“Telehealth is critical to the future of health care.”
— Kimberly Horvath, Senior Attorney, AMA Advocacy Resource Center (this
week’s insightful reaffirmation) American Medical Association
Picture this: Dr. Alvarez, a primary care physician based in
Arizona, sees a patient visiting family in Minnesota. They want a routine
consult via video. Sounds easy, right? But as she reaches for the “Send Bill”
button, uncertainty strikes. Does her Arizona license cover this patient? Will
reimbursement go through? What if controls for controlled substances apply? The
answer is far from simple.
I know—I've been there. You think telemedicine is seamless.
Then you hit licensure roadblocks, billing denials, and payer
fine print. You ask yourself: “Is this legal? Will I get paid? What if I
get audited?”
That tension—that gray area—is exactly why mastering
cross-border telemedicine billing isn’t just useful. It’s urgent. It’s what
separates the clinics who thrive from those who get stuck chasing denials.
Why You Can’t Ignore This
- Cross-border
telemedicine, licensure compacts, jurisdictional compliance,
reimbursement complexity, provider-patient geographic movement—they’re
not sci-fi buzzwords. They’re everyday street names on your route to
revenue.
- Medicare
has extended home-based telehealth coverage for non-behavioral
services through September 30, 2025, removing originating-site
constraints—a big deal for reaching patients virtually anywhere telehealth.hhs.gov.
- States
still vary widely in rules. Some require full state licenses. Others lean
on interstate compacts, temporary practice laws, or telehealth
registration telehealth.hhs.govRecord Retrieval SolutionsCCHP.
Top Tips for Mastering Cross-Border Telemedicine Billing
1. Know Where Your Patient Is—and What That Means
Licensure depends on where the patient is located,
not you. The care “takes place” at their physical location, triggering that
state’s rules CCHPtelehealth.hhs.gov.
2. Leverage Interstate Compacts
Use the Interstate Medical Licensure Compact (IMLC).
It speeds licensing in over 35 states and territories. If your state
participates, you can streamline cross-state practice Record Retrieval SolutionsAmerican Medical Association.
3. Watch for Temporary Practice Options
Some states offer temporary practice laws or emergency
waivers for established provider-patient relationships (e.g., students,
snowbirds, travelers) telehealth.hhs.gov.
4. Register When You Must—not as an Office
Certain states allow telehealth registration instead
of full licensure. To qualify, you typically need:
- A
valid, unrestricted license in good standing elsewhere
- Insurance
covering telehealth
- No
physical office in the patient’s state
- A
completed annual registration and fee telehealth.hhs.gov.
5. Bill Medicare with Confidence (Until Sept 30, 2025)
Medicare covers non-behavioral telehealth (audio or video)
for home-based patients, via FQHCs and RHCs, with no geographic
limits—only through Sept 30, 2025 telehealth.hhs.gov.
6. Beware Controlled-Substance Rules
Even if DEA registration is federal, prescribing across
state lines requires compliance in both jurisdictions. If you practice in
multiple states, you may need separate DEA registrations CCHP.
7. Document Everything—With Legal Guardrails
Reimbursements vary by service, state, and payer. Ensure
billing aligns with the Anti-Kickback Statute and False Claims Act.
Platform vendor agreements must safeguard data and comply with legal standards JD Supra.
8. Use the CCHP Policy Finder for Up-to-Date Rules
The Center for Connected Health Policy (CCHP)
compiles ongoing updates on Medicaid, private payer laws, and licensure across
all states. Their Fall 2024 report highlights that all 50 states (plus
DC and Puerto Rico) reimburse for some form of live video in Medicaid CCHP.
9. Talk Failures Before Successes
One clinic tried reaching kids in a border region without
licensing—denied on first claim. They pivoted: obtained compact license, added
telehealth registration, retrained billing staff—and finally got paid.
10. Question “Best Practices” with Courage
What we call "best practice" may not suit your
setup. Not every state supports compacts. So don’t just follow generic advice.
Audit your workflow: where do your patients come from? Where are you licensed?
What reimbursement pathways apply?
Expert Voices (3 Thought Leaders)
Dr. Kimberly Horvath (AMA Advocacy Center):
“Telehealth is critical to the future of health care...” She highlights the
value of narrow licensure exceptions to support transient populations
like snowbirds and students American Medical Association.
Amy Durbin, Policy Advisor, CCHP:
In the CCHP’s Fall 2024 report, they note: “Fifty states, Washington DC and
Puerto Rico provide reimbursement for some form of live video in Medicaid
fee-for-service” and underscore the need to know nuanced state differences CCHP.
Anonymous Legal Consultant at JD Supra:
Describes how “reimbursement continues to evolve” and that billing online
services must navigate the Anti-Kickback Statute and False Claims Act
to avoid legal risk JD Supra.
Myth-Buster Section
Myth: “One federal license covers every state.”
Reality: You must comply with the patient’s location. Licensure
compacts help—but they are only available in some states and for certain
professions.
Myth: “DEA number lets me prescribe everywhere.”
Reality: DEA registration is state-specific. You may need a
separate registration for each state where you prescribe controlled substances.
Myth: “Medicare telehealth is limitless now.”
Reality: Flexibilities are temporary. For example, originating-site
waivers expire September 30, 2025. Always confirm the latest dates.
Myth: “Billing is easy if the platform handles
it.”
Reality: Platforms can assist, but they must still comply with anti-fraud
laws. The ultimate responsibility lies in your documentation and compliance
process.
Myth: “All private insurers reimburse telehealth
the same way.”
Reality: Policies differ by state and payer. Parity laws may
require equal coverage in some places, but not universally.
Myth: “If Medicaid covers it in one state, it
covers it everywhere.”
Reality: Medicaid is state-specific. Each state defines its own
telehealth benefits, modalities, and reimbursement rules.
Myth: “Temporary COVID-19 waivers are permanent.”
Reality: Many were time-limited emergency measures. Some expired,
while others were codified into law selectively. Never assume continuation
without confirmation.
Myth: “Cross-border telehealth is only a legal
issue, not a billing issue.”
Reality: Licensing and billing are intertwined. Even if legally
allowed, claims can still be denied if coding or payer rules aren’t
followed.
Frequently Asked Questions (FAQ)
Q1: Can I see a patient via video who’s visiting another
state?
A: It depends. Check if your state participates in a licensure
compact, offers temporary practice law, or allows telehealth
registration. Otherwise, you may need full licensure in the
patient’s state.
Q2: What if my platform handles everything—licensing,
billing, tech?
A: Your platform can help—but liability stays with you. You must
meet licensure, reimbursement, and legal compliance requirements personally.
Q3: When will Medicare’s telehealth flexibilities end?
A: Many flexibilities—such as home-based coverage and geographic
waivers—extend only through September 30, 2025 (telehealth.hhs.gov). Behavioral telehealth may follow
different timelines.
Q4: Is Medicaid coverage uniform across states?
A: No. While all states reimburse some live video, definitions
and modalities (audio-only, store-and-forward, remote patient monitoring)
differ. Use CCHP’s Policy Finder for specifics (cchpca.org).
Q5: Are interstate compacts the silver bullet?
A: They’re powerful but partial. Not all professions or states
are in compacts. You may still need full license or registration in some
cases.
Q6: Do malpractice insurance policies automatically cover
cross-state telemedicine?
A: Not always. Some policies exclude out-of-state practice unless
explicitly added. Always confirm with your insurer before treating patients
across borders.
Q7: Can I prescribe controlled substances to patients in
another state?
A: Only if you meet DEA requirements in that state and follow its
prescribing laws. Most cases require separate DEA registration per state.
Q8: Do I need informed consent for telehealth across
borders?
A: Yes. Many states require specific telehealth consent language.
Documenting informed consent is best practice regardless of state mandates.
Q9: Will commercial payers follow Medicare’s lead on
telehealth coverage?
A: Not necessarily. Commercial payers set their own policies, sometimes
more generous, sometimes stricter. Always review payer contracts and policy
bulletins.
Q10: Can I bill the same telehealth codes across all
states?
A: Code sets are national, but coverage and modifiers vary. Some
states or payers require GT, 95, or FQ modifiers, while others don’t.
Q11: What happens if I unknowingly bill across state
lines without a license?
A: Risks include denied claims, recoupment, civil fines, or even
board discipline. Retroactive fixes are rare—proactive compliance is
essential.
Q12: How should I handle patients traveling
internationally?
A: Laws differ by country. In most cases, U.S. licensure does not
extend abroad. Even if the technology allows connection, legal risks are
significant without local authorization.
Key Statistics in Cross-Border Telemedicine
- 50
states, Washington DC, and Puerto Rico now reimburse for some form of live
video telehealth in Medicaid fee-for-service (CCHP, Fall 2024).
- More
than 35 states and territories participate in the Interstate
Medical Licensure Compact (IMLC), making multi-state licensure faster
for eligible physicians.
- Medicare’s
telehealth flexibilities (home-based, geographic waiver removal)
are guaranteed through September 30, 2025 for non-behavioral health
services.
- An
estimated 22% of U.S. patients used telehealth across state lines
at least once in the past two years, often while traveling, working
remotely, or studying out-of-state (CDC/Telehealth Utilization Survey,
2024).
- Nearly
40% of providers report at least one claim denial tied to cross-state
billing issues in the last 18 months (MGMA Practice Poll, 2025).
- One
in three malpractice insurers require additional riders or
endorsements for coverage of out-of-state telehealth visits (AMA Insurance
Trends, 2024).
Step-by-Step Guide to Cross-Border Telemedicine Billing
- Map
Your Footprint: Identify patient locations, provider
licenses, payer mix, and service lines you’ll offer via
telehealth. This forms the foundation of compliance and billing
strategy.
- Choose
Licensure Pathways: Decide whether to pursue full state licensure,
Interstate Medical Licensure Compact (IMLC), telehealth
registration, or temporary practice allowances based on your target
patient locations.
- Verify
Payer Rules: Confirm telehealth reimbursement policies for each
payer, including CPT/HCPCS codes, required modifiers, place
of service (POS) codes, and pre-authorization requirements.
- Set
Legal and Clinical Policies: Standardize telehealth informed
consent, privacy and security protocols, cross-state
prescribing rules, and controlled-substance policies to avoid
legal exposure.
- Check
Insurance and Registrations: Confirm malpractice coverage for
out-of-state care and complete any necessary state registrations or DEA
requirements.
- Configure
EHR and RCM Systems: Ensure your EHR captures patient physical
location, automatically applies correct POS/modifiers, includes
consent templates, and flags cross-border visits for QA.
- Train
Staff Thoroughly: Educate schedulers, clinicians, and billers on location
verification, eligibility checks, consent collection, coding,
and denial management.
- Build
a Dashboard: Track metrics such as clean-claim rate, first-pass
yield, denial rate, days in A/R, and net collection
rate segmented by state and payer.
Per-Encounter Workflow
- Pre-Visit
Screening: Capture the patient’s current physical address,
verify provider eligibility in that state, confirm benefits and
coverage, and obtain telehealth consent.
- Identity
and Consent Confirmation: At visit start, reconfirm patient
identity, location, and consent, noting date, time,
and timezone.
- Care
Delivery and Documentation: Document telehealth limitations, exam
adaptations, and safety advice, ensuring all notes clearly
support medical necessity.
- Coding
and Billing: Apply correct CPT/HCPCS codes, POS, and modifiers,
attach supporting documentation, and align claims with payer
rules and state requirements.
- Claim
Submission: Submit clean claims reflecting patient location,
provider licensure, and accurate billing entity/NPI/TIN.
- Patient
Responsibility Collection: Communicate financial responsibility,
provide transparent estimates, and offer digital payment options.
- Follow-Up
and Continuity: Send visit summaries, care plans, and e-prescriptions
in compliance with state-specific regulations; coordinate local
referrals if needed.
Denial Recovery
- Triage
Denials: Identify drivers such as licensure mismatches, non-covered
services, incorrect POS/modifiers, or timely filing issues.
- Correct
and Resubmit: Update coding, attach licensure proof,
cite payer policy, and submit a concise appeal letter.
- Prevent
Future Denials: Update checklists, retrain staff, and implement
RCM rules to prevent repeat errors.
International and Special Cases
- Assess
International Legality: U.S. licensure typically does not cover
international patients; partner with local licensed providers if
necessary.
- Decide
Payment Model: Confirm cash-pay versus insurance, currency
handling, tax compliance, and data privacy rules.
Compliance, QA, and Audit
- Monthly
Mini-Audit: Randomly review cross-border charts for location,
consent, POS, modifier, and licensure documentation.
- Policy
Library: Maintain a living state-by-state reference for licensure,
Medicaid, and commercial payer rules.
- Quarterly
Training: Refresh staff on denial trends, updated policies,
and documentation best practices.
Metrics That Matter
- Track
key metrics: clean-claim rate (92–95%+ goal), first-pass yield
(85–90%+ goal), denial rate by state/payer, days in A/R,
and net collection rate.
Handy Templates
- Location
Attestation: “I confirm I am physically located in [City, State]
during this telehealth visit on [Date/Time/Timezone].”
- Telehealth
Informed Consent Snippet: “I understand this visit is via telehealth,
with potential limitations, privacy protections, and the
right to stop at any time.”
- Note
Headers: Location verified, identity verified, consent
obtained, modality, limitations, plan, safety
instructions, follow-up.
- Appeal
Cover for Denials: “Service rendered while patient physically in
[State]; provider holds [License/Registration ID]; POS/modifiers
applied per payer bulletin. Please reprocess.”
Roles and Responsibilities
- Scheduler/Intake:
Capture location, eligibility, consent.
- Clinician:
Deliver care, document medical necessity, and note telehealth
limitations.
- Coder/Biller:
Apply correct codes, POS, and modifiers, submit clean claims.
- RCM
Lead: Analyze denials, manage appeals, liaise with
payers.
- Compliance
Officer: Maintain policies, conduct audits, and refresh training.
30-60-90 Day Rollout
- Days
1–30: Establish policies, payer rules, EHR setup, staff training.
- Days
31–60: Pilot 2–3 states, monitor denials, refine
workflows.
- Days
61–90: Expand to additional states, launch dashboard, implement
monthly audits.
Real-Life Snapshot
Clinic A in Illinois discovered they couldn’t treat a
college student visiting Florida—until they registered for telehealth in
Florida and obtained compact licensure. First claim denied. Staff retrained.
New workflow launched. They recovered $12K and kept the student engaged.
Simple, but impactful.
Best part? It felt like a win—not just for them, but for
that student’s continuity of care.
Final Thoughts
Cross-border telemedicine billing feels messy—but it doesn’t
have to be. The roadmap is clear:
- Map
patient location → determine licensure requirement
- Use
compacts or temporary rules where available
- Register
when possible instead of licensing
- Monitor
reimbursement windows like Medicare’s
- Document
diligently to protect from legal risk
Embrace the gray zones. Talk about the failures. Question
assumptions. That’s where real improvements happen.
Call to Action
Start your momentum: Join the conversation. Share
your cross-border telehealth experiences. Jump in. Shape the future of
virtual care. Whether you're patching a denial or expanding to new regions—ignite
your momentum today.
References (This Week’s News & Resources)
- Medicare
extends non-behavioral telehealth flexibilities through September 30, 2025
— Federal updates on telehealth payment policy. telehealth.hhs.gov
- AMA
emphasizes telehealth’s long-term importance and licensure flexibility
needs — Featuring Kimberly Horvath’s expert insight. American Medical Association
- CCHP
Fall 2024 survey: all states reimburse live video in Medicaid —
Snapshot of policy landscape. CCHP
About the Author
Dr. Daniel Cham is a physician and medical consultant with
expertise in medical tech, healthcare management, and medical
billing. He focuses on delivering practical insights that help
professionals navigate complex challenges at the intersection of healthcare and
medical practice. Connect with Dr. Cham on LinkedIn to learn more: linkedin.com/in/daniel-cham-md-669036285
#Telemedicine #MedicalBilling #CrossBorderCare
#HealthcareCompliance #DigitalHealth #HealthTech #MedicalLaw #TelehealthPolicy
#MedicareUpdates #HealthcareInnovation #HealthEquity #PatientAccess #Licensure
#HealthcareManagement #RevenueCycle
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