The United States includes the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, The Northern Mariana Islands, and for purposes of services rendered on board ship, the territorial waters adjoining the land areas of the United States.
(2) Services furnished on board ship are considered to have been furnished in United States territorial waters if they were furnished while the ship was in a port of one of the jurisdictions listed in paragraph (a)(1) of this section, or within 6 hours before arrival at, or 6 hours after departure from, such a port.
(3) A hospital that is not physically situated in one of the jurisdictions listed in paragraph (a)(1) of this section is considered to be outside the United States, even if it is owned or operated by the United States Government.
Your Own Online Practice
I suspect that private insurers will eventually follow Medicare, as they traditionally do. Eventually, Bluecross won’t let us bill when we do telemedicine abroad.
For this reason, it’s better to build your own online private practice. It sounds complicated, but for me, it’s the only way forward.
Running a virtual primary care practice is not at all like running a physical practice… in a good way.
I have podcasts and YouTube videos dedicated to this topic. I don’t think it’s that difficult to build your own virtual practice and get the regulators off your back.
I did this so that I could live abroad. Not reside abroad permanently but have the option to travel.
Escaping the Micromanagement
You can do telemedicine abroad with your own private patients, and nobody will interfere with your practice.
Of course, if you’re not engaging in the practice of medicine, even better. Enter health coaching.
I do some health coaching, so I don’t have to worry about any state medical board.
Should state medical boards adopt a similar regulation, you keep your interactions based on information sharing and clearly indicate that you aren’t engaging in a patient-doctor relationship.
An attorney can help you make your intentions clear.
For whatever prescribing or treatment you need to do from abroad, you can contract with a PA or NP. However, I prefer to keep things less complicated.
I contacted The Doctors Company to request malpractice quotes, and they said they weren’t interested in underwriting an all-virtual practice.
Don’t worry, plenty of other companies will.
The other factor to consider is that if you are a permanent resident abroad, you may not qualify for malpractice insurance in the US.
I am not a fan of living permanently abroad. I prefer to retain my US residency and pay my taxes here.
Local Laws When Practicing Abroad
Do you need a work permit to work in another country? Maybe. If you are an employee, you might need a work permit even when working for a company abroad.
Physicians can also work in non-clinical positions such as in research or the government. A third area is to practice clinically in the U.S. via telemedicine, which is what Bojarski does currently as a psychiatrist in private practiceopens in a new tab or window.MedPage Today
Do you need a work permit in your foreign country when you’re running your own business? Depends.
I doubt the police will show up on my doorstep in Spain because I have a rental income property in California. Nor would they be handcuffing me because I own a roofing company that runs itself.
The main issue is taxes; that’s what most people care about. And the business pays taxes in the country in which it is formed.
Dr. Mo is a business. This handsome face you’re looking at is not Mohammad Ashori, MD but a business entity that pays taxes to California even if Mohammad Ashori resides in Sweden.
China, however, might be a different story.
In China, the Medical Practitioners Law generally refers to the “practice of medicine” as medical diagnosis, disease investigation, medical treatment and the issuance of corresponding medical documents by physicians. Rendering remote diagnoses normally constitutes practice of medicine in China and would be limited to locally licensed physicians and foreign physicians holding a Short-Term Foreign Practice License at approved hospitals. These requirements remain the same even under COVID-19 conditions. Physician-to-physician consultations, however, do not necessarily fall within the “practice of medicine” in China.JDSupra
Data Privacy and HIPAA
If your practice is mostly based outside of the US, it’s important to have a competent attorney draw up appropriate patient agreements addressing data privacy and HIPAA.
Your patients have the right to know if their medical information crosses international borders.
Does doing telemedicine from abroad really put your patient’s data at risk? Unlikely.
Will your patients report you? Unlikely.
Could something happen that might make this information discoverable? Definitely.
More importantly, you don’t want the headache. It’s easy enough to build the kind of online medical practice that lets you sleep comfy at night.
What I consider ethics and what a court considers ethics are light years apart.
Deborah Baker, JD believes that it’s okay to wield an emergency call from a psych patient when traveling across state lines but not as appropriate if it’s a routine virtual appointment.
Attorneys are the ones who convince judges and jurors. So, if you’re going to travel abroad, or even worse, across state lines, you’ll have to know local laws.