Anybody know a way I can practice tele-psychiatry abroad?

[twospadz]

Is it possible?

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[psychacad]

Yes. As long as you don't bill medicare/medicaid.

 

[wolfvgang22]

Per the APA:
The Ryan-Haight Act requires any practitioner issuing a prescription for a controlled substance to conduct an in-person medical evaluation (with certain specified exemptions). A conservative recommendation to support compliance with the act is to conduct an in-person exam at least once every 24 months.
Also, psychiatrists need to make sure they comply with other federal, state and organizational rules and policies around the prescription of controlled substances.

 

[the5thelement]

A DEA-registered Practitioner acting within the United States is exempt from the requirement of an in-person medical evaluation as a prerequisite to prescribing or otherwise dispensing controlled substances by means of the Internet if the Practitioner is engaged in the practice of telemedicine and is acting in accordance with the requirements of 21 U.S.C. § 802(54)

 

[dl2dp2]

It's fine except for the fact that it's probably harder to develop a practice abroad. Unless you use an agency. There is a plethora of these agencies, and they are in the process of consolidating, but most pay a staggeringly bad rate (~ $125-150 per hour).

Facility-based telemedicine gigs typically require you to be in the US.

 

[Monocles]

Yes. As long as you don't bill medicare/medicaid.

Wait! So let me understand this correctly - let's say you move to a developing country to minimise your expenses, are you allowed to start a private practice telepsych clinic that sees US patients?

Or is the OP asking if they can see international patients from a US-based office?

 

[Bartelby]

My understanding is that by U.S. law legally you are practicing medicine wherever the patient is. So if your patient is in Massachusetts and you hold a Massachusetts license, you are practicing medicine in Massachusetts no matter where you are located.

 

[psychacad]

Wait! So let me understand this correctly - let's say you move to a developing country to minimise your expenses, are you allowed to start a private practice telepsych clinic that sees US patients?

Or is the OP asking if they can see international patients from a US-based office?

Yep, absolutely. Private practice, no question. There are a few outpatient telepsych companies which bill private insurance that also allow this. It's also possible to do ER work, since hospitals pick up the expenses and medicare/medicaid aren't billed. I know several people in India, Nepal, Cyprus, Portugal and other places.

And yes the rates are possibly on the lower side, but you more than make it up with taxes and COL. There are some countries which will give you huge tax breaks (for ex 20% flat rate). It's very enticing.

 

[wolfvgang22]

A DEA-registered Practitioner acting within the United States is exempt from the requirement of an in-person medical evaluation as a prerequisite to prescribing or otherwise dispensing controlled substances by means of the Internet if the Practitioner is engaged in the practice of telemedicine and is acting in accordance with the requirements of 21 U.S.C. § 802(54)

Do you have a link or source where I can read more about this?

 

[TexasPhysician]

Do you have a link or source where I can read more about this?

That just rehashes Ryan Haight. No controlled meds without in-person unless you meet one of few exceptions. If you are doing a telemedicine private practice, odds are NO controlled meds.

 

[the5thelement]

Do you have a link or source where I can read more about this?

https://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/telemedicine-dea-guidance.pdf

 

[wolfvgang22]

https://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/telemedicine-dea-guidance.pdf

Thanks, I have read this previously. It doesn't seem to address practicing while the practitioner located outside the U.S. and it's territories while seeing a patient in the U.S., though.

Further, it says DEA registered practioners must follow state law regarding prescription of controlled substances, which may or may not have rules about prescribing controlled substances outside the state.

 

[Monocles]

Yep, absolutely. Private practice, no question. There are a few outpatient telepsych companies which bill private insurance that also allow this. It's also possible to do ER work, since hospitals pick up the expenses and medicare/medicaid aren't billed. I know several people in India, Nepal, Cyprus, Portugal and other places.

And yes the rates are possibly on the lower side, but you more than make it up with taxes and COL. There are some countries which will give you huge tax breaks (for ex 20% flat rate). It's very enticing.

This is incredible!!

 

[Mass Effect]

That just rehashes Ryan Haight. No controlled meds without in-person unless you meet one of few exceptions. If you are doing a telemedicine private practice, odds are NO controlled meds.

Why would there be no controlled meds if you're doing telemedicine private practice?

 

[TexasPhysician]

Why would there be no controlled meds if you're doing telemedicine private practice?

Ryan Haight laws ban controlled meds across the USA without an in-person visit. The exceptions being government facilities like a VA and having a prescriber on site with a patient. This is not feasible for most pp telepsych practices.

 

[toros102]

I’ve searched all over the internet for information on this, and I’ve mostly found speculation (like in this thread). It seems legally it’s a gray area because the technology making it possible is relatively new. I’d love to meet someone who has actually pulled it off.

 

[TexasPhysician]

I’ve searched all over the internet for information on this, and I’ve mostly found speculation (like in this thread). It seems legally it’s a gray area because the technology making it possible is relatively new. I’d love to meet someone who has actually pulled it off.

Decent sized telepsych companies have existed for at least 8 years. I’ve known 1 psychiatrist that has started and sold a telepsych practice that would cover hospitals and ER’s and cruise ships. They had many psychiatrists on staff with at least 1 on nights. They used someone that was a psychiatrist across the globe (his days were our nights). There are USA psychiatrists working from overseas. You just either need to find one of the few companies that don’t need you for Medicare/Medicaid (require being in the USA) or have a telepsych pp without controlled meds.

 

[wolfvgang22]

Ryan Haight laws ban controlled meds across the USA without an in-person visit. The exceptions being government facilities like a VA and having a prescriber on site with a patient. This is not feasible for most pp telepsych practices.

I've have done a mix of in person and telepsych with the VA for several years now, and this has been my understanding.

Of course, I love the idea of semi-retiring to an exotic locale and see U.S. patients via telepsych and would love to hear from anyone actually doing it.

 

[Mass Effect]

Ryan Haight laws ban controlled meds across the USA without an in-person visit. The exceptions being government facilities like a VA and having a prescriber on site with a patient. This is not feasible for most pp telepsych practices.

That part I knew, but there's nothing specific about telepsych that forbids, right? Like if someone made a policy that all patients on controlled subs had to been seen in person once every 24 mths, they could get away with prescribing?

I've wondered too what happens to all the patients people got for initials during the pandemic once the pandemic rules are lifted. Do all those patients have to now be seen in person?

 

[TexasPhysician]

That part I knew, but there's nothing specific about telepsych that forbids, right? Like if someone made a policy that all patients on controlled subs had to been seen in person once every 24 mths, they could get away with prescribing?

I've wondered too what happens to all the patients people got for initials during the pandemic once the pandemic rules are lifted. Do all those patients have to now be seen in person?

Yes, when the national emergency ends, all will need an in-person appt before further controlled meds are prescribed.

There is nothing that stops you from seeing patients in-person then prescribing controlled meds then following up from Greece the next 2 years.

 

[brazilianpsych]

Would it be possible for a supervised NP/PA to see the patient in-person and the supervision be done from Greece? In that case, is it possible to prescribe controlled meds?

 

[Bartelby]

Thinking more about this for those who are interested in living abroad and doing telepsychiatry it could also set you up well for doing overnight coverage shifts remotely (which for you could be daytime shifts depending on the time zone).

 

[Psychresy]

Thinking more about this for those who are interested in living abroad and doing telepsychiatry it could also set you up well for doing overnight coverage shifts remotely (which for you could be daytime shifts depending on the time zone).

I want to do this from the states. How do I find a telepsych company that would allow for something like Ed overnight coverage?

 

[calvnandhobbs68]

Per the APA:
The Ryan-Haight Act requires any practitioner issuing a prescription for a controlled substance to conduct an in-person medical evaluation (with certain specified exemptions). A conservative recommendation to support compliance with the act is to conduct an in-person exam at least once every 24 months.
Also, psychiatrists need to make sure they comply with other federal, state and organizational rules and policies around the prescription of controlled substances.

I mean easy way around this is just don’t prescribe controlled meds...there are already people that have this policy in their private practice so they don’t have to deal with people seeking benzos and stimulants constantly.

 

[liquidshadow22]

I mean easy way around this is just don’t prescribe controlled meds...there are already people that have this policy in their private practice so they don’t have to deal with people seeking benzos and stimulants constantly.

LOL cash practice would not be sustainable without controlled substances unless your rates are very cheap

 

[Ironspy]

LOL cash practice would not be sustainable without controlled substances unless your rates are very cheap

Not true. I’ve prescribed one 14day supply of klonopin in >2 years. I don’t prescribe controlled substances as a rule and all prospective patients are informed prior to scheduling their intake

 

[liquidshadow22]

Not true. I’ve prescribed one 14day supply of klonopin in >2 years. I don’t prescribe controlled substances as a rule and all prospective patients are informed prior to scheduling their intake

How many hrs a week do you fill? Mind sharing what state you are in?

So you lose out on essentially all ADHD patients. That is a large patient population to avoid treating

 

[calvnandhobbs68]

How many hrs a week do you fill? Mind sharing what state you are in?

So you lose out on essentially all ADHD patients. That is a large patient population to avoid treating

Yeah a large population that a lot of psychiatrists don’t mind missing out on having to evaluate. “Adult onset ADHD” evals are a huge pain in the butt for lots of people right now. It’s also pretty difficult to be in compliance with the stuff you really should be monitoring for stimulants anyway if you’re doing telepsych from another country (accurate blood pressure/pulse, really should be getting a urine drug screen for adults every now and then). If you’re a candy man who hands out adderall to everyone who comes in complaining of inattention, you probably don’t care about the monitoring you’re supposed to be doing anyway. This just ends up being more of a pain than a lot of people want to do.

There are plenty of people with treatment resistant depression, anxiety, bipolar disorder, OCD, PTSD, etc that don’t need controlled meds as an option.

 

[Ironspy]

How many hrs a week do you fill? Mind sharing what state you are in?

So you lose out on essentially all ADHD patients. That is a large patient population to avoid treating

1 day/week and I’m full. I get >10 inquiries/week. I work 4 days elsewhere and do not want to expand at this point. I’m licensed in 2 northeastern states but only keep an active dea in one bc I need it for my main job.

 

[liquidshadow22]

1 day/week and I’m full. I get >10 inquiries/week. I work 4 days elsewhere and do not want to expand at this point. I’m licensed in 2 northeastern states but only keep an active dea in one bc I need it for my main job.

Exactly, 1 day per week. Out of your 10 inquiries, what % actually follow through? I have a hard time seeing a cash practice go full time-4 or 5 days of clinic, without prescribing controlled substances.

 

[Ironspy]

Exactly, 1 day per week. Out of your 10 inquiries, what % actually follow through? I have a hard time seeing a cash practice go full time-4 or 5 days of clinic, without prescribing controlled substances.

I’m not accepting new patients right now and haven’t for at least 6 months

 

[liquidshadow22]

I’m not accepting new patients right now and haven’t for at least 6 months

How long did it take you to get to this point? How do you do your advertising mainly? What is the total census of your PP?

 

[Ahamis]

And yes the rates are possibly on the lower side, but you more than make it up with taxes and COL. There are some countries which will give you huge tax breaks (for ex 20% flat rate). It's very enticing.

whatever money you make by doing telepsych (seeing U.S. patients) you will still be required to pay federal U.S. tax, even if you are living in a fiscal paradise.
And depending on the country you will be living you might be required to pay taxes on part of that income to the hosting country.

 

[TheTravelingShrink]

Not only is it possible, but many people do this. And with regards to taxation, many countries have tax treaties preventing double-taxation.

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