When Your Provider Is Abroad: The Hidden Compliance Trap in Cross-Border Telehealth

By Elena Pak, Credentialing Department, WCH

Telehealth has made geography feel irrelevant. A physician in Portugal, a therapist in Thailand, a radiologist in India — all can connect with U.S. patients in real time. The technology works. The reimbursement often doesn’t. And the legal exposure can be significant.

This is not a niche issue. Post-pandemic workforce mobility, clinician burnout, and the normalization of remote work have pushed more providers — temporarily and permanently — outside U.S. borders. Many assume that if they hold a valid state license and the patient is sitting in Ohio, everything is fine. That assumption deserves serious scrutiny.

The Foundational Rule: It’s About the Patient, Not the Provider

Start with the principle that governs nearly all telehealth legality: the state where the patient is physically located at the time of the encounter is what determines whether care can be provided at all. A California-licensed physician treating a patient who happens to be visiting New York must be authorized to practice in New York. The provider’s location is secondary — but only up to a point.

That “secondary” status evaporates quickly when the provider crosses an international border.

Licensing boards in U.S. states regulate the practice of medicine within their jurisdiction. When a provider leaves the country, a second regulatory layer enters the picture: the laws and professional standards of the foreign jurisdiction. Some countries restrict or prohibit foreign licensed clinicians from practicing medicine on their jurisdiction, even if no local patients are involved. Providers who fail to check these requirements before logging on from a hotel in Barcelona or an apartment in Mexico City may be exposing themselves to unknown legal liability.

Beyond that, profession-specific rules add further complexity. Many boards require in-person visits before prescribing, particularly for new patients or controlled substances. If a provider is overseas and cannot easily fly back, those requirements become operational constraints, not just paperwork.

Where Reimbursement Draws a Hard Line

Legal authority to provide care and reimbursement for that care are separate questions — and the reimbursement rules are considerably less forgiving.

Medicare’s position is unambiguous and has been for years: payment will not be made for services furnished by providers located outside the United States. The Medicare Benefit Policy Manual cites the example of a radiologist in India reading imaging studies for U.S. patients — services Medicare will not reimburse regardless of the patient’s location or the radiologist’s U.S. credentials. The underlying logic is that federal payment programs are not designed to support services rendered from foreign territory, period.

This position was tested directly in RemoteICU LLC v. U.S. Department of Health and Human Services, a case involving a telehealth company whose critical care physicians were located abroad while treating U.S. ICU patients. The court dismissed the challenge on procedural grounds without ruling on the merits, but CMS’s underlying position — no reimbursement for services rendered from outside the U.S. — was left entirely intact. For providers considering international work arrangements, that litigation is a cautionary tale with a very clear takeaway.

Medicaid adds state-by-state variation on top of federal complexity. Kentucky explicitly prohibits reimbursement for services furnished by providers not physically located within the United States or a U.S. territory. New York defines a “distant site” as a location within the United States or its territories. Oregon prohibits payments to any financial institution outside the country. Dozens of other states simply don’t address the issue at all — which creates its own problem, because silence is not permission.

Private payers are not required to follow Medicare rules, but many have adopted similar restrictions, and their contracts rarely address the scenario of a provider working from abroad. Assuming coverage extends internationally without confirming it in writing is a compliance risk most providers cannot afford.

What Providers Actually Need to Do

The practical takeaway here is that this requires active verification — not assumptions, not guesswork, and not relying on telehealth technology vendors who have no obligation to flag legal or billing exposure.

Before furnishing any telehealth service from outside the United States, providers should confirm three things independently. First, what does the regulatory authority in the foreign jurisdiction say about providing medical services to patients in another country? Second, what does each state licensing board say about the provider’s ability to serve patients in that state while physically abroad? Third, what does each applicable payer — Medicare, state Medicaid, and any private insurers — require regarding the provider’s physical location?

None of these questions have universal answers, and none of them can be safely skipped.

Professional liability coverage deserves special attention. Many malpractice policies contain territorial exclusions or require notification when a provider practices from outside the country. A provider who files a claim after an adverse event that occurred during a session conducted from abroad may discover that their coverage does not apply — at exactly the moment they need it most.

Finally, providers using interstate licensure compacts — the most common workaround for cross-state telehealth — should note that those compacts address practice across U.S. state lines, not international borders. They offer no protection for providers located outside the country.

The Bigger Picture

The structural drift toward globally mobile clinical workforces is not going to reverse. The same forces that made remote work normal in every other knowledge profession are reshaping how clinicians think about where they work. Health systems that employ telehealth providers, staffing agencies that place them, and platforms that connect them with patients all have compliance obligations they may not be fully meeting.

For individual providers, the cost of getting this wrong is not just a denied claim. It is potential licensing action, insurance disputes, and — depending on the jurisdiction abroad — legal exposure in a country whose regulatory system they did not consider. The asymmetry is significant: the upside is the flexibility to work from another country for a few months, and the downside is a compliance crisis that follows a clinician home.

The technology makes it easy. The rules make it complicated. Knowing which rules apply — and verifying them before the first session — is the only defensible approach.

Sources

1. Center for Connected Health Policy (CCHP) — TA Spotlight: Can Providers Legally Furnish Telehealth Services From Outside the United States? (June 2026): https://www.cchpca.org
2. Medicare Benefit Policy Manual, Chapter 1, §10.4 — Services Furnished Outside the United States (CMS): https://www.cms.gov/medicare/regulations-guidance/manuals/internet-only-manuals-ioms-items/cms012673
3. RemoteICU LLC v. U.S. Department of Health and Human Services et al — Case summary and CCHP analysis: https://www.cchpca.org/resources/remoteicu-decision
4. Kentucky Administrative Code, 907 KAR 003.170 — Telehealth Services
5. New York Public Health Law, Article 29-G, §2999-cc — Telehealth Definitions
6. Oregon Administrative Rules, 410-120-1180 — Medicaid Payment Restrictions
7. CCHP Telehealth Policy Finder — Cross-State Licensing and Licensure Compacts: https://www.cchpca.org/telehealth-policy