What should be in a telehealth contract? Telehealth is also known as telemedicine. The pandemic accelerated telemedicine and telehealth across all specialties. It is now possible to conduct practice in any specialty via telemedicine. Most of the state licensing boards, I would say, significantly increased the ability of physicians to utilize telemedicine. Whereas maybe, in some ways, it was prohibited in the past. I find that more and more people are contacting me to review telehealth employment contracts or telehealth independent contractor agreements. And some things need to be thought about before the physician enters them. There’s no huge difference between a telehealth contract and just a normal employment contract.
The Big Difference in Telehealth Contract
If you join a hospital network or a private physician-owned group, the agreements will be relatively the same, with one big exception. And this is the reason why I wanted to talk about this today. The following sentence goes for any physician contract. In the typical agreement, you’re going to have: the term, how long it last, how to terminate the contract, what the compensation is going to be, whether there are any benefits, what the employer is going to pay for, so licensing, DEA, society, associations, continuing medical education, time off potentially. However, it’s a little different for most telehealth agreements. And then, the big one is the non-compete. Now, I wish I had a bright line answer: Okay, this is how it works with telehealth agreements, but I don’t.
First, non-competes or at least non-compete law is probably one of the only things that change from state to state. If you were to review a physician contract, nothing would be state-specific for the most part. It’s all the same. However, each state views non-competes differently. There are very few states, but some completely prohibit non-competes for physician employment contracts. So, California, New Mexico, Massachusetts, and then there are varying degrees of what’s considered a reasonable enforceable non-compete based upon the state. The tricky part with telemedicine or telehealth is determining where the non-compete applies. If you think of a normal non-compete, it’s going to say:
- For this period
- After the contract terminates
- Usually, one year, sometimes up to two
- The physician can’t compete
- Can’t either work within their specialty
- In a specific geographic area
- Somewhere between 5 to 15 miles from their primary practice location
And that’s simple, you just stick a pin in a map, put 15 miles around it, and then that’s where the physician cannot work during the period of the non-compete.
Why is the Non-Compete Clause Complicated in Telehealth?
Well, that doesn’t work in telehealth. I find that most physicians who are working in telehealth usually are licensed in multiple states. And so, let’s say they live in Florida, they’re licensed in Florida, but they’re also licensed in Georgia and South Carolina. The telehealth company services all those states. And so, the physician has no say in where the patient is located. And then they’re just seeing the patients that are in a queue. Different telehealth companies do it differently. Some literally the physician when they’re available or when they want to, they’ll just log in, there’s a queue of patients.
And then they tee up whoever is available and do the consult or whatever they do. Others will have, like in, maybe telepsych. They’ll have a set patient base for which they continuously see and write scripts—the difference between a normal non-compete, where it’s just a region. And most of the telehealth agreements will say, you cannot compete with current patients or provide care to current patients in this state that you’re providing care for us. Or you can’t work for another telehealth company that competes in the state that we’re currently in.
They’re much broader and, in my opinion, much more unenforceable than a standard one year, 10 to 15 miles. Now, these are just working their way through the court systems in various states. And in some states, it’s completely open as far as whether these are enforceable or if there’s a way of making the non-compete enforceable by limiting the area.
Some Examples Why It’s Complicated
But let’s give a couple of scenarios. Let’s say a physician is doing radiology while living in Georgia but then doing reads from multiple states nearby. And then, the radiology company offers a non-compete. It states that the physician can’t work for any other competing radiology company where you’re doing reads in different states. Or you can’t provide radiology services for any of the facilities that that company has been doing reads for over the last year. Or some scenario like that. I mean, you can see how complicated it can get. If someone leaves the first job, they move to a second job.
They have no control over which facilities they’re providing care for the patients they’re seeing or anything like that. And then maybe there’s some change in a business relationship. And so, there may be no problems in the first six months of the non-compete. Then, in the second half, maybe your new company starts servicing the old organizations that your first radiology job is servicing. What do you have to do? Do you have to stop providing care for those places? Was there any caveat in the original non-compete that the physician would be free to provide care to those facilities if the contracts ended? Another one would be if it were just a patient base. Let’s say it’s telepsych. The telepsych company would say the physician can’t provide care to any patient that received services from the telepsych company within the last year.
Physicians Do Not Have Control Over the Patients They See in Telehealth
And not even specific to the physician, just any services from their company. Well, once again, let’s say the physician leaves. They have no control over who the patients are that they see. They have no idea of who the previous companies were that the patients used. So, how do you determine or track whether they’re breaking the non-compete or not? And then another factor is how to track everything. Like how would an employer who made a physician sign a non-compete? How would they know if that physician is servicing patients in a new position? It would be challenging. So, I wish I had an answer: yes, it’s enforceable, or no, it’s not. The courts have to go through these areas and then decide on, alright, this is what would be considered enforceable.
And this is what would be considered not. Now, I think it makes sense for the physician to bring up these issues to their company before signing the non-compete and get into those scenarios and say, well, how am I supposed to if our company provided care to someone? Then I switched to a different company, and it’s a patient I never had, I had no relationship with, but they utilized another physician in the organization. I mean, there are so many different complications when it comes to this.
Have a Lawyer Look at the Contract Before Signing
So, it would probably make sense to get it looked at before signing the non-compete. But I guess there will be some limitations from what some of the bigger telehealth companies are making physicians sign right now. Putting a blanket, you can’t work for another telehealth company in the entire state. I don’t think that’s going to hold up at all. It will have to be limited, most likely by geography in some way, which in these scenarios may be impossible to do. So, that’s a brief breakdown of what should be a telehealth contract with a significant focus on the non-compete because that’s the most important part.
What to Know Before Signing Your First Physician Contract | Contracts
What should you know before you sign your first physician employment contract? This question is a broad topic, but we’re going to hit the main areas, things to think about before signing your first employment agreement.
Ways to Determine if Compensations Offered Are of Fair Market Value
First, determine whether the compensation you’re being offered is fair market value. There are a couple of, I guess, good ways of going about trying to find that. The MGMA, the medical group management association, collects annual salary data from across the country. If you can access that, they have a lot of good information about total compensation, average net-collections, and average RVUs generated by specialty. It’s hard to get that info sometimes.
I mean, if you Google around, you might be able to find some of the compensation data that’s a couple of years old. Or you can talk to someone who has access to the data, like for our firm, we have access to the data. So, we can tell the physician exactly what the numbers say. Now, that’s certainly not the be-all-end-all. There are other services out there that offer something similar. But I also think it’s limited because some specialties have a tiny sample size. In addition, just total compensation should not be the determining factor when looking for a job. Alright, so that’s compensation.
Another way of thinking about it would be, if you have classmates in your training program, you need to ask them what they’re receiving. It’s going to vary based upon geography and then setting. Are they going into a hospital network? Are they going into the federal facility? Or are they going into private practice in some way? It is good to speak to people you train with to see what they’re being offered. And then mentors are another excellent place.
How To Terminate Contracts
If someone is already out and maybe they’ve been a teacher for you or a mentor, ask them if they’re willing to talk about the type of compensation they’re receiving. Next would be how to terminate the agreement. Something you need to consider. There are four ways to terminate a contract if the initial term ends. Let’s say you have a two-year contract, and no language states it automatically renews. It just ends, and the contract terminates. You can complete a contract by mutual agreement. Then you can also terminate a contract with-cause. So if one of the parties breaches the contract, either party can terminate the contract if the other party doesn’t fix the breach. It’s called cure. And then lastly, and this is what I want to hit on, is without-cause termination.
Every contract you sign must have without-cause termination in it. There are minimal circumstances where no without-cause termination would be okay. If you’re a J-1, that one would probably benefit you not to have that in there. But without-cause termination means you can terminate the contract at any point, for any reason, with a certain amount of notice to the other party. Contracts that don’t have without-cause termination, meaning you must work out whatever the initial term is. There’s no way of terminating the contract for any reason. They would have to breach it if you wanted to get out of it.
Why Do I Need No Cause Termination on My Contract?
The reason why you need that is, let’s say you start with the job, you’re paid on productivity, and the volume is not there. It’s not your fault, or maybe the employer brought you in telling you it was going to be one way, and the call is just excessive. Or perhaps it’s just a terrible personality fit; whatever reason you’re not happy in that job, you need the ability to get out of it if you want. So, it would be best to have without-cause termination in the contract. Somewhere between 60 to 90 days is standard for physicians.
Legal Mistakes Physicians Make are not going through Non-Compete.
Alright, next, the non-compete. A non-compete says the physician can’t work after the contract terminates for a period within a specific area. For example, most non-competes are one year, sometimes up to two.
And then, a reasonable mileage would be 10 to 15 miles from your primary practice location. Often, the employer will try to tag multiple locations. So, maybe if you worked in three outpatient clinics in a hospital or something. They try to attach it to all four of those, or perhaps the employer has many facilities in the area. You’ve only worked at one of them, and they might try to attach it to all the facilities they own. That’s not fair either. You want to try to get it to one year, 10 to 15 miles from maybe at most two locations. Anything beyond that would be considered unreasonable. There are a few states where it’s entirely unenforceable to have a non-compete. But for the most part, most states allow non-competes for physicians.
Health Care Malpractice Insurance, Do Not Practice-Without It
Lastly, the employer should almost always pay for your underlying annual premium with malpractice insurance. How much must they pay each year to insure you? Depending upon the policy, whether it’s a claims-made or an occurrence-based approach, it will determine if you must pay what’s called tail insurance.
If it’s a claims-made policy, tail insurance is necessary. A good rule of thumb is that tail insurance costs about twice your annual premium. In some specialties, it can be costly. OB-GYN, some of the higher-level surgical things could have tails that are fifty to a hundred thousand dollars. You want to avoid having to pay for that. So, make sure that there’s either a fair split between the employee and employer or having the employer pay the total cost of the tail insurance, or there’s also insurance called occurrence-based coverage. And in that scenario, tail insurance is not needed at all. It’s about a third more expensive than claims-made, but you won’t have to pay for tail insurance in that scenario.
Now, you probably need to think about dozens of other things. I would say, in my mind, those are probably the foremost important. But you have benefits, bonus structure, contract length, other restrictive covenants with the non-solicitation agreement, non-disparagement, confidentiality, your hours worked, and the call. I mean, you need to think about a ton of things. So, I would suggest reaching out to someone with experience reviewing contracts. When you’re signing a contract that could be worth a million dollars, I think it would be foolish not to get it looked at by someone who knows what they’re doing.
Family Medicine Contract Negotiation Tips | Negotiate Physician Contracts
Negotiation tips for family medicine physicians who have a new employment contract. There are two scenarios. If you’re just coming out of training, the second would be if you’re an established physician in an area and you are either moving into a new practice in the area or potentially getting bought out by a larger practice or hospital network. The negotiation tips may be a little different for both, but I guess the general strategy is probably the same.
Contract Negotiation: Look at the Compensation
For anyone in family medicine who’s been offered an employment agreement, the first thing you need to look at is the compensation. If you’re entering a new area with no ties, you need to make certain there’s a guarantee for the first two years, which means that many organizations are now requiring productivity components either through RVUs or net collections.
So, suppose you immediately start a job and are on productivity from the beginning. In that case, you will make a significant amount less than you would if you were given an income guarantee just because it takes time to build a practice—usually, somewhere between 12 to 18 months for practice to reach maturity. If you’re just paid, let’s just say on net collections. If the average accounts receivable cycle for a claim is 30 to 90 days, you could be working for a month before you see a dime of that. You need to ensure an income guarantee for the first two years. Then if it does shift into maybe just RVU based, or as I said before, just net collections-based, you’ll be able to gauge your compensation.
And they’ll usually use the second-year data to indicate what you’ll make in years three and beyond. You need to identify the compensation structure and then ensure that you’re guaranteed for the first two years.
Finding out what is kind of going rate in the area is beneficial. MGMA data is what I generally use. It’s not the be-all and end-all, meaning the numbers are helpful to know what’s the median salary for a family medicine physician in the south or the east or the west or hospital-owned versus private practice, but it can still vary greatly.
Contract Negotiation Tactics Beyond Compensation
The benefits matter, malpractice insurance, and the restrictive covenants like the non-compete all those factors can determine whether a job is good or not. And so, just basing it off one number is kind of shortsighted. I find it very helpful to talk to your classmates, especially if you’re just coming out of training, seeing what they’re making or what they’re being offered from their jobs. If you’re established, it’s kind of, I wouldn’t say, unprofessional, but most people aren’t willing to talk about how much they make after you’ve been out for a long time. So, that probably won’t be as effective, but you also know your value.
If you’ve been out for a while and you know how much you make like, I generate this many RVUs per year. These are my net collections. That kind of data is very helpful. Don’t be afraid to ask for more. Now, it has to be a reasonable amount. If you’re being offered 200 and you ask for 400, and it’s a family medicine physician, they will laugh you off. Small jumps are kind of, I think, almost expected on the employer’s side.
And then you also must think about bonuses like signing bonuses and relocation assistance. These are also things that should be in the contract as well. The signing bonuses vary wildly from, I guess, based upon geography. If you’re going into a city or an area that’s hard to recruit to, it’s more rural. It’s not as desirable for the general population, you’re simply going to make more money and get a higher bonus.
Moving into a Big City vs. Rural Areas
If you’re moving into a big city or there’s a lot of competition because people want to live there, the salaries will be depressed. I know it’s counterintuitive when you’re like, well, if I’m moving into a more expensive area, the salary will reflect the cost of living. It’s not. It doesn’t because, for instance, I live in Scottsdale. People want to live here, and when you have 50 candidates applying for one position versus a rural town in South Dakota where there are two, there’s less leverage for the physician to negotiate a higher salary. So, don’t be surprised if you’re looking into a bigger city where the salary is just not going to reflect the cost of living compared to other places.
Negotiation Skills: Talk to Your Classmates
But once again, set up a meeting, talk to your classmates, and see what they offer you. There are some programs if you’re moving into a hospital network that can also offer student loan assistance. You’re not going to get that from private practice. They won’t offer you student loan assistance if they’re in private practice. So, if it’s important to you, you need to look in more rural and with networks and they may have that opportunity. Some states also offer that as well. If you work in certain healthcare shortage areas, that might also be something you investigate.
Negotiating the Type of Malpractice Insurance
The next thing to look at is what type of malpractice insurance they offer. Is it occurrence-based, or claims made? Or I guess if you’re with a hospital network, they could be self-insured. If you have a claims-made policy, which is more for private practice, you need to look at who must pay for tail insurance. Tail insurance is generally about twice what your annual premium is. For family practice, usually somewhere between 6,000 to 8,000 annual premium. So, your tail cost would be somewhere between 12,000 to 16,000. That’s a one-time payment, but that’s one thing you don’t want to look at. You can certainly negotiate for the employer to pay for tail insurance. Or, if it’s an occurrence-based policy, you don’t need tail insurance.
An Important Thing to Know: Non-compete Clause
Another thing you want to think about and attempt to negotiate is non-compete. These vary wildly as well. Normally, one year is the maximum length we’d want for a non-compete. And then really, depending on the area, it could be anywhere from 5 to 30 miles. Two things you want to think about as far as that and trying to negotiate: one, you want the specialty as specific as possible. What I mean by that is that some family medicine physicians can do multiple things. They could do urgent care. They could do primary practice. Some could be a hospitalist or whatever.
If you have a job, you want it narrowly tailored to that job. Let’s just say you have a non-compete where you can’t be in family medicine and private practice for a year within 15 miles of your location. Well, if it’s just like, you cannot move under any circumstances and you must stay in that area, well, you want the specific specialty that you’re in for that employer to say that it’s just family practice in private practice in that area. And therefore, you could just do urgent care, be a hospitalist or whatever for the year, and then move back into private practice if you want.
You also want to limit the number of locations. Is it just your primary location, or if you’re working in multiple locations, is it the non-compete attached to each of those locations, or if they’re a bigger corporation or health network? They have facilities throughout the city. Is it 10 miles from everything that they own? You want to narrow that to just your primary practice location, or maybe if you’re splitting your time, but you’d want to completely avoid non-competes that state it applies to everything the employer owns.
Do You Have to Repay Anything?
And then the last thing to think about, do you have to repay anything if you terminate the agreement? If you’re given a signing bonus, relocation assistance, or student loan assistance if you don’t stay for a certain period and were to terminate the contract without cause, you would have to pay back some of those things. Some things to negotiate would be, for instance, let’s say you had a $30,000 signing bonus and a three-year initial term, you want to make sure it’s forgiven either, I mean, monthly would be the best. So, 1/36 forgiveness, meaning, for every month that you’re there, 1/36 of the signing bonus is forgiven. And so, if you stay for three years, you don’t have to pay anything back.
Now, some places will try to do it yearly. And in that scenario, let’s say you’re in year three, and you terminate the contract in the middle of the year. Well, if it’s yearly forgiveness, you just gave up six or seven months of forgiveness, and then you must pay back $10,000 instead of maybe four or five. Honestly, there are a million things you can negotiate in a contract. I was just trying to hit the highlights and the things that are usually most important to family medicine physicians.
What is a Non-Compete for a Physician?
What is a non-compete in a physician contract? Of all the things in a contract, besides compensation, this is probably the area I discuss the most with the physicians I’m reviewing their contracts. It can have enormous ramifications on a professional’s career depending upon several factors that we’ll get into. Let’s do some basics as far as non-competes go. In most physician contracts, there’ll be restrictive covenants. Restrictive covenants are things that the physician can’t do when the employment contract ends. Standard restrictive covenants would be a non-disparagement clause. You can’t badmouth the employer in some way. In the non-solicitation clause, you would be prohibited from actively soliciting patients, employees, other physicians, independent contractors, and business vendors from the employer. And then there would also be a non-compete.
What Does Non-compete Prohibit Health Care Providers From?
The non-compete essentially prohibits the physician from working within a specialty for a period in a certain geographic area. Let’s get into the details of that. First, in every contract, in the non-compete, there will be a section that details what the physician can’t do, meaning, let’s say, it’s an internal medicine physician working as a hospitalist. The non-compete would state that the physician can’t work as a hospitalist for some time within the specific area. One thing to consider here is if you are in a specialty where you can do different things, let’s take the internal medicine physician as an example. They could do primary care, they could do urgent care, they could do ED, and they could be a hospitalist.
If the non-compete says you can’t practice medicine within that area, that can pose problems if the physician needs to be in that area. So, you want to ensure that it explicitly states your specialty for the employer. If you’re a hospitalist, it just needs to say, the physician can’t work as a hospitalist within that area, within that time, not the practice of medicine. For many physicians who can do multiple things, an easy way around the non-compete, although maybe not a perfect scenario, could for a year do something else. And then, after that year, they return and work within their desired specialty. That’s the first thing. What does it entail? Is it the complete practice of medicine, or is it just in your specialty? It should be just in your specialty.
How Long Is the Non-compete?
Next, how long is the non-compete? Well, most non-competes are in a year. Many employers will stretch it out to two years. I don’t think anything above two years would be enforceable anywhere. If you are a physician, you do not want a non-compete longer than one year. It’s just a fair amount of time. I think, no, this is state-specific, right? I’m giving you a broad outline of this. I can’t go through all the states in this video, but most courts have held that one year is the limit that they would consider a reasonable non-compete length. If you have a non-compete, you want to limit it to at least one year, nothing beyond that.
Geographic Restrictions of a Non-Compete
And then the geographic restriction. This is probably the most important one. Once again, generally, anywhere between 5 to 15 miles would be considered a reasonable non-compete. Now, in some states, they’ll push it for whatever reason. The Midwest states seem to put more than that. So, 20 miles is not uncommon. It would be best if you also thought about where your location. Twenty miles in a rural location that completely knocks you out of a city is certainly a lot different than 20 miles in a big metropolitan area which can knock out many potential opportunities.
Maybe you’re a cardiologist in a small town in a smaller state, and it says 20 miles from your office. Well, there may not be another office you could even get into within those 20 miles, so that doesn’t matter. Let’s say you’re in Phoenix, where I am, and 20 miles here could potentially knock out hundreds, thousands of jobs. So, you would like to limit it to a small geographic restriction. I’ve seen so many variations. It could be by county. In the south, they seem to use counties more than just mileage; typically, it’s as the crow flies. If it says you can’t practice within your specialty for one year within 10 miles of the office, it’s not a Google map road of 10 miles. It is as the crow flies. So, stick a pin in it, 10 miles around that. That’s how it’s calculated.
Non-Compete Matters to Most Health Care Providers
For many people, a non-compete might be the most important thing in a contract. On some others, it might not matter. For physicians who are in a city that they don’t have any ties to, they’re just there for the job. They don’t care if they’re there after the fact, then we would spend more capital on getting different things changed in the agreement. Maybe the compensation or providing tail insurance or something like that. But if you are a physician who is either moving to an area to be near a family, or maybe you have a family yourself, and you don’t want to pull your kids out of school and move them across the country. Well, then the non-compete could be the absolute most important thing.
How Negotiable Are Non-competes?
If you’re with a private physician practice, I find much more leeway in negotiating the non-compete. Many larger hospitals and healthcare networks may say, take it or leave it. We’re not going to negotiate. I also find that some of those big hospitals change their non-competes frequently. We have a huge healthcare network where I live, and I think every year, it fluctuates between different mileage and whether you can join a private practice, and that’s exempted just kind of goes back and forth. You certainly have leverage in getting that changed in some instances, but honestly, I wish I had a better answer for you, but in some cases, it’s going to be a take-it-or-leave-it offer.
So, you need to think about, alright, what’s the most important to me? And then you always have to get to the point where once again, if you have to stay in a community, you won’t have any options to practice there under the terms of the non-compete, then you have to figure out a way to move on. Some jobs are not worth it. And if you accept a job, you’re accepting the non-compete, they are enforceable, and nearly there are only a few states where it’s not enforceable. When you sign that agreement, you need to understand that that non-compete will likely be enforced if necessary, and whatever terms you agree to are the terms that will hold.
Non-Compete Negotiation Tips
Lastly, if you are negotiating a non-compete, you may offer some concessions in other areas. For instance, with the non-solicit, it may say you cannot attempt to solicit patients, employees, whatever. Well, you could say, for example, I agree not to hire, not just solicit. I will not hire any employees or any other physicians or independent contractors. That way, you’re less of a threat. If you’re like a primary care type specialty, you will open a new office. The biggest concern of any employer is they bring a physician in, leave, then take all patients and employees, and that old employer is stuck. Maybe giving somewhere else might be worth the employer agreeing to amend the non-compete in some way. So, those are the basics of a physician’s non-compete.
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