Jan 15, 2007 By: Anne Baye Ericksen LocumLife

Ben Lockmiller, CRNA, has been practicing as a certified registered nurse anesthetist for more than 2 years. While maintaining a permanent position found through a mobile opportunity, he continues to supplement his income with local locum tenens contracts via Easter Anesthesia Staffing Inc., based in Austin, Texas.

Ben Lockmiller (BL): My ability to adapt as a practitioner has increased tremendously since accepting temporary opportunities. As a CRNA, I need to learn new policies and procedures, locate the equipment and supplies, and get to know the surgeons at each location. Figuring that out makes me a more well-rounded clinician. I am conscious of everything, and that, in turn, makes me better at what I do.

Pedro Siazon, MD, has been practicing psychiatry for 26 years. This retired Army physician began his locum tenens career in 2002 with Alpharetta, Georgia-based Jackson & Coker. Currently, he is on contract on the East Coast.

Pedro Siazon (PS): I like the flexibility locum tenens provides. Moreover, I appreciate that you can pack up and go when it fits your schedule.

Laura Siazon (LS): Our colleagues are very professional and the patient load—12 to 15 per day—is not too heavy. Being able to practice Monday through Friday, 9:00 a.m. to 5:00 p.m. is a definite benefit.

BL: There are many positives to locum tenens. In particular, I have enjoyed observing how anesthesia is practiced in diverse settings across the country.

TH: In terms of benefit to client organizations, locum tenens physicians and non-physician providers fill immediate needs. Sometimes, they are called in for emergency coverage because a permanent staff member is out due to illness or vacation. There are also situations in which clients are looking for permanent replacements and they rely on mobile professionals until staff physicians can be found. In these cases, contingent staffing is invaluable because the practices can keep functioning. In fact, there are many hospitals that cannot operate without a radiologist on duty, depending on the institutions' bylaws. Today, there are very few hospitals that do not provide 24/7 radiology services.

TD: For clients, a locum tenens physician may have skills or areas of expertise that the organization (particularly if it is a solo practice) may not regularly offer its patients. When a practitioner comes in with additional skills, the office can keep those services in-house instead of shipping the revenue out to another provider.

Plus, from a management standpoint, mobile providers lessen some of the burden of the existing staff. The additional personnel can increase the number of patients seen in a day and can elevate the profitability of the practice.

3. What should locum tenens professionals expect from their staffing firms?

TD: To begin with, staffing company representatives should be able to answer a number of pertinent questions, including: How long has the firm been in business? What specialties are represented? What do some of their typical practice opportunities look like? Do they represent group or solo practices? Small or large acute care facilities? Are opportunities regional or national? What about commercial or government contracts? Providers also need to ask about malpractice coverage. Do the agencies pay for medical liability insurance? What are their carriers' ratings?

TH: Medical professionals should expect regular pay, malpractice coverage, and some type of assistance with credentialing. Travel arrangements and lodging are likely taken care of by the staffing firm as well. Providers ought to make sure that they receive written confirmation of the contract and compensation.

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TD: Staffing representatives also should encourage candidates to speak with other physicians or non-physician providers at potential client facilities for a realistic look at the communities and at patient acuity levels—before they accept opportunities—so they can ensure a better fit.

PS: When it comes to selecting staffing companies, the best thing to do is to talk to other locum tenens physicians in your specialty who have provided services in similar settings. Ask if they were disappointed with any aspects of the experience and specifics on what they liked about the relationship.

BL: I could arrange my own opportunities, but it is easier to go through a staffing agency. With independent contracts, I would have to handle all the details, such as credentialing and securing malpractice coverage. Personally, I feel that would be a headache.

TH: It does take a lot more effort for physicians and non-physician providers to find opportunities on their own. They not only have to discover the position, but also negotiate the rates, make the housing and travel arrangements, and provide their own credentialing. It is more convenient to let an agency represent them.

Also, it is becoming less and less common for individuals to arrange their own contracts typically because the malpractice premiums make it cost-prohibitive. Some carriers will not even cover a provider if the position is contracted independently, or individuals can be charged an additional premium.

4. What steps help ensure a smooth credentialing process?

TD: Finding candidates for opportunities and getting them credentialed to practice at the contract facility can be equally challenging. The key is how quickly can we get them through the credentialing process. We need to confirm physicians and non-physician providers' licenses and references. In addition, we require proof of residency training, internships, medical schools, work history, and so forth.

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If professionals want to travel to states that take longer to complete the licensing process—in some cases, 9 to 12 months—they should make their wishes known to recruiters at the earliest possible point. Physicians need to keep in mind that no two clients are alike when it comes to credentialing requirements. Some outpatient, primary, or urgent care centers may not require hospital privileging, while others might insist on extensive checks. Furthermore, private hospitals often demand primary source verification, which can also delay the process.

BL: Going through the credentialing process with each new facility can become an ordeal. This is where the staffing agency can really help because representatives keep all of my information on file. I actually spend only a couple of hours on credentialing by updating my details and making sure everything is correct.

TH: Locum tenens physicians and non-physician providers must give their staffing representatives documents that verify their education, training, experience, references, and malpractice insurance. They should be able to provide any documentation of current and historical malpractice cases. It is their responsibility to keep their curricula vitae (CVs) and their hospital affiliations current. And, depending on their specialties or disciplines, they should maintain an ongoing list of continuing medical education (CMEs) or continuing nursing education (CNE) credits. For example, if you read mammographies, you must have a mammography log available.

LS: As we earn CMEs, we submit that information to our agency so they have our most current data.

PS: We write a formal letter to the facility's medical board and update our locum tenens company with our information and they present it. Later, the director of the medical center will send me a certified letter of acceptance.

5. How do government and commercial contracts differ?

TD: From the physicians' standpoint, I do not know if there is a tremendous difference. What we see is more paperwork. It may take physicians time to figure out some of the processes within the federal system, but ultimately they are providing similar services in both contexts.

In terms of credentialing, federally run facilities almost always require primary source verification. It is very detailed and good information—there is little chance that it will be inaccurate—but this can take several months, and considering the speed at which facilities need physicians, the requirements often create a backlog. Therefore, if physicians or non-physician providers are interested in accepting government contracts, they should allow for this possibility and begin the credentialing process as early as possible.

TH: Also, any agency presenting physicians for government contracts needs to make sure the professionals are available for a minimum 90-day block. In exchange, doctors are guaranteed 3-month opportunities with the option to extend, plus they become networked. Once medical providers have practiced in a VA facility, for instance, they have the ability to accept opportunities at similar institutions. The VA only requires one active license. Some branches of the military, however, require state-specific licenses for locum tenens physicians, and there is a more extensive application process often tied to security clearance.

TD: Locum tenens opportunities at military bases have grown recently because of the number of physicians who have been called back into active duty. Government facilities may see an increase in contracts for psychiatric services when more military personnel return and cases of post-traumatic stress disorder rise.

6How are transportation and housing handled during contracts?

TH: Since most locum tenens providers do not have time to spend looking for flights and hotels, they can give their staffing representatives a travel profile, listing their airline and housing preferences. Plus, they can still use their frequent flyer miles or preferred cards at hotels.

TD: The majority of larger agencies have agreements with car rental companies so people have transportation while on contract. Additionally, some staffing organizations assign travel representatives to coordinate with doctors or to handle any situations that may come up.

Housing generally is determined by the contract length. For example, if the opportunity is for 2 weeks or less, locum tenens practitioners probably will stay at a hotel or an extended-stay suite. With longer-term contracts, it is more cost-effective for the agency to set up an apartment, although in some areas, it may be difficult to find a lease for fewer than 90 days.

PS: We have liked the apartments our company has secured for us. Our most recent complex has a swimming pool and fitness room. It is situated in a convenient location with a golf course across the street and plenty of shopping available nearby.

LS: Knowing that our recruiters can assist us with any special transportation requests or apartment preferences gives me peace of mind. They are very dependable and accommodating. Should there be a problem with our living arrangements, they immediately contact the complex's superintendent to get it resolved.

7. When it comes to contracts, what are some of the key points to consider?

TD: There is a lot of standard verbiage within contracts. Some agreements are more favorable for agencies and others benefit the healthcare professionals. It is imperative that physicians and non-physician providers read the fine print carefully so they are aware of what is expected of them and what they can expect while on location.

TH: Clinicians should pay particular attention to whether or not a staffing agency has carte blanche authority to present their information to any opportunity with or without their permission. Everyone should review each contract before signing. It cannot be emphasized enough that physicians and non-physician providers need to read everything carefully and ask questions if they want any clarifications or corrections. The document should name the specific practice environment as well as the dates and times of the contract and shifts. It should disclose the compensation, whether it is a daily or hourly rate. And, the agreement should state rates for additional hours and on-call responsibilities, if applicable. Finally, the contract should also contain the names of the person to whom the locum tenens provider reports at the facility or practice, as well as the agency contact.

Another important point to consider is the cancellation clause. Can an opportunity be cancelled for no reason or is notification required? The industry standard is 30 days, from the signing of the contract.

TD: Many of the firms require a "30-Day Out Clause." If a physician is planning to start on January 1, for example, and the client calls on December 15 to cancel, that client must still pay for the remaining 15 days. While cancellations are very rare, the majority of agencies include this type of "out" clause, which applies to both clients and locum tenens professionals. We do not want a clinician committing to several months of coverage only to be told that a permanent replacement has been found only a few days after the opportunity starts. It is not fair to physicians to have positions pulled without notice, and the same applies to clients. If a doctor must leave, administrators have to be able to plan for the departure. Generally, the staffing agency will do its best to find another candidate to fill the position.

TH: Also, there are usually 2-year non-compete clauses, barring physicians and non-physician providers from competing directly with an agency for a permanent or locum tenens agreement once they have been at a location for a period of time. There may be restrictions prohibiting practitioners from accepting contracts with other agencies as well. For instance, if a clinician is told about an opportunity—whether it is accepted or not—and the same contract comes up later, the provider can only sign on with the agency that introduced it.

Since it is not unusual for professionals to register with more than one company, it may be difficult to keep track of whom they speak with and where their CVs have been presented. We recommend that clinicians be very diligent in recording their discussions and documentation. If they select agencies that are members of the National Association of Locum Tenens Organizations, professionals can be assured that their confidentiality is protected and companies will work with each other to resolve any conflicts that may arise.

8. How is compensation handled during a mobile contract?

TD: Professionals should inquire about their agency's payment schedules—biweekly or weekly —prior to accepting a contract, and the need for direct deposit services should also be discussed up front during contract negotiations.

LS: We turn in our timesheets to the medical director's office on a weekly basis. Staff there sends them to our locum tenens company, whose representatives charge the medical center.

TH: While compensation is based on the time submitted, clinicians should find out in advance whether their pay is contingent on an agency's payment. Does the client have to pay the staffing company before the professionals receive their checks?

Also, since locum tenens physicians are independent contractors and receive 1099 tax forms, there are specific federal guidelines regarding what they can and cannot do. These providers should research the rules carefully and seek advice from tax experts. Something as simple as the staffing company paying a license renewal fee in advance may be construed as a change in status from independent contractor to employee.

BL: Because I am a 1099 independent contractor, I sought out tax advice from my staffing agency, a CPA, financial advisor, and lawyer. They all helped me come up with tax and retirement strategies.

9. Is orientation provided by most facilities?

BL: I receive orientation about 10% of the time. Usually, it involves a tour so staff members can show you where they keep the supplies, like epidural carts or airway equipment, and where the different operating rooms and departments are located in the facility.

TH: Typically, a contract begins with some sort of orientation, from getting a badge to training on the computer system. Since locum tenens clinicians are at a facility or practice for a short period of time, the program will not be similar to that received by full-time employees. Rather, it will most likely be specific to the procedures or protocols of the department where the professional will provide temporary services. Clients expect locum tenens practitioners to learn the systems pretty quickly. Physicians and non-physician providers often begin practicing by noon on their first day.

TD: As a company, we do not demand that orientation be offered by clients. Some physicians request it and others do not. Often, it comes down to whatever the client and physician can work out. This is another item that can be discussed with recruiters prior to accepting an opportunity. When provided, most orientations include a tour of the hospital or clinic and an explanation of the files and the computer system. Generally, the government does require physicians to go through an orientation. For VA hospitals, that usually lasts about a couple of hours.

10. What are the keys to a successful locum tenens career?

TH: Try to be open-minded and flexible. Remember, communication and interpersonal skills go a long way when you are in an unfamiliar setting. It is critical that locum tenens clinicians, especially those new to a facility or a staffing agency, communicate problems as soon as they arise.

TD: Flexibility and a willingness to try new things are essential. If physicians and other professionals are hidebound about where and how they practice, if they are dependent on routine, then locum tenens may not be the right choice. It also helps to go into a contract as informed about it as possible. In addition to speaking with fellow clinicians at the contract facility in advance, I recommend professionals arrive a few days early so they can acclimate to their new surroundings and find the best route from their apartment to the practice environment. Remember that locum tenens is serious medicine, not a vacation, but there is no reason why professionals cannot enjoy the variety and stimulation of new settings.

BL: Since I usually accept 1-week contracts, I try to arrive in the community a day or so before I am scheduled to begin providing services. I introduce myself to staff, request a tour of the facility, and find out whom I should contact if I have any questions. On my first day, I make a point to arrive early so I can get a head start on filling out the paperwork.

To be successful in changing practice environments, you need to have strong clinical skills and enjoy autonomy—because you never know how much help you will have. Since each facility has different protocols and procedures, you also need to be willing to learn new techniques and accept alternative ways of reaching the same goals.

PS: Some key attributes include patience and professionalism. When encountering new sets of patients and staff members, always be professional and express a lot of empathy. You likely will find locum tenens to be a great learning experience.

LS: You have to be dependable and maintain good relationships with patients and staff. Taking the time to relate to them and providing for their needs as best as possible during your stay is very rewarding.

LEARNING AS YOU GO

Chances are, as you accumulate locum tenens experiences, you will learn something in every setting. You also will develop your own system of how to adapt to new environments and deal with the challenges of each new opportunity. Hopefully the 10 issues addressed here have prompted you to think about joining the ranks of locum tenens practitioners, or provided impetus for ensuring that your time spent on location is enjoyable and stress-free. Remember, for a mobile lifestyle that is both personally and professionally fulfilling, all you need is a little forethought and an open mind.