Telehealth has made it possible for practices to treat patients almost anywhere. It’s convenient, flexible, and something patients rely on now more than ever. But once you start offering care across state lines, the billing side becomes a whole different story. What works perfectly fine in your home state suddenly doesn’t apply somewhere else. Claims get held, documentation rules change, and payer requirements shift faster than anyone expects.
If your practice is already offering multi-state telehealth or is thinking about expanding into new states, it’s important to understand the specific challenges that come with it. Not because the process is impossible, but because being aware of the differences helps you avoid the delays and denials that frustrate so many providers.
1. State Telehealth Rules Don’t Match
One of the biggest roadblocks is the fact that every state plays by its own rules. Some states treat telehealth almost the same as in-person care, while others set stricter boundaries on what counts as a covered telehealth service. Something as small as whether audio-only visits are allowed can make or break a claim. And if you use one uniform billing approach for patients in different states, you’ll run into problems faster than expected.
The best way to handle this is by having a simple way to confirm each state’s telehealth guidelines. Not a giant document that overwhelms your team, but just clear information your billers and providers can quickly refer to, so no one is guessing what a specific state or payer expects.
2. Licensing and Credentialing Slow Billing Down More Than People Realize
Many practices don’t realize how much licensing impacts billing until claims start getting denied. Telehealth doesn’t mean a provider can automatically treat a patient in any state. The provider must be licensed there, and they must be fully credentialed with that state’s payers. If they see patients before everything is approved, billing becomes a mess. Claims don’t just get delayed; they often get denied outright.
A smooth system for tracking licensing and payer enrollment becomes essential once you work across multiple states. Keeping everyone aligned, like providers, credentialing staff, and billing teams, prevents accidental billing before approval and protects the practice from long reimbursement delays.
3. Payer Rules Shift From State to State
Even when you’re dealing with one national payer like Aetna or Blue Cross, their telehealth rules don’t stay consistent across states. One state may require modifier 95, while another sticks to GT. Some want POS 02, some prefer POS 10. And if billing teams aren’t working off state-specific guidance, errors are almost guaranteed.
It helps to treat each payer differently based on the state you’re billing for. When your team knows the exact code and modifier combination needed for that state, claims move without back-and-forth corrections.
4. Documentation Requirements Aren’t Universal
Telehealth documentation is stricter than a lot of practices expect, and the rules vary by state. Some states want you to clearly note where the patient was during the call, while others want the provider’s location as well. Some want the length of the visit recorded, or whether it was video versus audio-only. Leave out even one detail, and you risk a denial later, sometimes during an audit rather than upfront, which is even harder to clean up.
A consistent approach to documentation helps prevent that. When providers follow the same telehealth note structure across all states, you don’t end up rewriting notes or defending documentation months after the visit happened.
5. Payment Rates Don’t Line Up Across States
Reimbursement rates for telehealth can vary widely from one state to another. Some follow Medicare’s rates. Some follow parity laws, meaning telehealth gets paid the same as in-person care. Others pay less, and a few pay more for certain telehealth services. If you assume all states pay the same, you’ll end up confused about underpayments or overpayments.
Monitoring state-level fee schedules, only for the payers you bill frequently, helps you stay ahead of payment discrepancies. It doesn’t need to be complicated; it just helps you understand what should be coming in.
6. Denials Increase When You Apply the Wrong State Rules
Most denials in multi-state telehealth billing aren’t due to complicated coding mistakes. They’re caused by small, avoidable errors like using the wrong modifier, sending claims before credentialing is complete, or submitting a telehealth service that isn’t covered in that particular state. These errors build up quickly, especially if your practice expands into several states at once.
A good approach is to review denial patterns regularly. If you notice the same denial reason repeating for one state, that’s a sign that something in your workflow needs to be updated. The fix is usually simpler than it seems.
7. Compliance Gets Harder As You Expand
The more states you serve, the more rules you’re responsible for following. That includes licensing laws, payer updates, telehealth regulations, and documentation guidelines. None of these stays the same forever. States adjust their policies, payers refine their requirements, and what worked last year might not work now.
To stay compliant, you don’t need a huge legal team or a complicated system. What you do need is someone keeping an eye on regulatory updates, ideally on a monthly or quarterly basis. Even quick high-level checks help your practice stay ahead of changes.
8. Front-Office Workflows Aren’t Built for Multi-State Telehealth
Scheduling telehealth across multiple states creates new tasks for your front-desk team. They suddenly need to confirm patient location, check the provider’s eligibility for that state, and make sure the payer covers telehealth for that specific service. When these details aren’t confirmed before the visit, billing problems show up afterward.
Smooth workflows don’t need to be long or complicated. What matters is that staff know exactly what to verify before the visit begins. When the basics are checked up front, the billing cycle becomes much more predictable.
Final Thoughts
Multi-state telehealth billing isn’t just “telehealth with extra steps.” It comes with its own rules, challenges, and expectations that change from one state to another. But once you understand those differences and build simple systems around them, everything gets easier, as claims move faster, denials shrink, and your revenue stays steady.
It is not necessary to memorize all the state rules. It is to maintain your workflow transparent, uniform, and in line with the needs of each state. When your team does so, multi-state telehealth is an opportunity, not a burden.
