Telemedicine/Telehealth

Regulation of telemedicine/telehealth

Licensing requirements for telemedicine/telehealth

Prescribing controlled substances via telemedicine/telehealth

Reimbursement for services via telemedicine/telehealth


COVID-19 UPDATE

Last updated 6/8/2020 3:15pm CDT [expiration of enforcement discretion will be upon declaration of end of health emergency]

In order to practice safe social distancing and inhibit the community spread of COVID-19, the Board and Commission encourage physicians to utilize telehealth visits whenever it is prudent to do so.  Board and Commission rules will be interpreted broadly during the health emergency.

Many regulatory bodies and third-party payors have relaxed requirements previously in place surrounding telehealth.  Please review the information below for more on these relaxed regulations.

HOWEVER, it is not the case that a physician may practice telemedicine in any state as long as there is a license in at least one other state.  To practice telemedicine in Alabama, the physician must hold one of the Alabama medical licenses that are available.

Prescribing controlled substances via telemedicine during health emergency (DEA/ALBME/ALBOP)

Payors and telemedicine during health emergency


Physician, Physician Assistant, and Anesthesiologist Assistant temporary emergency licenses effective March 22, 2020


Prescribing controlled substances via telemedicine during health emergency

Notice:  Relaxed regulations and enforcement discretions continue until the health emergency has ended

The Alabama State Board of Medical Examiners (“BME”) and the Alabama State Board of Pharmacy are both charged with regulating and enforcing the prescribing and dispensing of controlled substances by Alabama health care providers. During the state and national public health emergency brought on by the rapid spread of the Severe Adult Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), health care providers subject to the Alabama Controlled Substances Act are being encouraged to communicate with patients, and provide telehealth services, through remote communications technologies.             

The DEA has recently relaxed prescribing rules to permit the prescribing of controlled substances using telemedicine. The DEA has stated that, so long as the public health emergency remains in effect, DEA-registered practitioners in all areas of the United States may issue prescriptions for all schedule II-V controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:

  • The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice;

  • The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system; and

  • The practitioner is acting in accordance with applicable Federal and State laws.  

The DEA noted that if a prescribing practitioner has previously conducted an in-person medical evaluation of the patient, the practitioner may issue a prescription for a controlled substance after having communicated with the patient via telemedicine. In other words, the DEA’s requirement that practitioners utilize a real-time audio and visual telemedicine methodology only applies to the prescribing of controlled substances to new patients who have not been physically examined by the practitioner. The performance of an audio-only telemedicine consult with an existing patient by a practitioner would satisfy DEA’s guidelines, provided at all times that the controlled substances are prescribed for a legitimate medical purpose and in the usual course of the practitioner’s professional practice.            

The DEA further stated that practitioners could electronically transmit, fax, or call in the controlled substance prescription to the pharmacist. This guidance included calling in Schedule II controlled substance prescriptions, subject to state and local laws. Alabama does not currently permit a Schedule II prescription to be called in as DEA’s guidance provides.   

In addition, the DEA recognized that there may be instances where providing a paper prescription as follow up to a call in to an emergency oral prescription may be challenging or impossible. To that end, the DEA has allowed for the practitioner to provide the follow up prescription via facsimile, photograph, or scan of paper prescription in place of the paper prescription.

On March 27, 2020, the DEA distributed additional guidance outlining temporary exceptions to Schedule II prescribing during the state and national emergency. The DEA recognized the potential infeasibility for a practitioner to deliver the follow-up paper prescription for a call in prescription to a pharmacy within 7 days as required by 21 CFR 1306.11(d)(4). Therefore, the DEA granted practitioners 15 days within which to provide a follow-up prescription to the pharmacy. The practitioner must ensure that, regardless of the method used to communicate the prescription, the written prescription must include all required information as outlined in 21 CFR 1306.05 and 1306.11(d), including the statement “Authorization for Emergency Dispensing.” Practitioners exercising this exception must maintain the original paper prescription in the patient’s file. Regardless of any exceptions DEA has made, pharmacists continue to have a corresponding responsibility to ensure any controlled substance prescription filled was issued for a legitimate medical purpose by a practitioner practicing in the usual course of his/her professional practice. 21 CFR 1306.04(a).       

Coextensive with the DEA’s guidance, the BME and BOP will exercise their enforcement discretion and will not impose penalties for noncompliance with state controlled substance-related regulatory requirements on health care providers who, in good faith, utilize telemedicine to care for their existing patients during the COVID-19 nationwide public health emergency. 

This notification is effective immediately.            

In particular, the BME and BOP will allow for the communication of a Schedule II controlled substance prescription by a practitioner to a pharmacist via telephone or fax where the practitioner or pharmacist is not equipped or otherwise impeded from utilizing electronic prescribing. Similarly, BME Rule 540-X-4-.08(2)(a) requires that a physical examination be conducted when prescribing a controlled substance for the treatment of chronic pain. For a limited time, and to allow for health care providers to keep themselves, their staff, and their patients safe, the Board will not enforce this physical examination requirement so that health care providers can continue to care for their chronic pain patients.

This use of the BME and BOP’s enforcement discretion is aimed at removing regulatory barriers to the use of telemedicine to meet the legitimate health needs of Alabama patients in a time when people are being directed to avoid in-person contact.

Federal laws require written prescriptions for call-ins to be provided to the pharmacy within one week; however, DEA has announced that during the state of emergency this has been extended to 15 days, and the follow-up- prescription may be sent via fax, photo, or scan to the pharmacy.

The prescription must contain all required information and a statement that the prescription is "Authorized for Emergency Dispensing."

Important note: If the prescribing practitioner has previously conducted an in-person medical evaluation of the patient, the practitioner may issue a prescription for a controlled substance after having communicated with the patient via telemedicine, or any other means, regardless of whether a public health emergency has been declared, so long as the prescription is issued for a legitimate medical purpose and the practitioner is acting in the usual course of his/her professional practice. 

Federal laws concerning controlled drugs


Payors and telemedicine during health emergency

3/30/2020 CMS expanded telehealth to allow for audio only communication

The Telehealth Services During Certain Emergency Periods Act of 2020 (TSDCEPA) was passed by Congress in early March 2020 in response to COVID-19 and specifically allows for telehealth services for Medicare patients to be provided via smartphone or smart-device.

Medicare Telemedicine Health Care Provider Fact Sheet

Medicare Telehealth Frequently Asked Questions (FAQs)

CMS Telehealth Fact Sheet

BlueCross and BlueShield of Alabama Expands Telehealth Coverage

Telemedicine payor coverage update

END OF COVID-19 UPDATE


Regulation of telemedicine/telehealth

The Board of Medical Examiners does not currently have any statutes or rules in place that specifically regulate telemedicine vs. the traditional, in-person practice of medicine. There are federal regulations (such as HIPAA, DEA regulations, third party payors) regarding telehealth that should be discussed with your attorney.

Physicians are held to the same standard of care irrespective of the modality of treatment.  This includes rules concerning the establishment of a physician-patient relationship, the prescribing of controlled substances, general prescribing guidelines, and prescribing without having had a physical exam. 

All Board rules can be located here

There is no requirement for a contract with the patient before providing medical care via telemedicine.


Licensing requirements for telemedicine/telehealth

Physicians:  Alabama full traditional license, a license via the Interstate Medical Licensure Compact, or special purpose license to practice medicine across state lines.

Please see the physician license applications page

Physician Assistants:  Alabama license to practice as a physician assistant and approved registration to a supervising physician. 

NOTE:  In the event of a national emergency, natural disaster, or state emergency, a physician assistant may provide emergency medical treatment without immediate physician supervision or direction to patients within the affected areas of the state, provided that the treatment is within the scope of the assistant’s education, training and approved job description.  The physician assistant in such circumstance shall make reasonable efforts to inform his or her supervising physician of the location and type of emergency medical services being provided and shall act in conformance with the direction of local medical supervisors.  The authority granted under this paragraph shall extend only for the duration of the declared national emergency or state emergency or natural disaster.

Please see the physician assistant license applications page


Prescribing controlled substances via telemedicine/telehealth

The Board has no rules to prohibit the prescribing of controlled substances via telemedicine

DEA regulations currently require a previous in-person examination before prescribing controlled substances via telemedicine, except in a declared health emergency

Federal laws concerning controlled drugs


Reimbursement for services via telemedicine/telehealth

Some third party payors and CMS require various levels of contact with a patient before prescribing for reimbursement purposes, except in a declared health emergency

 

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