State Licensure for Telehealth Post-Op Follow-Up: What Providers Must Know
Providing post-operative follow-up via telehealth across state lines requires understanding a patchwork of licensure laws. This guide covers the Interstate Medical Licensure Compact, state-specific temporary practice exceptions, and practical compliance steps for surgical practices offering virtual recovery check-ins.
The Baseline Rule: Licensure in the Patient's State
Under the prevailing legal framework in the United States, the practice of medicine occurs where the patient is physically located at the time of the encounter, not where the provider is located. A surgeon in Texas conducting a telehealth follow-up with a patient who has returned home to Oklahoma is practicing medicine in Oklahoma and must hold an Oklahoma medical license. The Federation of State Medical Boards (FSMB) reaffirmed this principle in its 2023 policy update on telehealth.
This rule applies to all synchronous telehealth encounters (video visits, phone calls) and, in most states, to asynchronous communication (secure messaging, store-and-forward) when clinical decisions are made. Simply answering a patient's post-operative question via the patient portal about whether their incision looks normal constitutes a clinical encounter under most state medical practice acts.
Penalties for practicing without a license in a patient's state range from cease-and-desist orders to license revocation in your home state, malpractice insurance coverage gaps (most policies exclude unlicensed practice), and, in some states, criminal misdemeanor charges. The Federation of State Medical Boards tracks enforcement actions and shares data across state boards.
The practical impact for surgical practices: if your patients routinely travel from neighboring states for procedures and then return home for recovery, every virtual follow-up visit occurs in the patient's home state. Practices near state borders (Kansas City MO/KS, Memphis TN/AR/MS, Portland OR/WA) face this issue most frequently.
Interstate Medical Licensure Compact (IMLC)
The IMLC (imlcc.org) is a voluntary agreement among participating states that creates an expedited pathway to obtain additional state medical licenses. As of January 2026, 42 states plus the District of Columbia and Guam are IMLC members. Notable non-member states include California, New York, Florida, and Massachusetts.
The IMLC does not create a single national license. It streamlines the application process: you apply through the IMLC portal, designate your state of principal licensure (SPL), and select the additional states where you want licenses. The Compact verifies your credentials once, and participating states issue their own licenses based on that verification. Processing time is typically 2 to 4 weeks, compared to 2 to 6 months for standard state applications.
Eligibility requirements for the IMLC: you must hold a full, unrestricted medical license in your SPL, have no history of disciplinary actions, have no criminal history, hold board certification in your specialty (or be within the ABMS/AOA initial certification period), and designate a state of principal licensure where you live, practice, or maintain at least 25% of your clinical activity.
Costs vary by state. The IMLC charges a $700 application fee (2026 rate), and each additional state charges its own license fee (typically $200 to $600). Annual renewal fees apply per state. For a practice near a two-state border, this often costs $1,000 to $1,500 initially and $400 to $800 annually. Budget this as a cost of offering telehealth follow-up to out-of-state patients.
State-Specific Exceptions and Temporary Practice Provisions
Several states have enacted specific telehealth exceptions that permit out-of-state providers to treat patients without a full state license under defined circumstances. These vary significantly. Arizona allows out-of-state telehealth providers to register (not full licensure) to treat up to 10 Arizona patients per year. Florida requires full licensure with no telehealth exception for out-of-state providers.
Post-COVID temporary practice waivers have expired in most states. During 2020 to 2022, nearly all states issued emergency orders allowing out-of-state telehealth practice. By 2025, the majority of these waivers had sunset. Do not rely on pandemic-era guidance. Check the current status through each state's medical board website or the Center for Connected Health Policy (cchpca.org), which maintains a state-by-state telehealth policy tracker updated quarterly.
Some states recognize a 'continuity of care' or 'established patient' exception that allows a limited number of follow-up encounters with a patient you initially treated in your licensed state. Texas, for example, permits up to 5 follow-up telehealth visits within 12 months for patients initially seen in-person in Texas who subsequently relocate. These exceptions are narrow and state-specific. Document which exception you are relying on.
The Psychology Interjurisdictional Compact (PSYPACT) and the Nurse Licensure Compact (NLC) provide models for other professions. Physical therapists have the PT Licensure Compact (active in 27 states as of 2026). If your post-operative care team includes PTs, psychologists, or nurses providing telehealth services, each profession has its own compact or lack thereof. Verify licensure requirements for every provider type in your practice who communicates with patients across state lines.
Compliance Steps for Surgical Practices
Step one: audit your patient population. Pull the home addresses for all patients seen in the last 12 months and identify every state represented. For practices near state borders, this is often 2 to 4 states. For destination surgery practices (bariatric centers, orthopedic sports medicine, cosmetic surgery), this may be 10 to 20 states. Prioritize licensure in states that account for 80% or more of your out-of-state patient volume.
Step two: obtain additional licenses through the IMLC for participating states and through standard applications for non-IMLC states. Assign a staff member or credentialing service to manage multi-state license renewals, CME tracking (many states have state-specific CME requirements), and DEA registrations (a separate DEA number is required for each state where you prescribe controlled substances).
Step three: configure your EHR and telehealth platform to verify the patient's current physical location at the start of each virtual encounter. The patient's home address on file is not sufficient. A patient may be traveling. Record the patient's physical location in the encounter note. Most telehealth platforms (Doxy.me, Zoom for Healthcare, Teladoc Health) include a location verification prompt that can be enabled.
Step four: update your malpractice insurance. Notify your carrier of each additional state where you hold licensure and practice telehealth. Coverage must explicitly include telehealth encounters in those states. Some carriers charge a modest premium increase (5% to 15%) for multi-state telehealth coverage. Practicing in a state not listed on your policy creates a coverage gap that the insurer will cite to deny claims.
Do I need a separate DEA number for each state where I do telehealth follow-up?
Yes, if you prescribe controlled substances to patients in that state. The DEA requires a separate registration for each state where you dispense or prescribe controlled substances. If your telehealth follow-ups only involve wound checks, recovery guidance, and non-controlled medication adjustments, you may not need an additional DEA registration. However, if a post-op patient in another state needs a pain medication refill (even a Schedule IV like tramadol), you must hold a DEA registration in that state. Applications are filed through the DEA Diversion Control Division (deadiversion.usdoj.gov).
Can I use the IMLC to practice telehealth in California, New York, or Florida?
No. As of 2026, California, New York, and Florida have not joined the IMLC. You must apply for a full medical license through each state's medical board using their standard application process. California (Medical Board of California) takes 60 to 90 days for a complete application. New York (NYSED) takes 8 to 16 weeks. Florida (Florida DOH) takes 30 to 60 days. These timelines assume no application deficiencies. Budget 3 to 6 months for non-IMLC state applications.
What if a patient calls me with a post-op concern while traveling in a state where I am not licensed?
For a true emergency, the FSMB recognizes that a physician may provide emergency guidance regardless of licensure status, consistent with Good Samaritan principles. For non-emergency concerns (routine wound questions, medication timing), the safest approach is to advise the patient to send a photo or message through your patient portal (asynchronous, lower regulatory risk in most states), schedule a formal telehealth visit after the patient returns to a state where you are licensed, or refer the patient to a local urgent care or emergency department if the concern cannot wait. Document the interaction and your reasoning.
Does telehealth licensure affect my reimbursement from insurance?
Yes. Most commercial payers and Medicaid programs require you to be licensed in the state where the patient is located to bill for telehealth services. Medicare is the exception: CMS does not impose geographic restrictions on telehealth licensure for Medicare-enrolled providers (the originating site and distant site rules were relaxed through Congressional extensions of pandemic-era flexibilities, most recently extended through December 2025 with further extensions proposed). Check current CMS Fact Sheets for the latest Medicare telehealth policy status.
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This blog provides general information about healthcare compliance and aftercare best practices. It does not constitute legal, medical, or regulatory advice. Consult qualified professionals for guidance specific to your practice.
