Telehealth made it easy to see patients anywhere, but licensing rules did not move as fast. A clinician in Kirkland who follows up by video with a patient spending the winter in Arizona, a group that hires a remote nurse in Idaho, a behavioral health practice serving college students out of state: each raises questions about licensure, prescribing, insurance and employment law. This article explains the basic rules, the interstate compacts that help, and the coverage points that are easy to miss.
The starting point: where the patient is
As a general rule, state licensing boards treat care as delivered where the patient is physically located at the time of the visit, not where the clinician sits. A clinician licensed only in Washington who treats a patient located in Oregon is generally practicing in Oregon and needs to satisfy Oregon's licensing rules.
States handle exceptions differently. Some allow limited follow-up care for established patients who are temporarily out of state, consultations between clinicians, or care in emergencies; others allow very little. Because the rules vary by state and profession and change often, confirm the current rule with each state's board before seeing patients there.
Verify location at every visit. Record the patient's physical location at the start of each telehealth encounter. It determines which license applies, which state's practice rules govern, and where emergency services must be sent if something goes wrong.
A few common situations show how the rule plays out in practice:
The seasonal patient
An established patient spends winters in another state and wants video follow-ups. Unless that state has an applicable exception, the clinician needs a license there, or the patient may need to be seen by a local clinician during those months.
The student away at school
A behavioral health practice continues therapy with a client who moved out of state for college. Counseling and psychology licenses are state-specific, so the practice should check the other state's rules and any compact privilege before continuing.
The remote nurse
A clinic hires a triage nurse who lives across the border. Licensure depends on where the patients are, while workers' compensation and employment law generally follow where the nurse works.
The visiting specialist
A physician reads studies or consults for a facility in another state. Some states allow limited physician-to-physician consultation; others require a full license. Check before the first case.
Licensure compacts that make multistate practice easier
Interstate compacts reduce the paperwork of holding multiple licenses. They work differently by profession.
| Compact | Who it covers | How it works | Washington |
|---|---|---|---|
| Interstate Medical Licensure Compact (IMLC) | Physicians (MD and DO) | An expedited pathway to obtain separate licenses in other member states; each state still issues its own license | Member; enacted by HB 1337, signed in 2017 |
| Nurse Licensure Compact (NLC) | RNs and LPN/VNs | One multistate license allows practice, in person or by telehealth, in all member states | Member since 2023; Washington began issuing multistate licenses January 31, 2024 |
| Other professional compacts | Psychologists, counselors, physician assistants, social workers and others | Varies: some grant practice privileges, others expedite licensure | Status and start dates vary; check each compact and the state board |
Two cautions. First, compacts do not cover every profession: the NLC does not cover advanced practice nurses, and Washington does not issue a multistate license for ARNPs. Second, a compact license is still subject to the practice laws of the state where the patient is located. Our article on nursing liability risks covers the NLC in more detail.
Prescribing across state lines
Prescribing raises extra issues, especially for controlled substances.
- Federal telemedicine flexibilities. The DEA and HHS issued a fourth temporary extension of the COVID-era telemedicine flexibilities, allowing DEA-registered practitioners to prescribe Schedule II-V controlled substances by telemedicine without a prior in-person evaluation through December 31, 2026, subject to other federal and state law. The DEA has proposed, but not finalized, a longer-term special registration framework. Watch for changes before the end of 2026.
- State law still applies. State rules on telehealth prescribing, controlled substance registration, prescription monitoring programs and in-person examination requirements remain in force and differ by state.
- Pharmacies and payers. Pharmacies may decline out-of-state or telehealth prescriptions they cannot verify, and payers have their own telehealth rules. Medicare telehealth coverage in particular has depended on a series of temporary extensions by Congress, so confirm current status before relying on it.
For clinical and documentation risks in virtual visits, see telemedicine liability.
Standard of care, consent and privacy
A virtual visit is held to the same standard of care as an in-person visit. Claims often allege that a clinician should have brought the patient in for an exam or sent them to emergency care. Practical steps:
- Define which conditions and visit types are appropriate for telehealth, and when to convert to an in-person visit.
- Obtain and document telehealth consent that meets the requirements of the patient's state.
- Keep an emergency plan for each patient location: local emergency number, nearest emergency department, and a backup contact.
- Use platforms that meet HIPAA requirements and sign business associate agreements with vendors. See HIPAA compliance essentials.
- Document the patient's location, who was present, the technology used, and any limitations of the exam.
Insurance questions to answer before you expand
Multistate practice affects several policies, not only malpractice.
- Policy territory. Confirm that your medical professional liability policy covers telehealth services and patients located in every state where you practice. Some forms limit coverage to listed states or require notice of new states.
- Licensing defense. A complaint can come from a board in a state where you rarely practice. Check whether your policy includes licensing board defense and whether it extends to all states.
- Unlicensed practice. Policies commonly exclude or limit coverage for services outside the scope of a valid license. Seeing a patient in a state where you are not licensed can put coverage at risk.
- Cyber. Telehealth platforms, remote staff and home networks expand cyber exposure. See cyber liability for healthcare practices.
- Remote employees. Staff who live and work in another state generally need workers' compensation coverage that meets that state's law, and they bring that state's employment rules with them. Washington's state fund has specific rules for out-of-state work; see state-specific workers' comp requirements.
Coverage terms and exclusions vary by carrier and policy, so confirm each of these in writing rather than assuming.
A checklist before seeing patients in a new state
Work through these items for each new state, and keep the answers on file so they can be reviewed at renewal or during an audit.
- License or compact privilege confirmed for each clinician and profession, with renewal and continuing education tracked.
- State-specific telehealth, consent and prescribing rules reviewed, including any controlled substance registration.
- Payer enrollment and telehealth billing rules confirmed for that state.
- Malpractice carrier notified and policy territory confirmed in writing.
- Workers' compensation and employment compliance set up for any staff located there.
- Patient location capture, emergency protocol and documentation templates in place.
When to call a broker
Talk to your broker before you start seeing patients in a new state, hire a remote clinician, launch a telehealth service line or join a compact. As a broker, we compare options across the market and confirm that professional, cyber and workers' compensation coverage follow your practice wherever your patients are. Contact us to plan the expansion.
Sources
- Washington State Department of Health — Osteopathic physician licensing and the Interstate Medical Licensure Compact
- Washington State Board of Nursing — Apply or upgrade to a multistate license
- NCSBN — Washington to allow nurses with multistate licenses to practice
- Hooper, Lundy & Bookman — DEA issues fourth extension of telemedicine flexibilities through 2026
- Federal Register — Fourth temporary extension of COVID-19 telemedicine flexibilities (Doc. 2025-24123)