The Telepsychiatry Advantage: Episode 9

5 Biggest Mistakes Telepsychiatrists Make that Hurt Patient Care

Introduction 

Hello everyone, and welcome back to the Telepsychiatry Advantage. I’m your host, Dr. Edward Kafterian. I’m a psychiatrist and chairman and CEO of Orbit Health Telecine, the longest running telepsychiatry company in the world. The goal of the Telepsychiatry advantage is to give you the practical tools you need to practice telepsychiatry safely, effectively and confidently.

In today’s episode, we’re wrapping up our four part series on the Ryan Haight Act by tackling the topic that’s on everyone’s mind right now the DEA Special Registration, and specifically some highly concerning operational hurdles buried in the proposed rules.

The Looming 2026 Deadline and the Four Scenarios

To understand where we are right now, we have to look at the timeline. As of today, we’re operating under temporary telemedicine flexibilities that were initially introduced at the start of the Covid19 pandemic. These flexibilities waived the Ryan Haight Act’s requirement for an in-person medical evaluation before prescribing controlled substances via telemedicine.

The DEA and the Department of Health and Human Services have extended these flexibilities multiple times, I think this is the fourth time now, to prevent a sudden drop off in patient care, with the extension now being until the expiration date of December 31st, 2026. As we look forward to the end of 26, there are four distinct scenarios that could play out.

Scenario One: The Ideal Path

In a perfect world, the DEA will decide to treat telemedicine exactly the same as onsite care, making the pandemic era flexibilities permanent. This would mean allowing us to prescribe controlled substances via telemedicine without any requirement to see the patient in person. This is what drove the rapid adoption of telemedicine since 2020 and significantly benefited patients. Reverting to the costly and impractical in-person model is unfeasible.

However, this scenario is highly unlikely where the DEA would just leave us alone, because the DEA remains deeply concerned about the currently high rate of controlled substances that are being prescribed. And I can tell you from a recent conference that I went to that a DEA policymaker, I believe, was telling people that change is coming soon, and it’s unlikely that that change is going to be the best case scenario.

Scenario Two: The Special Registration Process

The DEA will very possibly finalize the proposed special registration process before the end of 2026, establishing a permanent, structured and regulated pathway for telemedicine prescribing. And we’re going to talk about their current proposal later in this podcast.

Scenario Three: A Further Delay

where the DEA does not finalize the rules in time and we get very nervous, and they keep us in suspense until December 31st, 2026, and then at that point, they issue another extension. And I think this is probably the most likely scenario, because this is what’s been happening and we are now in the fourth extension. So I think a fifth extension is probably the most likely scenario.

And then the scenario that none of us want, which is the doomsday scenario…

Scenario Four: The Doomsday Telemedicine Cliff

With the telemedicine cliff, that means that the DEA will not have any special registration process ready, and the extensions will expire without anything further in place. And this would mean that patients would suddenly not be able to get their medications, doctors would not know what to do, and health systems would be thrown into panic and chaos.

And we already got a taste of this, because in September of 2025, with the government shutdown, this happened. Suddenly, the Ryan Haight Act, the rules went into place and people had to do an in-person visit, or they had to stop prescribing the controlled substances to their patients. And this was a very chaotic time. And lots of people, millions of people, in fact, went without essential medication. And we do not want this scenario to happen. So that’s why we call it the doomsday scenario of the telemedicine cliff.

The Proposed Framework and Fees

The DA’s latest special registration proposal introduces a three tier system:

• Tier number one: telemedicine prescribing registration. This authorizes clinicians to prescribe schedule three through five controlled substances via telemedicine. And they talk about not only psychiatrists but mid-levels. And we assume what they mean by mid-level is PA’s and psychiatric nurse practitioners. And so that would be schedule three through five. So if you notice, it does not include schedule two. And that’s where we get to the next tier.

• Tier two: The advanced telemedicine prescribing registration. So this is now the next higher level, which means that you have the ability to prescribe Schedule Two in addition to Schedule Three through Five. And so that would include medications like Adderall, they’re stimulants that are on schedule two. Now, in order to even qualify to even apply for this type of special registration, they say that you need to be a specialized practitioner and luckily they included psychiatrists, neurologists, hospice and some others, In terms of the people who are able to apply for this special registration, which would allow Schedule Two medications. Now it comes with certain requirements, and we’ll talk about that a little bit as well.

• Tier three: would be the telemedicine platform registration. Which we’re not going to talk a lot about because it doesn’t apply as much to what we’re discussing. But it would require the online platforms to facilitate visits by complying with federal oversight and some other rules and regulations. So a bunch of hoops that the telemedicine platform would have to comply with.

Registration Cost Breakdown

So to apply for a special registration, they propose a fee of $888 for a three year cycle. So that would be in addition to your regular DEA license. You would need a special telemedicine license, which would cost $888.

Now, we were quite concerned about this when they first proposed a special fee because we thought, well, that would mean that we’d have to pay for a fee in every state where the patient is located, where we want to practice medicine. Fortunately, the DEA was merciful enough to allow a state medicine telemedicine registration that allows us to practice across state lines and cost $50 per state.

So what that means is you would need to pay for your regular DEA registration, your telemedicine registration, which is $888 and then $50 per state for wherever you want to practice medicine, meaning wherever the patient is located.

The Operational Nightmare, the 50% Rule, and Same State Requirements

While having a specialized tier for psychiatrists to prescribe Schedule Two medications like Adderall is a win, the DEA has proposed several practice requirements for Schedule Two that will create a massive operational burden. If you do 100% of your practice via telemedicine, pay attention because this is going to affect you significantly.

The DEA has proposed limiting a special registrant’s telemedicine prescriptions for Schedule Two, so that the average less than 50% of the total number of schedule two prescriptions issued by that clinician in a calendar month.

So let me translate this for you. If you look at the calendar month, look back at any calendar month, less than 50% of the total number of Schedule Two prescriptions that you are issued need to be via the on site care that you do. So what does that mean? If you do all of your psychiatry via telemedicine, you won’t meet that criteria and therefore you cannot prescribe Schedule Two drugs. And that is going to be a big problem for all the patients that depend on telemedicine for their ADHD medications.

So let that sink in a bit. This would cause massive disruption to our nation and you, as a 100% telepsychiatry focused person, would be barred from prescribing Schedule Two medications, and all of your patients would have to be seen in person.

But remember, a lot of patients can’t be seen in person because they are in rural areas or underserved areas. So this is very unfair to the people that won’t get the medication because they are in areas that are underserved and they won’t have access to it. So essentially it’s discriminatory and it’s untenable.

The Same State Requirement

So if the 50% rule wasn’t enough, the DEA is also considering a requirement that the clinicians must be physically located in the same state as the patient when prescribing a Schedule Two controlled substance via telemedicine.

Now, this rule doesn’t make any sense, because what difference does it make what state you’re in if you’re doing telemedicine? I don’t understand this rule. I think it’s arbitrary. And what that means is that it completely obliterates the advantage of telehealth, being able to prescribe medication and see patients across borders.

According to the American Telemedicine Association, in various workforce studies, there are hundreds of counties across the United States. The lack of single licensed psychiatrists . Telepsychiatry psychiatrist bridges that geographic gap. And if we have to physically, let’s say me as a California psychiatrist, have to physically fly to a state like Illinois to treat my patient who lives in Illinois, it ceases to be telemedicine now. It adds unnecessary costs and barriers and delays care and is, I think, medically unjustified and it will widen health care disparities.

The Strategy: Act Immediately

We don’t know when or if the specific rules will be finalized exactly as written, but when the final application does go live, I have one major piece of advice.

File your special registration the absolute second you are aware of it, and I will try to keep everyone up to date. But as I’ve said many times before, I’m a psychiatrist, I’m not a lawyer, and it’s not my responsibility to keep you up to date. So what I would do is, in addition to following the podcast, make sure that you follow the telemedicine news. You can even put Ryan Haight act as a Google search every day or every couple of days to see if the special registration process has been unveiled.

But don’t wait because once the telemedicine special registration process has been opened up, there will be a massive industry wide rush of applications hitting the DEA desk all at once. And I don’t know that the DEA will be able to accommodate everybody’s application in a timely manner. The DEA is likely to be flooded by applications, administrative backlogs would severely delay your ability to practice and prescribe, and generally there would be, I think, a lot of disruption to your practice.

So get your documentation ready now and be ready to pay for that fee, because you are going to have a massive delay if you don’t act quickly once that special registration process goes into effect.

We’ll be watching the DEA regulatory pipeline very closely over the coming months. Stay tuned to the podcast. Like I said, and the moment these rules are finalized, make sure that you apply for a special registration and the states where you think that you’re going to see patients.

Conclusion

Thank you for joining me today. Keep elevating the standard of care and I’ll see you on the next episode of The Telepsychiatry Advantage.