017: How to Practice Medicine From Anywhere Without Losing Your License

Thinking about practicing telemedicine across borders? This episode unpacks the legal landscape of practicing US medicine from abroad, addressing common fears and offering practical guidance for physicians seeking location independence. Get clarity on licensure, compliance, and structuring your practice for success.

Key Topics:

• Legality of practicing US medicine from abroad based on patient location vs. physician location
• Key considerations for licensure, licensing requirements, and state-specific rules
• How to safely prescribe medications from outside the US, including mention of controlled substances
• Navigating Medicare and Medicaid restrictions for international practitioners
• Important decisions on practice type, payment models, state licensure, and entity structure
• Practical advice for legal and cybersecurity preparedness
• Insights from telemedicine attorneys
• Free Resource: A downloadable legal guide for tailored attorney discussions

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Transcript

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Is it even legal to practice US medicine from another country? That is one of the most common questions I get in my DMs and emails from physicians who want location freedom but are afraid that the legal side of this is either impossible or so complicated that it will cost them their license before they even get started. Today I am walking you through the questions I had and what I have learned from dozens of healthcare attorneys over five years of doing this and helping clients do the same so that you know exactly what to think through before you ever even sit down with an attorney. And if you're ready to get clear on your practice type, your states, your structure, and what building a location-independent life actually looks like for your specialty, book a one-to-one freedom call. The link is in the show notes. Let's get into it. You're listening to Doctors Abroad, the podcast for doctors who want to build remote income and create location independence. I'm Dr. Christine Goins, founder of Nomad MD. I've exceeded my hospital income while working part-time and living abroad. And on this show, we break down how to make hospital income optional. Let's get started. I want to start by saying I am not an attorney. So nothing in this episode is legal advice. What I am is a physician who has been practicing remotely from abroad for over five years, who has spoken with dozens of healthcare attorneys about this specific situation, and who has helped clients navigate it for their own practices both inside and outside of the United States. What I found and what I want you to hear is that the telemedicine lawyers I spoke to were not alarmed. They treated this as something they had seen before, something navigable, something that, with the right structure and the right guidance, is far more routine than the fear around it suggests. So today I'm going to do three things. First, I'm going to address the questions I hear most. Is this even legal? What about my license? Can I prescribe from abroad? Those kinds of questions. Second, I'm going to walk you through the decisions you need to think through before you ever sit down with an attorney because that clarity will save you time and money. And third, I'm going to share what I actually learned from speaking with dozens of healthcare attorneys about this, including what surprised me about those conversations. At the end of this episode, I am also going to tell you about a resource I put together, a guide of the exact questions to bring to your own attorney to ensure that you are set up for success. That guide is available for download, and I will share where to get it for free at the end. So is it illegal to practice US medicine from abroad? For most physicians practicing telemedicine with US patients, no, it is not illegal to do so from another country. That's a broad generalization, but here is how most states actually frame this. And I stress most states, not all. But what matters is where your patients are located, not where you are physically located. So if you are licensed in a state and your patients are in that state, most state medical boards do not have rules that prohibit you from being physically located abroad when you provide those services. What they care about is that you are practicing within your scope, within your standard of care, and within the licensure requirements of the states where your patients are. And I want to be careful here because this is not a blanket statement that applies everywhere without variation. There are state-specific rules, there are payer-specific rules, and there are practice-specific considerations. And this is exactly why you need an attorney who specializes in healthcare and telemedicine law to review your specific situation. But the general framework is that licensing follows patient location. And this is what I've heard consistently across multiple attorney consultations. New Jersey, for instance, has a rule that requires licensure if you, as the physician, are physically located there, in addition to where the patient is. So that is one of the notable exceptions to be aware of. And there are others as well, depending on your specific state and circumstances. So you always want to verify with your own attorney. Will I lose my license? Another common question, a question I had. So practicing telemedicine ethically, in good faith, within your standard of care and with proper licensure in the states where your patients are physically located does not put your license at risk simply because you are physically abroad. Your license is attached to the state that issued it. What the medical board in that state typically cares about is how you practice, not where you are sitting when you do it. The physicians who lose licenses lose them for practicing outside their standard of care, for practicing without proper licensure, or for ethical violations, not for being in another country. That said, right, and I can't say this enough, that you do want to verify, right, with an attorney for your specific state practice type. So it's not a one-size-fits-all answer. Now, can I prescribe from abroad? So for non-controlled substances, let's say blood pressure medications, antidepressants, and similar medications, yes, in general, right? Prescribing these medications while physically located abroad is not prohibited by federal law as long as you are practicing within your standard of care, your licensure, and maintaining proper practitioner-patient relationships established via video conferencing. Now, for controlled substances, this is where it gets more specific. There are federal regulations under the Ryan Heid Act that have implications for prescribing controlled substances via telemedicine. During COVID, there were waivers that expanded telemedicine prescribing of controlled substances. Those waivers have been subject to extensions and changes. And this is an area of law that is actively evolving. So if control substance prescribing is part of your practice, then you need current specific legal guidance on this, not a podcast episode. Okay. Now, what about Medicare and Medicaid? Though this wasn't one of my specific questions because I was always doing cash pay, this is what I'm asked very, very often, and it's an important one. Medicare has a prohibition on providers billing from abroad. So if you bill Medicare, you cannot do so while physically located outside the US. Medicaid is more complex because it is a combined federal and state program, and rules vary state by state. For each state Medicaid program you participate in, you would need to look at that state's provider manual to determine whether there is a prohibition on providers being abroad when billing. Now, my understanding from attorney conversations is that Medicaid rules tend to mirror Medicare rules in this regard, but this requires verification for each specific state. The simplest path around this, and the one that my clients and most physicians building location-independent practices take, is a cash pay or direct pay model. When you remove government payers from the equation, you eliminate a significant layer of regulatory complexity. And this is worth thinking about as you design your practice. Okay, so here is something that is going to save you significant time and money. I'm going to talk about the decisions to make before you talk to a lawyer. You want to walk into your attorney consultation with clarity on what you are building. Attorneys, unlike some of us physicians who do a lot of serving for free, attorneys build by the hour. And the more you have thought through your business before that conversation, the more efficiently they can help you. So these are the decisions I recommend thinking through first. Number one, clinical, non-clinical, or both. So are you building a clinical practice, seeing patients, prescribing, providing direct medical care or medical advice or consultation? Are you building a non-clinical practice? Maybe you're doing non-medical consulting, advising, coaching, content, or education. Or perhaps you're doing a combination of both, right? This matters because the legal requirements are very different. Telemedicine practice comes with licensure requirements, standard of care obligations, malpractice considerations, and HIPAA compliance. Non-clinical consulting or coaching has its own legal considerations, but is generally less regulated. So many physicians I work with build both, right? A clinical practice in one or two states where they are licensed, and a non-clinical consulting or coaching that operates independently of those licensure requirements. But being clear about which you are building or how you are combining them really shapes everything about the legal structure that you will need. Okay, number two, cash pay versus insurance. So as I mentioned earlier, cash pay simplifies the regulatory picture significantly. If you accept insurance, you need to understand payer contracts and whether those contracts have provisions about where you can be physically located when billing. If you participate in Medicare or Medicaid, the abroad restrictions I mentioned before apply. So decide on your payment model before the attorney conversation. It changes the scope of what you need reviewed. Number three, which states? How many? So your licensure determines where your patients can be located. If you are licensed in two states, your patients must be in those states. If you want to expand to additional states, you need to obtain licensure there or explore the Interstate Medical Licensure Compact, which streamlines the process of obtaining licenses in multiple states for eligible physicians. Corporate structure also becomes a consideration as you add states. About half of U.S. states have what is called the corporate practice of medicine doctrine, which affects how your business entity can be structured. Virginia has it, Florida does not, California and New Jersey are states where a professional corporation or a professional LLC structure is required. So this is something your attorney will walk you through, but knowing which states that you are targeting really helps to give you some direction and it helps them to give you relevant guidance. Number four, one country or multiple countries. So if you plan to stay in one country abroad, the legal picture is relatively straightforward from the US side. If you plan to move through multiple countries, which many location-independent physicians do, the US side legal framework is the same, but you should do some basic diligence on each country you plan to spend significant time in. The lawyers I spoke to consistently noted that the country you are in is generally not going to be alarmed if you are providing services to US patients, if you are a US provider, as long as you are not actively seeking patients within their country, right? But for countries where you spend extended periods of time, it is worth a brief check with their local counsel as well. Number five, entity structure. So you will need a business entity, most commonly a professional LLC or PLLC for physicians. Where you form it matters. And in some states, you may need to foreign qualify your existing entity if you already have a business rather than forming a new company there. Your attorney will guide you through this, but going in, knowing whether you have an entity, what entity you have, if any, and what states you want to operate in makes that conversation much more efficient. So working through these decisions before your attorney consultation is exactly what saves my clients thousands in legal fees. And if you want to get clear on what your specific path looks like, the practice type, the states, the structure, all of it, including recommendations to the best telemedicine attorneys in the US and UK, that is exactly what a one-to-one freedom call is for. And the link is in the show notes. So now I want to share a few things that really stood out from my conversations with healthcare attorneys over the years that I think will reframe how you think about this process. Again, every telemedicine attorney I spoke to treated this entire process as navigable. They were not alarmed at all. One attorney noted that compared to what their firm typically works on, global telehealth companies that are operating across multiple companies simultaneously, that a physician wanting to practice from abroad while licensed in one to two US states was, in their words, a relatively light lift. Like it was baby stuff for them, really, is what they were saying. And that perspective matters, right? The fear physicians carry about the assumed legal complexity of this is often much larger than the actual legal complexity. And that doesn't mean you skip the attorney. It means you go in knowing that this has been done before. It is still being done. It is a normal process for them. Lawyers know how to handle it, and you're not walking into some uncharted territory. Now, for every attorney I spoke with, the conversation started by them asking me the same questions. They always start with what type of practice you want to build. What do you want? Cash pay or insurance? One state or multiple? Which states, clinical only or also non-clinical, right? So these answers really shape everything about the legal structure. Another piece is for physicians practicing telemedicine from abroad, you know, using a VPN and having cybersecurity insurance in addition to, you know, a HIPAA compliant EHR is the standard recommendation. And this isn't dramatically different from what a US-based telemedicine practice would need, but it's still worth confirming your existing systems are adequate. And then lastly, malpractice. So maintaining your malpractice coverage, of course, this is going to be a non-negotiable if you're continuing to work in medicine, whether you're in the US or in the UK or anywhere else, right, in the world. So if you are building a direct contract or a telemedicine practice outside of your employed role, where you are going to be providing any medical recommendations, make sure that your malpractice coverage covers your remote work. Some policies are employment specific. So review yours carefully and discuss with a broker who specializes in telemedicine if needed. So at the beginning of this episode, I mentioned a resource, a guide of the specific legal questions to bring to your own healthcare attorney when you are ready to have this conversation. Through these questions, you will be able to assess whether your lawyer has the expertise you need to navigate telemedicine laws and set up your location-independent practice. I put it together based on my own consultations and what I have helped clients navigate as well. The free legal guide is in the show notes. So download it before your attorney consultation. And again, I say, you know, although it is really not as complicated or complex as we make it seem, I still wouldn't skip the attorney consultation. What I have shared today is really a framework for thinking through creating your location-independent practice, but not a substitute, right, for the legal advice that's tailored to your specific situation, your states, your practice type, and the countries that you plan to be in. Okay, I hope this one took something that may have felt impossibly complicated and made it feel more feasible and navigable because it really is. The legal side of practicing remotely from abroad does require attention and you need qualified legal guidance, but it is not the barrier that most physicians assume that it is. And the physicians that I have helped navigate this are practicing ethically, compliantly, and from wherever they want to be. And if today raise questions about what kind of remote income model you're actually building, episode 10, do you actually have to start a business to work remotely, is a good place to go back and listen. It breaks down the different paths of remote work and what each one actually requires of you. Thanks for listening to Doctors Abroad. If this episode was helpful, share it with a colleague who's been thinking about building more freedom and flexibility in medicine. And if you're ready to make hospital income optional, book a one-to-one freedom consultation at thenomadmd.com. I'll see you in the next episode.