Can I Do Telemedicine From Abroad?

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 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 state license in the US.

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 which I recommend perusing.

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 girlfriend now works for Teladoc, and they are okay with her doing telemedicine abroad. I read her contract – it had nothing about where the physician is. (1/2023 update: Teladoc now forbids performing telemedicine while residing abroad).

So, if your employer allows it, you can practice telemedicine abroad.

Insurance Billing

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.

CMS Billing

Now, Medicare or Medicaid and all the other stuff that falls under CMS is a different beast.

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 always do. Eventually, Bluecross won’t let us bill when we’re doing telemedicine while abroad.

For this reason, it’s better to build your own online private practice for those interested in what I am doing and how I am doing it. It’s not at all like running a physical practice.

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.

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 you clearly indicate that you aren’t engaging in a patient-doctor relationship.

For whatever prescribing or treatment you need to do from abroad, you can contract with a PA or NP. I’ve helped physicians navigate this as they build their own online practices. Not hard.

Malpractice Coverage

I contacted the Doctors Company to request quotes, and they said they didn’t want to underwrite an all-virtual practice.

The other factor to consider is that if you are a 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.