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, 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 licensed 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. Thus, I offer you some articles:
- Can I Practice “Skype Therapy” Across State Lines?
- Telehealth Services Across State Lines (Zur Institute)
The rules of telemental health are maddeningly varied. 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 (will they cover your telemental health activities?)
- Your professional liability insurance (will they cover your telemental health activities?)
- 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, there is no universal advice that can be given regarding whether or not any particular insurance plan will cover telemental health services and under which circumstances. As such, you’ll need to look into reimbursement on a case-by-case basis. The good news is that reimbursement is getting increasingly common.
When submitting claims for telemental health services, Jay Ostrowski tells us that you’ll need to add the modifier code, “GT.”
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. Where they exist, licensing board rules are often the most restrictive ones you need to consider when thinking about the issues you must cover in telemental health practice.
For example, some boards require training before you can do text-based therapies (e.g. therapy over secure email.) Some other boards prohibit text-based therapies altogether.
The Arkansas Counseling board requires their licensees to get special training before using digital tech in their practices in any way. The Georgia Counseling board requires a 6-hour training program before those licensees may perform telemental health.
Search your board’s website for rules and laws relating to telemental health, distance therapy, distance counseling, online therapy, and related terms. If you find nothing definitive, contact them and ask. Try to get anything they tell you in writing.
If you’re working across state lines, repeat for every state involved.
Some states have nothing in particular to say about telemental health, and some are highly restrictive. Discovering your state’s laws about telemental health could be tricky to do without consulting with a lawyer who would specifically know. 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.
Some states require special training or certification before you are permitted to perform telemental health. Some do not allow out-of-state practice. Some require that clients must be assessed in-person before telemental health work can begin. Once again, it varies. So be sure to do your legwork before beginning practice. And, of course, do this for each state involved in your practice.
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:
- 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.
The Feds mostly get involved in telemental health practice through the security and privacy rules in HIPAA. Those are complex, of course, and you can learn more about them by reading this website’s many free articles and perusing our training offerings.
It is universally recognized among professional organizations and experts that informed consent for telemental health treatment requires certain items in addition to those needed for in-person therapy. What is not universally recognized is a specific list of informed consent items that are needed, however.
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. This may be another item to ask your attorney about.
Not everyone is in agreement on whether or not training is an ethical requirement before starting telemental health practice. Some licensing boards do require it, however. What is universally recognized among professional organization guidelines and ethics codes, however, is that professionals looking to start telemental health practice need to first ensure that they have the needed competence.
You can get training on HIPAA and technology issues from us here at Person-Centered Tech through our online courses. There are several institutions that provide training specifically for the deeper complexities of telemental health practice.
For telemental health training that includes coursework from Roy Huggins (the author of this article), look to The Zur Institute’s Telemental Health Certificate Program.
There is also extensive training involved in the Distance Credentialed Counselor (DCC) credential. Several different organizations offer the DCC training, and you can see them all at the Distance Credentialed Counselor (DCC) Credential website.
You have likely already guessed that this isn’t the whole story. My hope is that this article helps guide you on where to go and what to do, but there is a fair amount of legwork to do before starting telehealth practice. Best of luck!