The past few years, I have had a lot of providers ask about my experience getting licensed in multiple states and building a multi-state, virtual, private practice. I decided to answer all of the most common questions around this endeavor in one place with the hope it might help others as they consider growing their practices.
1. Was it difficult to get licensed in multiple states? What steps did you take?
Some states required more than others but overall it was more tedious and expensive then difficult. I was originally licensed in NC as an LCSWA in 2017, getting my full licensure in 2019. When my family and I decided to relocate and I was hired in VA, I applied for licensure by endorsement there and was thankful that in a matter of months, I was granted my VA LCSW by their Board of Social Work. I had to complete their paperwork, send copies of my ASWB exam results and MSW transcript along with my NC licensure information.
All the other states required a similar process, though some also included fingerprint background checks, letters of recommendation, and MD also required additional hours of clinical supervision, which was the biggest headache of the entire process. At the time I applied to MD, they required 144 hours of clinical supervision if you had been licensed for less than 5 years whereas all the other states just required 100, so I met their eligibility for endorsement straight away. MD has since changed their requirement of supervision hours and it is comparable to surrounding states.
2. How did you end up licensed in so many states?
While I started my new job with a Bariatric Surgery Center licensed both in VA and still in NC, COVID very quickly necessitated expanding that reach. I was the only behavioral health provider on staff and we had patients residing in WV, PA, and MD who would typically travel to our offices in VA for appointments. Due to COVID, everything converted very quickly to tele-health and while there were a lot of temporary allowances to see clients across state lines, I was uncertain how long they would last. I was uncomfortable with establishing therapeutic relationships that could be ended with minimal notice due to a practice permission order expiring and was unwilling to risk the liability of practicing in a state without a license.
So in a matter of a few months, I had added PA and WV clinical licenses (by endorsement) and had permission from MD to practice for 6 months as my license was pending and I was acquiring additional supervision hours to meet their requirements (again by endorsement).
While that job ended up not being the fit I was hoping it would be, the clinic did cover all fees for initial licensure and the additional supervision MD required. I am thankful I held that position for many reasons, including that I don’t think I would have pursued multi-state licensing on my own.
This past year, in 2022, I became licensed in DC as well in order to provide versatility to my clients who commute around the DMV.
3. Why do you continue to maintain all 6 licenses?
Two main reasons, one driven by client care and one for personal flexibility.
First, doing so allows me to offer a more expansive area of service to clients as they may be traveling to visit family or commuting for work. It also allows me to work primarily with the clients I feel I can best serve with my skill set because I can pull from a larger population.
Second, I have aging family members in some of these states, so being able to go visit or provide care for them and still be able to work within that jurisdiction is a huge part of why I made the transition to be fully virtual. Unsurprisingly, I am very conservative with risk around my clinical work and it is general best practice to be licensed both where your AND your client’s feet are on the ground, not just where they are located. Regulations around this vary state by state and across disciplines, but this allows me to broadly know I can see any client virtually so long as both they and I are in NC, VA, WV, PA, MD, or DC.
4. How much does it cost you to renew your licenses?
It varies year to year, but I budget about $600 annually for renewal fees. I budget $500 a year for CEUs and to simplify things, make and effort to attend the NASW conference at least every other year to get my live hours and ethics hours from them. Since different states accept CEUs from different providers, the NASW is one of the few places I don’t have to worry about a Board accepting (since it’s the national organization for social workers).
5. How do you keep everything organized?
I have a spreadsheet that I keep updated with my state license numbers, renewal dates, CEU requirements (every state requires a different number of hours, combination of delivery, and some have specific requirements around child abuse, veteran care, special populations, implict bias, and/or suicide), telehealth allowances, mandatory reporting regulations, etc.
In the spreadsheet, I also have quick access links to the renewal website, regulations, and CEU requirements and once or twice a year set aside an hour to go through and update my spreadsheet in case there have been any changes.
I have also started keeping an additional spreadsheet page in that document to track my CEUs so I can clearly indicate which credits count towards which state licenses and which renewal periods.
One other thing to note is that I have decided to only work with clients 18 years and older as a way to simplify my practice and not have to keep the different regulations regarding treatment of minors straight in my head. When seeing young people, you need to know the confidentiality restrictions, age of consent to treatment, and other state specific laws around behavioral health care that can change with frequency. While I still need to know mandatory reporting requirements when working with adults, I have found the need to report tends to be lower when you only see adult clients.
6. How do you market yourself?
I use a number of therapist directories (Psychology Today, Therapy Den, and Mental Health Match, Therapist.com, etc), network in local and virtual clinical spaces, and work with Alma (who does a good bit of marketing on behalf of members). I also facilitate a few provider consultation and support groups which allows me to build additional connections that can result in referrals.
As an INN provider through Alma, I’m also listed in Aetna, Cigna, and Optum’s provider directories. Being a provider whose practice is highly insurance based reduces the amount of marketing I find I have to do and Alma credentials me in all states I’m licensed in, so I love being able to provide uniform insurance coverage for all my clients, regardless of their location.
7. What are the business (legal and tax) repercussions of a multi-state virtual practice?
This is a tricky one to answer because while I am not a CPA or an attorney, I have talked to a number of them in my efforts to inform my business practices. So while none of this is advice, it is based on the numerous conversations I’ve had with professionals about the tax and business regulations in my various states of licensure. For my own peace of mind and to cover myself, I have records of all the information they shared clearly documented in my records should it ever need to be referenced in the future. Through these efforts, I have settled on a plan I’m comfortable with and can clearly justify should it ever be challenged, which is something I feel strongly that each provider needs to do for themselves.
My PLLC (Professional Limited Liability Corporation) is registered in WV where I live and where I pay state income taxes. It's also where my home office is located and very rarely do I conduct sessions in a different location, much less a different state (though if I do, it is always somewhere I am licensed or have written permission from the Board to practice).
Since the vast majority of my work is done from my home office here in WV, that is where I understand my “business nexus” to accumulate, which is the volume of work you do and is used to determine if and where you are “doing business” (possible, in another state). While clinically, I am practicing where both I and my client are; regulatorily, business is occurring where the work is done. As I am the one who is providing clinical services, I understand that the state where my feet are on the ground is where that work happens. This is why WV remains my primary location for delivering services.
It is also why I intentionally spread my client caseload across all 6 licensing locations, so if a state does define “doing business” differently then I’ve been advised, I don’t have a majority of nexus located in any one state (outside of WV). In the past, most states used the concrete metric of whether or not a business had a “physical presence” in their territory to determine if someone was “doing business” but with all the virtual work being done now, that measure isn’t as appropriate as it once was.
However, since my PLLC is in WV, I live in WV, I am in WV for over 95% of my sessions, and I am also looking to expand to doing nature informed therapy/workshops in local nature preserves in WV, I am making it abundantly clear that my business is based out of WV, even though I serve people outside of the state. This is also the justification I lean into registering the decision not to register my business in other states… I don’t have a majority of business nexus there and I don’t have a permanent physical presence.
I feel it is important to acknowledge that it IS possible that a state other than WV could decide I owe them income tax. That is a risk. However, I feel it is very small and seeing as how I have decided not to register my business in any state outside of WV, I don’t know how I might show up on their radar. However, if the situation arises, I’ll cross that bridge when I need to. I could see this being a bigger risk if I was filing as a resident of a state without income tax, meaning that I could be perceived by the IRS as avoiding paying taxes I owed in states I serve that might have state income tax. For me, the important thing is I’m not forgoing paying state income tax and I have very clear rationale for the decisions I have made for my business.
8. So what should I do now? Is it worth it?
At the end of the day, as clinicians and business owners, we take on risk and have liability as part of the work that we do. You need to decide what risk you are comfortable with and how informed you feel it’s important to be around the decisions you make to mitigate it. For me, having a multi-state, insurance based practice (through Alma) is well worth it.
I am probably far more conservative in my business management practices than many other providers, and that’s their prerogative. There are also those out there who may hear what I do and be uncomfortable with certain liability I find acceptable. Inter-state clinical work in the absence of a licensure compact that also addresses business regulations is always going to be a bit murky. If it’s something you decide to consider, I really encourage you to be well informed and do your own due diligence, because at the end of the day, it’s your license on the line and it’s your responsibility to protect it.
9. Can you help me figure out how to do this for myself?
I do offer consultation for providers looking to expand their practice, sharing my experience and processes more in depth to help you streamline the process and navigate the different systems at play. To request a consultation, please contact me here.
I also strongly recommend the following resources which cover some of what I've already touched on here as well as some biggest questions around insurance, traveling, and marketing:
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