Licensed in More Than One Jurisdiction (Or Thinking About It)? You Need to Read This
Each additional license increases your risk of disciplinary action. Here’s what you should know.
Thanks to telemedicine, it’s never been easier to practice in more than one state in the US. All you need, other than a HIPAA-compliant internet connection, is to be licensed wherever your patient lives. But don’t let the simplicity of the process fool you. Multi-state practice is a lot more complicated than you may think. Each state has their own laws and regulations regarding telemedicine. Each license subjects you to the oversight of another regulatory board and each board has reciprocal agreements with every other state board. If you’re not careful, these so-called sister-state laws can make you wish you never heard of telemedicine.
PBI faculty member and Texas attorney Jon Porter, JD, explains it this way: “Every state in America has a statute that essentially reads, ‘If state A takes action against you, we can take action against you just because state A did. We don’t care about the underlying causation. The mere fact that state A took action is enough.’”
Sindy Paul, MD, a past president of the New Jersey Board of Medical Examiners and its former Medical Director, points out that these sister-state laws are designed to protect the public. According to Paul, who is also a PBI faculty member, “If a physician does something really bad in one state, no one wants them simply moving to another state and continuing to harm patients,” she explains. Sister-state laws give boards the power to prevent that.
The devil, of course, is in the details.
You Must Report Disciplinary Actions to Any State You’re Licensed In
Since most disciplinary actions are reported in the National Practitioner Data Bank (NPDB), state boards are almost certain to learn about violations committed elsewhere. But that takes time, during which the public remains at risk. For that reason, all sister-state laws require licensees to self-report promptly. Most states require clinicians to self-report within 30 days; however some restrict this timeframe to only 14 days.
Failing to report discipline within the state’s time limit can have serious consequences. In fact, says Porter, even if the original offense was something minor, the failure to report it can cause much more serious trouble. “From a board’s point of view, failing to report is the same as lying,” he says. “It’s a lie of omission in their eyes, and falsifications or lies of omission to medical boards are frankly one of the worst possible things you can do. Boards can tolerate a lot of things. They cannot tolerate lies.”
There are no exceptions. Since boards can disagree about the severity of a violation, even minor actions labeled “non-disciplinary” should be reported. “You really don’t have a choice,” says Porter.
Sister-State Actions Can Trigger an Avalanche of Problems
While many states simply mirror the disciplinary action of sister states, there are cases when they take independent action. PBI faculty member and medical-legal consultant Dan Tennenhouse, MD, JD, knows of a case in which a state suffering a severe shortage of doctors granted a license to a physician whose license in another state had been revoked. “At the other extreme,” Tennenhouse added, “I’ve also seen a physician who had been reprimanded for a minor violation in his home state have his license revoked by a sister state.”
When the second action is more severe, it can lead to a devastating chain reaction. The first sign of trouble may be the loss of specialty board certification. If that happens, the hospital where the practitioner works is likely to take away their privileges. Insurance companies tracking actions on the NPDB may remove the practitioner from their panel, effectively cutting them off from the vast majority of patients who can’t afford out-of-pocket costs on their own. Malpractice insurance carriers may also pile on, either denying the practitioner coverage or raising their rate exorbitantly. At this point the suspended practitioner’s partners are likely to drop their colleague because, says Tennenhouse, “It’s an almost universal rule that in a partnership every partner is liable for the negligence of every other partner within the scope of the practice.”
The avalanche may not be over yet. If the Department of Health and Human Services decides to act, the Department’s Office of the Inspector General may add the suspended practitioner to its List of Excluded Individuals/Entities (LEIE). Once you are on the LEIE, you cannot work in any organization that accepts federal funds. As shared in a previous PBI blog, The Most Powerful Federal Watchdog You’ve Never Heard Of, “that includes hospitals, clinics, social service agencies, managed care facilities, the VA, and research groups. It doesn’t matter how remote the connection to healthcare is. A company that provides cleaning or billing services to a hospital cannot hire you, not even as an unpaid volunteer.”
Suggestions for Anyone Considering an Additional License
- Think hard about holding onto additional licenses.
If you are regularly treating patients remotely or planning to move in the near future, another license makes sense, despite the challenges. However, if you’re not going to be using an additional license, you’re probably better off getting rid of it.
- Keep up with the laws in states where you are licensed.
It is your responsibility to know and obey the laws governing your license. Since those laws vary from state to state, you need to learn what is and is not allowed in each state where you are licensed. You’ll find this information on each licensing board’s website. It’s also a good idea to find out which issues are of special concern to your licensing and specialty boards, either by visiting their websites or subscribing to their newsletters.
- Get a lawyer in any state where you are licensed.
Licensing board members are appointed by governors, so they change pretty regularly. Since new board members often adopt new policies and focus attention on new issues, it’s important to stay on top of these administrative changes. That’s not always easy, because policy changes are not always publicly posted, according to Tennenhouse. The best way, really the only way to stay abreast of changes, is by hiring a local administrative healthcare attorney in each state where you are licensed. “And it has to be an attorney who practices before the board,” Tennenhouse explains. “No other type of attorney knows as well how that state’s Board is likely to act.”
- Make sure you have enough malpractice insurance.
Retaining counsel is not cheap. But Porter says some malpractice policies help cover these costs, which is one reason he urges practitioners with multiple licenses to increase their malpractice coverage. The primary reason, of course, is to help cover any board actions you are involved in. “Most malpractice carriers will pay somewhere between $25,000 and $50,000 for what they call administrative actions,” says Porter. He recommends having enough to cover you in each state where you are licensed.
- Keep track of all your licenses.
According to PBI founder Stephen Schenthal, MD, MSW, practitioners sometimes fail to notify sister-state regulators because they mistakenly think their license in that state has expired. Unless you actively cancel your license in another state, it may well remain in force, even if you have never practiced in that state or recently renewed the license. Even cancellation may not free you of sister-state requirements. State laws can differ drastically, so be sure to check on the status of any state license you have had at any point.