Telehealth Tensions: Navigating DEA Scrutiny, CPOM Landmines, and State Board Enforcement in a Post-PHE World

By Shannon Smith, DNP, APRN, FNP-C, PMHNP-BC, PMHNP-C · 2026-04-17

The healthcare regulatory landscape continues its rapid evolution, presenting both opportunities and significant compliance challenges. This week's digest unpacks critical developments from the DEA, DOJ, and state boards, highlighting increased scrutiny on telehealth prescribing, the enduring complexities of Corporate Practice of Medicine doctrines, and what these mean for your practice's operational integrity and growth strategy.

The post-Public Health Emergency (PHE) era has ushered in a new chapter of healthcare regulation, marked by a recalibration of telehealth flexibilities and an intensified focus on enforcement across federal and state lines. For telehealth founders, practice owners, and compliance officers, the message is clear: adaptability and rigorous adherence to evolving standards are no longer optional, but foundational to sustainable growth. This digest cuts through the noise, synthesizing the most critical compliance developments and offering actionable insights to safeguard your operations.

> For more on this topic, see our analysis: [Medspa Expansion: Navigating the Regulatory Minefield for Compliant Growth](/blog/medspa-expansion-regulatory-minefield-compliant-growth-compliant-growth).

The Shifting Sands of Telehealth Prescribing: DEA and DOJ Intensify Scrutiny

Perhaps no area is experiencing more dynamic regulatory pressure than telehealth prescribing, particularly for controlled substances. The Department of Justice (DOJ) and the Drug Enforcement Administration (DEA) are sending unequivocal signals: the era of broad, unchecked telehealth prescribing for controlled substances is over, and enforcement is escalating.

> For more on this topic, see our analysis: [Telehealth's Tightening Grip: DEA, DOJ, and State Boards Signal a New Era of Scrutiny](/blog/telehealth-tightening-grip-dea-doj-state-boards-scrutiny).

DEA's Evolving Stance on Controlled Substances via Telehealth

The DEA's proposed rules for prescribing controlled medications via telehealth, including buprenorphine for opioid use disorder (OUD), represent a significant pivot. While the initial proposal was met with industry concern, the DEA's subsequent supplemental proposed rule extended COVID-19 PHE flexibilities until November 11, 2023, and for an additional year (until November 11, 2024) for patient-prescriber relationships established during the PHE. This provides a temporary reprieve but underscores the eventual return to stricter requirements.

Key Implications for Your Practice: * In-Person Evaluation Mandate: Prepare for a future where an initial in-person medical evaluation, or a referral from a practitioner who has conducted one, will likely be necessary for new prescriptions of Schedule II and certain Schedule III-V controlled substances. This directly impacts telehealth models, particularly those in mental health, pain management, and weight loss, that rely on purely virtual encounters. * Buprenorphine Specifics: While OUD treatment via buprenorphine has specific, slightly more flexible provisions, the trend is towards requiring a robust initial assessment that may necessitate an in-person component post-PHE waivers. * Cross-State Line Complexity: The expiration of PHE waivers reverts the regulatory environment closer to the Ryan Haight Act. This means providers must not only be licensed in the patient's state but also hold a DEA registration in that state if prescribing controlled substances. This demands a sophisticated credentialing and compliance infrastructure for multi-state operations.

DOJ's Aggressive Enforcement Against Telehealth Fraud

Complementing the DEA's regulatory shifts, the DOJ has significantly increased its focus on prosecuting telehealth companies and practitioners involved in illegal prescribing and distribution of controlled substances. This isn't theoretical; it's manifesting in real-world enforcement actions. The 'legitimate medical purpose' standard is under intense scrutiny, and the DOJ is actively investigating whether telehealth platforms facilitate practices that circumvent this fundamental requirement.

What This Means for Your Practice: * Beyond Technical Compliance: Merely adhering to emergency waivers is insufficient if the underlying medical practice lacks a legitimate medical purpose. The DOJ is looking for systemic failures, fraudulent schemes, and instances where platforms incentivize or enable diversion. * Robust Compliance Programs are Non-Negotiable: Practices prescribing controlled substances via telehealth must implement rigorous protocols for patient intake, comprehensive medical evaluations, provider training, and meticulous record-keeping. Regular audits of prescribing patterns and clear policies prioritizing patient safety and regulatory adherence over rapid patient acquisition are essential. * Indirect Scrutiny: Even if your practice doesn't directly prescribe controlled substances, if you partner with or refer to telehealth platforms that do, you could face indirect scrutiny if those platforms are found to be operating illegally. Due diligence on partners is paramount.

Corporate Practice of Medicine (CPOM): A Persistent Hurdle for Growth

The Corporate Practice of Medicine (CPOM) doctrine remains a formidable barrier for many innovative healthcare business models, particularly for telehealth and medspas seeking to scale nationally. This week, we saw specific emphasis on states like Kentucky and Iowa, highlighting the critical importance of compliant legal structures.

Strict Enforcement in Key States: Iowa and Kentucky

Iowa stands out with a particularly strict CPOM doctrine, generally prohibiting non-licensed entities from employing licensed healthcare professionals or owning medical practices. This means traditional corporate structures are largely impermissible. Similarly, Kentucky maintains a CPOM doctrine that generally prohibits corporations from employing physicians or controlling medical decision-making.

Impact on Telehealth and Medspas: * Professional Entity Ownership: In states with strict CPOM, the entity providing medical services (diagnosis, treatment, prescribing) must typically be a professional corporation (PC) or professional limited liability company (PLLC) owned by licensed professionals. * Management Service Organization (MSO) Models: While MSOs can provide administrative, marketing, and technological support, they cannot dictate clinical decisions, employ licensed professionals who render medical services, or share professional fees. The MSO agreement must meticulously delineate clinical and administrative functions, ensuring the MSO does not exert undue influence over the professional entity. * Fair Market Value: Financial relationships between the MSO and the professional entity must be structured at fair market value for administrative services, independent of the volume or value of referrals or medical services. This is a critical area of scrutiny for regulators.

DTC Telehealth Weight Loss Brands Under the Microscope

The rapid growth of direct-to-consumer (DTC) telehealth weight loss brands, especially those prescribing GLP-1 agonists, has put CPOM compliance squarely in the regulatory crosshairs. The tension between scalable, technology-driven business models and state laws designed to protect the physician-patient relationship is acute.

Actionable Steps for DTC Brands: * Physician Independence: Ensure all clinical decisions, prescribing, and patient care protocols remain solely under the control of licensed medical professionals, not corporate entities or non-clinician management. * Avoid Fee-Splitting: Any arrangement where a non-physician entity directly or indirectly profits from medical services rendered by a physician can be deemed a violation of CPOM. This includes compensation structures that incentivize specific prescribing patterns. * Marketing Clarity: While DTC brands can market services, it must be unequivocally clear that medical care is provided by licensed, independent practitioners. Misrepresenting the nature of the medical practice or implying corporate control over clinical decisions can trigger regulatory action.

State Board Enforcement: A Microcosm of National Trends

Beyond federal actions, state medical and professional boards are actively enforcing regulations, often providing a leading indicator of national trends. Michigan and the District of Columbia offer recent examples of targeted enforcement and specific requirements.

Michigan's Focus on Telehealth and Medspa Compliance

The Michigan Board of Medicine is actively monitoring and enforcing regulations related to telehealth and medspa operations. Disciplinary actions often stem from issues like unprofessional conduct, scope of practice violations, and inadequate supervision. For telehealth brands, this means ensuring all practitioners are appropriately licensed in Michigan, patient-provider relationships are established in accordance with state law, and prescribing practices strictly adhere to Michigan's Public Health Code.

Medspa operators in Michigan face unique challenges related to scope of practice and delegation. The Board expects clear delineation of services that can only be performed by a physician, those delegated to nurses or PAs under appropriate supervision, and those outside the scope of non-medical personnel. Active, engaged medical directors providing direct, on-site supervision as required are crucial.

District of Columbia: Establishing Valid Telehealth Relationships

The District of Columbia has specific regulations governing the establishment of a valid provider-patient relationship via telehealth, a prerequisite for prescribing. Practitioners must adhere to standards, including a real-time, interactive audio-visual examination, to ensure compliance. This directly impacts business models relying on asynchronous or audio-only consultations for initial patient intake or diagnosis.

Chiropractic Telehealth: Defining Scope and Modalities

State chiropractic boards, as exemplified by a recent review of regulations across all 50 states and DC, are increasingly issuing guidance on telehealth for chiropractic care. This includes defining what services are permissible via telehealth (e.g., initial consultations, follow-up visits, remote patient management), requiring patient consent, and specifying documentation standards. The ability to conduct initial consultations and establish a patient-provider relationship remotely varies significantly by state, impacting business models for telehealth-focused chiropractic brands.

CMS Expansion: Opportunities Amidst Compliance Imperatives

Amidst the tightening regulatory environment, the Centers for Medicare & Medicaid Services (CMS) continues to expand telehealth services and provider eligibility under Medicare. This reflects a sustained commitment to integrating telehealth into the permanent healthcare landscape, moving beyond pandemic-era flexibilities.

Opportunities and Compliance Needs: * Growing Market: More services becoming reimbursable under Medicare means a growing market opportunity for telehealth brands, medspas (with medical services), and even dental practices for certain pre/post-operative consultations. * Meticulous Billing and Documentation: This expansion necessitates meticulous attention to billing codes, documentation requirements, and compliance with originating and distant site rules. Providers must ensure systems can accurately capture and submit claims for newly eligible services. * Scope of Practice Alignment: For medspas and chiropractic offices, the scope of practice for licensed medical professionals on staff must strictly align with state licensure and Medicare's specific service definitions for telehealth. Compliance infrastructure and ongoing staff training are critical to capitalize on these expansions while mitigating risk.

What This Means For Your Practice

The current regulatory climate demands a proactive, sophisticated approach to compliance. The days of relying on temporary waivers or ambiguous interpretations are rapidly fading. Here are your immediate action items:

1. Re-evaluate Telehealth Prescribing Protocols: If your practice prescribes controlled substances via telehealth, conduct an immediate, comprehensive audit of your patient intake, evaluation, and prescribing protocols. Ensure strict adherence to federal DEA requirements and state-specific laws, preparing for the eventual return to in-person requirements for initial encounters. 2. Scrutinize CPOM Structures: For multi-state operations, or if your business model involves non-clinical ownership, engage legal counsel to review your corporate structure, MSO agreements, and physician compensation models. Ensure absolute clarity on physician independence and avoid any appearance of fee-splitting or corporate control over clinical decisions, especially in strict CPOM states like Iowa and Kentucky. 3. Bolster State Board Compliance: Stay abreast of specific state board guidance for your profession (medical, dental, chiropractic, nursing) regarding telehealth, scope of practice, and supervision requirements. Michigan's increased scrutiny of medspas and telehealth is a bellwether for other states. 4. Invest in Compliance Infrastructure: Robust compliance software, continuous staff training, and regular internal audits are no longer luxuries; they are essential investments to mitigate the significant financial, legal, and reputational risks associated with non-compliance. 5. Monitor CMS Updates: Leverage the expanding CMS telehealth opportunities, but do so with meticulous attention to billing codes, documentation, and the evolving rules for eligible services and providers.

The regulatory environment is not static; it's a dynamic ecosystem. TrueEval remains committed to providing the intelligence and infrastructure you need to navigate these complexities, ensuring your practice not only survives but thrives in this evolving landscape. The future of healthcare is digital, but its foundation remains regulatory compliance. Make it your competitive advantage.