Are you a psychiatrist who’s wondering WTF the telepsychiatry guidelines and procedures are now that the Public Health Emergency (PHE) has ended? What will happen to the Ryan Haight Act? What exemptions will there be for those of us who practice telemedicine exclusively?
If you’re confused, don’t worry, you’re in good company.
This topic comes up a lot on my bi-weekly Q&A career mentorship calls so I wanted to write this post clarify and consolidate the information we do have from the American Psychiatric Association (APA) and DEA on the telepsychiatry policies, procedures, guidelines, and special exemptions as of June 2023.
Do I have all the answers? No. Honestly, not even the governing bodies who are making these policies do either because the new telepsychiatry guidelines and telemedicine special exemptions have not yet been finalized.
If you’re new to my blog, my name is Elana Miller, MD, I’m an integrative psychiatrist and 2X cancer survivor with a telehealth private practice based out of Los Angeles, CA. I’ve been a telepsychiatry OG since October 2019 when my cancer relapsed and I received a life saving stem cell transplant (about six months PRIOR to COVID). I also have a career mentorship program where I teach psychiatrists and psych NPs how to build successful integrative psychiatry private practices.
As someone who has been providing telepsychiatry services for the last four years, I can tell you that the changes brought on by the PHE have been a game-changer for our industry. Patients can now receive care from the comfort of their own homes, and providers can see patients from anywhere, as long as the patient is located in a state where they’re licensed.
Telehealth has proven to be a valuable tool for delivering mental health care, and I’m excited to see how it will continue to evolve in the coming years.
Things are changing quickly, so let’s jump in.
When Did The Public Health Emergency End?
After several years of being extended for three-month increments, the federal public health emergency (PHE) officially expired on May 11th, 2023.
Although the public health emergency is a federal mandate, many states developed their own rules and exemptions over the last two years. Therefore, make sure you’re following your state’s telepsychiatry guidelines. If you have questions about what these guidelines are, you can contact your malpractice insurance for the specific rules.
DEA Telepsychiatry Guidelines
While the PHE has ended, the DEA is at least aware that after so many years of the practice of medicine in general (and psychiatry in particular) has shifted to tele, and that it would not be reasonable to patients and practitioners to change things overnight.
Therefore, while the details of the Telemedicine Special Exemption are being worked out (see below), the telemedicine flexibilities and exceptions we have been granted under the PHE have been officially extended six months, until November 2023.
Therefore, at this time, nothing has really changed for us telepsychiatrists now that the PHE has ended. Even more, after November 2023, we will still have another year, until November 2024, before we need to see patients in person for whom we established care during the PHE.
Will There Be Exemptions To The Ryan Haight Act (RHA) after the Telepsychiatry Flexibilities Expire?
Yes. On March 1st, 2023 the DEA released their proposed regulations for the Ryan Haight Act (RHA), specifically on how practitioners should proceed if they currently have patients on controlled substances who they’ve never met with in person. The good news is that both the DEA and APA recognize the nuance involved and are working together to make new telepsychiatry guidelines, policy, and procedure exemptions that make sense for both the providers and their patients.
Take my telehealth practice for example – I’m licensed in California and see patients from all over the state. Requiring my patients to travel hundreds of miles to come see me for frequent in-person appointments is simply not practical. This would obviously have major negative implications on my practice and limit my patients’ access to care.
DEA Proposed Exemptions
In recognition of these challenges, the DEA has proposed several telepsychiatry exemptions that providers can take advantage of to continue seeing their patients via telehealth. These regulations are currently receiving comments and have yet to be finalized, but here are the proposed exemptions that I think are most relevant to us telepsychiatrists in private practice:
- For schedule IV controlled substances, you can prescribe a 30 day supply as long as you see the patient for an in-person appointment within 30 days.
- For either schedule II or schedule IV controlled substances, you can prescribe without seeing the patient in person as long as a primary care physician has seen the patient in person and provided you with a referral. This can be particularly helpful for patients who live in remote areas or for those who find it difficult to travel long distances for in-person appointments.
To me, #2 above seems like a totally doable workaround for those of us who have tele-dominant practices and may have patients for whom it would be cumbersome to travel to see us in person.
My plan is to create a templated letter to give to patients that can be easily signed off by their PCP and sent back to me (I will be sharing this letter with the mentees in my mentorship program so they can use it too). .
Honestly, I think the final version of the telemedicine exemptions currently being drafted/revised will be even more flexible than this. Honestly, the cat is out of the bag. Everyone – clinicians and patients alike – prefer the flexibilities of telemedicine. Baring irresponsible prescribing by large corporations (I don’t want to get sued, so let’s just say a little company that stars with “C” and ends with “erebral” there is no reason why an in person exam is necessary for most patients.
If you’d like to read all of the DEA’s proposed exemptions, you can do so here.
4 Ways To Prepare For Telepsychiatry Guideline Updates Post-PHE:
1. Be Sure Your Malpractice Insurance Covers Telehealth
This was new information I learned at the APA webinar in January, but not all malpractice insurance policies cover telehealth visits.
Take the time to double check this!! While the PHE is still in effect, we are all technically operating under your state’s Ryan Haight Act telepsychiatry guidelines. At this point, I would be less worried about citations, and more about liability. If you were to have an adverse event and don’t follow the rules explicitly, there is potential that your malpractice insurance won’t cover you.
With major telepsychiatry regulation changes like the Ryan Haight Act, the goal is to prevent catastrophic issues from happening – like getting sued – which is why it’s always safe to follow the rules and make sure you’re covered.
This takes 5 minutes to do, so give your malpractice a call after reading this article.
2. Prepare to Apply For a DEA License In ALL The States You Prescribe Controlled Substances In
Under the current telepsychiatry guidelines, if you see patients who are located in a different state other than where you’re located, you do not need a separate DEA registration for each of those states. However, this will change once the telemedicine exemptions expire in November 2023/2024.
At that point, the new telepsychiatry policy is that you WILL need a DEA registration in all states where you prescribe controlled substances.
Now, I only have one DEA License because I only see patients in California, but there are several members in my mentorship program who are licensed in multiple states and say that the turnaround time for DEA license is pretty quick, about 1-2 weeks. When you apply for a new DEA license in a separate state you will need to have a physical address in that state in order to submit your application. More information on this below.
Quick tip: if you are moving to a new state you can move your existing DEA license for free.
3. Make A Plan To Sublet An Office for In-Person Appointments
As an FYI, according to the American Psychiatric Association, it is likely that virtual addresses will be audited in the future.
I have several members in my mentorship program who sublet office space from coworking businesses like wework or Regus where you have the option to pay for different membership plans based on your needs (e.g. office space, a mailbox, etc). As a side note, most coworking businesses have a front desk staff who can be there to accept and forward your mail.
I currently have my public-facing practice address as a virtual address. This is what I use on my medical license, which is publicly searchable. However, my DEA license is registered to my home address because this is where I see patients (which is what the DEA requires). However, I don’t believe a clinician’s DEA address is publicly searchable (I tried to find mine online via the DEA website, and couldn’t). If anyone wants to try to find my home address online via the DEA website, go for it and let me know if I’m incorrect in the comments!
In terms of prepping for the end of the telemedicine exemptions, my plan is to sublet an office part time (I mean, could be as little as one day a month) to see patients in person once in a while to make sure I’m compliant with the rules.
4. Document Your Patients’ Physical Location
A simple proactive measure that you can start doing now is to document where your patients are physically located in your treatment notes.
This will make it easier to keep track of which patients on controlled substances will need to come in for in-person appointments or need a PCP referral once the public health emergency ends.
Additionally, at some point it will be required to note in your electronic prescriptions where the patient is located when prescribing a controlled substance.
My Telepsychiatry Plan For 2023-2024
I hope you found this information helpful! As updates continue to emerge from the DEA and federal policies, I will try to keep this post updated and keep my email list updated as well (if you’d like to join, you can enter your email address on this page).
Remember, you will have a grace period of six months to adapt to the new telepsychiatry policy and procedure changes now that the PHE is lifted. Don’t stress too much, and just take it one step at a time.
To summarize, here are the action items I recommend for you you take right now:
- Be sure your malpractice insurance covers telehealth visits
- Document which patient’s are currently on controlled substances and note their physical location in your treatment notes
And here are the action items I will be taking before the telemedicine exemptions have expired in November 2024:
- I will check on subletting an office to see patients in person.
- I will write a templated email to any patient’s who are on prescribed controlled substances with an option to come in for an in-person visit or getting a PCP referral
- I will write a templated letter that I can give those patients to give to their PCPs to simplify the process of getting a referral.
I know telepsychiatry legal policy and procedure changes can feel scary, especially when it comes to healthcare and prescribing controlled substances. I think especially as solo private practice owners we can over-worry about doing something wrong and inadvertently putting our business and patients at risk.
It’s a major relief to be part of a community where everyone is in the same boat, and experiencing the same changes together. Especially during a time like this, I am really proud of the 100+ psychiatry providers in my mentorship program who can collaborate on making post-PHE plans, stay up-to-date on the latest information, and support each other through the transition.
To learn more about my career mentorship program you can enter your email address below to join my list and receive access to my free webinar training, How To Build Your Dream Integrative Psychiatry Private Practice.
You can also follow me on Instagram @thepsychiatrymentor and on YouTube The Integrative Psychiatry Private Practice Hub for more valuable private practice and integrative psychiatry tips and resources. I hope to connect with you soon!