Building a private practice – particularly one that exclusively utilizes telemedicine while you are outside of the US – is daunting. Here are 10 tips for developing your own telepsychiatry private practice while abroad.
1. Build Your Telepsychiatry Practice Within State and Federal Regulations
I emailed all 50 state medical boards several months ago, and of the 36 that responded, none took issue with a physician being abroad and seeing patients in their state through telemedicine. However, Pennsylvania – one of the states rumored to frown upon this – did not respond to my enquiries.
If prescribing controlled substances, the Ryan-Haight Act requires you to see a patient face-to-face before prescribing a controlled substance and then at least every two years. Individual states have their own regulations around prescribing controlled substances, with some mandating face-to-face visit more often than every two years. Finally, per DEA regulations, physicians are ineligible for DEA registration if they are located outside of the United States. Per my communications with the DEA, one possible interpretation of this regulation is that prescribing controlled substances from abroad is forbidden.
Make sure to set up your practice in states that allow you to see patients from abroad. It is wise to set up a practice that is not within a tight niche where controlled substances are first-line (i.e ADHD), and if prescribing a controlled substance, do so at your own risk. At the very least, make sure that you see your patients in person regularly enough to meet the needs of the Ryan-Haight Act and the regulations of your state.
2. Know Which Insurances Will Reimburse You While Abroad or Consider Self-Pay
Per CMS regulations, physicians are not eligible for Medicare or Medicaid reimbursement if located abroad at the time of service. This is typically the reason why many telemedicine companies do not allow their physicians to be abroad, and it applies to your private practice as well.
Some insurances, such as Blue Cross Blue Shield of Massachusetts, require a brick-and-mortar address in your state of practice, while others, such as Optum do not and will allow you to be abroad. Confirm with insurance companies that they will reimburse while you are abroad, before your move. Otherwise, consider a self-pay model where you provide a superbill that patients can submit for out-of-network reimbursement with their insurance.
3. Select an EMR Software Bundle That Works For You, and Ask For a Trial Period
- Does the calendar adjust to your new time zone?
- Is the patient portal user friendly?
- Can you build and administer consent forms and symptom questionnaires?
- Is their pharmacy database complete?
- Can you order and review labs?
- Is customer support responsive?
- Is the EMR’s functionality preserved when accessing from abroad?
Some EMRs are not accessible outside the US, although a Virtual Private Network is an effective workaround. Ensure that your video-conferencing software, phone line, virtual fax system, and other additions are also accessible from abroad long before your move. If starting out, ask for a free trial period to ensure the EMR fits your practice workflow, before committing to a yearly contract.
4. Find a Malpractice Insurance Policy Which Covers Telemedicine While You Are Abroad
If the company does not provide malpractice coverage you could buy your own that will cover you while residing abroad.
5. Nurture Your Referral Network
Word of mouth remains one of the biggest referral sources for psychiatrists. You can build a referral network by being responsive to your patients, collaborating with therapists and primary care physicians, introducing yourself to colleagues, and having an attitude of curiosity and lifelong learning,
In every community you serve, cultivate a network of colleagues to ensure you are up to date on local resources such as partial hospitalization programs or intensive outpatient programs and know how to access these resources quickly for patients needing a higher level of care.
6. Schedule Virtual Peer-Supervision and Never Worry Alone
Never worry alone. The thousands of miles separating you from a decompensating patient might amplify your worry, and peer supervision will provide access to a trusted curbside in challenging times. Set up a regular virtual peer-supervision session with a fellow psychiatrist that you respect and admire. Review your caseload, starting from the cases that feel acute, to the cases that follow you outside of work hours, and even cases that excite you or bore you, and encourage your peer to do the same. You’ll learn from each other’s cases and grow together as psychiatrists.
7. Patient Safety Comes First
Research suggests similar outcomes between telepsychiatry and in-person visits. Telemedicine allows for the visit to take place inside your patient’s home, which can provide insight into a patient’s functioning and their day-to-day life. It is also easier to miss signs of self-harm; poor hygiene; the scent of cannabis or other recreational drugs; and to assess for catatonia, cogwheel rigidity, or obtain reliable vital signs. Know what *you* feel comfortable treating through telemedicine. Before scheduling an initial consultation, screen your patients with a carefully-crafted intake form and an introductory telephone call. During the call, be upfront about your current status or future move abroad. It is wise to frame the first appointment as an initial consultation, rather than a firm commitment of accepting the patient into your practice.
There will be unfortunate times where, despite your best efforts, your patient may need a higher level of care. Make sure you that you confirm your patient’s location at the beginning of every session; establish an emergency contact; and know how to summon an ambulance to their home in case your patient decompensates medically or psychiatrically.
8. Develop An Online Presence
Consider building a cost-effective website with Squarespace or Wix. Your website can link to your EMR and offer patients online scheduling and an automated pre-intake process. Once your website is live, it is unlikely to rank highly on a google search unless you invest in Search Engine Optimization. Your website can still serve as a modern business card for your word-of-mouth network.
List your practice and build a profile in Psychology Today, which typically offers a six-month free trial if invited by a colleague. It is a worthy complement to your word-of-mouth referral network, particularly early on in your practice before your network is fully established.
9. Be Honest With Your Patients About Moving Abroad
For some patients, your move abroad will bring up fears of abandonment, even if you were seeing them virtually before your move. Being honest about your move – several months before it happens if possible – can allow your patient to work through these fears and can strenghten your patient’s object constancy. Don’t wait until after you have moved, as some of your patients will feel blindsided and betrayed. For new patients, be honest about your current circumstances before the first appointment. Most patients won’t mind if you are upfront.
10. Effectively Manage Time Zone Differences
Time differences can be a blessing in disguise; some of your patients might *love* your newly available time slots before work or after school. That said, consider planning a few days per week where you begin work earlier than usual or later than usual depending on the time differences.
I keep my electronic medical record time zone on Eastern Standard Time and highlight my “work hours” during which I schedule patients to spare me of embarrassing arithmetic mistakes during appointments. Be aware that Daylight Savings Time may not be observed at the exact same time in the US as in your new home, leaving you with slightly awkward weeks of making adjustments to your schedule by an hour.
The Bottom Line
Building a telepsychiatry private practice that enables you to be abroad requires a few additional considerations than practicing locally, but it is very doable, and the freedom it provides is priceless.
Dr. Emeric Bojarski is a Child, Adolescent, and Adult Psychiatrist and founder of Equilibrium Behavioral Health, a tele-psychiatry private practice. He attended Harvard Medical School, completed residency at Yale-New Haven Hospital, and fellowship at Massachusetts General Hospital and Mclean Hospital.
Check out our list of telemedicine companies that allow you to work from abroad (and those that don’t)For a personalized approach to building your own telepsychiatry private practice, learn about how our Guidance Service can help.