Should I Start a Telepsych Practice? Questions and answers for PMHNPs

I follow many NP forums, and one of the things I see mentioned that I felt needed some exploration is whether and how to start a telepsychiatry practice. So let’s look at this! 

Telepsych looks like the new gold rush, but our calling goes far beyond chasing a paycheck. We are healers, educators, advocates, and now, business owners. As an entrepreneur and business owner myself, I want to help others think long and hard before making the dive into starting their own telepsych practice.

Let’s talk candidly about what’s coming down the pike and how to do it right, not just fast. Below is a Q&A that reflects current federal rules as of July 23, 2025, along with my other experiences and research.​

1. Are telehealth laws about to change? Should I wait?

Many of the pandemic-era flexibilities are set to expire on Sept 30, 2025, unless Congress acts. Medicare patients can still receive non-behavioral/mental health telehealth visits at home, without geographic restrictions, through that date. For mental health, the six-month in-person requirement is waived until Jan 1, 2026, for FQHCs and RHCs. The DEA has extended the ability to prescribe controlled substances via telemedicine through Dec. 31, 2025, and is developing special registrations that would allow certain practitioners (e.g., psychiatrists and hospice physicians) to prescribe Schedule II–V medications without ever seeing the patient in person.  DEA will also require telemedicine platforms to register and plans to build a national prescription-drug monitoring program. 

My take: Be thoughtful here. You can open a compliant telepsych practice now, knowing the rules could evolve. Or wait until you are sure where things will be a few months down the road. Stay plugged into updates from HHS and the DEA so you can adjust when final rules are published.

2. What equipment and hardware do I really need?

Quality care starts with quality technology. The New York Office of Mental Health says telepsychiatry must use videoconferencing equipment that allows synchronous video and voice exchange; they outline three setups: dedicated telepresence systems, PC-based solutions (computer + webcam, speakers, and mic), or tablets with remote-control cameras. The American Telemedicine Association likewise recommends professional-grade cameras and audio and stresses having a backup plan for equipment failures.

In practical terms:
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• Computer or tablet with a high-definition camera and microphone. eVisit notes that most telemedicine apps work with standard cameras, but an external webcam/mic may improve quality.
  
  
• Reliable internet connection. Test bandwidth and provide patients with a speed-check link.
  
  
• Backup communication. Keep a phone number handy for audio-only sessions if video fails.
  
  
• Secure environment. Use a private, well-lit room; lock the door; and mute notifications so patients feel safe and respected.

3. What software and platforms should I use?

Legally, any platform you use must comply with HIPAA. HHS warns that providers must use vendors that will sign a business associate agreement and provide secure, encrypted video. That means consumer apps such as FaceTime or Zoom’s free version won’t cut it unless there is a signed HIPAA addendum.

In practice, think about two categories of software:
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1. Practice management/EHR with telehealth integration. Some providers recommend IntakeQ/PracticeQ because it handles charting, scheduling, intake forms, and billing, and integrates with HIPAA-compliant telehealth platforms.
   
   
2. Telehealth video platform. Doxy.me is a popular HIPAA-compliant option; it offers a free tier and a low-cost day pass if you need screen-sharing. Other PMHNPs use Zoom for Healthcare, VSee or integrated modules in Athenahealth.
   
   

Make sure the platform has business associate agreements, encrypted video/audio, virtual waiting rooms, and the ability to document patient location and identity for each visit.

4. What about billing and business models?

Telepsych billing can feel like navigating a minefield. Here’s a quick primer:
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• Medicare and Medicaid: Telehealth flexibilities remain in place until Sept 30, 2025. Behavioral health visits can be audio-only if patients can’t use video. FQHCs and RHCs can bill as distant-site providers. Use appropriate place of service codes and modifiers (95 for synchronous telehealth). An in-person visit is not required until 2026 for mental health services.
  
  
• Private insurance: Many states require parity, meaning telehealth must be reimbursed at the same rate as in-person care, but rules vary. Check your state’s parity laws and each payer’s telehealth policy. The Center for Connected Health Policy notes that private payers often require the same standard of care as in-person visits and may impose utilization review and cost-sharing requirements.
  
  
• Cash pay vs. insurance: Some PMHNPs recommend a “lean and scrappy” approach. Start small, get a few patients, and streamline before investing heavily. Use credit-card processors like Stripe or Square to ensure payment and reduce administrative time.
  
  
• Entity type: In most states, you can form an LLC or professional LLC, but in California, licensed professionals (including NPs) must form a professional corporation. If you see patients in multiple states, you may need to register your entity as a foreign corporation. Check with a lawyer to be sure. ​

5. What policy shifts should I be aware of?

During the public health emergency, many restrictions were lifted. Those flexibilities are slowly sunsetting. Key items:
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• Licensure: Telehealth is considered to occur where the patient is located, so you must be licensed in each patient’s state.
  
  
• DEA registration: You still need a DEA registration tied to a physical address in each state where you prescribe controlled substances. The DEA is proposing special registrations to allow prescribing without in-person exams, but those rules are not yet final and have been delayed until December 31, 2025.
  
  
• National prescription drug monitoring program (PDMP) and platform registration: The DEA intends to require telemedicine platforms to register and will establish a national prescription drug monitoring program.
  
  

Your next steps: Work closely with a health-care attorney and stay updated through professional organizations. Make sure your malpractice insurance covers telehealth and multi-state practice; some carriers exclude telepsychiatry or require riders.

6. How do I treat patients with substance use disorders via telepsych?

In January 2025, the DEA issued a rule (not yet fully implemented) allowing DEA-registered practitioners to prescribe buprenorphine via audio-video or audio-only telemedicine for up to six months, provided certain conditions are met. Patients would need an in-person evaluation for refills beyond six months. The rule’s effective date has been delayed, but the existing pandemic-era flexibilities remain in force until the end of 2025.
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Practical tips:

1. Screen carefully. Determine whether telehealth is appropriate based on the patient’s stability and risk for diversion.
   
   
2. Document identity and location. Always verify and record the patient’s location and a backup contact.
   
   
3. Coordinate with local resources. Know where your patient can go for in-person care or emergency services. Have a plan if the patient needs labs, urine drug screens, or in-person evaluation.
   
   
4. Stay on top of regulations. Even with new rules, some states or pharmacies may limit tele-buprenorphine prescriptions; check state law and payer policy.

​Final thoughts

Starting a telepsych practice takes more than a Wi-Fi connection and a Zoom account. You need to align your mission (improving access and care) with compliance (licensure, business registration, and DEA rules), technology (HIPAA-compliant software and quality hardware), and business acumen (billing, insurance, and pricing).

​But you might not want to wait for the dust to settle.  If you do start now, build a lean practice, and stay flexible as rules evolve. Patients deserve conscientious providers who are prepared for both today’s regulations and tomorrow’s changes.