In this episode of Telemedicine Talks, Phoebe Gutierrez sits down with healthcare attorney Brigid Maloney to unpack the exploding risks in cash-pay telemedicine, from marketing unapproved peptides and white-label clinician shells to call-center “nursing,” influencer deals, and the coming wave of state enforcement. They explain why low barriers to entry create dangerous naiveté and why everything still lands on the physician’s license.
In this candid episode of Telemedicine Talks, host Phoebe Gutierrez welcomes healthcare attorney Brigid Maloney for a deep dive into the compliance landmines facing cash-pay telemedicine companies.
They discuss the flood of low-barrier platforms launched by marketers and coders who don’t understand clinical or regulatory rules, the marketing of unapproved substances like BPC-157, and the rise of white-label telemedicine companies that obscure physician accountability. Brigid highlights emerging trends such as non-licensed, sometimes offshore, call centers performing triage and the difficulty patients face reaching the original treating clinician.
The conversation covers upcoming regulatory shifts like DEA telemedicine registration for controlled substances, California’s private-equity ownership approval requirements, and growing medical-board scrutiny, while debating whether meaningful enforcement will come from federal agencies or the states. They stress the importance of physician involvement in governance, rigorous vendor and influencer due diligence, and building compliant systems from day one rather than trying to retrofit them later.
Listeners leave with a clear message: in cash-pay telemedicine, the physician’s license remains the ultimate backstop. Companies that treat doctors as true partners, protect patients, and prioritize compliance from the start are the ones positioned to last.
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About the Show:
Telemedicine Talks explores the evolving world of digital health, helping physicians navigate new opportunities, regulatory challenges, and career transitions in telemedicine.
About the Guest:
Brigid Maloney is a healthcare attorney specializing in digital health, telemedicine, MSOs, and corporate practice of medicine issues. She advises telemedicine platforms and physician groups on compliance, contracting, marketing arrangements, and regulatory risk, and serves as personal counsel to the hosts of Telemedicine Talks.
About the Host:
[00:00:00] you had the Cerebral case and the Dunn case and some of those, like what I would consider, the worst of what, what's happened in this kind of industry. But even there, they were able to make other companies and did anybody go to jail? it's some of those things that are just a little, yeah, there's a lot of unknown.
So I think some of the stuff I'm tracking that I think would be like interesting to talk about is on the cash pay side, you have a lot of, people that are either really good at marketing or really good at building, a product or really good at, building a technical tool, and then they go out and they are, which to me is like rookie move number one, is I'm gonna go market all the illegal things that I'm doing because I'm not educated enough to even understand that I'm not supposed to, right?
Yeah. Like every day I have to tell a company like, "If you're marketing BPC 157, like I wouldn't do it. It's not [00:01:00] approved. I don't care what happened at this committee meeting or whatever you think."
it, it's pretty black and white to me. It's not approved for human use at this moment, so please don't market it.
And as I think we've talked about before, but-- and then they'll say, "Yeah, but my competitors are doing it and they're making a ton of money on it." But I think that the level of naivete in cash-only telemedicine is sky high right now because the barriers to entry are so low. If you can write code, you can build a platform, you can cobble together a very simplistic EMR with a video platform,
You're in. And you don't need to know medicine. You don't need to understand clinical protocols. You don't need to understand reimbursement, any of that. All you need to do is get your marketing out on TikTok and point patients to your website, and you are making money. And that terrifies [00:02:00] Me, especially because everybody now knows how to connect the MSOs with PCs, and so any kid can start a platform, connect with a PC of doctors that he doesn't know, and channel patients through to those doctors.
It's scary, scary times in telemed. And it always comes back to the doctors, like we have to trust because they're the only people really today, at the end of the day, who are accountable. There's pharmacies involved, there's marketers, there's IT developers, and then all of these things are put in place to channel patient, channel the business to patients.
And We need the doctors to do their jobs and to uphold their Hippocratic oath and to help keep these patients safe.
Yeah.
And to remain objective in the decisions that they're making clinically when they're prescribing and treating patients.
Yeah. No, Completely. I think [00:03:00] there, back to even the marketing, to your point, right?
You'll get a lot of people that are, nowadays configuring an EHR is you could probably do in a couple of days, for a single state. You're talking about a national platform. How are you assessing asynchronous versus synchronous visits, right? I get a lot of companies that are like, "Oh, no, we can do async in every single state."
And that's like- ... my first identifier is like, "You don't know what you're talking about."
Exactly. And our competitor has every initial visit as a video visit, store and record, and no, that is not gonna meet the requirements of a synchronous initial visit.
Yeah. No, Exactly. no, I think, some of the stuff that you and I have talked about is as much as people harp on, let's say, the paperwork, the business entity registration, the, you know, even having the approved formulary and having kind of the, [00:04:00] what I'll say is like compliant on paper set, there's a lot of these like operational things that, again, from my perspective, happen every single day in the insurance industry, right?
Yeah. Whereas on cash pay, it's they're incentivized, like they want, like their salespeople are wanting to sell. They wanna close deals. They want to market and see as much growth, and it's a little bit more controlled and slow by design on the insurance and like payer side. So I always say if you don't know your physician that you're supposed to be working with and you think that's good, that's pretty problematic for your arrangement, right?
Like you should be Doing all that hiring. So yeah, there's a lot that I, see, and again, I think as things progress, every single day I'm almost seeing a new telemedicine company or a new, [00:05:00] there's been a wave of like even white label telemedicine companies, which-
I'm really curious what your thoughts are on some of those that are, we're your clinical infrastructure. You bring your, your branded webpage. And I feel like that's kind of the new wave that's been like the Q-Q3, Q4 2026 trend that I've noticed.
Yeah. And it gets Scary when we talk about white labeled clinicians because it's company, shell company within shell company.
And to find out who these doctors are, who they're working for, who they're accountable to, gets very difficult. And many of these docs work for a number of different platforms. So they're flagging 100 or more calls at 10, 12 bucks a call, and they're putting their note in, hopefully in the appropriate EMR, but it's tough for [00:06:00] patients to circle back and be able to get back in touch with that doc if they have follow-up questions.
And to that end a lot of the white labeled medical practices will send their follow-up patient calls through a call center that is staffed with non-licensed customer service agents. They're cheaper. Much cheaper, right? Yeah. Some of them are- Yes ... offshore. And a lot of those people, I've found when I'm hearing from my clients who are describing the workflows to me, a lot of those people sitting in those call centers are essentially practicing nursing.
They're triaging, they're listening to symptoms and suggesting this or suggesting that, and they're standing as a barrier between the patient and the clinician that first treated them. And that's another emerging trend that I've been seeing a lot of this summer that, that makes me nervous, and especially so [00:07:00] in these white labeled deals.
Yeah. No, I think you bring up a good point. A lot of times for a lot of these companies, to keep costs down, they do try to mitigate and minimize as much like asynchronous type of, back and forth. Interestingly enough, I had a, a physician that I was working with once tell me like, I'm not being paid to respond to the message."
And I'm like you kinda are though, 'cause you wrote a prescription and you have established provider-patient relationship because-" "... of your review." So to me, my, my recommendation to that physician at the time was like you real- it's your due diligence to follow up even if you're not being compensated.
But it's, if a person's coming back saying, 'I'm having this symptom or this side effect,' I wouldn't wanna leave that open-ended."
And that brings us right back to what we said at the top of the segment, which is everything falls on the physician's license. And boy, [00:08:00] I hope that the physician that you're working with is prepared to stand by his license and be there for the patients that he's formed these physician-patient relationships with.
Yeah. I completely agree. again, I think it always comes down because the industry is not super regulated as we, we know, right? I do have, my own theories that it is going to start being a little bit more regulated, I think with theit's for final review right now, the DEA flexibilities and, thinking through the telemedicine registration and what that's going to look like.
I think that's gonna be one element of having some sort of like oversight and regulation. I know that there's other kind of emerging states that are putting in some more I'll say guardrails around funding and having to disclose funding, sources and ownership and making sure that those things get approved like California just did.
There-- I think it's like a final rule draft, so I don't know what that means, but It's is it a final rule or is it [00:09:00] a dra- but, I think it's, again, it's like tail end of almost gonna be set in stone, and once regulations are set, we all know they're pretty locked in.
California has also said, if you're gonna get investments from, private equity, you have to get approval from us as a state going forward. So I think there is going to be some, a little bit more checks and balances. But from your perspective, some of the clients that you're working with, are they thinking through some of these emerging changes that I personally see on the horizon?
But I know a lot of the companies that I work with kind of look at me, you know, deer in headlights when I'm talking about like these preparations.
Yeah. Phoebe, this is a fast-moving industry and most of these people are entrepreneurs, right? They're not health system administrators that have grown up in the healthcare executive world.
These are entrepreneurs who are flying. And when I suggest to them that they slow down or consider pivoting in advance of the [00:10:00] changes that we're seeing, particularly in California, Oregon, Texas, there's legislation in New York, Massachusetts, a dozen other states that really require these MSOs to rethink the way they're papering their relationships with their physicians.
And it's a tough sell because they're making so much money and moving so quickly that any minute they're spending to try to shore up their compliance framework is a moment that they're not spending in the money-making part of the business. So that's a tough one. And the other thing, and this is true, and I actually, I wanna turn this back on you.
You have been saying for a while now that the enforcement landscape is changing. We are gonna see more enforcements. You mentioned the DEA and I'd like you to elaborate on that because I'm not sure what's going on with the DEA vis-a-vis Telemed right now. I don't know what you're referring to, so I'm excited to hear more about that.
But when I think about the DEA, the [00:11:00] FTC, the FDA, I think about warning letters and no teeth, no actual enforcement actions. And we are Regardless of political affiliation or preference, we are in an era of very small government in the United States. So I don't think that we're gonna see our federal agencies unleashed and using their few resources that they have left remaining, chasing down telemedicine when they have bigger, more dangerous threats to life and human welfare.
So I'd be interested to know from you when you imagine a, a more ramped up enforcement landscape, do you envision that coming through federal agencies, or do you envision it coming from the states where typically the boards are pontificating
and certainly [00:12:00] disciplining physicians' licenses, but not reaching so far as to do anything about the overall telemedicine operations of the entire platform? So if we're gonna see more enforcement, too long, didn't read. If we're gonna see- Yeah ... more enforcement, where do you s- where do you think it's gonna come from, Phoebe?
Yeah. I-- my thought is enforcement usually always lives with the states, right? So the, the federal government, of course, is gonna say, "These are our guardrails." You might see a couple that might be made as examples, but usually that will stem from a state. Again, I'm thinking a state, probably California would be the first.
And really what I think is going to happen is I think you're going to start to see it, and that already is happening. Medical boards are getting, not necessarily inundated, but they're getting a lot more complaints, targeting a lot of these telemedicine companies, and they don't know how to handle it at scale.
So my best [00:13:00] hypothesis is there's gonna be some policies put into place, not from an enforcement perspective, but from an oversight perspective, right? So one of the things when I was a regulator that I had to oversee was, I had to make sure that every health plan or medical group or, clinic had the appropriate, licensure, the appropriate composition of their network, right?
So if you had 2,000 people assigned to you, you had to h- make sure that you had one doctor. If you had 2,001 assigned, you had to have two doctors. I am assuming that there's gonna be a little bit more reporting coming in from telemedicine companies in terms of what is your network composition, who are using, and almost just more checks and balances.
And to your point earlier, in, we've had extension after extension of the controlled substance, allowances via telemed. And, every year it's about to expire. We come back, and it's [00:14:00] fine. You get another, another year. this year, I think last month, they pushed those, proposed regulations to codify some of those flexibilities into law.
That is now in the final stages of being reviewed and approved and released. Now, some of the stuff that were included in that was a telemedicine registration. So if you are providing telemedicine services in the United States And you are offering, controlled substances, you would have to complete this registration process.
And I don't think it's an approval process, it's more of just like a tell us that you're there, and there might be more questions or more reports or something, that again, just is going to- Yeah ... give them some sort of visibility in, into what's happening. From a regulator's perspective, and this is why I would always say, a lot of people say, "Oh, it's less risky to do cash pay than it is insurance."
And it's like, no, like the risk level's the [00:15:00] same. The only difference is in order to get an insurance contract, your providers have to go through credentialing. Somebody's doing background checks. If you're a startup, you should also be doing background checks on your- Yeah ... your clinical staff, but it's not so much of a requirement to get payment.
So- ... on the insurance side, it's just more of like they do their checks and balances, you're on a log, they're following up with you, you have to report, and because of that, there's a layer of oversight and some, protections put into place from a consumer. Whereas with cash, that doesn't exist.
So we have our medical boards right now, which are our main honestly the really only thing like regulating the cash pay industry. Of course you have- the corporate practice of medicine, but as we all know that if you don't wanna get a PCMS, so let's say you wanted to practice medicine under an LLC in New York, you could, right?
It's illegal. Yeah. But nothing's gonna preclude you from doing that, right? [00:16:00] Yeah. So it's this interesting thing where I think there are going to be a little bit more checks and balances in the sense of, what they have to report, who they have to, if there is an approval process, like California now has the $25 million threshold.
You're getting $25 million from private equity or an investor, you're selling your company, you have to get state approval now. Within, within 90 days you gotta get state approval, and they could deny it what happens then? So I think there's going to be a little bit of a wake-up call between some of these new and emerging, I'll s- call them activities, that are gonna have to be layered into the operations.
Or there's gonna be a lot more companies that are just operating out of compliance, fully end to end.
And t- to that point, it's so much more time-consuming and expensive to try to get your house in order from a compliance perspective after the fact. It's so lumpy, [00:17:00] it's so slow And it takes, it takes forever to get around and fix every knob that was put into place a little bit off.
I always joke 'cause I, I don't quite understand what goes through some of the founders' heads a little bit. because to me it's like doing things the compliant way sure it might slow you down two weeks or a month because you have to, do some paperwork and really, think through it.
But for a scalable product, regulations and, following a compliant roadmap actually just makes sure you built it the right way. it is a little bit of, guidance on what the heck you're supposed to do. Interestingly enough, I was, working on a project and we've been going in circles a little bit about, e-prescribing, and it's like, I know for e-prescribing we gotta get this certification.
And it's like,let's see. It's like you get to the point, it's oh no. Oh, we need the thing that I flagged three months ago
and they don't realize it's gonna take a while to catch back up. [00:18:00] Yeah.
But yeah, I think, from my perspective, there's, their compliance is there. It's not sexy, it's not fun, and it's not supposed to be. When I was a regulator, my main goal, I was over all member rights, right? So it was like, I gotta make sure that there's enough doctors.
I have to make sure that they're marketing everything correctly. I have to make sure that, people can file grievances and review those grievances. the element of, you know, medicine is actually around the human, and we have to... I think a lot of companies forget that when they're moving, fast and loose in digital health.
Yeah. That's really well said. That's a good reminder. That's the number one reason anybody should be in this business, is to help people. you mentioned the controlled substance prescribing rules and how the, th- we may or may not have a, a definitive end in sight. But I feel so conflicted when I think about controlled substance prescribing [00:19:00] via telemed, and here's why.
On the one hand, the important hand, is it's an important service that's reaching people that otherwise would not have access to the medications that are medically necessary. So we're thinking rural people that are nowhere near the doctors or the health systems that they need to get these things. And so for that reason, I want doctors to be able to prescribe controlled substances with some ease.
But on the other hand, we've seen what happens when prescribers run wild, when pharmaceutical companies are incentivizing prescribers to run wild. Then all of a sudden it's no longer about the rural patient that can't otherwise get access to healthcare and the medicines they need.
Yeah.
Exactly. So on your side, what are some of the, things that your clients are slowly starting to experience, explore, and maybe struggle with?
I've been reviewing a lot of influencer agreements lately, ... and I don't [00:20:00] think I should get-- I'm, I don't think I'm prepared to get too deep into this.
I wish I had brought some notes on it. But it's funny, the telemed platforms are becoming very aggressive in advertising on social media, and creative, and it's been fascinating for me to watch because so quickly these influencers on TikTok and Instagram, Facebook, I think to a lesser degree, can really attract a lot of patients.
But what the influencers are allowed to say and what disclaimers need to be posted are one sort of area that needs to be handled in a thoughtful way by the telemed companies. The other is the contracts with the marketing companies that go out and get leads online, and how our telemedicine companies are paying those marketing companies for the leads to me, it's an emerging area that I'm learning as I [00:21:00] go, but that's one to keep an eye on because the volumes of patients that are being channeled to the platforms are staggering.
And so if the FTC were to decide that our clients are engaging in deceptive advertising practices, the fines against them and the penalties are gonna multiply like crazy given the high volume of patients that are coming in. Yeah. So stay tuned. We can talk more about that on another episode when I'm more prepared to, but that's a fascinating area that I've been hearing a lot about.
Yeah. No I completely agree with you. I talk a lot about vendor due diligence and partner due diligence. Yes. And- Oh, let's talk
about that, please.
I think that is such an important thing because, again, from a telemedicine perspective, you want to get the influencer that has a really solid, base of 200, [00:22:00] 300, thousand, followers.
And, but how are they marketing? What are they saying? What are they selling to their people? Are you as a company or a partner kind of guiding them a little bit on compliance because they don't know, right? So to me, I think that's where it really comes into play in the contract at the very least to say "This is what you can do and this is absolutely what you can't."
I've seen a lot that have, guaranteed claims. "Use this clinical partner and you can 100% get a prescription." I'm like, "You can't guarantee that." It's up to the clinician, right? Yeah. but I think it, it falls like on the same side as as they're doing vendor due diligence and making sure that the vendor covers all their checks and balances because, for me, compliance is al- it's delegated down.
So it's always sure, I can be s- totally solid com- compliantly, but if I'm partnering with all these fraudulent companies or companies that are doing [00:23:00] things, uncompliantly, then, it, yeah, it also doesn't help, So to me it's like you gotta kinda cover both bases.
Yeah, absolutely.
We worked with someone during COVID that was selling high volumes of COVID tests, and they had some aggressive marketers as contractors, not as employees, and marketers as contractors for Medicare reimbursed companies is highly risky. OIG does not like that these marketers were hustling and they were sending us thousands of leads to this COVID test company and lab.
And the test company was shipping out COVID tests under our Medicare program in accordance with the leads that were provided by the marketers. it turns out these were not clean leads. These were dark web leads that were obtained without the patient's consent. [00:24:00] And the naiveté of our client that was just trying to sell their COVID tests because they didn't vet their vendor, they didn't know where their vendor was getting their leads, resulted in our client getting fined significant dollars because they were shipping tests to people that didn't ask for them
Yeah.
that's what I'm saying is there's usually a lot of... in the non-compliance, once something bubbles up to the top to where you're, being investigated or you're, you have fines going, the, the piece that I think people forget about is, sure, today you might wanna take that risk, right?
You might be, "It's fine," right? What are the fines? But in, once the federal government kind of gets involved, and if it's something that, they wanna, pursue, do some sort of sanctions, the fines are pretty astronomical. I... And again, this is, kind of- ... comparing apples and oranges.
But, on my side, one of the rules for health plans, in California is you have to notice [00:25:00] people. You have, you could do it electronically, but you also have to mail them a written notice because it's in the contract, right? You just got- Yeah ... you gotta do what you're supposed to do. it's a rule.
And we found health plans that weren't doing that, and they're like, we don't need to." And we, there was, like, I think it was, like, a $10 per one that they didn't send out. And by the time that the regulators caught wind of the severity of it, w- I think we were trying to sanction them $10
million.
Wow.
it was something... And, our hands were tied. It was like, we're gonna have to get a settlement. You're gonna have to spend a bunch of money on legal fees and, turn into this whole rigmarole. But, that's, again, is I think a lot of times in healthcare, a lot of it is, per time you've committed that act of non-compliance, not a, "Oh, we think we're gonna throw...
you're gonna get fined, $100,000." A lot of it really expands and grows.
It does. It multiplies very quickly. And again at Telemed, the volumes of patients even coming through smallish [00:26:00] Telemed companies are staggering when compared to bricks-and-mortar medical practices or med spas in towns and cities.
Yeah.
And higher volume patients means higher dollar fines and sanctions, which is interesting.
Yeah. there's a, yeah, there's a... that's the whole point of this episode, right? There's a lot of these things that for people who are either new to healthcare, new to digital health or coming over because of the, like the gold rush or the wave, there's a lot of I'll say historical process.
There's a lot of things that you have to consider, and it should definitely go into when you're setting your pricing, when you're coming up with what you wanna offer, when you're building workflows, when you're thinking of, the, the clinical arm and what, and that, PC to contract with and what physician to use .
There's a lot of decisions that, that fall into that you have to, have a good lawyer to [00:27:00] guide you. And, really make sure that you're working with people who understand kind of the whole healthcare ecosystem because it, it really gets, complicated, and you can honestly make some really bad decisions accidentally that could implicate and impact your growth.
And another thing that breaks my heart in this industry is when the MSO and the platforms are making bad decisions, but the clinicians who are seeing the patients are well-intentioned and are doing a great job of taking care of the patients, but because they're part of an ecosystem that is flawed- Yes
that, that again, f- ends up falling on the doctor's license . So th- another reason to be a responsible telemedicine company, to start out right, there's lots of wrong ways to do it. There are some right ways to do it as well, and I think the two biggest reasons to build it right is so you don't let your [00:28:00] patients down, and so you don't let your doctors down, because if you have no doctors, you have nothing.
Yeah. And I- No, I completely agree And I'm finding that the telemedicine companies that treat their doctors the best, that have the most robust clinical policies and protocols, that have their shareholder, their PC shareholder at the table for governance decisions, for hiring and firing decisions, that involve their PC shareholder at least in quarterly meetings to review the finances, the comings and goings of the PC, those are the telemedicine companies that have the best luck of retaining doctors and building a legacy f- for the long term, which is really important because the telemedicine platforms that are relying on the white labeled docs that are contracted through shell company, through shell PC, there is, there's no legacy there, and once that system falls apart, there [00:29:00] are no doctors left for the telemedicine company.
So I love to see my clients building relationships personally with the doctors that are serving their patients. I know it's hard to do. You need a large network of doctors, but that doesn't mean you can't be very close to your physician leadership.
Yeah. I completely agree. I feel like, after being at so many startups and just being in like my role on the, clinical operations and compliance side, like if you don't have a good relationship with the clinical, at the very least clinical leadership team, you are going to make way more mistakes that are completely avoidable by just talking to the right physicians and making sure that you're, building the things with k- like them in mind.
So it's- Right ... I think it's definitely a really big call out. That's why I always say for the physicians out there that are like, "Oh, I have this, this opportunity and I don't really wanna be too involved and I want passive income," it's like, well then - For the, from the risk adverse, p- biggest risk adverse population I [00:30:00] know is probably isn't the best industry to be in if you don't wanna, put in, roll up your sleeves, do a l- you know, give a little elbow grease.
But also get to flex, your kind of clinical expertise, which I think has been the fun part. Leo's not here today, he had a conflict, but the fun part with Leo is, he's getting to help companies build homegrown EMRs that have- Yeah ... don't exist on the market, or come up with, a, an approach to lab testing.
So it's cool that, if you tap the doctor in, they'll actually tell you exactly like, what to do, and it make your life way easier.
So true. We need more Leos in this industry.
We definitely need more Leos. thank you so much, Bridget. We're coming up on time. Sure.
No problem with that. if there's... if anyone, of course, has, questions or is looking for, solid healthcare lawyers, Bridget is,me and Leo's personal lawyer, for our endeavor. So as long as there's no conflicts. [00:31:00] but reach out to Bridget, of course, and,have her, give you her assessment on your digital health industry.
You can also always reach out to us, phoebe@telemedicinetalks.com or leo@telemedicinetalks.com depending on where you're at in your build or operations. Or even if you just need somebody to gut check something, always reach out to us. We're happy to help. Thank y'all for another great episode of Telemedicine Talks, and we'll see you next week to talk more telemedicine.