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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 certain rules.

If you are taking cash-pay patients and it’s your own practice you can do whatever you want. It’s 100% legal for you 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.

Working for Teladoc

The classic example is that you are working for a telemedicine company as an independent contractor or an employee. 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 100% okay with her doing telemedicine while abroad. I read her contract – it had nothing about where the physician is located.

So, if your employer allows it then you are allowed to practice telemedicine while abroad. Just to confirm, my GF reached out to Teladoc and they said they had no problem with it.

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 doing your own billing for your own online telehealth practice then 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 whole 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 Fed 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, for those who are interesting in what I am doing and how I am doing it, it’s better to build your own online private practice. It’s not at all like running a physical practice.

With your own private patients, you can do telemedicine while abroad and nobody will interfere with your practice. Should state medical boards adopt a similar regulation then 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. This is what I’ve helped physicians navigate as they build their own online practices. Not hard.

24 replies on “Can I Do Telemedicine From Abroad?”

I’ve heard about this being a problem from a Medicare/Medicaid perspective, but I’ve also heard there’s a DEA rule against prescribing controlled substances on foreign soil? However, I can’t seem to find any actual DEA rule when I research this. Also, is it clear if it matters if you are only temporarily visiting a foreign country while practicing rather than residing there? While still having a US address & permanent residence?

I don’t think it’s clear in regards to just traveling temporarily abroad versus being a resident abroad. The reality is that all of these things are open to interpretation by the law once you are on someone’s radar. Laws are, some say, intentionally written vague enough that more laws can be piggybacked on them and they can be fought in court. But if that’s too cynical of a perspective for the readers here I would say that the documents I have read haven’t made it clear but if you don’t want the headache then stay stateside when doing telehealth with 3rd party payers.
I haven’t come across anything with the DEA. I’ll keep an eye out for it.

what about using a VPN while abroad? I know it sound sketchy but how would an insurance actually find out that I am abroad? I’m only asking because I travel a lot, not because I live overseas. And when I travel I see patients online with my VPN.

I use a VPN and I don’t feel it’s sketchy. My location and what I transmit over wifi is my business and nobody else’s. Nobody but me has the right to know where I am located unless what I am doing is breaking a law. With that said there are many types of VPN and many levels of security when it comes to blocking your location. You ISP could be displayed, the time stamp from your laptop in the local time zone can leak, your unblocked IP address can leak without a kill switch, and the is the IPv6.
I am less worried about the insurance company or even CMS finding out. I am more worried about a physician who might think their location is secure because of a VPN and then tell a governing body that they weren’t overseas when they fact were overseas. Then an investigator confiscates your cell phone or subpoenos your mobile provider and tracks the towers you connected to which happened to be overseas and now you lied to some agent of the law. It gets messy.

Thanks for your transparency and thoroughness! I am appreciative of your website.

I’m finishing fellowship and considering moving abroad for a year with family. I’d like to do telework–wouldn’t need to do much to keep us afloat. I’m wondering whether you think it’s important to be up front with any potential employer about the prospect of working abroad. You mentioned that your GF didn’t have any exclusionary language in her contract. Did she disclose in her recruitment process that she’d be working from abroad? Is it possible to perhaps instead state that you’re not going to take Medicare/Medicaid patients? How much does having a US VPN make a difference?

I see the point of private practice in avoiding the headache, but I’m not sure it’ll be a permanent move. Don’t want to transition patients out of a practice in a year if we decide to move back to the US and I want FT work.

I am an United States citizen and I have been a teladoc provider for over 2 years. My family and I are planning to relocate to Ireland in January 2023. I am a family medicine trained MD and am seeking a job based in Ireland as a GP however I would ideally like to continue to work with teladoc on the side, similar to as I do now in the States, averaging 200 – 400 patients per month just to make ends meet. I have been reassured that my employer in Ireland will cover my medical indemnity insurance for that job, but I am still trying to find out if I need to do anything different while seeing US-based teladoc patients if I am living abroad in Ireland but retain my US licensure which allows me to see patients in Louisiana and Florida. Will I’ll be taxed differently? Will I have to seek out some other kind of medical indemnity even though I’ll be working remotely as an American citizen with American credentials and only treating American patients? Will things be any different at all from the telemedicine standpoint if I am physically living in Ireland? Any insight will be greatly appreciated.

Would you happen to know if Psychiatric DNP’s are under similar legislation and able to practice telepsych remotely internationally? As long as the State allows for independent practice for the NP. Thanks for the information.

So I am planning on working a remote psychiatric position and residing outside of the US. It sounds like as long as I do not bill Medicaid and Medicare there are no real issues with this. Is that understanding correct? Or for you who are using another VPN are you billing Medicaid and Medicare as well?

The VPN won’t affect your billing abilities. If you are audited and asked where you were located when billing CMS they would do their due diligence to find your actual location. There is hardly any money to be made through CMS so the risk doesn’t seem worth it.
The topic remains complicated because some attorneys argue that it’s your residency status while others say it’s simply your location.

Before buying your “Starting a Virtual Private Practice” course on Teachable, I just wanted to be sure, can a foreign Psychiatrist that was certified overseas and has never been in the U.S. nor has any state licenses provide telepsychiatry to U.S. citizens?
Also, how would they provide prescriptions to such citizens, pharmacies wouldn’t just dispense a prescription written by a foreign Psychiatrist.
If you may, I’d love to hear your input on such obstacles because I really want to enroll in that course.

Any US citizen can pay money to a foreign psychiatrist for treatment but you couldn’t prescribe medication to someone in the US without a state license.
It’s not really an obstacle in that regard, it’s just basic state licensure. If you don’t have the license you can’t prescribe here. But you can offer mental health treatment without prescriptions. I am not sure if my course is the right fit for you since it’s geared towards US physicians.

Can you work as Collaborative Physician from outside of US, no direct patient care involved, only supervision of NPs aand PAs? Thank you!!

The thing with these kind of questions is that there is a lot of “it depends”. I know that’s not as sexy as a one-line answer but it would depend on who is the payer. Who is the employer? Are there US based malpractice contracts which you have to consider? Do you need to be physically present based on your state medical board in the same state or within a certain driving distance?
For example, I have considered running a practice with just an NP/PA whom I supervise from a distance. In such a case I would prefer an NP because they can be more independent in my state. I don’t see any issues with it as long as my malpractice carrier and my business insurance is aware of my location. I also would attempt to remain a resident of the US by traveling there regularly and avoiding being in another country long enough that I would be a tax resident abroad. This isn’t as big of a deal but there are reasons why this makes the most sense for me.

For the purpose of the medical service provided, the location is where the patient is, not where the doctor is. That’s why you have to be licensed in the state where the patient resides. Why isn’t this clear to everyone else?

Thank you for sharing your thoughts I believe you are referring in regards to 3rd party payers, correct? Your statement here highlights why this is a bit of a complex matter. Many states allow patients to continue to get care or get a second opinion about their care from a physician not licensed in the origination state (which is what you might be referring to).
Sadly, healthcare has gotten quite complex and hard for physicians and patients both to navigate.
Fortunately, healthcare has gotten quite complex and many loopholes now exist that offer physicians the opportunity to practice the kind of medicine they’ve imagined.

I am a FM physician living abroad temporarily but hold an active medical license in 3 states. Can I start a virtual private practice? If so should I contact my home medical licensing body to get approval?
Any companies that help set up a virtual platform?

You don’t need approval from any licensing state to start a virtual practice.
Many companies help with setting up a virtual practice but it depends on the kind of help you’re looking for. Marketing? Hiring staff? Legal documents? Registering the business? The actual telemedicine part? I think most physicians are often eager to find a website name and start the platform so for that I would recommend going with a company like Akute Health which I’ve reviewed on my YouTube channel. Or you can go with something more complex such as atlas.md

I am a NP locally employed by an MD in California. my future career path will require me to travel a lot mostly abroad and would want to continue my employment but purely telehealth. Our payers are mostly third party payers we dont have medicaid patients.
Who do I need to talk to see the feasibility of this setup? I will maintain a local address in the US and will be visiting regularly. I will be treating the same patients i am treating now. I will be maintaining my licensure. The only change is the geographic location outside the country when I call patients.

You would likely need to reach out to your human resources department. They will tell you what the legalities are and what their rules and regulations are regarding you being abroad.

1-What about Canada? Does it matter which country? You’ll be paying US taxes anyways.
2- how would someone find out (or even investigate) if you’re working for a telemedicine company (1099) but live abroad?
3- does it matter whether you keep your US residence or not?

1. what about what regarding Canada?
2. I suspect if the telemedicine reported you to the state medical board for breaking their contract and logging in from a foreign IP address or you get sued and the state medical board finds out that you were abroad
3. it does

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