What Should be in a J-1 Physician Contract?

Many physicians coming out of training are for medical grads. To assist in their immigration, they must enter a J-1 waiver employment contract with their first work out of training. I will go through the basic elements that a J-1 physician employment contract needs to include. Hopefully, maybe make it a little easier to understand. So, what is an employment contract? Simply it’s just an agreement between you and the employer about what the terms of the business relationship will be. Every state has requirements of what needs to be in a J-1 visa contract. Most of them are almost the same.

How to Get Started in the Program

Some states either require or don’t require many things. I’m going through what everyone will have and a few things that vary from state to state. First, the J-1 contract must contain sites where the J-1 physician will be working and the services they’ll be providing. It must state that the J-1 physician must start within 90 days of receiving the J-1 visa waiver. Since I’m in Arizona, I’m going through the Arizona department of health services. The requirements for the contract, and get into what varies from state to state. It must be for three years—that goes for any state. It must express that the J-1 physician will work a minimum of 40 hours on average. 

That must be in every contract in every state. Then the employer and J-1 physician must both sign the agreement. Those are just the bare-bones things that must be in every J-1 contract. 

Things That Change From State to State 

Some of the things that change from state to state. And this might help a J-1 physician looking in multiple states for different opportunities. Arizona, for instance, prohibits any non-compete in the agreement. Arizona does allow and enforce reasonable non-competes for J-1 physicians in the state, but they prohibit them in a J-1 contract. Which can change from state to state whether it needs to be in there or not. If the contract changes in some way, if there’s an amendment, it must still reach those basic amendment requirements. If they amend it, they must run it through the state’s health department or whoever oversees the contract.

Visa Petition Approved Medical Contract

Regarding negotiating a J-1 contract, I mean, every contract negotiation is based upon leverage. A J-1 physician probably has less leverage because they need to be in that position. But different specialties always have different leverages than others. Then if you’re willing to go into certain places. The entire point of the J-1 visitor program is to bring physicians to health service shortage areas or under-served communities. So, you’re likely going somewhere that’s more rural, not in a large city, and is probably harder to recruit to. The visitor program intends to bring good J-1 physicians into these areas where recruiting is harder. Then after three years, they can go through the process and get their green card. So that’s the basics of what needs to go into a J-1 employment contract.

Other Blogs of Interest

• Is a Physician an Independent Contractor?
• When Should a Resident Physician Start Looking for a Job?

J-1 Visa Waiver Program

The J-1 Visa Waiver Program is designed to bring in physicians from abroad for a temporary period. J-1 physicians are required to work full-time at their assigned location and have an employment contract that includes those requirements. J-1 Physician Contract Requirements list all the criteria J-1 Physicians must meet before being approved for the J-1 waiver program. A visitor program granting entry into the United States of America. Here is a breakdown of what you must know about getting your J physician contract set up ready for approval!

International Medical Graduates

The US Citizen and Immigration Services provides valuable information for those interested in the J-1 process. The J-1 classification is for those who want to participate in an approved program. A program allowing them the opportunity to teach, instruct, lecture, study and observe, consult with others, or demonstrate special skills. You can also receive J-1 training while you are there!

Visa

The United States Department of State has named public and private entities to act as exchange sponsors. These visitor programs are designed to promote the interchange of persons, knowledge, and skills in fields like education, arts, or science.

The US Secretary appoints a designated sponsor for each J-1 Exchange Visitor program. They have goals set out on behalf of those visiting America from their home country. Those who will bring back new ideas and unique perspectives when they return home at the end of their stay. And attaining this through cultural exchanges that help broaden international understanding of different cultures. Which we can all learn something about during this experience.

Visa Application Process for J-1 Visitor Program

The US Department of State plays the primary role in administering the J-1 exchange visitor program. So, you want to get a visa for this J-1 trip. But your sponsoring agency is not helping. Then it’s time to start getting creative. You will need Form DS-2019: Certificate of Eligibility for Exchange Visitor Status (formerly known as an IAP-66). This means working closely with officials at your sponsoring embassy or organization who are assisting through this whole ordeal. But don’t worry, they’re there every step along the way!

A responsible officer has the power to grant a student their Form DS-2019, otherwise known as an I-20. Your RO will be your point of contact for any questions you may have during this process. And can help answer any questions. They’re also in charge of issuing documents like letters or transcripts if needed before we issue them our coveted document!

The US Department of State provides Form DS-2019 to those interested in going abroad for educational purposes. And receiving the J-1 visa after acquiring it through their school’s sponsor. Which is typically an American university or college with international programs on an F, M, or Q status. The waiting time for your interview appointment can vary, so submitting as early as possible is strongly encouraged. Though you may not enter the United States more than 30 days before your program starts.

Physicians

A J-1 physician should not enter into a contract without having the agreement reviewed by legal counsel first. You need someone to protect your interests. You need a firm grasp of the key terms and their implications. When we do a thorough review of your J-1 physician employment contract, you will receive:

• Available in any state where that J-1 physician is
• Flat-rate pricing, with no hidden costs
• Review of your proposed employment agreement
• Phone consultation with Attorney Robert Chelle reviewing the contract term by term
• Follow up with a review of the needed clarifications

Knowing you have professional and experienced help with an employment contract will enable you to take the stress out of trying to do a vital business transaction. You can then focus on what is important — your patients.

J-1 Waiver Visa Contract Requirements

The employment agreement between the J-1 physician and the employer must contain a number of terms. Each state where the J-1 physician will practice will have its requirements. But all states require the following in the Employment Agreement:

• The contract must specify the name of the service site(s). And the address where the J-1 physician will provide their services. (A separate service site application must be completed and submitted.  Where? For each site where the J-1 physician will perform their required full-time hours per week.)
• J-1 waiver program contract must be for at least full-time (at least 40 hours per week). And specify the approved primary care/specialty services the site will provide.
• The contract must be for at least 3 years.
• J-1 physician must agree to begin employment at the approved service site(s) within 90 days of receiving J-1 waiver. (must state in the contract)
• Until the J-1 physician completes the three-year commitment, the J-1 physician must provide services:

• At the service site(s) specified in the employment contract,
• To the patients specified in the employment contract, and
• In the manner specified in the employment contract

GME Programs and Medical Schools

Alien physicians must, to be eligible for a work permit. J-1 applicants must have completed the appropriate educational requirements and training in their home country before coming to America. Successful candidates will need at least an associate degree in accounting from American universities. Or equivalent experience working as an accountant abroad.

Foreign Medical Graduates

The requirements for an international student vary from program to program. J-1 applicants must be able to adapt to the educational and cultural environment they will experience in their visitor programs. And have the necessary background, needs, and experiences suitable for the fields of study offered at university or college-level institutions. Also, competency with oral communication. Such as speaking English fluently so that one can easily comprehend what is being said without any difficulty whatsoever.

Some universities desire international students because it allows them more diversity on campus, giving intellectual stimulation through new perspectives. Also allowing those who may not especially enjoy interacting with people outside of their own culture might create less stress. Worry-free during school days if they had someone close enough culturally similar around them all day.

Looking for the most comprehensive and rigorous medical exam? Look no further than The National Board of Medical Examiners. There are three different ways to pass this examination: Part I & II from either an American or Foreign school. Step 1&2 passing with ECFMG (Educational Commission For Foreign Medical Graduates) and a Visa Qualifying Exam(VQE). One must pass all parts before their education begins, as some US schools require it even after graduation!

The National Board of Medical Exams

The National Board of Medical Exams exists so J-1 physicians can ensure they have the best training available. They do this by offering multiple options for completing your certification process.

The country’s government required a physician with the skills to provide care. The alien had filed an offer, along with a written assurance that he would return after training was complete. And they issued permission for him to train.

The passage begins by stating their need to be physicians who are needed within the area first. Before further assessing any individual’s qualifications or willingness to serve. Alongside providing documentation, ensuring their willingness, educational background, and proficiency must also reflect what’s required. Once they meet these requirements, if approved, it will permit them to enter this new opportunity.

The agreement includes a contract from the US accredited medical school, an affiliated hospital, or a scientific institution. In order to provide accreditation graduate medical education for the alien physician. Both parties sign it:

The United States has strict requirements for granting citizenship status that one can meet with various documents. Documents such as diplomas, transcripts, degrees, etc. One of these additional documents required is one detailing how you will receive your training in medicine. That is, via affiliation agreements between institutions like colleges/universities that offer this type of training. And hospitals where physicians train after graduating too called “accredited” schools. Meaning their credits towards certification are recognized nationally (or internationally). This document must detail what year(s) you plan on studying at the said institution.

Employment Agreement Review

Contracts are a pervasive and obligatory part of nearly all company and legal transactions. Well-drafted contracts help to enumerate the responsibilities of involved parties, divide liabilities, protect legal rights, and ensure future relationship statuses. These touchstones are even more crucial when applying their roles to the case of a provider employed by a hospital, medical group, or other health care provider. While contract drafting and negotiation can be a long and arduous process. Legal representation is necessary to ensure that your rights are protected.

The present-day conclusion is simple. A physician should not enter into any contract without having the agreement reviewed by legal counsel.

There is too much risk for physicians to take contract matters into their own hands. In addition to the specific professional implications, contract terms can significantly impact a provider’s family, lifestyle, and future. There are many essential contract terms and clauses which can present complex and diverse issues for any provider, including:

• Non-compete clauses
• Damages
• Indemnification
• Verbal guarantees
• Insurance statements

Why Do You Need to Have Your Contract Reviewed?

Additionally, often the most influential terms and clauses in any employment contract are the ones that are not present. With the advent of productivity-based employment agreements, any physician must have an employment agreement reviewed before executing them. Attorney Robert Chelle has practical experience drafting and reviewing provider contracts for nearly every specialty, including physician contract reviews.

A thorough contract review can benefit new residents, attending physicians, and doctors entering their first employment contract. Or established physicians looking for new employment. By employing an experienced attorney for your representation, you’ll fully understand the extensive and complex wording included in your contract. By fully understanding the contract, you’ll be in a better position to make your own decision. Decision on whether or not you want to enter the agreement, which will affect your career for years to come.

The financial benefits gained from having your contract reviewed and negotiated by an experienced healthcare attorney far outweigh the costs. You are a valuable resource, and you should be treated and respected as such. Attorney Robert Chelle will personally dedicate his time to ensure that you are fully protected. And assist you in the contract process so that we fairly represent your interests.

Every physician contract is unique. However, nearly all contracts for health care providers should contain several essential terms. If the contract doesn’t spell out these essential terms, disputes can arise when there is a disagreement between the parties. For instance, if the physician expects to work  Monday through Thursday and the employer expects the provider to work Monday through Friday. Still, the particular workdays are absent from the agreement. Who prevails?

Physician Agreement Checklist

Spelling out the details of your job is crucial to avoid contract conflicts during the term of your employment. Below is a checklist of essential terms that contracts should contain (and a brief explanation of each term):

Contract Basics

1. Practice Services Offered: What is the clinical patient care duties? Are you given time to review administrative tasks? How many patients are you expected to see (like in pediatrics)?
2. Patient Care Schedule: What days and hours per week are you expected to provide patient care? What is the surgery schedule? Are you involved in the planning of your schedule?
3. Locations: Which facilities will they schedule you to provide care at (outpatient clinic, surgical sites, in-patient services, etc.)?
4. Outside Activities: Are you permitted to pursue moonlighting or locum tenens opportunities? Do you need permission from the employer before you accept those practice medicine-related positions?
5. Practice Call Schedule: How often are you on call (after-hours office call, hospital call (if applicable))?
6. Electronic Medical Records (EMR): What EMR system do they use in the practice of medicine? Will you receive training or time to review the system before providing care?
7. Practice Assignment: Can the employer assign the Agreement?
8. Term: What is the length of the initial term? Does the Agreement automatically renew after the initial term?
9. Without Cause Termination: How much notice is required for either party to terminate the Agreement without-cause?
10. For Cause Termination: What are the grounds for immediate termination for-cause? Is a review provided to dispute the termination?
11. Non-Compete: How long does the non-compete last, and what is the prohibited geographic scope?
12. Non-Solicitation: How long does it last and covers employees, patients, and business associates?
13. Notice: How is the notice given? Via hand delivery, email, US mail, etc.? Does it have to be provided to the employer’s attorney?
14. Alternative Dispute Resolution: If there is a conflict regarding the contract, will mediation or arbitration process be utilized? What is the standard attorney review process for conflict? Who decides which attorney oversees the process?

Monetary Considerations

1. Medical License:  Will the medical practice offer expense repayment for your license? Will an advisor be provided?
2. Base Compensation: What is the annual base salary? What is the pay period frequency? Does the base compensation increase over the term of the Agreement? Is there a yearly review or quarterly review of compensation?
3. Productivity Compensation: If there is productivity compensation, how is it calculated (wRVU, net-collections, patient encounters, etc.)? Is there an annual review?
4. Practice Benefits Summary: Are standard benefits offered: health, vision, dental, life, retirement, etc.? Who is the advisor of human resource benefits?
5. Paid Time Off: How much time off does the job offer? What is the split between vacation, sick days, CME attendance, and holidays? Is there an HR guide?
6. Continuing Medical Education (CME): What is the annual allowance for CME expenses, and how much time off are they offering?
7. Dues and Fees: Which financial expenses are covered (board licensing, DEA registration, privileging, AMA membership, Board review)?
8. Relocation Assistance: Is relocation assistance offered? What are the repayment obligations if the Agreement terminates before the expiration of the initial term?
9. Signing Bonus: Is an employee signing bonus offered? When is it paid? Do you have to pay it back if you leave before you complete the initial term? Are student loans paid back? Is there a forgiveness period for student loans?
10. Professional Liability Insurance: What type of liability insurance (malpractice) do they offer: claims-made, occurrence, self-insurance?
11. Tail insurance Insurance: If tail insurance is necessary, who is responsible for paying for it when the Agreement terminates?
12. Disability Insurance: Is disability insurance provided (short-term and long-term)?
13. Financial Retirement:  Is a financial retirement plan offered?
14. Practice Post-Termination Payment Obligations: Will you receive production bonuses after the Agreement terminates?

Hire A Contract Attorney

If you have questions about claims-made or occurrence coverage and your current malpractice insurance. Contact Chelle Law today if you are interested in having your employment agreement reviewed.

How to Negotiate a Physician Contract

How do you negotiate a physician contract? What are the goals to consider during the contract negotiation process to win the terms of the negotiated agreements? So in my mind, there are three different scenarios. One, you’re either just coming out of medical training. Two, you’re switching jobs to an area of the country that you’ve never been to before. Or three, you’re moving from somewhere within the area where you already live. So negotiation is always based upon leverage. Do you have it, or do you not? So let’s just take coming out of training, for instance. Often, negotiating job offers, the only leverage someone from training has, is in a specialty that’s hard to recruit for. That’s just the truth.

What to Negotiate in a Contract

You are not bringing in any established PA patient base. You’re also all relatively new to being out on your own. So, a learning curve will go into moving into any position. Consider this, if you are either in an area that’s very difficult to recruit. That could apply to any specialty. Or you’re in a specialty that’s all to bring in and is super profitable. Those are two things to consider.

When you’re looking into it, how do I negotiate the terms of the contract? And when people say negotiate, most of the time, they think about the bottom line, what is my base salary. But I think that’s kind of a narrow mind. And this will apply to anybody looking for work. There are some other goals to consider during contract negotiations. At least in my mind, things that are more important than just the base compensation. One, what are the terms of the restrictive covenants?

Non-Compete is Important to Most People

My advice if someone lives in an area, they have family in the area, they have kids in it. They absolutely cannot move after the contract ends since they will have to also think about things related to moving. Like the schooling of the kids, or your wife’s job, or if they are also running a business. Sometimes, the non-compete could be the most important thing in a contract. A non-compete says you cannot practice within a specific area for a period.

Negotiate Tail Insurance

Another important piece is who pays for tail insurance. Depending upon specialty, this could be an enormous part of a contract. If you’re an OB-GYN. You have to pay for your own tail; your underlying premium is $40,000 yearly. Your tail insurance cost will be higher compared to other specialties. Probably going to be around 80,000. Who pays for tail insurance certainly could be the most important thing in an employment agreement during a contract negotiation.

Employer Practice Negotiations

My advice if you’re being paid on production. Let’s just say you’re in a contract that’s just pure net collection. An average range for a physician is 35 to 40% of collections. Is there language in the contract stating that when the contract terminates, you will be able to collect for a 60 to the 90-day window after the contract terminates? If you don’t have that, then you worked for free for two or three months, which nobody wants to do.

Going back to what is important, it depends upon the person what his goals are. Having the numbers is important when you’re looking at base compensation. They’re not always easy to obtain. Most places, or the majority of the places, use MGMA numbers. It’s a medical group management association. Most of the time, you have to pay for that, and it’s expensive. So no physician, at least most physicians, will not do that. 

You could find someone with access to those numbers or try to get them. Or if you Google around on the internet, sometimes you can find the average RVU production and average compensation. It is broken down into areas of the country. I honestly don’t think those are accurate when determining exactly how much in what part of the country. There’s a feel for what someone is getting in this area, but also consider all the other things I said. If someone has a base that’s $10,000 less, but employers will not make you pay for tail insurance. Or the non-compete is extraordinarily small. That’s worth way more than $10,000 in some instances. That is kind of a few factors during contract negotiation to think about.

Physician Employment Contracts

If you’re just coming out of training, let’s say you’re established in the community. Either you’re a primary care PE, it’s cardiology, you have an established space, and just moving into a new practice. Well, this is the highest leverage you can have during contract negotiation. There’s gonna be no, or at least there shouldn’t be much time needed to ramp up the practice. You’re just bringing people with you. Plus, when you have numbers in a community, your net-collections, the RVUs you produced, or the weekly patient encounters. Those are absolute hard numbers that you can use to negotiate compensation terms, moving to a different practice. 

In that case, you have the highest leverage possible. Then obviously, you can negotiate all the ancillary things I’ve already spoken about. The last thing would be, if you’re moving, out of training. You’ve been in medical practice for a while, and you’re moving from one city to another. You don’t have an established patient base. That takes away some leverage. There are two factors that kind of work for you for your contract negotiation strategies.

One, are you moving to an area of the country that’s difficult to recruit to? Very rural communities certainly pay more. Simply because it’s harder to find physicians in certain specialties and make them move and live in those areas. Or two, if you’re in a specialty that is just simply hard to recruit to or extremely profitable. So obviously, surgeons are difficult to find, or some of the other GI subspecialties are always difficult as well.

Doctors Can Negotiate Effectively

If you’re moving to a different part of the country, then the same analysis applies to some kinds of training. However, you benefit from having some numbers of what you produced in your previous position. You can tell them during your contract negotiation, this was the net collection that I generated in my last position. Now, it doesn’t always translate from one state to another or one situation to another. And maybe you’re going from private practice into an employed group.

But having any kind of data to back up what your production was is essential during contract negotiation. Especially in determining your new total compensation in a new position. So, those are some tips on things to think about. I mean, honestly, just doing this blog, I can think this could be broken down into ten different articles. But this is just kind of an overview on negotiating.

How to Negotiate a Physician’s Salary

How to negotiate a physician’s salary? Initially, I don’t personally believe that the salary shall be the driving factor in a decision for a physician. Now, clearly, if there’s an enormous gap, a hundred thousand dollars, maybe 50. But if it’s $10,000 just going with the job that offers the most when maybe the benefits are different. The work environment is different, the ability to learn, have a good mentor, a good teacher, and a good team.

I think all those things are probably more important than just the absolute base salary amount. But it certainly is important. And so, when someone asks me, all right, well, what do I do? How do I get a better salary during contract negotiation? How can I make them offer terms that are my goals in the hiring process? There are a couple of ways of doing it during contract negotiations. 

Know Your Worth

One, you need to know your worth. How does a physician find out what’s a reasonable salary? Well, there’s data. The MGMA medical group management association is, I would say, probably the industry standard as far as compensation numbers go. But it is not the be-all and end-all of whether something is fair or not. They break it down into regions: West, East, Midwest, and Southwest. Those kinds of quadrants have different salary numbers associated with them. 

Potential For A Partnership

But just the base salary could be great or not depending if there’s productivity compensation in the agreement as well. Or there’s potential they can offer partnership. So, there are many scenarios where a physician is out of training, and they’ve given a two-year, three-year agreement. That’s probably below what’s a reasonable or average amount for someone just coming out of training. Kind of with the carrot on the stick if you take below market for these two or three years. Then you’ll get away above-market. Once you become a partner, be careful of the situation. Do you need to find out how many people are partners? How many people have they not offered partnership to? And then what will you make once you’ve become a partner? That’s certainly important. 

MGMA Numbers

Now, as far as the MGMA numbers go, they are kind of hard to find. I mean, you can Google around and find, I would say, data from maybe a year or two old. I found that people are relying on 2020 numbers. They’re completely screwed up due to COVID. Some of the RVU compensation factor numbers are way out of whack. Some of the comps are just way out of whack.

I would not use 2020 data to compare the contract offer. 2019 is probably the safest and most reliable number that we have right now. 2021 hasn’t been released, at least at this point while I’m making this video yet. So, Google and read around. You can try and find some numbers to help you with negotiations. I’d say the best tactic is to go out, find multiple job offers and see what you’re being offered initially.

Colleagues in Training

And then also, anyone in training has other people in their specialty that are also looking for jobs. Reach out to your colleagues, and talk to the people you’re in training with. What have you been offered? Where have you been offered this? 

Cost of Living in the Area

One difficult thing is that some people automatically think that they’re in a high-cost city and that they’ll make more. But have not considered other factors, like a higher cost of living. And that’s just not the case. It’s almost the opposite. If you’re looking for a job in a city, that’s kind of a desirable location. Usually, the salaries, or at least sometimes the salaries will be depressed. I live in Scottsdale, Arizona, which is a great place to live.

And when I speak to physicians who are moving into the area, they’re surprised sometimes. Because the salaries may not be adjusted to the cost of living in the area. California as well. If you’re in San Diego or LA or even in San Francisco, the cost of living is very high. And the housing is very high, but the salaries are not commensurate with that. Be aware that just because you’re in a bigger city with higher living costs doesn’t mean you’ll be making more. It’s the opposite, really.

If you’re in a rural location that’s hard to recruit, you will almost always make more money in those scenarios. So, if money is the bottom line you’re looking for. Then you need to look in the smaller cities that are simply difficult to recruit to. You will make more money on average if you’re going to go to a small rural community. That’s a fact. 

Negotiating Numbers

Once you have a number in mind, what do you do with the employer? You ask them for more. 

If you’re being offered 300 and you want 325, you don’t ask for 325. You ask for more than that. So, if they offer 300 and you want 325, then ask for 350. Just kind of easy arithmetic, try to meet in the middle. Now there is a point where you will look either greedy or potentially just kind of dumb. If you’re offered 300, and you’re asked for 450, they’re going to say, well, that’s ridiculous. They may even yank the offer.

You need to know your value. Specialty is also a big part of what kind of leverage you have. Any kind of contract negotiation is based on leverage. Do you have it, or do you not? You simply have more leverage if you’re in a specialty that’s hard to recruit to or is in high demand. If you’re in a specialty that’s plentiful or saturated in the market that you’re looking in, your leverage is less.

So, you need to take that into account as well. If you’re switching jobs in the community and bringing your patients with you. Then you’re worth more than someone coming into the community. Like peds or primary care, that must build up a patient base that takes time. 

Summary

Those are tips on getting a better salary and where to start. Contacting an attorney and trying to maybe get a feel for the area certainly might be helpful. It’s fairly specialized in people that just focus on physician contracts. It’s possible you won’t find somebody in the area you’re looking at, so maybe do a wider search for that. But anyway, the last point is that some employers simply will not negotiate. They’ll say it’s a take-it-or-leave-it offer, you’ll then have to be willing to walk if you’re unhappy with your salary. 

But some people say, no, we’re not negotiating. This is what we’re offering, and I wouldn’t be offended by that. That’s just kind of the tech that they’re taking as far as employing somebody. So, don’t be surprised if you have an employer that says no. But if you’re unhappy with an offer, you need to be willing to walk as well. Accepting a deal that you think is well below your value is never a good feeling. Don’t just accept that because you need a job. Find the right job.