Transitioning to Online Therapy in Response to COVID-19: How to Start, Legal and Ethical Concerns, Products, and Documentation

If looking at this is giving you the TL;DR skip to the meat-and-bones to your teletherapy questions, scroll past my musings to the header "Getting Started."

Online Therapy: My Dream

I graduated from my master's program for Marriage and Family Therapy and Art Therapy in 2012. For newer therapists, that seems so long ago, for more seasoned ones, that may not seem like much time at all. While working towards licensure, clinicians have to be supervised. They operate under the license of someone else. When this happens, it also means that certain forms of treatment, methods, and modalities are not taught to us. If your supervisor doesn't know about it, or the agency doesn't allow it, then you don't get to do it.

In my case, it was teletherapy. As a millennial, I grew up making relationships on the computer screen. In grade school, I would ping my classmates during class, in middle and high school I would use chatrooms and instant messaging through AOL Instant Messenger and MSN Messenger, and in college, I learned (mild) HTML and coding to make my MySpace page more attractive for friends. Even in college, I was meeting people nationally and internationally through the multiplayer video game, Left4Dead. I had a natural affinity with making connections online. Never once did I question these relationships. The emotions, thoughts, and reactions I had to all these experiences mirrored the ones I have offline.

It was only right that, because of this natural affinity, I would want to combine it with online therapy. None of my supervisors or agencies allow this. There were so many fears, ethical concerns, legal concerns, and technology concerns for them to be willing to try. I wouldn't be able to dip my toe into using teletherapy until I became licensed in December 2015.

Once I became licensed, I became obsessed with learning how to make teletherapy a thing. I had spent a year researching the practice of online therapy. I learned as much about the possible benefits and risks for my clients. I created protocols and procedures to ensure both their safety and my own. After getting a contract with the military, I even learned how to provide treatment internationally. My practice grew enough that, just this year, I was able to turn it into a group one.

Still, any clinician I ran into that wasn't an online therapist, poo-pooed the whole experience. I got the same reactions from my colleagues that I got from my supervisors when I wasn't licensed. When I mentioned that I provide treatment online, I'd get a look like I grew three heads. I'd then hear any combination of:

• What about the safety of your clients? What about the risks? What if they are suicidal? You can't help them online. What would you do? You couldn't do anything.

• There's no way you can make a real connection with a client online. It would feel fake. It wouldn't be real. Having a screen in front of you isn't as impactful as a person in the room. You're just having a diluted therapy experience with them.

• Is that legal? There's no way that is legal. Is it even confidential? It sounds like a legal and ethical nightmare.

• Why don't you want to practice real therapy?

Honestly, it was shocking and disheartening to hear these comments from people who are supposed to be my equal. From people who learn to be clinically sensitive and attune to others. From people who are expected not to pass judgments.

Still, I decided this was going to be my expertise. Teletherapy is a benefit to a variety of people. It's an excellent method of providing treatment to individuals with specialized needs and a lack of access to care (need for ASL interpreter, etc.). Individuals with a processing disorder, who may need time and space to think of responses to questions will benefit from asynchronous conversations (messaging). Growing up a portion of my life in Kansas, I found how valuable it was for individuals in rural areas where access to care is limited. It's even helpful with individuals who are severely agoraphobic and may avoid going outside to seek therapy to start building a support system.

New People To Teletherapy

What my fellow clinicians now have learned, as well, is that it is excellent for individuals who have a compromised immune system, maybe bedridden, quarantined, or otherwise unable to leave their home with ease. That's right. With what we are learning, daily, about the spread of COVID-19 (coronavirus), and the precautions people, facilities, organizations, and heck even the NBA are taking, therapists rightfully want to switch over to telehealth services.

Networking groups I'm a part of are seeking advice on how to provide the treatment. They are wanting to learn which insurance is covering teletherapy or expanding coverage during this time. They want to know how to approach the subject with their patients. Heck, they are even sliding into my DMs for information!

I will be honest. I don't know how to process the thoughts and feelings around how this crisis is pushing others to jump headfirst. I hope that this will finally shine a light on us clinicians who have always loved providing treatment digitally. I fear that without doing the proper research, obtaining necessary training, and gaining the right support, clinicians will continue to view online therapy as a second-best solution. I dread that clinicians will provide subpar, boarding unethical, or illegal treatment. This will not benefit them or their clients, causing many therapeutic ruptures for already established relationships, or leaving new clients with a bad taste in their mouth.

Therefore, as someone who came into this field intentionally, and has expertise I feel I have a duty to share some knowledge to help my fellow therapists who want to transition their care online. Ultimately, we want to work conscientiously. Let's provide clients the ultimate care they need. I believe with the proper guidance, we will foster clinicians and clients enjoying online therapy and lobbying it to be covered by all insurance and EAP programs.

Getting Started

Notifying Clients: If you have never offered teletherapy sessions with your clients before, this may be an awkward conversation to start. When factoring in fear of COVID-19 (coronavirus), you may be wondering what you should legally and ethically say. Access the letter I drafted for free, which gives your clients information about the changes you are incorporating. The goal is to provide them with an option to receive treatment that may be safer for both of you, not to scare them.

Additionally, many organizations have commented in support of utilizing teletherapy in response to COVID-19 (coronavirus).

• California BBS

• New York Office of Mental Health

HIPAA Online: For products to be HIPAA compliant, the individual or company utilizing them needs to sign a Business Associate Agreement (BAA) with the company. A BAA is a legal document between a healthcare provider and a contractor. A provider enters into a BAA with a contractor or other vendor with that vendor might receive access to Protected Health Information or (PHI). If any of the products you use do not have you sign a BAA, they are not HIPAA compliant.

Permissions and Legal and Ethical Considerations

Check Liability Coverage
Check State Regulations
Ethics Codes & Guidelines

Check Liability Coverage: First, you must speak with your malpractice to ensure that you are covered to provide this therapy. Call them. Explain if you are using video-conferencing, asynchronous conversations, and/or via telephone (reminder that most insurance and EAP companies do not consider this teletherapy because they require the therapist be able to visually see the patient). Discuss if you are covered to provide these services. If not, have it added. Do not put yourself at risk. Even if you do not see yourself continuing this form of treatment, if you're providing it now, make sure you are covered. Also, make sure the location you are utilizing if you choose to give sessions at home or another site, then where your office is.

WHAT I USE: CPH & Associates. Their plans are comprehensive, they allow for discounts if you’re connected with certain ethics orgnaizations (like CAMFT), and they cover telehealth. They also have some cool add-ons, like Cyber Liability Coverage, which I added to my plan.

See below what they recently released regarding telehealth coverage:

Image from CPH & Associates

Check State Regulations: Look into the ethical and legal practices of your state board and licensing body. There are many things to consider. Does the patient need to physically be in the same state as where you hold your license? Do both you and the patient physically need to be in the same state that you maintain your license? Do you need to be licensed in multiple states if each party is remotely in another state or country? These things may not be a problem for anyone who's been providing in-person treatment, and then transitioning that client online. Either way, you are still bound to hold the laws and ethics of your license and state, and are subject to legal ramifications, even if you "didn't know."

Ethics Codes & Guidelines: Learning the best practices to ethically provide teletherapy, as well as best practice guidelines to incorporate, like how to confirm the identity of the patient.

Here are some helpful links to start your research:

• To learn about what your states say regarding the specific profession of telehealth: Epstein Becker Green's 2017 50 State Telemental Health Survey

  • Note that if you want to get the most up to date version 2019, you'll need to download Epstein Becker Green's Telemental Health Laws app. It's free to download (data and message rates may apply), and is very comprehensive with the information it provides. It separates out states, professions, and keywords for searching. It's a tool every clinician online should have.

• To learn ethics codes about telehealth, the Zur Institute has a comprehensive list of "Professional Association Codes of Ethics and Guidelines on TeleMental Health, E-Therapy, Digital Ethics, & Social Media."

  • Note that the CAMFT information on the Zur Institute is outdated, as they updated their Code of Ethics in December 2019.

  • Note that they do not have any of the ethics organizations for the expressive arts, such as Art Therapy. To learn ethics about telehealth for Art Therapists, here is The American Art Therapy Association's "Ethical Principles for Art Therapists."

• To learn about legal paperwork and ethics codes around subjects such as dual relationships, electronic health information storage, or even social media and your profession, the Zur Institute offers "Ethics, Standard of Care, & Risk Management." The information is categorized by profession and topic.

• Free templates that include privacy statements, if you are functioning as a HIPAA covered entity or function as if you are one, be obtained from the Health Information Privacy website.

• American Telemedicine Association has put together state legislation information for telemedicine in their State Policy Resource Center.

• The U.S. Department of Health and Human Services has provided a guideline for e-therapy in their Considerations for Provision of E-Therapy.

Coverage

Insurance and EAP
Private Pay
Glitching

Insurance and EAP: Right now, coverage of teletherapy by insurance and EAP programs vary from each health plan, and by each state. Check with whom you are paneled and ask if this means of providing behavioral health treatment is covered. Again, explain if you're using video-conferencing, asynchronous conversations, and/or telephone as your means of providing services. Ask what billing codes you will need to use and if you need to use any modifiers (such as 95). Also, ask if they will be reimbursing you full in-person rate. If not, you will need to decide if you will charge the patient for the remainder, or eat the loss. Include these changes to all your legal documents and marketing materials. Also, document the discussion in the patient's record to show you informed them.

• To learn about some of the states that have parity laws that require insurance companies to reimburse at the same rate as in-person Doxy.Me provides information on Telemedicine Reimbursement.

• Mend provides a simple understand around telemedicine billing, including the modifiers and location in their Telemedicine Billing: How To Make It Easy.

• Simple Practice also has a tutorial on how to add the modifiers for teletherapy on their billing site in their Adding CPT Modifier for Telehealth Appointments.

• Billing Codes for Medicare Fee For Service Providers

• Blue Cross Blue Shield of Michigan covers both video and phone teletherapy sessions.

Some insurance plans are requesting therapists to sign attestations which state that they have the scope/specialization to provide telehealth (and means to do so). Be sure to inquire if your insurance company is adopting this practice in response the mass interest and need for teletherapy.

• For the attestation form for Cigna.

Private Pay: You will need to discuss with your patients if you are going to charge them your full rate. Patients will need to use their products to do video, phone, or message conferencing. They may also feel unsure about the transition to online. These things may factor into them requesting to pay a reduced fee, as they are no longer receiving any of the advantages of your office space. Include any changes to fees in all your legal documents and marketing materials. Also, document the discussion in the patient's record to show you informed them.

Glitching: You will need to discuss with your clients how much a session will be charged if it is shorted because of a glitch. If your or their system crashes during the meeting, will you charge for the amount of time provided in the session (20-30 minutes)? Will you excuse the session (not charging at all)? Will you reschedule the rest of the session (completing the session at a later time to allow for full billing)? It is illegal and unethical to charge a patient for a full service they did not receive. Include any changes to fees in all your legal documents and marketing materials. Also, document the discussion in the patient's record to show you informed them.

PLEASE BE AWARE THAT THERE WILL BE GLITCHES MORE FREQUENTLY NOW THEN THERE EVER WERE! The sudden rush to obtain telehealth systems are causing crashes, delayed images, etc. due to system overload. Many business, including physical therapy, speech therapy, even schools, are all transitioning to online services. Be patient, as this is not the usual experience, and you’re in very unprecedented territory.

Products

Method to Accept Payment
Equipment
HIPAA Secure Video
Records Storage Plan/Product

(For anyone wanting a more extensive buyer's guide list of products, including email, patient collaboration tools, and notary services, TeleBehavioral Health Institute has a Telehealth Buyer's Guide.)

Method to Accept Payment: This is something to consider, especially for providers who obtain payment from patients via cash, check, or in-person card reader. Now that you are both remote, how do you collect payment? If you don't have an EHR that is integrated with your payment/billing process (such as Simple Practice or Therapy Notes), you still have a few options to obtain payment online. They include Square, Stripe, or Ivy Pay. DO NOT USE PAYPAL/VENMO! They are not HIPAA compliant.

WHAT I USE: Ivy Pay. It is super easy. Download the app on your mobile device, fill out the information, sign a BAA with them, create a PIN, and you're good to go. Once in, you can input your client, the amount you're charging, and then if the client is paying via Ivy Pay, cash, or check.

My code for Ivy Pay is "aril541" which, when you use it to sign up, you'll get a $1000 in free charges as a gift. Full disclosure if you use my code, I will also get a $1000 in free charges once you've completed your first $1000 charges.

Person Centered Tech completed a Comprehensive Review of Ivy Pay.

Equipment: Many desktops, laptops, tablets, and even mobile devices can provide video, microphone, and audio equipment, so these may not need to be considered. If you don't have access to these, however, I would suggest using: HD Webcam 3 in 1 eMeet C980. It's got a microphone, speakers, and a camera and is compatible with Mac and PC. Additionally, you will want to ensure there is ample lighting. This will make the session online feel more inviting for your client. It will also help them feel secure in identifying that, it’s really you.

WHAT I USE: iMartine LED Ring. I chose it because it was affordable, has two lights so that my background could be light up as much as my face (foreground), and could bend around my laptop for sessions. It isn’t perfect though. It also had a really long cord, which was helpful as all my sockets are far away from my desk. The only way to plug it in is to have an adaptor that accepts USB one end and a socket for the other. This may not be a good option for you if you don’t have this.

HIPAA Secure Video: This is the one a lot of therapists who haven't provided teletherapy are scrambling to understand. If you aren't using an EHR that offers HIPAA compliant video (such as Simple Practice or TheraNest), then you may feel unsure of where to find this software.

One popular free option, with paid upgrades, is Doxy.Me. They are a not-for-profit company, and their system is designed to be HIPAA compliant. You don't need the paid version to make it HIPAA compliant, either. They also allow for "group therapy," though it is limited to 4 participants. Lastly, their paid versions allow for billing.

Another free option, with paid upgrades, is VSee. NASA uses this software, so you know they are secure. They also allow for "group therapy," with up to 10 participants. Their paid version allows for billing and ePrescriptions (something to let the psychiatrists you work with or receive referrals from, know)

Another option is Zoom Healthcare. A common misconception is that the free and regular paid versions for Zoom are HIPAA compliant (they are not). This product is pretty pricey, running to about $200 a month. Zoom will be a better option for larger companies, group practices, and providers who do extensive group therapy (as this allows for 100 participants during one session). Wondering how to ensure the safety of your Zoom call? Knoji’s Zoom Safety Guide offers a number of helpful and informative safety tips on navigating the Zoom video conferencing platform. You’ll be able to learn some great tips and tricks that range from enabling waiting room features to removing unwanted participants in a call so that you can focus on staying connected with your clients without the worry of encountering unwarranted “zoombombers.”

DO NOT USE FACETIME OR SKYPE! They are not HIPAA compliant. Also, do not use Facebook Messenger or Snap Chat. Seems silly to say that, but you’d be surprised.

WHAT I USE: Google Hangouts Meet from G Suite. The paid version of G Suite is HIPAA compliant, which includes HIPAA compliant video and messaging. Google Meets allows for 100 participants in one call. This is perfect for group therapy, family therapy, and couples therapy. To me, they were also the most affordable option.

Paperwork

Online Documentation
Risks and Benefits of Online Therapy
Emergency Response Plan
HIPAA Compliant "Opt-In" for Non-Secure Communications
Tech Explanation and Troubleshooting Plan
Progress Notes

Online Documentation: If you use paper documentation or an electronic system downloaded by an agency, and won't be in the office when you're providing sessions, then you may need to invest in an Electronic Health Record (EHR). You may also need to invest in this if you are going to start new sessions with new patients online, and require them to complete Intake Paperwork, sign Informed Consent and Consent for Treatment, or complete other documentation. Many people use Simple Practice, Therapy Notes, or TheraNest. All of these systems have a lot of upgrades and integrations that are worth looking into. Some of them allow you even to put a login portal on your website so patients can log in, access documents, fill them out, and you'll get an alert. You can also scan and email documents back and forth with patients, but make sure this is covered in your paperwork.

WHAT I USE: Google Docs and Google Forms through paid version of G Suite because, as previously mentioned, its HIPAA compliant. I have set up my Google Forms to integrate with Google Docs to help autofill specific fields in my progress notes. I also provide all documents with needed signatures to my patients. I even use it to give out questionnaires to help assess the effectiveness of treatment. To me, they were also the most affordable option.

Risks and Benefits of Online Therapy: Make sure your informed consent includes the risks and benefits of online therapy. Make sure you educate your clients on this and answer any questions they have.

Emergency Response Plan: You MUST create an emergency or crisis response plan with your patient. Your client must be educated on what to do if they are in an emergency or crisis. These issues are addressed in my paperwork. During treatment, you must also have a regular safety play that they can rely on when you are not accessible, or if a glitch prevents access to the session.

HIPAA Compliant "Opt-In" for Non-Secure Communications: HIPAA allows clients to "opt-in" to less secure means of communication. They updated their policy to include this so that clients have the freedom to request less reliable means of communication they are comfortable with and find clinically helpful.

Tech Troubleshooting Plan: It is your responsibility as the provider to explain to your patients how to access the tech and the troubleshooting needed to address any issues. You will need to educate them on if they are downloading software, using in-browser, or app software.

Progress Notes: There are many things to consider when documenting your online sessions in progress notes. Information around client location safety, considerations on identity clarification, etc. For anyone billing insurance, it is important that you note in your progress note that you used “a HIPAA compliant 2-way secure video system” in every session. This is a common thing insurance companies audit to find, and will recoup money if not in every note.

Training

Free Online Training
Paid Online Training

Free Online Training: It is essential to get training NOW! The sooner, the better. Remember, teletherapy was initially not in your scope of how to provide treatment. You are making the switch to ensure safety for you and our clients. Training is vital in maintaining safety.

• Person Centered Tech has a free online CE that, to access, you simply sign up. Gives you access to sample disclosure statements, to boot.

• Epstein Becker Green offers crash-course webinars, which include expansion of a telehealth practice, telehealth portal essentials, and understanding how to prescribe via telehealth.

• Telehealth Certification Institute offers a variety of free webinars to learn about providing telehealth.

• eLuma has a webinar on YouTube titled Making Teletherapy a Viable and Long-Term Solution for the school-based treatment of behavioral health, speech, and OT therapy.

• Sign up for regular webinars from The National Institute for Health Care Management Foundation, as they provide a variety of free webinars that cover a whole host of topics and often include telehealth information. Some of their most recent webinars, which include telehealth components, are Health In Rural America and Social Determinants of Mental Health.

Paid Online Training: Sometimes, the problem with free is you get what you paid for, which isn't much. With these online courses, you get access to a variety of information about how to provide teletherapy, legal and ethical concerns, and certifications as a telehealth provider.

• If you want to be a Certified E-Therapists, then take the online course with AllCEUs.

• Person Centered Tech is, in my opinion, the best provider for teletherapy training. They even provide a certification course. Until the end of March, these courses are offered at a discount.

• Zur Institute offers a variety of online courses for teletherapy, including considerations for group practices and practical applications for delivering treatment via telehealth.

• TeleBehavioral Health Institute offers three packages for Telebehavioral/Telemental Health Training & Micro Certifications.

• Telehealth.Training is a good option for large organizations and practices, as they can hire them as training consultants to train based on your companies' specific needs, policies, and procedures.

• The Practice of Therapy is a great resource to learn how to use GSuite with their GSuite for Therapists course.

• CE4Less has a course that offers 5 CEs titled A Practitioner's Guide to Telemental Health.

• ECare Behavioral Health Institute has a variety of Live Webinars that cover many mental health topics, including teletherapy.

Other Considerations

Get Connected
Conducting A Session
Client Abandonment and Emergency Response
Canceling Because of Coronavirus Issues

Get Connected: Get connected to other therapists and providers offering teletherapy. Join Facebook Groups for online therapy providers and search in them for any of your frequent questions. Connect with your local Telehealth Resource Center. Don't do this alone. Stay connected with the community!

• Facebook Page: Online Therapists Page with Dr. Amber Lyda

• Facebook Group: Online Therapist Group

• Facebook Group: How to Build an Online Therapy Group Practice

• Facebook Group: Online Therapy Professionals

• Facebook Group: Online Therapist Academy

• Facebook Group: G-Suite for Therapists Users Group

Conducting A Session: Some standard courtesy practices for providing online therapy include an ample amount of lighting so the client can see you fully (this creates the warm and inviting feel). Making sure the camera shows your head and shoulders at a minimum. You and your client should avoid using a smartphone for a camera, as it will tire your arm holding it, and with the screen so small, it can damper the intimacy of therapy. Make sure you and your client are in a quiet location where you both can speak openly and freely. If possible, have your license displayed behind you, so that it can be seen in the background. Lastly, try to look at each other and not the screen. This creates a real connection.

Client Abandonment and Emergency Response: Our patients may have, or currently are, displaced due to the closing of borders or travel regulations. They may be stuck internationally or nationally in another state. Usually, you need to be licensed in the state which your client is currently in.

Breaking that down, we look at the word "usually," because there are a few states that consider the Origin of Service to be where both the client and the therapist are. In those few outlier cases, you'd need a license in both states. Most laws use "is currently in," instead of "the state in which a client resides in," so it will incorporate travel. This allows for addressing emergency situations. You'll need to understand the state regulations on emergency responses to break confidentiality, reporting laws, involuntary hospitalizations, etc.

Legally and ethically, therapists can rely on two things regarding these uncertain times: client abandonment and emergency response. If your patient is unable to access your care in-person, mainly because they are quarantined, you have the right to continue to provide them treatment. You are then permitted to transition that treatment to teletherapy to minimize client abandonment and to respond to their emergency/crisis situation. Protect yourself with this knowledge.

Canceling Because of Coronavirus Issues: As fear and panic spread, along with large and small events, even work meetings, are rescheduling, canceling, or being postponed, there will be chaos around both you and your client’s schedule. You will need to consider how stringent you will be around your late cancel/no show policy. People are waiting hours in-line to purchase necessities, attempting to get last minute appointments with doctors, or coordinating child care as schools close. This will cause both anxiety, frustration, and forgetfulness in your clients. They may feel penalized if they are charged a fee for something that was out of their control. Additionally, you have to use clinical judgement if late cancel/no show has always historically been a problem for your client and now you believe your client is abusing any new protocols you’ve set in place.

I wish you safety and luck, as well as welcome you to the fantastic world of online therapy!

What questions do you have about providing teletherapy. Let me know in the comments section below!

---

---