Published 12/31/2019
Daniel Schlatterer, DO, FAAOS; and Alfred Atanda Jr, MD

Liability and Billing Concerns

Editor’s note: This article concludes a two-part series on telemedicine (TM). Part two discusses liability and compensation concerns associated with TM. Part one appeared in the December 2019 issue of AAOS Now.

Part one of this series covered the early days of telemedicine (TM) in space and military applications. The earliest report of TM use in trauma was in 2008 by Duchesne et al., who reported their experience with trauma patients initially treated at seven rural emergency departments (EDs) before transferring to trauma centers. Authors have reported that TM offers shorter visits and reduces travel and expenses for patients. Higher patient satisfaction rates are reported with TM.

What you need to know

Is TM compensable? (Table 1) Does TM require specific underwriting? Yes, a malpractice policy should be sought that recognizes TM services. Every state medical board differs regarding licensure requirements. Some states require a full medical license in order to provide TM services, whereas others offer a limited license for TM services, and some require both a full license and a TM license.

Consultation with your practice administration is recommended to ensure your TM practice follows state laws and steers clear of potential conflicts of interest. Continuity of care, charting, and documentation are important. Several companies have established platforms for storing patient information in ways that are compliant with the Health Insurance Portability and Accountability Act; the information then can be viewed by doctors on a panel or within a specific group or practice.

Documentation is no less important in TM than in any other patient encounter. TM malpractice suits have yet to surface, but well-documented differential diagnoses and care plans are always advised. If possible, a written or printed care plan with follow-up information and office telephone numbers should be given at the end of a TM visit. A TM visit should end much like discharge from the ED. Provide educational materials about prescriptions and warning symptoms of untoward potential events.

In terms of compensation for professional services, many states that have experienced natural disasters with ensuing loss of healthcare facilities have been very proactive in mandating that private insurance carriers reimburse TM consultations. For example, central Georgia was recently devastated by extreme weather; in response, the state government enacted proactive laws that recognize TM and assigned Current Procedural Terminology codes for TM visits analogous to new patient encounters in the office or ED (Table 2). The 12 states that currently permit TM are Arkansas, Colorado, Connecticut, Delaware, Georgia, Idaho, Indiana, Maine, South Carolina, Texas, Virginia, and West Virginia.

Several TM companies now provide credit card fee-for-service options. The companies retain doctors in multiple specialties. Nurses triage patients and connect them with doctors who can address certain complaints. Fee-for-service can be between doctor and patient or between a specialist and an ED or urgent care facility.

Table 1 Top five questions regarding telemedicine (TM)
Sources: Information Culled from The Following: Atanda Jr A: Using Telemedicine for Orthopaedic Follow-Up. Available At: http://www5.aaos.org/aaosnow/2017/Jun/Clinical/ Clinical08/. Accessed November 7, 2019; Atanda Jr A, Pelton M, Fabricant Pd, Et Al: Telemedicine Utilisation in A Paediatric Sports Medicine Practice: Decreased Cost and Wait Times With Increased Satisfaction. J Isakos 2018;3:94-7
Table 2 Comparison of telemedicine (TM) versus face-to-face visitsSource: Debakey, ME: Telemedicine Has Now Come of Age. Telemedicine J 1995;1:3-4.

A TM visit can be a face-to-face encounter in real time, which is called a synchronous visit. Or, in an asynchronous TM consultation, a clinician responds minutes to hours after images and history have been sent electronically. Currently, there is no consistent legislation across all states on which method is reimbursable. Eighteen states currently require only Medicaid to cover TM service; 37 states have parity laws requiring private insurance companies to reimburse for services provided through TM. Most states observe medical practice parity standards, regardless of the delivery method.

Recent legislation

In October 2019, the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act was introduced in the Senate. The legislation would include four points related to TM:

  1. Provide the Secretary of Health and Human Services with the authority to waive telehealth restrictions when necessary.
  2. Remove geographic and “originating site” restrictions for services such as mental health and emergency medical care.
  3. Allow rural health clinics and other community-based healthcare centers to provide telehealth services.
  4. Require a study to explore more ways to expand telehealth services so that more people can access healthcare services in their own homes.

As this legislation moves forward, stay tuned for further TM updates from the AAOS Medical Liability Committee. Learn more about the legislation at https://bit.ly/2Pf5qqA.

In conclusion, TM offers many potential benefits. Patient demand for faster knowledge transfer via TM will increase as TM expands into other specialties and geographic regions. Due to physical examination constraints, TM will likely best serve as a triage platform for orthopaedics and as a follow-up option for remote or infirmed patients.

This article was supported by the AAOS Medical Liability Committee.

Daniel Schlatterer, DO, FAAOS, is a member of the AAOS Medical Liability Committee and an orthopaedic trauma surgeon based in Atlanta. He can be reached at danschlatterer67@gmail.com. He has established TM consultation services in orthopaedic trauma and stroke.

Alfred Atanda Jr, MD, is a pediatric orthopaedic surgeon based in Wilmington, Del. He can be reached at aatanda@nemours.org.


  1. Duchesne JC, Kyle A, Simmons J, et al: Impact of telemedicine upon rural trauma care. J Trauma 2008;64:92-7.
  2. DeBakey, ME: Telemedicine has now come of age. Telemedicine J 1995;1:3-4.
  3. Atanda Jr A: Using Telemedicine for Orthopaedic Follow-up. Available at: https://www5.aaos.org/aaosnow/2017/Jun/Clinical/clinical08/. Accessed November 7, 2019.
  4. Atanda Jr A, Pelton M, Fabricant PD, et al: Telemedicine utilisation in a paediatric sports medicine practice: decreased cost and wait times with increased satisfaction. J ISAKOS 2018;3:94-7.