Multi-State Virtualist Operations: How to Manage Licensing, Credentialing, and Compliance Across 25+ States

Your health system wants a national virtual care program. You decide to serve 25 states with 15 virtualists.

Each virtualist needs to be licensed in the states they serve. Each state has different licensing requirements, continuing education rules, and renewal timelines.

Each virtualist needs to be credentialed with Medicare, Medicaid, and multiple commercial plans in each state.

You're now managing:

• 25 state medical boards
• 50+ insurance credentialing processes (multiple payers per state)
• Different CME requirements per state
• Different renewal dates per state
• Different scope of practice rules per state

Without a system, this becomes chaos.

What Dr. Berkowitz Built: A 50-State Operating System

Dr. Lyle Berkowitz faced this exact problem when building KeyCare into a national virtual medical group.

Berkowitz articulated the challenge of scaling across multiple jurisdictions:

"The issue is all about execution. When can we do it? When does it make sense?"

For multi-state operations, execution means managing compliance across 50 different regulatory regimes simultaneously.

Berkowitz's approach to KeyCare was to build from the ground up with compliance as the foundation, not an afterthought.

He describes the result:

"We've built a 50-state national medical group, and we put them on Epic and we connect it to all the other Epic sites to be a workforce augmentation tool."

This national footprint didn't happen by accident. It required:

• Understanding licensing in all 50 states
• Building credentialing processes that work across multiple payers in each state
• Creating compliance infrastructure that tracks everything
• Scaling operations without shortcuts

The Compliance Requirement

You cannot operate as a physician without the right license. Full stop.

A physician practicing in New York without a New York license is illegal. You can be fined. The physician can be subject to disciplinary action.

This is non-negotiable. You must track:

• Which physicians are licensed in which states
• License expiration dates (and ensure renewal before expiration)
• Scope of practice differences (some states restrict certain procedures)
• Continuing education requirements (rules vary by state)
• Telehealth restrictions (some states have unique telemedicine regulations)

State Licensing Complexity

Example: Comparing licensing requirements across four states

Just managing CME requirements across four states requires tracking which physicians need which hours and ensuring completion before deadlines.

The Credentialing Multiplier

Each state, each payer = separate credentialing process

A physician licensed in New York needs to credential with:

• Medicare (national, but different requirements by state)
• Medicaid New York
• United Healthcare (if operating in that region)
• Aetna
• Cigna
• Empire Blue Cross

That's 6 credentialing processes for one state.

Multiply by 25 states and 15 virtualists: 25 states x 15 virtualists x 4 payers (average) = 1,500 credentialing processes

Managing 1,500 credentialing timelines manually is impossible.

How DirectShifts Manages This

DirectShifts maintains:

1. Physician license database

• State of licensure
• License expiration date
• Scope of practice by state
• Continuing education tracking

2. Credentialing workflow system

• Tracks each credentialing application
• Notes expiration dates (re-credentialing needed every 2-3 years)
• Flags compliance risks
• Manages documents and submissions

3. Regulatory compliance calendar

• CME deadlines by state
• License renewal dates
• Re-credentialing deadlines
• Audit trails for compliance

4. Payer relationship management

• Pre-established relationships with Medicare, Medicaid, major plans
• Fast-tracked submissions
• Expedited approval processes

Result: A health system using DirectShifts doesn't need an internal credentialing administrator. DirectShifts handles this.

When discussing how KeyCare grew to 50 states without compromising quality, Berkowitz emphasizes execution:

"We've armed our doctors with both Epic tech as well as our own tech, um to make them as efficient as possible."

This principle applies to compliance. You don't compromise on licensing and credentialing to grow fast. You build systems that handle compliance at scale.

DirectShifts applies this philosophy: compliance infrastructure that scales from 1 to 100 virtualists across multiple states.

A national health system launched a 25-state virtual urgent care program with 20 virtualists.

Cost savings: $80k-120k per year in avoided salaries, plus avoided compliance violations and fines.