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Online Telepsychiatry from Abroad

One of the greatest things about telemedicine is that you can technically do it from anywhere. You need a physician, an internet connection, and a phone or laptop. Doing online telepsychiatry from abroad should thus be simple, but here are a few problems to consider.

The US medical system is a big moneymaker. From policymakers to lawyers to private lobby groups. The intention is to channel a lot of money from the US healthcare system into private companies.

This isn’t a distorted or pessimistic view of US healthcare. It’s how any functional government generally operates. The problem we have as physicians is that the policies aren’t in favor of physicians or patients.

The US healthcare system is a top-down system, starting with large corporations, down to the government entities, to government-affiliated entities, to physicians, and finally the patient.

US Policy And Telemedicine

I chatted with a telemedicine doctor who has a roster of only VIPs and lives in Beverly Hills. He has been doing telemedicine since 1978 – that’s when I was born.

Telemedicine has been around for decades. However, structured reimbursement and legal coverage of telemedicine services is only a decade old. And medicine evolves very slowly – so a decade is nothing.

Over the past few years, US policy has tried to make sure that all US healthcare spending and related taxes stay in the US. This means US physicians won’t be able to practice abroad.

In this report from the Office of Inspector General (OIG), CMS paid out for visits that didn’t qualify. One of the items mentioned is that US physicians were not physically in the US when billing. This is a mandate by CMS and is included in their Medicare Benefit Policy Manual (chapter 16).

“For one claim, a physician residing and practicing psychiatry in Pakistan provided psychiatric counseling services through telehealth technology to a patient located at a rural medical center in the United States. The service was unallowable because the physician was located outside the United States.”

Who told us that we need to be in the US when practicing medicine? That’s not the agreement I had when I entered medical school or agreed to a residency program.

Check out this article I wrote which discusses this rule in more detail.

Practicing Online Telepsychiatry from Abroad

Practicing telepsychiatry from abroad is still possible but now we have to factor the current laws and whatever will come down the pipeline.

Whatever CMS (medicare, Medicaid) private insurance companies will inevitably adopt. It’s a matter of time before private insurers, too, won’t pay for services provided by physicians outside the US.

But nobody can keep you from taking cash – not yet. Meaning, you can have your own private practice or see non-CMS patients and still practice telepsychiatry from abroad.

Starting Your Own Telepsychiatry Practice

It sounds daunting to start your own virtual practice but it’s 2021 and doing anything online is far easier than ever before.

If you don’t want to undertake it yourself, you can hire capable people from Upwork or Fiverr.

You can also purchase my online course where I teach you how to start your virtual practice online. It doesn’t matter whether you want to be a health coach or a gastroenterologist or a psychiatrist.

You’re a psychiatrist and there are only so many of you out there. A patient can see you and bill their insurance separately. You can even provide them the necessary forms. All you’re have to worry about is collecting their payment.

If you’re worried about reimbursement rates, my course addresses that in detail and why it’s far less relevant than you think.

Seeing Telepsychiatry Patients for Private Offices

Lots of private practice psychiatrists have patients whom they cannot see. Maybe they are difficult patients or they have unique medical conditions.

It could also be because the practice is at max capacity. For a referral fee or a cut of the visit, you could see these patients. The best way to find these patients is to contact private practices and see what their needs are.

It’s not like telepsychiatry jobs aren’t available, but you have to look for them. And look for companies which are friendly to telepsychiatrists practicing abroad.

Consulting in the Telepsychiatry Space

Your talents as a psychiatrist span beyond your in-office clinical abilities.

Small companies and healthcare startups need psychiatrists to build out their products. They need such input in order to create something competitive in the marketplace.

You can find such businesses on LinkedIn or Startuphealth or Angel.co.

I have been consulting in the healthcare space for some time and it remains profitable. In fact, I think it’s only going to grow in the future.

If you want to practice telepsychiatry from abroad, you have lots of options, but you have to create these opportunities. Just because they aren’t mainstream, it doesn’t mean they don’t exist.

17 replies on “Online Telepsychiatry from Abroad”

Regarding CMS reimbursement and the OIG report, I think there is some legal wiggle room in the ambiguity. Firstly, that one particular case was a physician practicing “in Pakistan” which might be distinct from a Physician with a US address working via a US based telehealth company. Following the footnotes of the Pakistan example in the OIG report and reading the Social Security Act and other referenced articles (and so on down a superscript rabbit hole), Identifying where a service is “provided”, “furnished”, or “performed” is key… Much of the context in these statues hint that the spirit of the law is for CMS to avoid reimbursing for care when both the beneficiary and the provider are outside the US (minus those detailed exceptions of boats, emergency transit, etc). They don’t want to reimburse foreign medical care. But the question you and I (and many others) care about is what about when the beneficiary is in the US and the provider isn’t.
This is the question of originating site (where the patient/beneficiary is) vs distant site (where the provider is).
The provider has to be licensed in the state of the originating site, which might hint that the originating site is the location where the practice of medicine is occuring, even if the provider is outside the US. This doesn’t seem to be breaking the intention of the law with the SSA.
In any case, the risk may be low of being charged with fraud as long as the address used for enrollment is CMS by the provider is in the US, and that submitted claims by the distant site have corresponding claims at the originating site. The provider can their home address for CMS enrollment or use an office/clinic address for CMS enrollment long as they “practice [at the office] part time”, which might leave a loop hole for a provider who is willing to spend a days in a clinic office or even at a workspace set up for telehealth within the US.

Lastly, to these laws are in flux right now and I suspect the question of CMS reimbursement for digital nomad providers will be clarified, either by statues, or case law.

I don’t see them going in favor of a physician who is residing overseas while performing the telemedicine visit and billing CMS. Since it is against their billing guidelines it would be considered fraud. But I agree that one could fight it and see where it goes. It doesn’t seem like a battle worth fighting unless the physician is up for that and wants that kind of confrontation for publicity or otherwise. There is a mile-long case log of physicians who have done jail time for much less ambiguous stuff.

Can I ask which, if any, telehealth groups are allowing US licensed physicians to practice telemedicine via a US based company, with a US license, to patients in the US (seeing patients in the state the license is held) but the provider is located abroad?

About 1 year ago I deleted my entire blog, my podcast, and my YouTube channel because I was quite public about mentioning companies with which I worked and information I had about things they even publicized. However, once you reveal things which are written in your contract, even though you’re allowed, those companies can make your life hell even though they may not have any legal authority over you.
All this to tell you that I can’t answer anything like that publicly but I’ll review your email and I’ll get back to you. There are many telemedicine companies which are working outside of the insurance model. However, is the income enough? If you’re trying to replace your 300k a year income with telemedicine it’s tough to do unless you’re doing something rather mainstream and that often means insurance and that often means medicare and Medicaid and you know the rules there.
No company advertise that you can live abroad – lots of legal issues there because it’s not just the telemedicine company but the malpractice company and workman’s comp and the software provider – all of these can have their own rules and regulations as to where you can be when you use their services. On top of that, your state medical board may not be okay with it. Of course, if you trust your state medical board it’s as easy as sending them an email and asking if you’re allowed to practice while abroad.

I have a similar question. I plan on living in Taiwan for a couple of years to take care of my elderly parents. Trying to see what options I have to do telehealth. I’m not asking for much but $5000- $6000 a month or even less. If there are any options please let me know!

I think the US is making it harder for physicians to be abroad if you’re planning on using insurance. I have discussed finding your own patients to create an income from a private pool of patients or else work for telemed companies which are okay with you being abroad. But I know this isn’t the perfect answer.

Do you know of telemedicine companies that are doing this? Have been researching and haven’t found anything. Thank you for your time!

I don’t. All the ones I have come across that are on my radar are using insurance and accept some sort of CMS pay so they are going to hold physicians to the regulations of being in the US when seeing patients and billing. I would recommend looking on docjobs.com and indeed and linkedin jobs regularly to see if you see a private practice pop up looking for an associate physician. And I’ve suggested reaching out to private practices to see if they need someone to cover patients who are cash pay.

Thank you for your help! Will have to keep looking. Hopefully will find some solution soon.

Sounds like James Bond. Worth a try. I think in the end it all has to do with your employer. They can let you go and report you to the NPDB and once that happens you’ll have to report that on every one of your future employments. Would they report you? Maybe not. If they do is it a big deal – it might be.

What about the senerio- US based physian providing telehealth services to US Citizen living abroad with Part B medicare?

From the most recent documents I reviewed and the 2018 document here it seems that if it’s anything CMS related and billing is done with the physician residing outside of the US it’s against their billing guidelines. What isn’t so clear is whether it’s okay if the physician is only traveling or a resident abroad. I don’t want to fuck with CMS because they have the guns and plenty of physicians have served jail time for billing practices which definitely would pass the sniff test but didn’t pass their criteria.

“A PRACTITIONER WAS LOCATED OUTSIDE THE UNITED STATES
In general, Medicare payment is not allowed for services provided outside the United
States.
The Medicare Benefit Policy Manual states that the professional services of a
physician are covered if provided within the United States.
For one claim, a physician residing and practicing psychiatry in Pakistan provided psychiatric
counseling services through telehealth technology to a patient located at a rural medical
center in the United States. The service was unallowable because the physician was located
outside the United States.”

Hi, what about malpractice insurance for providing telehealth services to patients outside your country or state of professional registration?

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