Since the pandemic, mental health providers from across the country have had to quickly transition and adapt to providing virtual mental health services. If you find yourself enthusiastically considering to expand your virtual mental health practice outside of your local jurisdiction, make sure you read this article in its entirety and consider it a cautionary tale!
Why I’m writing this article:
I am a clinical psychologist who is licensed in three Canadian provinces, and I currently practice in two out of the three jurisdictions. No, I did not decide to register in different provinces because of the pandemic. It actually mostly happened by accident long before it was cool or trendy.
Let’s get the disclaimer out of the way. I’m by no means a legal or tax expert, nor do I claim to be the expert at interprovincial mental health services. Everything in this article is based on my personal experiences and opinion at the time of its publication. Since I am a Canadian psychologist, most of the information is relevant for psychologists practicing in Canada. However, any mental health professional in the US and Canada may still find the information helpful as it might inform the types of questions you might like to ask your own regulatory body, tax professionals and/or lawyers.
Who am I? I am a psychologist with an interprovincial mental health practice who has spent a painstaking number of hours researching, consulting many tax and legal professionals (in various jurisdictions), the various colleges that I am a member of, and has basically had to learn everything I’m about to share with you the hard way! When I was embarking on my multi-province practice, I desperately wanted an article that would lay out all the factors that I should think about or consider. Unfortunately, I did not find any as virtual mental health especially across jurisdictions is still a relatively new area of practice especially for psychologists. So, since I’ve put what feels like months and a million hours of research into this, here’s a summary of what I’ve learned through my journey and I hope you find it helpful.
Licensing and Registration:
In most circumstances, if you are a psychologist, you MUST be registered where your patient resides. For example, if you live in British Columbia (BC), and your patient lives in Alberta, you must be registered in Alberta. Make sure to consult the jurisdiction where you hope to expand services to in order to determine all legal requirements of practicing there.
Each province, has its own unique set of requirements for licensing. Oh yes, psychologists don’t do simple, we like complicated, you know the whole lean into the messy mentality! Different provinces have different requirements for entry into the profession. The Labour Mobility provisions of the Canadian Free Trade Agreement (CFTA) sets out parameters such that if you are a psychologist in one province, you can obtain permission to work in another province. However, you do need to complete a number of steps which vary province by province. Generally, be prepared to submit your training and credentials, criminal record check, reference letters, complete jurisprudence and/or ethics exams. Sometimes, you may also be required to complete additional supervised practice hours or even coursework. The process can take several months up to over a year to complete depending on the province.
This is an expensive $$ endeavour. Look, before you jump into this interprovincial business, think it through carefully. This is an expensive process. Remember that not only do you have to pay annual licensing fees (which can be close to $1000 per year per province), you also need to account for all the fees for the applications, jurisprudence exam, criminal record check, etc. You may also need to get the highest liability insurance coverage which will increase your costs. The more places that you are licensed in, the higher probability of trouble. Therefore, I recommend that you get the highest possible professional liability coverage. Also, if you get in trouble in one jurisdiction, you will have to answer to all jurisdictions you are registered in!
Clinical Practice Considerations:
Different provinces have different standards of practice, legislations, and rules. It is YOUR responsibility to know them all and practice accordingly AND to keep up to date as they continually change. Let’s take a look at a few examples of this:
- Limits to confidentiality: Limits to confidentiality is not the same across the country. Let me share an example with you. In British Columbia (BC), registered psychologists are obligated to report patients whose driving ability is in question. This legal duty does not apply to psychologists in Alberta. So, if you plan on practicing in multiple jurisdictions, your informed consent must take into consideration all relevant and applicable legislations and laws. You must then clearly explain the applicable laws and standards to the patient based on their place of residence.
- Age of majority: If you work with young adults or have a pediatric practice, you must be mindful of age of majority in the province in which the patient resides. For example, in Alberta, a child is defined as an individual younger than 18 while in BC, the age of majority is 19. This is important because if you are dealing with a minor, you need parental consent, and likely a different informed consent process in each jurisdiction that you practice in.
- Standards of practice: Sometimes the practice standards are different across provinces. For example, in BC bartering is allowed between psychologists and clients when a series of specific conditions are met. In Alberta, bartering is simply not permitted. When you practice across jurisdictions, there are a great deal of nuances to be aware of. The onus is on you to have researched all those nuances, be familiar with them, and apply them accordingly, and not to mix them up. At times, it can be difficult to keep all the differences straight in your head, so proceed with CAUTION.
You ought to be aware of local resources. If you practice in more than one jurisdiction, you have to be familiar with local resources in cases of an emergency, or if you need to refer a patient. For example, you need to know the local distress numbers, local hospitals, and mobile mental health resources to ensure your client is connected to appropriate resources in a timely manner.
Third party payers and insurance companies are not ready yet! I was not prepared for this one and it caught me totally by surprise! Insurance companies are not quite ready for the same person to be registered in more than one place. Now, I’m not saying this is the case for every single third party payer or insurance company, but I’ve personally encountered it on more than one occasion. Here’s an example of what can happen: I see a patient for psychotherapy. The patient pays for the service and submits a claim to their insurance provider to get reimbursement. Their claim gets denied!! They are surprised! I am surprised! Through our bewilderment, we clarify the reason why the claim was denied. And Voila! They cite the reason as me not being registered where the patient resides and say that I’m registered in another province. Now it doesn’t happen like that every day, but it happens more often than I would like. I then have to get permission from the patient to call the insurance company on their behalf. Once I call the insurance provider, I am on hold for 35 minutes to then explain for 45 minutes that I practice in more than one place. We then wait a few days for them to figure out how they can add my dual registration somewhere to their pre-existing online forms only to go through the process again a few weeks later with a different patient! Oh the joys of interprovincial practice!
Double the paperwork! When you fill out your annual renewal application with the College to get your practice permit, some provinces also require you to complete a self-assessment, a quiz, continuing competency forms, etc. The more jurisdictions you are registered in, the more paperwork you have to complete.
Scheduling and different time zones! Be mindful of different time zones as you plan your schedule. Sometimes, the time difference might be small. For example, if you practice in Alberta and BC, you’re only adjusting for 1 hour time difference. However, if you practice in BC and Ontario, you have to adjust for a 3 hour time difference which can be significant both for you and your patients.
Professional Executors and Caring for Psychological Files: In some provinces such as BC, you are required to annually declare a Professional Executor (PE) who will care for your files in case you become incapacitated. In other provinces such as Alberta, this may not be as clearly outlined or mandated. The inherent challenge to consider in assigning a PE is: do you assign the same PE to your files in all jurisdictions that you practice in or do you assign multiple PEs for each jurisdiction. At first glance, it might seem most straight forward to assign the same person. Well, I can tell you from experience that in practice it proved to be a much more challenging process than I had anticipated. Many psychologists don’t feel comfortable taking the role of professional executor in a province they are not registered in. So, unless I find another psychologist who happens to be registered in the exact same provinces as I am and would be willing to take that role on, I have to go with multiple PEs. Now, with the possibility of multiple individuals involved, we face a whole new set of challenges. If I assign PE A to province A, and PE B to province B, I also must find a way to clearly have files in province A labeled and separate from files in province B. Furthermore, I must be able to give access to files in each province such that the PE in one province will not have access to files outside of their assigned province because that can create confidentiality and/or liability concerns. Depending on whether you have physical paper files or electronic files, all of these factors are important considerations before you decide how to proceed with assigning professional executors and how you set that up logistically.
Finances, Taxes, and Accounting:
Do you pay taxes where your PATIENTS are or where YOU are? I have consulted at least 6-7 different accountants and some have said it’s based on where I am and some have said it’s based on where the patients are. The general consensus amongst the accountants seemed to be that Canada Revenue Agency is catching up on virtual mental health services and a number of factors were to be considered to determine where you pay taxes and that things could change quickly. So, I strongly recommend that you have a way of clearly identifying which patients are from which province and have the ability to differentiate the income generated from each province. In this way, when you consult your accountant, your record keeping is set up to adapt to any changes or any direction that your accountant gives you. You are set up for success rather than at tax time, trying to work your way backwards through a year’s worth of appointments to determine where you provided services.
Do your research to determine if you need a business licence. Consult a lawyer or the jurisdiction you practice in to determine if you need any kind of business license.
What if I’m incorporated or want to incorporate? Well, this one is a doozy, and if you’re even considering this question, call up a lawyer right away because I’ve found this one to be fairly complicated! In some provinces such as Ontario, you must register your corporation as a professional corporation (PC). Professional Corporations must meet a number of specific criteria as set out by the appropriate laws and the College’s standards. In other provinces such as Alberta and BC, the College of Psychologists does not regulate psychology corporations. As a result, if you are practicing in provinces where you are required to be a PC in one jurisdiction and not the other, you may need to have two separate corporations. Call a lawyer! seriously, you need a proper consult on this one. Now let’s assume a simpler situation where you’re not required to be registered as a PC in the provinces that you’re thinking of practicing in such as Alberta and BC. In this situation, I also found that different professionals I consulted with had different perspectives on what I should do. From what I gathered, the safest bet is to extra-provincially register your incorporation in the province that you are planning on expanding to. Having said that, again I can’t emphasize enough the importance of consulting with a legal and accounting expert as there are many factors that play a role in the decision and the process. Also, keep in mind that this process will add significant expenses to your operation.
In conclusion:
I have learned a lot about the complexity of practicing across jurisdictions over the years. I wanted to share what I’ve learned with anyone else who might be considering this venture. It’s certainly a significant decision and not one to be taken lightly. Don’t fall into the allure of expanding your practice without considering all the responsibility, liability, cost, and complexity that comes with that expansion. I’m very proud to have the knowledge of different laws, legislations and local differences in the practice of psychology across the three Canadian provinces. I also find it very rewarding to be able to support my patients who might move across provinces where I am registered or be able to support patients in more remote parts of Canada. I hope you found some value in this article. I wish you the best and I would love to hear what your experiences have been.
Resources:
College of Alberta Psychologists Telepsychology Services Practice Guideline (2018)
College of Psychologists of British Columbia Telepsychology Services Checklist (2016)
College of Psychologists of Ontario Standards of Professional Conduct (2017)
