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.
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.
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.