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A colleague and friend of mine recently told me that he is moving back to his home town and is closing out his practice. Letting go of clients is hard in both directions, and several of his clients have asked if he would be willing to continue via “Skype Therapy.” He asked me to help him figure out how to get started with that. Here is my answer, publicly posted in hopes that it will help many more folks.
First, don’t use Skype (or Facetime), even though it is often called “Skype Therapy.” The most widely accepted name for this style of work is “telemental health,” and I will call it that from here forward. Why not use Skype? The reasons are a little more complex than I have space for here, and they are well explained in this article on how Skype became a no-go.
And don’t work across state lines unless you’re permitted to practice in the state where the client is (and the laws and rules of both states allow that arrangement.) This issue is kinda complex, and requires further reading:
When practicing telemental health, there are a lot of different authorities whose rules can impact your work. Thus, a prudent approach to starting telemental health practice would have you investigate the rules and guidelines of every body that presides over your practice. It sounds daunting, but it’s doable. Here I’ll try to lay out where you’ll need to inquire for information:
- Insurance companies you’re paneled with. Many private insurers are requiring special paneling in order to get reimbursed for telemental health services. Inquire with the companies where you are paneled for details on the process.
- Note that Medicare and various state Medicaids will have their own particular rules regarding telehealth in general. Find CMS’ 2018 telehealth guide here.
- Your professional liability insurance. Similar to the private insurers, many liability insurance companies are now requiring special riders in order to cover telemental health practice.
- Licensing Board Rules/Laws
- State Law
- State and Local Professional Organization(s) Guidelines or Rules
- Major Professional Organization Guidelines and Ethics Codes
- Federal Law (generally HIPAA)
Reimbursement policies vary from state-to-state and contract-to-contract. As such, you’ll need to look into reimbursement with each insurer. The good news is that reimbursement is getting increasingly common, and many insurers now have a process for getting paneled Licensing boards are in no way standardized in their approach to telemental health. Within a single state, every profession may (and often does) have its own particular rules around it. If you’re working across state lines, you’ll need to know the rules of the relevant board there.
Some states have nothing in particular to say about telemental health, and some say a lot. Be aware that if your state doesn’t have specific laws for telemental health and/or your licensing board has no specific rules, you could be subject to state medical laws regarding telemedicine where they apply.
A great starting point for investigating the rules of a particular state is the Epstein, Becker, Green 50 State Telehealth Survey. Don’t stop there, however. Follow the links in the survey document to check on what the current rules are in the state where you wish to work with clients. Also, remember that interpreting law can get complex, and that’s one of the many reasons why we have lawyers.
I listed state and local professional organizations as people to check with not so much because they may have special rules for you (although they might) but because they can be a good resource for learning how telemental health works in your state and under your board. It doesn’t hurt to drop them an email or make a call as part of your process.
National professional organizations are a different issue. Every major professional organization’s ethics code requires us to maintain digital confidentiality, and counselors, MFTs, social workers and psychologists all have guidelines for practice in the digital realm.
Part of your due diligence should be to read the telemental health-related guideline and/or ethical standard that is most applicable to you.
- AAMFT’s Code of Ethics, Specifically Standard VI (2015)
- ACA’s Code of Ethics, Specifically Section H (2014)
- APA Guidelines for the Practice of Telepsychology (2013)
- NASW & ASWB Standards for Technology and Social Work Practice (2017)
- NBCC Policy Regarding the Provision of Distance Professional Services (2012)
We also recommend studying the telemental health guidelines published by the American Telemedicine Association (you’ll need an account on their website to view these documents):
- Practice Guidelines for Video-Based Online Mental Health Services
- Evidence-Based Practice for Telemental Health
Federal laws that directly relate to telemental health will be through specific federal programs or agencies, such as Medicare or the VA. If you are working within those domains, you will need to get specific information on how they handle guidelines, reimbursement, etc. Once again, find CMS’
It is clear that informed consent for telemental health treatment requires certain items in addition to those needed for in-person therapy. What is not entirely clear, however, is a specific list of the special informed consent items that are needed.
ACA’s Code of Ethics, Section H, includes specific items that are required for informed consent in distance counseling. The American Telemedicine Association’s Practice Guidelines for Video-Based Online Mental Health Services also contains some specific information on what is needed in telemental health informed consent.
A number of state laws have requirements for telehealth informed consent, as well.
Not everyone is in agreement on whether or not training is, specifically, an ethical requirement before starting telemental health practice. Some licensing boards do require it, however.
What is universally recognized in professional ethics is that professionals looking to start telemental health practice need to first ensure that they have the necessary competence.
One area of concern among licensing boards is that licensees may not “know what they don’t know,” and thus may be unaware of whether or not they lack any of the competencies necessary for ethical and professional telemental health practice.
There are a number of sources for getting telemental health training and/or studying up on the competencies.
- Person Centered Tech’s telemental health certification program
- NBCC’s Board Certified Telemental Health credential
- Telehealth Certification Institute
- Zur Institute certificate program (developed and presented primarily by Huggins.)
While this article paints a picture of a highly complex landscape of rules and standards, it is not actually as difficult to navigate as it may seem. Remember back to being a student and how complex and overbearing the legal-ethical requirements of practice seemed at that time. For many of us, there is a repeat of that process in learning to navigate telemental health standards and laws.
But just like happened after school, practice and assimilation of the standards will cause it all to become second nature. So be sure to get the help you need in order to develop competence in telemental health, but don’t hold back from getting started, either!