Out of country coverage in PP

[SakuraBloom]

Hey all,

New here reaching out for some friendly advice! I have a private practice, totally solo, about 20-30 hours weekly. Patients are mostly very stable, etc. I have some that are on stimulants and I only send 30 days at a time and have them message for refills. I’m fine doing my own coverage normally, and I have a 24/7 call service for after hours emergency.

My issue is when I am traveling abroad, which I do fairly frequently, what do I do for refilling controllers? These cannot be sent from outside the US per regulations I have read. Is there some service that does refill coverage for solo practices? What are my options? Thanks!

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[Cath Up]

In my residency we routinely send in 3x 30 day scripts (separately) with month-separated start dates of stimulants for stable patients who we see every 3 months. Usually works out.

 

[hamstergang]

Become friends with others in a similar situation and provide cross coverage.

 

[calvnandhobbs68]

if you can keep track of everyone, send in 30d x 2-3 months before you leave.

If you need to send in the occasional controlled script and don’t happen to be in the USA at that moment, I’ve heard that prescription software will think you’re in the USA if you use a VPN. So I hear.

 

[romanticscience]

If you use iPrescribe and international data from your domestic cell phone carrier, it will work. This is because the ISP the software “sees” is from the US.

 

[SakuraBloom]

More worried about legality of sending controlleds from outside the US since DEA can be kind of nitpicky (and they are law enforcement not healthcare).

 

[finalpsychyear]

More worried about legality of sending controlleds from outside the US since DEA can be kind of nitpicky (and they are law enforcement not healthcare).

If your doing everything by the book please hire a locums or pay someone to cover you during your time away. The alternvative is to cross cover with another collegue and then you can return the favor and its the most cost effective. There are no other options than these if your doing everything by the book. Actually a call center is fine but not good enough if your not in the country. most insurances will require you have an appropriate physician available. You can call your insurance and confirm with them on this. Its not just controlled meds.

Good luck. end of thread.

 

[calvnandhobbs68]

If your doing everything by the book please hire a locums or pay someone to cover you during your time away. The alternvative is to cross cover with another collegue and then you can return the favor and its the most cost effective. There are no other options than these if your doing everything by the book. Actually a call center is fine but not good enough if your not in the country. most insurances will require you have an appropriate physician available. You can call your insurance and confirm with them on this. Its not just controlled meds.

Good luck. end of thread.

You can answer calls when you’re out of the country. Nobody’s coming to hunt a doctor down for covering calls for their own patients while they’re in Japan. Chill out.

 

[Bartelby]

Interesting discussion. I have little to add aside from wondering which regulations prevent prescribing a controlled substance while out of the country. Are these federal regulations or specific to your state?

But in general if such regulations exist, you are stuck either refilling everything before you go or arranging for coverage as mentioned above. Coverage seems like the best route if you want to be sure everything is as safe and by-the-book as possible.

 

[TexasPhysician]

Interesting discussion. I have little to add aside from wondering which regulations prevent prescribing a controlled substance while out of the country. Are these federal regulations or specific to your state?

But in general if such regulations exist, you are stuck either refilling everything before you go or arranging for coverage as mentioned above. Coverage seems like the best route if you want to be sure everything is as safe and by-the-book as possible.

This is a Federal issue. Technology has come a long way, but the legal world is very slow to adapt. That said I don’t recall a single place where it says you “can’t” do this from oversees. The language is old and should be updated in my opinion. It says more to the fact that DEA privileges are provided in combination with the state you practice in (also why you need a new DEA for every state license) and that prescribing be done in a way that local jurisdictions can monitor/oversee the prescribing.

When you travel outside the country, you are not technically under USA jurisdiction. The DEA hasn’t granted such authorization to prescribe where it can’t monitor you. This is why EPCS software isn’t designed to work from connections in other countries.

The DEA rarely says what you “can’t” do which is also why it doesn’t list maximum doses of controlled meds or maximum quantities. It is more focused on what permissions it grants you, and maintains the right to come after you for any reason it sees fit.

 

[Ironspy]

I have paid someone to cover for longer trips. For shorter trips, I run through my caseload before leaving, see who is due for a refill soon, and I send before I go.

 

[PsyDr]

When you travel outside the country, you are not technically under USA jurisdiction. The DEA hasn’t granted such authorization to prescribe where it can’t monitor you. This is why EPCS software isn’t designed to work from connections in other countries.

The DEA rarely says what you “can’t” do which is also why it doesn’t list maximum doses of controlled meds or maximum quantities. It is more focused on what permissions it grants you, and maintains the right to come after you for any reason it sees fit.

The Ryan Haight Act, HHS' definition of telemedicine, and the newly released CSA would disagree with you.

 

[TexasPhysician]

The Ryan Haight Act, HHS' definition of telemedicine, and the newly released CSA would disagree with you.

Ryan Haight is inactive and may never return.

Where in the CSA does it allow or specifically disallow prescribing from another country?

 

[PsyDr]

Ryan Haight is inactive and may never return.

Where in the CSA does it allow or specifically disallow prescribing from another country?

It's in the definitions in 1301 or 1306, the old DEA Q&A's definitions, and the new proposed rules for telemedicine. And the DEA submitted commentary on the new proposed rules that, “a practitioner cannot use telemedicine to prescribe controlled medications while the practitioner is located outside the United States.”.

 

[Atreides]

My malpractice (PRMS) specifically says that their interpretation of the law is that physicians can not send controlled substances from abroad. I tend to take an international trip at least once a year so I do my best to get all controlled substance prescriptions figured out before then. Inevitably, there's 1-2 patients who fall through the cracks. I don't prescribe benzos so my patients kinda just deal with it (few days off Vyvanse isn't going to kill anyone).

Your alternative is to find another doctor and pay them.

 

[calvnandhobbs68]

My malpractice (PRMS) specifically says that their interpretation of the law is that physicians can not send controlled substances from abroad. I tend to take an international trip at least once a year so I do my best to get all controlled substance prescriptions figured out before then. Inevitably, there's 1-2 patients who fall through the cracks. I don't prescribe benzos so my patients kinda just deal with it (few days off Vyvanse isn't going to kill anyone).

Your alternative is to find another doctor and pay them.

Right but my experience with this is that malpractice is terribly unhelpful and will just do whatever is CYA the most for this kind of stuff. For instance, I asked my malpractice insurance about doing bridge telemedicine appointments while a patient is at college to another state where there is a clear provision for telemedicine appointments for patients who have already established care in person in their home state and their response was basically "I don't know maybe".

What exactly are you afraid is going to happen? Your established patient is gonna sue you for prescribing a 1 month supply of Vyvanse once while you're in Mexico?

 

[TexasPhysician]

It's in the definitions in 1301 or 1306, the old DEA Q&A's definitions, and the new proposed rules for telemedicine. And the DEA submitted commentary on the new proposed rules that, “a practitioner cannot use telemedicine to prescribe controlled medications while the practitioner is located outside the United States.”.

I’m familiar with 1301 and 1306 which don’t specify that (or I completely skipped over it). I’m unsure what “old Q&A’s” means. New proposed rules are not legal yet.

 

[Atreides]

What exactly are you afraid is going to happen? Your established patient is gonna sue you for prescribing a 1 month supply of Vyvanse once while you're in Mexico?

No, I’m afraid I’ll have my citizenship revoked.

 

[SakuraBloom]

So despite the back and forth I’m not going to send controlled from overseas so is there a service I can hire to do this for me? How do I go about finding someone for coverage to pay? Locums?

 

[calvnandhobbs68]

So despite the back and forth I’m not going to send controlled from overseas so is there a service I can hire to do this for me? How do I go about finding someone for coverage to pay? Locums?

If you literally know 0 psychiatrists in your area, join your local APA branch and go to an event or something to meet up with people or ask to use their listserve to send out an email offering to pay for cross coverage to fill controlled meds while you're away for X timeframe. Basically what others already said.

I've never heard of hiring formal "locums" to just cover controlled med refills while you're on vacation but maybe other people have done this?

 

[PsyDr]

I’m familiar with 1301 and 1306 which don’t specify that (or I completely skipped over it). I’m unsure what “old Q&A’s” means. New proposed rules are not legal yet.

Definition of telemedicine, definition of covered provider. The logic is that the CSA leads to DEA license, and if you are not operating under your authorization, you are breaking the law. It's like how employment contracts say, "Provides services commiserate with the professional standards of care". If you don't, they can say you were not acting as an employee when you were doing something wrong.

The Q&A is the DEA's term for their FAQ.

None of this matters, because the DEA has made the comment that you can't. The DEA has made the comment that you cannot prescribe scheduleds outside the USA, regardless of anyone else's take on the legality of their rules.

 

[ObsequiousAplomb]

Definition of telemedicine, definition of covered provider. The logic is that the CSA leads to DEA license, and if you are not operating under your authorization, you are breaking the law. It's like how employment contracts say, "Provides services commiserate with the professional standards of care". If you don't, they can say you were not acting as an employee when you were doing something wrong.

The Q&A is the DEA's term for their FAQ.

None of this matters, because the DEA has made the comment that you can't. The DEA has made the comment that you cannot prescribe scheduleds outside the USA, regardless of anyone else's take on the legality of their rules.

I can commiserate all day. Hopefully they ask for it to be commensurate though.

 

[Stagg737]

So despite the back and forth I’m not going to send controlled from overseas so is there a service I can hire to do this for me? How do I go about finding someone for coverage to pay? Locums?

How long are you going to be out of the country? If it's a week or two just tell patients at the prior appointment the dates you'll be gone and tell them you won't be responding to refill requests at that time. If they run out of scheduled benzos/it's an emergency they can go to urgent care or an ER like everyone else.

If it's longer like 3-4 weeks to months you could reach out to local private practices and see if they'll cover your messages for a cost (though they may try and steal your patients), but you could also check with any local academic centers in the area and see if there are residents with independent licenses looking for "moonlighting" opportunities willing to cover your messages/calls for $X/day or a flat fee. I'm sure there are residents out there willing to do this for $50-$100/day.

 

[comp1]

Every other thread on this board raises some horror of private practice that I hadn't thought of.

 

[Merovinge]

Every other thread on this board raises some horror of private practice that I hadn't thought of.

This is a serious non-issue for all the people I know in PP. We met monthly to discuss cases anyway and it's super easy to swap coverage, no need to pay for this stuff. When you are at work 2-3 refill calls over 1-2 weeks is a nothing burger, whereas when you are on vacation it's a huge headache.