The Uncertain Future of Telehealth: 10 Considerations for In-Person vs. Online Therapy

Many of us were thrust into the world of telehealth during the COVID-19 pandemic, requiring us to be reactive rather than proactive when it came to virtual care. As clinicians try to determine whether to stay virtual or return to the office, I’m noticing rising anxiety and concern among my colleagues.

I’m hearing therapists ask questions like:

“When does it make sense to make the leap to a fully virtual practice?”

“How do I go about it?”

And, for many, the question is a resounding “Do I have to only offer therapy via telehealth?” 

Adding to the difficulty of these decisions, there’s uncertainty about whether insurance companies will continue to pay for telehealth. Telehealth policies continue to vary by state, insurance company, and insurance policy. Therefore, unfortunately, there are no across-the-board answers to help clarify this nationwide. 

Considerations for in-person vs. online therapy

When deciding between teletherapy and in-person face-to-face care therapists need to look into the rules for their own states and insurance payers, and then make the best decision for themselves and their clients.

Here are 10 factors to consider, along with questions to ask, when comparing in-person vs. online care—plus some practices to put in place either way:

1. Are your clients a good fit for telehealth?

During the early stages of the pandemic, we didn’t have a lot of choice about the way we saw our clients, and many of us learned about best practices as we went along. However, now that we’ve been navigating this reality for two years, we have more of an opportunity to make decisions based on how good of a fit online therapy actually is for our unique clients. 

For instance, is the type of client you typically serve fairly self-reliant?

If they are, they might be a good fit to continue with at least some virtual sessions.

On the other hand, clients with more severe mental illness, high-risk behaviors, or dissociation tendencies would likely benefit more from in-person sessions.

Think about your caseload and the clients you work with, and use your professional judgement to decide which—if any—of them might be a good fit for more long-term virtual care. 

You can also think through questions like:

• Are the modalities you use effective virtually, or would they work better in the office? 
• Do you feel comfortable managing risk from a distance (i.e., not being in the same physical space)? 
• Are there clients who would lose access to services if you decided to discontinue any telehealth services altogether? Do you feel comfortable terminating with these clients and referring them out, or is it more ethical or therapeutic to continue those relationships? 

Many clinicians who are returning to the office are continuing a hybrid approach, so you can also consider continuing video or phone sessions some of the time, or with some clients.

2. How will returning to the office impact cost for your clients?

If you have only self-pay clients and don’t bill insurance companies, you may be able to make your decision based solely on clinical appropriateness and preference.

However, if you work with insurance companies and your clients’ copay or deductible costs have been waived during the pandemic, both you and your client should be aware that if they return to in-person sessions, they’ll begin to be charged again.

This may happen even if you continue telehealth. And when (not if) this happens, is your client in a position to afford this expense, or would it be a deterrent to continuing services? 

3. Is telehealth covered under your clients’ insurance? If it was, is it still?

This question is a source of a lot of confusion for clinicians and clients.

Whether you’re an in-network or out-of-network provider, the rules for each insurance company are different—and can even vary between members who seem to have the same type of policy. Many insurance companies were obligated to provide telehealth coverage during the pandemic, but this may change as federal regulations are lifted and changed. 

And, just as we all got the hang of things in 2021, each insurance company can change their regulations again for 2022. Some, like Centers for Medicaid and Medicare Services (CMS) have recognized the importance of telehealth coverage for increased access to services, but are suggesting this may not apply to all diagnoses, or may require occasional in-person sessions in order for virtual sessions to continue being covered. 

Some questions you can consider regarding changing insurance regulations are: 

• If my client’s telehealth coverage suddenly stopped, would they be able to attend in-person or pay out of pocket to continue virtual meetings? 
• If insurance mandates in-person sessions, can my clients attend? 

If you bill insurance, it’s also important to verify each clients’ benefits to make sure you can help them make an informed decision about their care. Verify with the insurance company, for each client:

• Will telehealth continue to be covered in 2022? At what cost to the member? Indefinitely, or is there a known stopping point? 
• Will this apply to both phone and video sessions, or only video? Does this depend on diagnosis or service codes? 
• For billing purposes, what are the CPT codes, place of service codes, and modifiers I should be using for 2022? (Some plans are suggesting a change in place of service code depending on whether the client is at home or somewhere else at the time of the session.)

4. What are your state’s policies regarding parity for telehealth services?

While your state may have paid the same rate for telehealth services as in-person services during the pandemic, there’s no guarantee that this will continue indefinitely. Many states don’t have telehealth parity laws that require them to pay the same amount for telehealth as they do for in-person sessions, even if you’re spending the same amount of time, or providing the same services, to the client. 

Although many more states are examining this post-pandemic, these changes may be slow—or may not come at all. As more federal mandates are lifted, be sure to check with the insurance companies you bill, whether you are an in- or out-of-network provider.

Check your budget, and ask yourself if you would be able to afford your expenses if your session rates were reduced for telehealth services due to a lack of parity. 

5. Are you licensed in multiple states? Do you need to be?

Some clinicians were able to take advantage of relaxed regulations and begin meeting with clients in other states where we weren’t previously licensed. As with all of these considerations, this was allowed during the height of COVID, but some states have already begun removing these allowances.

On the other hand, some states have decided to make permanent or semi-permanent changes to allow telehealth exceptions to licensure requirements, or to offer special certifications to bypass these laws.

As you consider whether you need to be licensed in additional states, here are some questions you can consider:

• Are there any updates to licensure compacts for my license type?
• Is it worth it financially for me to obtain licensure in another state in order to continue working with any clients?
• Even with additional licensure, will that client’s health insurance continue to cover sessions with out-of-state providers?
• Have I prepared myself and my client for the potential of sudden change, or do I need to refer them to a local provider? 

6. Are there additional costs for telehealth-only practices in my state?

For instance, in my home state, a new regulation began at the end of 2021 that mandated a separate state registration for any providers who planned to only offer telehealth services. This would involve paying a pretty hefty fee that would need to be paid annually, and completing an annual report—the same as we do to renew our business licenses.

This rule also varies by state, so make sure to check the regulations for your home state. 

While the cost of this registration is likely much less than what it would cost to rent and maintain an office space, it’s still something to be aware of and factor into your budget as you consider whether to remain virtual.

It’s also important to investigate your own state regulations and make sure you’re not violating any regulations that might incur a fine or disrupt your ability to continue working. 

 7. How does telehealth impact informed consent?

Telehealth best practices include having clients sign an informed consent document regarding the potential downsides of telehealth—like privacy concerns, as well as what happens if the chosen technology for the sessions stops working. If you aren’t already including such language in your informed consent documents, it’s worth considering going forward. 

For clinicians who decide to return to in-person sessions, I’ve seen several recommendations to have clients sign a separate informed consent regarding COVID-19 risk. Due to contract tracing and reporting considerations, you may need to inform clients of what information would need to be released if you become aware of an infection in your office.

Other topics for consideration include whether or not you feel comfortable with clients taking their masks off in a session or in the waiting room, and whether you’re willing to forego any last-minute cancellation fees if they’re experiencing symptoms of COVID. 

There are free document templates available for both of these types of consent, but if you have questions about what to include or how it’s worded, it’s a good idea to have any new documents you decide to use looked over by an attorney. 

8. Are you using HIPAA-compliant software and payment methods?

This is best practice regardless for clinicians offering both face-to-face and online counseling. When it comes to payment, many software platforms and forms of electronic payment are not truly HIPAA-compliant, so make sure you do your homework before you start using any.

The rule of thumb is that the company must offer a Business Associates Agreement (BAA) that outlines how Protected Health Information (PHI) is handled as part of their service. If this doesn’t exist (and, likely, if you’re not paying for it), it’s not compliant. Especially if you decide to continue offering online counseling, make sure you use a telehealth platform for therapists that protects your clients’ privacy. 

9. Are you prepared to follow documentation best-practices for telehealth?

There are unique considerations for what needs documenting if you’re offering telehealth services, particularly if you bill insurance.

Insurance companies can rescind payments, even years later, if things like the client’s location or the appropriateness of the session aren’t documented.

Here are some things to make sure you’re including in your telehealth documentation: 

• Specify what modality of telehealth is being used (i.e. phone or video call) and what secure platform you’re using. 
• Note your client’s physical location. “Client at home” should be adequate if you have their address on file, but be sure to specify at least the city and state if the client is anywhere unfamiliar—including if they’re parked somewhere in their car. Also include your location as the provider. 
• Get verbal consent at the beginning of each session. Even if you have a signed informed consent form it’s wise to get additional verbal consent to the session, including discussing the potential for technical difficulties and privacy concerns. Even if you see the client is home, you never know if someone is off-camera within earshot unless you ask. In your progress note, you can include a summary of this discussion and the client’s response. 
• Document if anyone else was present for the session and their role, like a minor’s parent, a family member for a group session, or your clinical assistant or intern. 
• Include your assessment of the appropriateness, and continued appropriateness, of telehealth treatment for each client. 

Be sure to verify if any additional information is required by an insurance payer, your code of ethics, or your state or local mandates. 

10. What addresses are acceptable to insurance companies and my licensing board?

This one may sound strange, but if you’re considering giving up your office lease, or are thinking of the tropical island where you could start practicing from, it’s actually an essential question.

Make sure to check on questions like:

• Will any insurance payers with whom you’re paneled drop you if they learn you’ve moved out of state, even if you only continue to see clients in the state in which you’re licensed? 
• Will they drop you if you don’t maintain a physical office space?
• Will they allow a PO Box or virtual office space instead? And if so, does that also apply to billing and claims?
• If you use your personal address and it appears on any public-facing documents, are you comfortable with that information being available to others?

Whether you’re continuing telehealth or considering a phased return to in-person sessions, these questions can be a helpful periodic check-in for how your clients and your practice are doing.

All of this due diligence and verification with insurance companies is time-consuming, but if you set aside time to take care of it, it may save you time and money in the long run.  

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