Can Your Physician Use Telehealth To Treat You When You're Out Of State?

 I was out-of-state when my doctor's office called to set up a telehealth appointment for me.  The date they wanted was when I was going to be back in Alaska.  I thought, wow, this is great.  If I'm out-of-state, I can still have an appointment with my doctor if needed.  

But they said, "No, you have to be in Alaska."  

For me, that makes no sense.  If I need a doctor when I'm not in Alaska, I'd rather see my doctor than a one I don't know.  [Of course if there's a need for physical contact or tests, it's not going to work as well.]  

So when I had my appointment, I asked, "Why can't we do this if I'm out-of-state?"

The nurse, the doctor, and the doctor's supervisor (this is through Providence) weren't exactly sure.  They'd been advised that it had to be Alaska only.  Licensing seemed to be a possible reason, but they weren't sure.  And they couldn't cite any documents I could see for myself.

Whether this was a state law, regulation, Providence policy or something else, they didn't know.  

So I decided I would try to track this down.  Here's what I've found out so far.

• During COVID emergency health declarations waived some interstate telehealth barriers, and much of what first pops up in searches are pandemic era webpages, some of which have dates on them.  
• A big issue IS the need to be licensed in the state where the patient is located
• Another issue has to do with payment for patients on the state medicaid or other health programs
• Some states allow out-of-state doctors to have telehealth appointments in their states, but the rules aren't easy to figure out for individual doctors.  There are various conditions one has to meet, and one has to be sure the source of information reflects the current law, that no changes have been made

Interactive at the site which appears
to be updated frequently

CCHP (The Center for Connected Health Policy) has some of the best information I've found so far.  Their Out Of State Providers page has a map that links to the policies for every state.  And they seem to keep it up to date.  One was updated this month.

For instance, here's what it says for Arizona:

"Arizona

Last updated 11/07/2023

A provider who is not licensed within the State of Arizona may provide Telehealth services to an AHCCCS member located in the state if the provider is an AHCCCS registered provider and complies with all requirements listed within A.R.S. § 36-3606.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 2), Approved 8/29/23. (Accessed Nov. 2023)."

AHCCCS refers to Arizona Health Care Cost Containment System. The link isn't really that complicated, but if I were a physician, I'd want an attorney to read it.  

From HHS:

"Some states have temporary practice laws to support existing provider-patient relationships and minimize gaps in care. These laws allow a provider to practice for a limited amount of time, usually less than 30 days, in another state if their patient is temporarily visiting that state for business, a family visit, or other reasons."

This includes what I would be after - treating one of their regular patients who happens to be temporarily out of state. 

What states clearly or not so clearlyseem to allow out of state doctors not licensed in the patient's state to provide telehealth services to patients located in their state?  Go to the CCHP map page to get details for each state.

• Alaska
• Arizona
• Connecticut
• Georgia - "Physicians with licenses in other states may be licensed under the Interstate Medical Licensure Compact"  You can read more about this Compact here.  They also have a map that shows which states are in various steps in the process of joining the Compact.  
• Indiana - "Out-of-state providers can perform telehealth services without fulfilling the out-of-state prior authorization requirement if they have the subtype “Telemedicine” attached to their enrollment.  See Module for requirements."
• Kentucky - this one seems particularly liberal.
• Maryland
• Minnesota
• Oklahoma
• Oregon - Looks like a liberal policy
• South Dakota
• Vermont
• Washington
• Wisconsin

Most of the concern seems to be with the State reimbursing for services to Medicaid patients.  There are various conditions placed on out of state providers.  Note that I said 'appear to allow out of state" providers.  And there were some states that might allow out of state providers who are not licensed in the patient's state, but I couldn't really tell for sure.  

So, the problem doesn't seem to lie with the State of Alaska. 

The issue is 

• with other states - some do and some don't allow it, and those that do have different requirements
• with Providence for making a blanket policy rather than tailoring it to the states that allow for out of state doctors.  Providence should know which
• which states do not allow out of state doctors to have telehealth appointments with people in their states, 
• which states do allow it, and 
• what the requirements are for those that do
• with doctors who have licenses to practice in other states letting Providence know that

I would like to think this is simply policy that hasn't caught up with technology changes and not simply stodgy hospital administrators not wanting to change or lazily using the law as an excuse

But I also understand that collecting all the necessary data and keeping it up to date is somewhat of a challenge.  But I was able to do this in less that four hours, so someone in the Prov administration should also be able to do it.  Especially since Providence serves Alaska, California, Montana, New Mexico, Oregon, Texas, and Washington.

Alaska's $400K Donation To Support DC Law Firm's Anti-Obama Care Campaign

How else can we explain this? 

Alaska Superior Court judge Frank Pfiffner soundly rejected the Legislative Council's court challenge to Gov. Bill Walker's expansion of Medicaid in Alaska.  The expansion will proceed next Tuesday, Sept. 1.  Some 40,000 Alaskans will gain access to affordable medical care.  The state will get an influx of over a billion dollars.

But it appears the Republicans want to appeal.  The ADN online post of Aug. 29 ADN reports

"By the end of the day, the Alaska Supreme Court had already received the Legislature’s request for emergency review and ordered Walker’s attorneys to respond by Monday at noon."

[UPDATE Tuesday Sept 1, 2015:  The ADN reports the Alaska Supreme Court agreed with the Governor's attorneys to let Medicaid expansion begin today, Sept 1.  They did not rule on other parts of the suit.]

In either case, the $400K has been appropriated to the DC law firm Bancroft PLLC.  I posted a bit about them two weeks ago.  The Nerve reported in Jan 2013 that Bancroft PLLC had charged South Carolina over $3 million to defend their voter id law. 

"Bancroft PLLC, located in Washington, D.C., billed a total of 6,290 hours from September 2011 through last September at hourly rates of $520 for attorneys, $200 for research associates and $180 for paralegals. With other litigation costs thrown in, the firm's total invoice came to $3,419,439. .  .

Federal online court records show that eight Bancroft attorneys represented the state in the voter ID case, which, based on a total cost of $3,419,438.28, works out to an average cost of $427,429.78 per lawyer."

If you read that quickly, you might not have realized that 6,290 hours equals 157 forty-hour work weeks, just about three years of work in about 13 months.   Divide that by eight (for eight attorneys) and that's over 19 weeks per attorney - almost five months full time each.  OK, I realize attorneys bill more than 40 hours per week and that there were paralegals and others.   But also note it was a Bancroft attorney who lost a case over billing when he charged for his commuting time.

One wonders how the Alaska legislature will monitor the bills from Bancroft.  Basically we're paying them for research work they will use to fight Obamacare in other states.  Again, I realize that's how things work, but I don't think most Alaskans want to be making this sort of subsidy to this sort of firm.  It's especially galling since a) it's likely to lose and b) for most Alaskans, based on their views on Medicaid expansion, it would be worse if they won. 

Do our state Republican legislators even care?  I don't think so.  This is a way for the firm to get its new friends in the Alaska legislature to move money from Alaska's treasury to theirs.  Nothing Chenault and gang say to defend their actions makes sense on the face of it.  Herz quotes House Speaker Chenault as saying,

“We are by no means looking for a way to stop Medicaid expansion; we are trying to do it the right way so that we have a reliable, sustainable system.”

Yeah, sure.  This appears to  really be  part of a national ideological fight against Obamacare. Every state that signs up for Obamacare is a loss for these anti-Obamacare forces.  I'm sure they've come to the legislative leaders and convinced them (using logic? promises of future support?) to fight this Medicaid expansion at all costs. That's why they hired Bancroft, the key law firm that specializes in anti-Obamacare lawsuits.  Who were the brokers who connected Chenault and his merry gang with Bancroft?  The same folks who pushed them to fight the expansion in the first place?  Even though a strong majority of Alaskans favor Medicaid expansion?  I'm sure Koch funded groups like Americans for Prosperity who opened an Alaskan office this year played a role.  Sourcewatch writes:

According to the Center for Public Integrity, Americans for Prosperity "spent a staggering $122 million (in 2012) as it unsuccessfully attempted to defeat President Barack Obama and congressional Democrats," including $83 million on "communications, ads, and media."^[3]
http://www.bancroftpllc.com/scott-v-u-s-dept-of-health-human-services/
 to the US Supreme Court.  They lost the critical one NFIB v Sibelius that would have shut down the Affordable Care Act  and won the second Scott v. US DHSS. 

Note:  Bancroft was the anti-Obama care law firm in both those suits - NFIB v Sibelius and Scott v. US DHSS.

[Addition 7pm - I forgot to mention that the Governor got an Anchorage law firm to work with the AG's office to represent his (our) side for free.  People of Kenai, really, are you going to reelect Chenault?]


Note 2:  The South Carolin Voter ID law mentioned above:  A Washington Post article reports that while the Department of Justice rejected the law in Dec. 2011, a unanimous three judge panel of the US Court of Appeals for DC approved it October 2012, but delayed implementation.]

I'd also like to salute Nat Herz who did a great job of sending out tweets from the judge's reading of the decision on Friday.  He also tried to live feed it, but I wasn't around for it live, so I'm not sure how that went.

Screenshot of Nat Herz tweeting from the courtroom Firday