How to Get Locums Work Without a Locums Agency

By Dr. Margaret Curtis, WCI Columnist

This year, my husband and I are both going to do some temporary medical work in addition to our long-term employment. I am going to provide three weeks of pediatric coverage at the Southeast Alaska Regional Health Consortium (SEARHC) in Juneau in September 2023. I’ve always wanted to work in Alaska, and since my kids will be out of the house this fall, the timing was perfect (also, running away to Alaska seemed like the perfect solution to my empty-nest sadness).

Mike wanted a job that would help us transition back to living in Vermont, and since May, he has been one of a group of urologists covering a small hospital about a half-hour from our house. This allows him to continue to work at the VA in Maine, and it may turn into a permanent position in the future.

Neither of us used a locums agency to find these jobs. The internet’s greatest achievement is, of course, Boaty McBoatface, but it also affords us the ability to create per diem locum tenens positions without an agency. You can choose a location, find an employer, and negotiate all the terms of your employment—including dates, pay, housing, etc.—just as an agency would.

Locums agencies can make the process of finding temporary work quick and relatively painless. They have a menu of open positions all over the US, and they assist with application, licensure, and credentialing. They provide medical malpractice insurance, and they assist with transportation, housing (either paid for or provided by the employer), and any issues that might come up during your stint. These agencies offer tremendous convenience.

This convenience comes at a price. Locums agencies are paid handsomely for the convenience they offer. They charge employers as much as 50% more than they pay the physician and keep the difference. These numbers won’t be known to you when you sign on. Agencies will generally start with a low salary offer and hope you will bite, because the less they pay you, the more they get to keep.

I was once cold-called by a locums rep about a job about six hours away from where I live. She told me the salary was $90 per hour. I told her that was unacceptably low for an experienced physician, and she countered with, “Um, $100?” I said no, thank you, and wished her well in her search. If you contract directly with a hospital, the hospital saves money because it’s not paying an inflated price, and you get paid more because no one else takes a cut.

Everyone is happy, except maybe the locums agency.

You will actually have more choices in location than you might with an agency. My new employer in Alaska does not use locums agencies and relies on word-of-mouth recommendations. Your new employer will benefit from having you as a per diem because you offer better value than an agency hire: you cost less, and you can offer consistency and a stable relationship. The other physicians and healthcare providers can get to know you and trust you with their patients. Community hospitals especially need specialist coverage but often can’t afford a full-time physician hire. Reliable, quality part-time physician care is incredibly valuable.

You can even take it one step further, as Mike and his colleague did, and form a small group to share duties. They function like any specialty group and maintain control over their staffing and schedules. They call themselves “The Stream Team.” And if you want to learn how to create your own temporary position, urine luck! No need to get testy or become prostate with fear: just follow these steps.

#1 Find a Temporary Gig

Once you have signed a contract with a locums agency, you can’t go around them and contract with the employer directly without the agency being involved and getting paid. There are people (not me, so don’t come at me in the comments) who check locums listings; ask a few questions like, “How far from the nearest big city?”; and figure out which hospital the agency is representing. They then contact that hospital on their own. There are also other ways to find short-term gigs:

1. Your specialty society website: Most of the jobs listed are permanent, although there are some that are temporary. You can call employers who are advertising permanent positions and see if they want some fill-in help while they go through the hiring process, especially if you have a license in their state and can start right away.
2. Online job listings: A Google search will bring you to a listing of jobs across websites, including sites like NEJM and Doximity. Some of these listings are from physician recruiters and some are on general job sites like ZipRecruiter. You can browse and request more information. Be aware that if you create an account with a recruiter, you will get flooded with emails from employers across the country.
3. Cold-calling: Locums agencies came into being before the internet, when there was no easy way for employers and employees to find each other. Nowadays, there is no reason you can’t identify somewhere you want to go, call the nearest hospital(s), and tell the physician recruiter you are interested in fill-in work. The worst that happens is they keep your contact information on file. The best that happens is they ask you to submit an application ASAP.
4. Your network: This is what we did. My job came to me through a friend of a friend, a pediatrician in Juneau who likes to leave for 3-4 weeks at a time—usually around the time the rain starts coming down sideways. Mike met his now-colleague, Dr. Amichai Kilchevsky, through a mutual friend. They started talking about creating an independent group of urologists who could provide coverage to rural hospitals, and they then approached a hospital that they knew (through some weird sixth sense that urologists have) needed urology services. The best part of getting a job this way is you can get reliable information on the potential employer from people you trust.

If you need me anytime soon, this is where I’ll be.

More information here:

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Negotiate Salary and Benefits

Next, determine whether you will be employed (W-2) or an independent contractor (1099). Your new employer may have a preference. SEARHC only takes per diem docs as W-2 employees. My husband’s new gig started as W-2 although they will likely transition to independent contractors in the future. There are advantages to both:

• As a W-2 employee, you can be covered by your employer’s malpractice and you may be eligible for some benefits. I can contribute to retirement accounts via SEARHC, although I don’t get a match. SEARHC takes care of tax withholding and pays the employer’s share of payroll taxes (6.2% for Social Security and 1.45% for Medicare in 2023).
• As a 1099 employee, you will probably have to purchase your own malpractice insurance, and you will have to pay the entire payroll tax (12.4% and 2.9%). The upside is that you can establish a SEP-IRA and contribute up to 25% of your self-employed compensation (net, after deducting the payroll tax). If you are considering per diem work as an addition to your regular W-2 job and have maxed out your employer retirement plans, this can be a powerful addition to your retirement savings.

Find pay range and typical schedules for your specialty (which will be different from MGMA averages, which are for permanent positions). Remember, these are salaries for physicians hired through locums agencies; since you will be doing the legwork on your own, you can reasonably ask for a higher salary. Look up what locums agencies are offering for a geographic area and add 50%, and you will be in the ballpark. You can also ask for: license fees, travel, food/lodging, and car rental. As in any negotiation, you won’t get everything you ask for, so make a list of what you need and what you want, in order of importance.

I was hired at $140 per hour, and I will be covered by my employer’s malpractice insurance. I also have the option of taking peds call at the local hospital for $500 per night. My license fee and travel were paid by SEARHC. I will have use of a car during my time, and I was offered employee housing but will stay with my friend instead (much more fun). Overall I will earn about 25% more than I did at my old job, even without taking call (and if these numbers look mighty small to you, you are not a pediatrician. Also my last job was lousy).

Mike’s group negotiated a fee schedule that is broken down by: clinic/OR day ($3,000), weeknight call ($500 from 5pm-7am), Friday night call ($1,500), and weekend call ($2,500 for each 24-hour period). They are covered under the hospital’s medical malpractice insurance, and Mike already had a Vermont license.

A word of advice: if you are negotiating to cover call for a busy service, ask for a “call-back” hourly rate to be paid if you are called into the hospital rather than a flat fee. To quote Dr. Kilchevsky of the Stream Team:

“I find that hospitals (especially the larger ones) don’t mind paying this additional rate because a busier doctor means more revenue (usually). This also protects the doctor from working at a discounted rate. Making $2,500 in 24 hours sounds great until you find yourself putting up that eighth stent of the day . . . but at $200-$400 an hour, that eighth stent may have just made you an extra $2,500. It’s a double-edged sword, but ultimately you are hedging your call pay against your sanity. That being said, I would strongly advise against a locum doc accepting a percentage of what they bill . . . this can take months to collect and is never as good as a lump sum hourly rate (been there, done that).”

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Apply for a State Medical License

If you are in a large market like California or New York City, you may not need to get any additional licenses—just check your non-compete(s) from previous employers to make sure you are in the clear. For any out-of-state gigs, you will need a new license.

First, you will likely need a Federation Credentials Verification Service (FCVS) account. FCVS is a service of the Federation of State Medical Boards and is a permanent online repository of credentials like diplomas, board scores, etc. Setting one up takes some effort and it’s not cheap (more on that below), but the majority of states allow you to submit documentation via FCVS and some require it. So, you might as well. FCVS isn’t cheap: $395 for the initial account, then $99 each time you ask that your profile be sent to a state medical board. If you request more than one profile at a time, it’s $99 for the first one and $65 for each additional one.

Even if you use FCVS, you will probably have to provide additional (and often duplicative) documentation to the individual state medical board and once again when you are credentialling and applying for insurance approval. I underestimated the time and hassle involved in applying for my Alaska license and credentials. This was largely my fault, because I hadn’t updated my FCVS profile in a while (also because I didn’t read the instructions carefully, but that’s a different story). Really organized people probably update their FCVS profile every time they get a new credential. I’m not that organized so I’ve uploaded my documents three times: when I graduated from medical school, when I finished residency, and the week before I wrote this column.

Some of the time involved was the fault of the state of Alaska for requiring a great deal of documentation. For example, my FCVS profile includes a copy of my medical school diploma. The Alaska Board of Medicine also required me to take a photocopy plus my actual diploma to a notary who could verify that they were identical, and then it still wanted to hear directly from my med school. People of Alaska, why so suspicious?

Now that I’ve gone through the process of getting the first license, any subsequent ones will be much easier. My FCVS profile is up to date, and I’ve got all my documentation ready to go. If you think you will look for locums work on your own or if you just think you might change jobs someday, I recommend you keep the following documents on file (hard copies or digital, your choice).

Copies of:

• Medical school diploma
• Certificate(s) of completion of residency and fellowship(s)
• Board scores
• State medical license(s)
• Specialty board certification or “in good standing” letters
• Any current certifications specific to your field (ACLS, BLS, NRP, etc.)
• ECFMG and J-1 visa status, if applicable

For each job you’ve had:

• Certificate of liability insurance that shows dates, per-claim, and total coverage
• Verification of credentials
• Procedure log

You can get all of these from your medical staff office.

You will also need:

• Names and contact info for anyone who might serve as a reference
• Record of vaccines and titers (from employee health and your PCP)

Once you have your documentation in order, there are multiple ways to apply for a state medical license:

1. The state’s online application portal: You use FCVS (if allowed) and then provide some additional documentation. Your application then goes through the usual administrative review. That’s it. It’s not even as hard as doing your own taxes. Each state has its own licensure fee which ranges from $75 in Missouri to $863 in California (Nevada has waived initial application fees for osteopaths in fiscal year 2022-23, so if you are a DO who loves the high desert, you are in luck). Be prepared for the process to take weeks (or more) after your application is complete.
2. The Interstate Medical Licensure Compact: The IMLC is a group of 15 states, plus Washington DC and Guam, that expedite licensure for licensed physicians in good standing who live in another member state as long as they meet certain criteria. Once approved by your home state, you are issued a “Letter of Qualification” (LOQ), and you can request a license from any state within the compact. Each state may request additional information to ensure you meet their qualifications. The IMLC says you can get a license in just a few days. Overall, the process is more streamlined but also more expensive than applying to each state individually. The initial fee for the IMLC is $700. You can apply to as many states as you want, but you still have to pay each individual state’s licensing fees. You can request additional licenses for one year after you receive your initial LOQ for an additional $100 per request (regardless of how many states) plus the state fees. The smart move here is to request as many licenses as you need and can justify paying for right up front with the initial LOQ.
3. The Uniform Application: The UA is a service offered by the FSMB, the same people who brought you FCVS. They are separate programs, but completing the UA is much simpler if you have an FCVS account; if you don’t, you will have to upload all the info yourself. The UA is accepted by multiple state boards and required by a few. The UA has a one-time fee of $60.
4. Medical license companies: You can pay someone $750 plus state fees to do what I just described and get you your medical license. Since you will still have to corral all your documents to hand over, you aren’t saving yourself that much work. In fact, if you want to pay me $740, I will fill out your license application for you.

Because I love a spreadsheet, here is all this information put in table form for you:

Of course, these are just the initial application fees. Renewing licenses is an ongoing expense. If your employer won’t reimburse these expenses, you can deduct them from your taxes as a business expense.

You will also need to credential and get insurance company approval, which your new employer’s med staff office will walk you through. You will need a new DEA license for each new state you work in. If you have only one job at a time, you can simply transfer your current DEA number to each successive employer: you can do this on the DEA website, and it might take a few weeks to go through. If you have overlapping jobs, you will need separate DEA numbers for each. Each DEA license is $888, so it’s not exactly cheap. I didn’t have to pay for mine because SEARHC is a subsidiary of Alaska Native Health, which qualifies for free DEA licenses. The same is true for federal agencies like the VA or IHS.

More information here:

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Malpractice Insurance

You will need this, obviously. If you go the independent contractor route, you can get your own insurance through a broker (remember to get occurrence or claims made with a tail) and include the cost in your negotiations.

Out of office.

There you have it, a field guide to creating your own temporary position. You might think that all this is way too much work and that using a locums agency is the way to go. No judgment from me—if you have limited time and are happy with the opportunities an agency provides, that makes perfect sense. Or you might decide that creating your own temporary position is just the ticket. You might take out a map and start looking for your next adventure. Maybe it will be down the street, or maybe it will be in Alaska. Wherever it is, I hope you find a job like the Stream Team that lets you pee all you can pee.

Have you ever forgone using a locums agency to get a locums job? What was your experience like? Would you do it again? Comment below!