program, telepsychiatry, and risk management considerations. Content in this presentation is intended solely to provide general information concerning the developments in the area of risk management. It is not intended as legal or medical advice, nor does it offer or solicit for offers with respect to any insurance product. Legal or medical advice should be obtained from a qualified legal counsel or other professionals to address specific facts and circumstances and to ensure compliance with applicable laws and standards, and listeners should consult their own insurance advisors for information pertinent to the purchase of any insurance product. This content may not be reproduced or redistributed in whole or in part without the prior written consent of Allied World. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American Psychiatric Association and Allied World. The APA is accredited by the ACCME to provide continuing medical education for physicians. The APA designates this enduring activity for a maximum of one AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity. No one is in a position to influence course content or has anything to disclose. My name is Kara Staus, and I will be your speaker today. I am an Assistant Vice President in the Risk Management Group for AWACS Services Company, a member company of Allied World. I provide risk management consulting services to Allied World's medical professional liability policyholders and insured psychiatrists, psychologists, psychiatric nurse practitioners, and physician assistants. So telehealth policy trends continue to vary from state to state, with no two states alike in how telehealth is defined, reimbursed, or regulated. And so our objectives for today's presentation will be to explain the current state of telehealth utilization and common uses in psychiatry, analyze relevant federal and state laws, regulations, medical practice, and reimbursement requirements that impact telepsychiatry, and to discuss key risk strategies to mitigate potential liability exposures when utilizing telepsychiatry. So let's review the two common terms which are often used interchangeably, telehealth and telemedicine. During the presentation, I will use the terms telehealth, telemedicine, and telepsychiatry. Telehealth provides a brighter scope of remote health services than telemedicine. The Health Resources Services Administration defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration. It can be used to conduct remote patient monitoring, holding therapy sessions, or reviewing and exchanging medical or lab reports. In addition, telehealth includes health applications for your smartphone or device, video conferencing platforms that you may use to provide services such as Zoom for Healthcare, DoxyMe, and Apple Watch or other wearable devices. While telemedicine includes only the delivery of remote medical services from a healthcare provider in one location to a patient in a different location, Medicaid defines telemedicine as two-way, real-time, interactive communication between the patient and the physician or practitioner at the distant site. Telepsychiatry is a subset of telemedicine with a range of services which may include psychiatric evaluations, therapy, patient education, and medication management. Definitions, laws, and regulations for telehealth and telemedicine do vary by state and federal agencies, and the Center for Connected Health Policy is a great resource to find telehealth-related laws and regulations across all 50 states and the District of Columbia, and at the federal level as well. This site is listed in the resources section at the end of the presentation as well. Telemedicine has grown in the United States over the last several years as a result of the pandemic. Telemedicine in psychiatry promotes health equity, and it will remain an integral part of medical care. It continues to provide critical access to healthcare services and became widely used to address the clinical shortage as well as provide access to patients located in rural areas. Some of the common uses in psychiatry are for telehealth to provide continued care and treatment to patients, to limit patient displacement to hospitals, and to help curb the spread of any disease. Telepsychiatry has been used to address the shortage of psychiatrists in rural and underserved populations for medical or medication management and psychotherapy, as well as routine follow-up and monitoring. There are three main types of technologies that are used for telemedicine. So the first is the asynchronous telehealth, which uses store and forward technology. So communication between providers, patients, and caregivers stored for future reference or response. Examples of this are online patient portals or even the use of telephones which connect to patients who don't have access to real-time video connections. And then there's synchronous telehealth, which includes real-time face-to-face interaction between the patient and physician. Synchronous telehealth is used most often by psychiatrists. It can be used as an alternative to in-person care delivery to diagnose, consult, and to treat patients. And then lastly, remote patient monitoring, also known as RPM, which is fast-growing. This includes transmitting and storing patient data and clinical measurements from in-home devices to patient portals. This may be asynchronous when the provider reads the data separate from the patient provider visit or synchronous during a provider visit. There are many trials currently underway in neuropsychiatry using remote patient monitoring. So an example of this being used in behavioral health is using a technology platform where patients can use an app for reporting on their anxiety, engaging in daily journaling or taking standardized assessments like the Generalized Anxiety Disorder 7 Scale, where health professionals can log in and look at the data and be able to respond to patients with simple interactions like sending the patients new content to read, providing feedback on the patient's assessments, and offering encouragement in between visits. So there are both benefits and barriers to the use of telehealth. So let's look at the benefits. So telehealth provided and provides improved access to care. It also provided care to patients in rural or underserved area where they might have to travel a distance to seek care. Telehealth was able to bridge that gap. It brings care directly to the patient's location. It also can reduce delays in care or unnecessary trips to an emergency department. It supports independence of seniors who may want to age in place and not want to depend on others to get them to their medical appointments. It also allows parents to have an appointment without the need to obtain child care. Again, we've talked about travel, so it is going to reduce the need for travel. It decreases wait times, reduces the rates of no-shows, and reduces the barrier of stigma in accessing medical care. Communication, there's more effective communication. You know, you're in your own home. There's less anxiety and pressure than in an office setting. You know, there's an additional patient data can be obtained by seeing the patient in their home and in their own environment. So with those benefits, there's also some barriers with technology. Technology can create technical challenges, whether it's the access to the internet or even, you know, having a strong device. So there may be, you know, some voice issues or clarity issues with technology. So limited patient access to the technology, so a patient might not have a smart device or a computer to access the platform, which could be a barrier. Or they may have difficulty using technology. Both the patient and psychiatrist, there could be a difficulty using it, whether there is a gap in understanding technology or just a simple, you know, barrier. The technology is not working, so what do we do about that? There could be financial barriers to access that broadband and reliable internet services and lack of in-person assessment. So again, we need to be sure that the person would be appropriate for, you know, that telemedicine, telehealth encounter. And then reimbursement, could there be uncertainty in certain circumstances of reimbursement? Licensing certainly is a barrier, understanding where the patient is and the patient's location does impact your license, needing to be licensed in the location where the patient is physically located at the time of the telehealth encounter. And then certainly, it goes without saying, with technology, there are privacy and potential cybersecurity risks as well. So as the telehealth laws continue to change at such a rapid pace, it is certainly an evolving area in the law. So it's important for psychiatrists and other mental health providers to understand that these laws, you know, are changing and fluid. And so to keep up to date with these changes, a terrific resource for information with up-to-date regulations by state can be found on the website for the Center for Connected Health Policy. But these are some of the considerations that we will go through. On the next several slides, we'll talk about licensure, international considerations, how to avoid litigation, informed consent, prescribing, malpractice, reimbursement, and technology. So we'll start off by talking about licensure. So the psychiatrist must be licensed in the state where the patient is physically located at the time of the visit. Licensing is not based on the patient's home address or where they might own property. But where they are physically located at the time of visit. So for example, if a patient's residential address is in Massachusetts, but the patient is physically located in California at the time of the visit, the physician needs to be licensed in California. If you do not have a valid license in the state where the patient is located, you may face a multitude of issues, including potential disciplinary action by the Board of Medicine for practicing without a license in that state, potential or possible criminal, civil, or administrative sanctions. Your malpractice insurer may not cover you in the event of a claim. And you also may not be reimbursed for services. So again, it's important to stay up to date, review the regulations specific to licensing when you are treating patients who may be portal and moving from state to state. When providing telemedicine, you must know those state laws, regulations, and guidance. So it's important to know medical practice laws in those states. What is your duty to warn? Is there any particular or, you know, specific mandatory reporting obligations regarding, you know, child neglect or abuse or elder abuse? And then what about civil commitment issues? Again, these are important factors to consider when looking at the licensure and cross-state care. Many states do not restrict where the physician is located during the time of the visit. So again, it's important for you to understand and review these state-specific laws so that you do remain in compliance when providing care to your patients. So each state has their own licensing rules. You know, the traditional route of applying for a license, you would approach the medical board in that state. There are special telehealth registrations that may be offered in some states. For example, Florida is one that offers registration versus full licensure. There are some specific criteria that need to be met. So it is important, again, to review those. And the Interstate Medical Licensure Compact, you know, is a great resource and path to licensure that may be a little bit easier. So we just mentioned the Interstate Medical Licensure Compact. Here is a graphic that comes directly from the Interstate Medical Licensure Compact website, the imlcc.org. So the medical and Interstate Medical Licensure Compact offers the expedited pathway for qualified physicians to obtain their medical license in multiple states. So there are licensure compacts for other professionals, such as psychologists, social workers, and nurses as well. So basically, how it works is that a physician lives in a state that is a member of the compact. So you have to, number one, live in a state that's a member of the compact and that you can use that compact to facilitate obtaining licensure in another reciprocating compact state. And so the compact basically streamlined an expedited process to obtain a full license in order to be able to practice in another state. So currently, 31 states, D.C. and Guam, fall under this category. So before providing international telemedicine to patients in another country, the psychiatrist should be aware that each state, providence, or country regulates licensing, prescribing, and medical practice regulations in the country where the patient is located. And again, it's important to understand and be aware of the considerations when looking to treat a patient who may travel overseas or temporarily move overseas. A terrific resource, again, is the World Psychiatry Association. Does have up-to-date information on international telepsychiatry. Again, their website is www.wpanet.org. So key considerations is to understand licensure. Those international countries may have licensure regulations in order to practice within their country. Prescribing. You know, consider prescribing. Is the patient that you are looking to treat, are they on medication? And how will they obtain that medication while they are in that country? Is there a limitation? Some countries do restrict medications being sent through the mail to their country. And some medications that we prescribe here in the United States may be prohibited in other states. Consider privacy and security. So, in the United States, we have HIPAA high-tech security rules. Do other countries have similar rules in order for you to maintain compliance with? So, they may have more stringent requirements for the protection of, you know, health information within those countries. So, it's also important, you know, to understand technology barriers. Is there technology issues, internet access issues within those countries? And then, cultural competence. So, is there a barrier with the ability for you to safely manage a patient that is living in a foreign country? Where are they located? You know, what resources do they have access to? Will you be able to know what to do in the event of an emergency, where to send them? Are there referral issues or barriers? And then, malpractice insurance coverage and considerations. Make sure you contact your malpractice insurer prior to engaging in any international consideration for telehealth outside the country, so that you can ensure that you would have coverage in the event you choose to treat a patient located in a different country. Avoiding litigation is important to consider, and following these areas, you know, in telepsychiatry will help to reduce that risk. So, consider the standard of care. In most medical malpractice lawsuits, when there's a claim initiated, there's typically a claim for negligence. Negligence in the care that you provided to them. So, in order, you know, for that claim to be proven, the provider must have reached the standard of care by something the provider did or did not do that resulted in patient harm could be the allegation that the individual is bringing forth. So, it's important to understand the expectation of the standard of care would be the same as if the person presented to you in an office setting. So, standards of practice, ethical and legal requirements are the same whether you're in person or you're using a telehealth platform. So, this would include patient evaluation, any handoff communications, your treatment plans, and documentation practices. So, make sure you're staying current with the standards for using telemedicine technology and exam methods. Patient selection. Selecting patients who are appropriate for telemedicine is really the important first step. So, are they appropriate? Is there a clinical need or treatment request? Does the patient have the capacity to participate in telepsychiatry? Not all patients will be suitable for telepsychiatry. You know, for example, if you're treating children, a very young child may need to be seen in person as well as an older person may need to be seen in person as well. Can the patient use technology? Is that video consultation adequate to assess the patient's mental status, physical state, and are you able to see any subtle cueing, you know, such as a tremor, you know, during that evaluation? Also, consider, you know, patient safety. Do you have access to referral sources wherever the patient is located? Do you know where they're located? Would you be able to contact the authorities or crisis center in the event the patient needs a well check? So, again, have all those considerations in play when determining whether or not a person is appropriate, and that might change throughout the plan of care or treatment with the individual. Be sure that you have authorization to speak with other treating providers, the patient's family, or an emergency contact. So, again, it's important for you to gain this and gather this information during the telehealth encounter. So, we often receive phone calls from our insured psychiatrists and psychologists who tell us that the patient has not authorized discussions to speak to other treating providers which may be interfering with the treatment. So, again, it's important at the start of care and upfront, even in a telehealth encounter, to obtain those consents and make sure that you make the patient aware that as part of treatment, you will need to speak to these other providers involved in care. Have you reviewed the medical records of any previous providers before you are agreeing to see the patient? So, what is your responsibility for identification? This is another area where we've received some calls about verifying their identity or location, so, again, it's important for you to have two identifiers if possible. Have the patient show their driver's license or valid photo ID and document the confirmation that you did look at it. In addition, it's important to have some other documentation to show, you know, where they're located, whether it's a, you know, bill, you know, for services, you know, to their home or insurance card, something that shows, you know, that they are who they say they are is important. Document the physical location of the patient each time of the visit as part of the verification process to ensure that the patient is located in the state in which you are licensed. And also, it's important to document your location at the time of visit for billing and compliance purposes. So, informed consent is an important piece of medical treatment, and it's important to discuss the informed consent process during a telepsychiatry encounter. So, the patient must be able and competent to make a voluntary decision to engage in telepsychiatry, and so it's important to have a conversation. Informed consent is not just a form, rather it's a conversation, understanding the risks and benefits of treatment, and ultimately the form is signed with the patient's acknowledgment of the discussion. Keep in mind that states have informed consent requirements in their statutes, administrative code, and or Medicare, Medicaid policies, and some have a specific requirement directly related to telemedicine. So, in a telemedicine informed consent, it's going to include other risks in addition to the traditional risks you would have in your informed consent in an in-person encounter. So, you want to, at a minimum, discuss telehealth, what it is and how it's used, the expected benefits and risks and alternatives, and inform the patient. They must be physically located in a state where you are licensed and insured. The HIPAA privacy and security measures, so whether recordings of this session are permitted, make sure the patient understands. If you don't want something recorded, then that should be a part of your consent policies and procedures. Make sure the patient is in a private location. We often hear that, you know, patients, you know, may be at school, at college, and not in a very private location. So, before starting that session, make sure that the patient is in a private location. Obviously, you don't want their confidentiality and privacy breached, as well as yours as well. And then have an explanation of the visit. So, understand that the patient can withdraw that consent for telehealth at any time. So, it's important to make sure, from a documentation standpoint, that you do have a patient signature of that informed consent in the medical record. So, whether you use a patient portal to send the information or you mail them a copy of the consent, they will need to return it to you so that you have it in the full, complete medical record. One of the issues we have seen with telemedicine encounters is that there is an informed consent often in the medical record, but it's missing a patient signature. So, be sure to follow up and make sure that the patient has signed that consent. So, online prescribing has been one of the hot buttons in telemedicine and telepsychiatry, you know, over the past few years. It's important to know that online prescribing is governed by both federal and state laws, and it is very important to stay up to date with all federal and state laws as it pertains to telehealth and prescribing. We recommend that you review the latest information published by the DEA and Health and Human Services for any telemedicine flexibilities related to the extension of the public health emergency. So, as you know, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 was created to regulate online internet prescriptions. It's enforced by the DEA, and it imposes rules around the prescription of controlled substances through telepsychiatry. So, the act essentially requires any practitioner issuing a prescription for a controlled substance to conduct an in-person medical evaluation. There are specified exemptions prior to prescribing controlled substances. Again, as I mentioned, the public health emergency does impact some of the original regulation, and so at the time of this recording, it's important for you to reference where we are in the current state of the public health emergency and extensions on the DEA website and the Health and Human Services site. So, per the act, the prescribing practitioner is required to at least perform one in-person medical evaluation with the patient via telemedicine, and this would be at the time and then the frequency of reevaluation is not mandated under the act. So, again, it's important to reference those current regulations in order to stay in compliance. The flexibilities that were in place through the COVID-19 public emergency health waiver, you know, may impact some of the regulation and may have changed that some bit, but again, as the regulation, you know, currently reads prior to the flexibilities, and it is very fluid and there are changes that could be made, but that is the way the law currently reads. So, prescribing via telehealth, there was a rule in place that you must see all patients in person prior to prescribing controlled substances. Again, the telehealth flexibilities do change that. We also see this as a best practice. If you can see a person in person, it is a best practice. If you have only seen patients by telehealth that have received prescriptions, you may need to see someone in person. Again, it could be confusing. So, please reference your state-specific laws and the federal laws surrounding those flexibilities regarding prescribing, and then it's important to note you do need a DEA license in the state where you're prescribing or dispensing controlled substances. So, keep in mind that the DEA has other specific requirements for you in terms of having an office location or address in the event they do need to perform any type of audit. When prescribing via telehealth, the PDMP, so the Prescription Drug Monitoring Database, should be something that you are looking at and considering. We've received several reports of patients seeing multiple psychiatrists to obtain the same prescriptions. So, again, at the start of care, it's important for you to check this, and then randomly check it throughout your treatment, whether it's, you know, every 90 days to ensure that there is no abuse going on in terms of the medication. So, with documentation and prescribing, make sure that you're documenting a physical and or mental status exam, any medication histories, and the review of pertinent medical records. Do not just take a patient's word for it. Ask to see any relevant or prior medical records if needed. Document what the medications are being prescribed, dosing and effects. Are they working, you know, or is there a benefit, improvement? The date and time the PDMP was checked. And then, obviously, we talked about consent to make sure that you have that proper informed consent. If you do suspect that your patient is involved with drug diversion, please seek advice from the DEA where the patient is located. And, again, it's always best to refer to DEA or SAMHSA and the HHS for the most current up-to-date information regarding prescribing and telemedicine. So, malpractice insurance coverage. It is important to just disclose the use of telemedicine services as part of your underwriting process with your malpractice insurer. So, even if they don't request it, it's probably a good idea to just ask about it to be ensured that you're covered. If you're licensed in multiple states or you travel frequently and you hope to use telemedicine, make sure it's clear to your insurance carrier that you are providing coverage in multiple states or traveling just to verify coverage. Review your professional liability insurance policy descriptions of coverage and or exclusions. So, lack of an exclusion for telemedicine services or a broad definition of professional medical services does not mean that the policy provides coverage for telemedicine services. So, it is important to ask these questions of your malpractice insurance provider. It's also a good idea to request written confirmation from the insurer of the coverage for telemedicine services. And consider obtaining a separate cyber liability insurance coverage to protect against any data breaches or hacking of your telemedicine platform. This is really something that we stress the importance of because in the age of technology and we see so many hackers looking for patient data, consider looking into a separate policy so your protections are covered. So, data and research on telehealth is still needed to inform, you know, really what risk mitigation strategies are out there. And so, it probably will take several years for us to have cases involving telemedicine that are litigated. So, lawsuits specific to telehealth are still rare and they will likely change as a result of the changing legislation. So, a major question that does come up is are you covered for telemedicine services? So, you know, each state and CMS does offer some form of reimbursement for telehealth, but policies do vary. So, certain policy restrictions for traditional insurances, there might be a number of visits that they limit it to. So, there might be provider types or disciplines that are limited or the type of service or the type of, you know, telehealth. So, again, it's important to understand those limitations of the patients that you are seeing and the insurance coverage that they may have so that you are reimbursed appropriately for those telehealth encounters. So, the Center for Connected Health Policy, you know, is the National Telehealth Policy Resource Center. It does summarize each state's telehealth policy and also goes into detail on the Medicare Medicaid and private payer reimbursement policies. So, it is a great resource to consider when looking at those interstate issues regarding telemedicine. So, some payers, you know, may not continue to pay for telehealth. We don't know that for sure, but these are the trends that we, you know, may see coming. You know, CMS is right now, I believe, the only permitting of audio technology unless a state requires it. So, again, keep in mind, if a state has, you know, a greater benefit, then the state is going to essentially take over, you know, from that federal policy if it's providing that greater benefit. So it is important to be mindful of your state and federal policies when considering all of these legal issues that we are reviewing. So Medicare reimbursement is allowing physicians to bill for both video and audio for telehealth. So telehealth related fraud and abuse, you know, is enforced by the DOJ and the Department of Health and Human Services under the Office of the Inspector General. And so they will be looking specifically at exclusions from Medicare or even, you know, civil penalties and holding individuals personally liable in the event there is telefraud leveraged. There has been a significant increase in telefraud scams that are leveraged, you know, through aggressive marketing campaigns. So just for example, those involved are telemedicine executives, company executives that may have medical practitioners, marketers, or business owners who have been scammed out of thousands of dollars and thousands of patients. So be aware of those marketing trends. So implement adequate controls to prevent inappropriate over-utilization of telehealth. So be mindful of that so that you don't run into an issue regarding any potential reimbursement issues because that is a trend that they're looking at. Is someone utilizing it or over-utilizing it too much? And then document the medical necessity, establishment of that patient-provider relationship and the care provided or ordered over the services. So again, those are going to be the trends that we're seeing and then how you can mitigate. So some examples of kickbacks that you may need to be aware of is that if you have a telehealth platform that integrates with marketing. So within your telehealth platform or product website, there's a direct link to the site. So patients might be confused that you may have some affiliation with them from a marketing standpoint. So just be mindful of those potential pitfalls when engaging in certain products or services. Keep an eye out for ethical practices. So one telehealth company has been accused of pressuring physicians to prescribe stimulants such as Adderall only after a 30-minute evaluation for ADHD and putting profits and growth before patient safety. And that was from an article in 2022. So some red flags to be concerned with if the telemedicine company you work for. So if you're working specifically for a telemedicine-only provider, if they're restricting your treatment options to a predetermined scope of treatment, you may want to consider, is that a good fit for you? Do they expect you not to follow up with patients or does it not give you contact information for the patient? So are there barriers or limitations for you and the provider to have contact with patients? Does the company compensate you based on volume and items of services or prescribed? So again, is there some type of benefit to you not really looking at the patient care aspect but over the volume? Are they only providing services to federally health qualified programs and not other insurers? And are patients recruited from the telemedicine company? So again, those would be the red flags that we'd want you to consider and be mindful of any federal anti-kickback statutes, understanding what they are and avoiding them at all possible. So telemedicine is the electronic transmission of information and we must meet HIPAA compliance standards with technology itself. So again, understand that the HIPAA platform you're using or the technology platform must be HIPAA compliant. So waivers from the public health emergency for the use of non-HIPAA compliant platforms have ended. Those waivers do not exist. And so you must have a HIPAA compliant platform and you also should have a business associate agreement with your vendor. That business associate agreement protects you and protects the patient from the improper exchange of data. What that does is it ensures that that vendor is also maintaining compliance with the HIPAA standards. So there is some forms of Zoom that are HIPAA compliant, such as Zoom for Healthcare. You wanna make sure that it is healthcare and HIPAA compliant. FaceTime is not HIPAA compliant. Skype is not HIPAA compliant. Again, unless it is specific and notates that it has compliance with healthcare and HIPAA. So at the end, we have a reference and resource slides that provides a list of HIPAA compliant platforms. So a business associate agreement, is that written arrangement that specifies your party's responsibilities when it comes to PHI. So it's not going to permit further disclosures of PHI or it's going to state when that disclosure of PHI can exist. So it is ensuring that there are appropriate safeguards in place to reduce any risk for a HIPAA privacy breach. So some risk reduction strategies with technology is make sure that you have network software security and authentication protocols in place, that you're implementing measures to safeguard data storage and transmission against unwanted disclosures. And you're performing cybersecurity testing on a regular basis to identify any cybersecurity vulnerabilities. And as I mentioned in the prior slide, recommending cybersecurity coverage, insurance coverage, there may be opportunities and resources within that coverage for you as well. So professional boundaries and telemedicine. So the cyberspace environment really has become a more casual and appears to be more relaxed, which is great for the patients to feel more relaxed and probably easier access. It makes it a better session. But it's also important for you as the physician providing the care and treatment to be sure to establish the appropriate boundaries when it comes to treating patients by telehealth. So make sure that the expectations are clear. And I had mentioned earlier that the standard of care exists, and it should be considered the same for in-person as it is in the telehealth session. So make sure the patients are on time to the sessions. If you have cancellation procedures or late or missed appointments, make sure that those are followed in the telehealth environment as well. Make sure that each time there is a visit that the patient is in a safe and private location. Make sure that you establish this during the informed consent process. Discuss your policies and procedures for email communication or messages or after hours emergencies. Again, in the age of technology, we all can communicate from the safety of our homes. And sometimes it may appear as a more relaxed environment. So set those boundaries. If you have a set period of time where you're going to be responding to emails or texts or messages that are routine in nature, make sure you keep to that schedule. And then obviously ensuring that your patients know of what to do in the event of an emergency. You should maintain the same professionalism as an in-person setting, such as your communication style, language, and attire. And telehealth and phone calls can become too casual. So again, make sure that you're establishing those standards at the onset. So let's continue with documentation. Clinical documentation helps to demonstrate regulatory compliance with medical necessity for billing and defending the provider in the event of a licensing board complaint or professional liability claim. In addition to the clinical encounter, documentation for telehealth should include the time and date of the clinical encounter and start and stop times, unless you're in an electronic system and you're documenting real time. The method of telepsychiatry. Did you use an audio only telephone or what type of telehealth did you use? Did you have any malfunction in the technology that affected the quality of clinical care? So was there an issue? Did the session have static or break up, or did you have to disconnect and reconnect? Notate where the patient is located at the time of the session. Are they in the state, their physical location at their house, at their place of work? You know, the verification is key in the event there was ever an allegation of a licensing that came up, or also for you, emergency management protocols. In the event of a crisis, you know exactly where that patient is and you have the ability to make a phone call for emergency services. If there's mandatory reporting requirements in play, that location is going to be key for you. And then any reimbursement that may be tied to where the provider or patient is located is also important. So patient consent and confirmation of their identity is important. If the patient refuses, you know, then an in-person visit may need to occur. And then if there's other people involved in that session, is there somebody else in the room? Make sure that you identify them, have the name and the relationship of the individuals present. So for example, if it's a family member, another healthcare provider, or even an interpreter. So remember that the DEA has proposed rules that will change documentation requirements for prescribing. So be mindful and keep an eye out for those changes. So as we finish this presentation for today, you know, some of the key risk management strategies to review that we've talked about is licensure. Remember, you must be licensed in the state where the patient is physically located at the time of the visit. Understanding that over the past few years, due to the public health emergency, there were flexibilities in place with this. However, it is important for you to know that your license is driven by where the patient is located physically, not where their address is, not where they receive mail. Again, be mindful of any state-specific requirements for licensure in the state where the patient is located. Understand federal and state telehealth laws. So keep up to date on these regulations. They do keep changing, and they are hard to follow. So your state medical practice acts. Are there any privacy considerations? Informed consent. Consider prescribing, billing and reimbursement, an in-person exam, and informed consent requirements. Telehealth requirements. Remember, the standard of care is the same for in-person and telehealth sessions. Privacy laws. Making sure that you are using a HIPAA-compliant platform, using an informed consent process for telehealth, and always make sure you are having and utilizing a business associate agreement. When prescribing, be aware of the current DEA guidelines related to the Ryan Hite Act. It's important to stay up to date on any changes to the act on an ongoing basis. And you can find this information at the DEA.gov website. If you are prescribing medication to patients, and you must see the patient in person prior to prescribing, again, look at the law, what is the requirement at the time? Be aware of the face-to-face requirements and the extensions of the public health emergency, and monitor for any changes that may exist. And understand that you will need a DEA license in each state where you prescribe. Billing and reimbursement. The Center for Connected Health Policy has tremendous resources that summarize all federal, state, and private payer reimbursement laws, and telehealth-related fraud and abuse enforcement is a priority under the Department of Justice and the Office of Inspector General. So be aware of these billing red flags. Your malpractice coverage. Review your professional liability insurance policy from time to time, and any descriptions or coverage and exclusions. Remember, you can call them if you have any questions or concerns to find out what is covered under your policy, and are there other policies to consider that may protect you further, such as do I need a cyber and technology policy to protect me for the amount and the volume of telehealth encounters you're performing? So it's important to mention to your malpractice insurer if you are practicing across state lines, just so that they have it documented. Does it change your insurance? It may not, but it's important to just have that dialogue with them so that you have the coverage in the event it needs to be triggered at any time. And then medical record documentation. It goes without saying that documentation is one of the key risk management principles, and it's one of the most important pieces of patient care, and it should demonstrate your regulatory compliance and the medical necessity for billing. So because telehealth is an evolving area of the law, it's important for psychiatrists and other mental health providers to understand these laws and learn about the changes. And so these are the resources that were utilized in preparation for this presentation. They are here on the slide for you to look at. There's tremendous resources out there. Again, there's a lot of information we covered, a lot of regulation. So take the time to take a snapshot of this so that you have these sites in the event you need to access them. And here's some additional resources. Again, the Center for Connected Health Policy, the Centers for Medicare and Medicaid, the American Psychiatric Association obviously has links to these as well. The Federation for State Medical Boards is another terrific resource for obtaining information for you on licensure specific to telemedicine, HIPAA, and health IT, and the DOJ, and then the PDMP monitoring program. So thank you for participating in our presentation today. If you have any questions on your insurance needs, you can contact the APA Endorsed Professional Liability Program, the American Professional Agency, Inc. at 1-800-421-6694, email psychiatry at americanprofessional.com or www.americanprofessional.com to access their website. Thank you.

telepsychiatry

laws and regulations

risk management

licensure

informed consent

reimbursement

technology

documentation

cyber liability insurance