[Editor’s Note: Here’s another guest post I strong-armed the author into writing. He sent me a long email suggesting I write more about contract negotiation, and then described his recent experience. His email was basically a half-done guest post already. So I asked him to finish it up and send it over, which he did. I did a little editing and Voila- a great post. The writer wishes to remain anonymous, but we have no financial relationship. If you do need help with contract review, check out this page for WCI-vetted recommendations.]

Dear WCI,

I work in the tech field for an analytic company and my wife, who is a doctor about to finish her fellowship recently turned me onto WCI.  I started reading a lot of your blog posts and I just finished your book.  I have one very important blog topic suggestion for you: Contract Negotiations and Review.

When my wife was applying for places she received an offer from just about every place she applied (and she applied to a lot of places). However, some of the offers (and some offers made to some of her colleagues) were horrible. If you just looked at the salary, you might think you were making $750,000 per year, but if you don’t see the fine print where it says that you need to be COLLECTING (not just billing) more than that, then you get almost nothing.  So I decided to write a few tips that others in a similar situation might find useful.

Tip #1 Start Looking ASAP

My wife went to a fellowship and she started interviewing for positions 6 months before the start date (not the end date) of the fellowship.  She looked at a lot of places and she signed a contract fairly early into her fellowship.  This gave us confidence that if the fellowship didn’t work out the way we intended she could start her other job early, and she wouldn’t have to rush later on.  We are always making back up plans.

Tip #2 REALLY Understand How You Are Paid

This should seem obvious but it is very easy to see large dollar values in a contract and get star struck.  Avoid contracts where your salary is 100% based upon collections.  I have heard of one doctor who ended up making only $80,000 a year because of it.  In other job sectors we call it “commission.” I understand some doctors hate that word, but that is the word we call it in other industries.  Even if you are just expecting a productivity bonus, you should be asking a lot of questions.

Ask for some examples to be included in the contract.  Is the amount based on how much they bill for or how much they collect?  As someone who has worked in the debt collection industry, medical debt is one of the least collected upon forms of debt.  How much do they take out for overhead?  How do they collect their debt? (You may not get anything specifically useful out of this, but if you benefit from their ability to collect what they are owed, then you should be interested in how efficient they are at collections). How are you going to know how much they have collected? (Make sure they are transparent).  You should know everything they are going to take out and each time you see a patient you should know how much you are going to get paid.  Likewise you should understand exactly what is expected from you to get a non-productivity bonus, and for how much.  If they say that everyone gets one, then great…let’s just make it a guaranteed bonus in the contract.  A bird in the hand is worth two in the bush.

Also before you enter into contract negotiations, you should read about and understand Relative Value Units (RVUs).  It’s not something you would have to deal with in residency but may be very important when you become an attending.  Just like with knowing about how a productivity bonus will get calculated you may need to know how your salary is impacted by your RVUs.  How many RVUs do you get from a new patient?  How many RVUs do you get from an existing patient (follow ups)?  If you can find a friend who is in a similar field, you might want to ask them the same questions to see if the answers line up.

Tip #3 Get Everything In Writing

Are they going to provide money for licensing, travel reimbursement, Paid CME days, if so, how many?  Anything that you agree upon, make sure it is in writing in your employment contract.  If you don’t, then it may be very hard to get in the future.  Even if verbal contracts are valid in your state, and they PROMISED it to you, you should have an email proving it … The effort to try and get them to deliver it later on may be greater than you expected. Think of it like this…if it is not in writing it doesn’t exist.

Tip #4 Bonuses Aren’t Guaranteed

Always go into it assuming you won’t get your productivity bonus. Make sure your base salary by itself is adequate for your needs. No matter what they tell you verbally, I am very skeptical about anything that is not guaranteed. Even if you have done everything right and asked all the right questions, I am always amazed at the ability of a big company to find a way to not pay you what you think they owe you.  You don’t want to hear these words, “Sorry, you must have misunderstood how the productivity bonus worked.”

Tip #5 Make Sure They Provide Malpractice Insurance

Most hospitals provide malpractice insurance but what younger doctors don’t know is that there are several nuances to insurance. There are 2 types of insurance:

  • Occurrence Policy – This will cover you for an incident regardless of what policy you have when a claim is filed in court.
  • Claims-Made Policy – This is the most typical type of insurance and will not cover you if you are under a different policy at the time a claim is filed in court. If you have a claims-made policy and switch jobs, you will need either tail coverage or nose coverage.
  • Tail coverage – This covers you in case of patients that you have treated in the past sues after you have left the practice and you have a Claims-Made Policy.  This can be very expensive to buy individually.  I have heard one quote of $10,000 per year, for each year you were at the practice. [Mine was $55K when I started with my partnership-ed.] INSIST that they cover this or walk away, otherwise you could be financially trapped. [Editor’s Note: Don’t be surprised if they say no. My group would have told me no. But that doesn’t mean there isn’t room to negotiate. For instance, my group agreed to cover it if they fired me, but I would have had to cover it if I quit. Luckily we have since changed to occurrence coverage, so this isn’t an issue for new hires.]
  • Nose Coverage – This covers you in case a patient that you treated, sues you before you started working at your current practice.  If you already have a contract at your current place where they don’t offer tail coverage, you can try to get your new employer to provide nose coverage.  Typically insurance companies don’t want to do that.  A patient can sue a hospital and you, and it’s easy for the former hospitals’ insurance company to cover both you and the hospital for the same event.  An insurance company at a new office typically won’t want to bother with it, but it’s something you can at least try for if you’re already stuck buying your own tail.

To Summarize: In your contract insist that they either have an Occurrence Policy or provide Tail coverage on a Claims-Made Policy [or otherwise compensate you sufficiently that buying your own tail in certain situations would be an acceptable outcome to you.-ed]

Yes, that's snow in the background, thus the wetsuits!

Yes, that’s snow in the background, thus the wetsuits!

Tip #6 Don’t Overpay for Contract Review

I read somewhere on this website that someone had paid $3500 for contract review. In my opinion, that’s way too much.  We paid about $500 and it was well worth it.  I have heard of people paying less than that.  You should be able to have a conversation with the person who is doing the review.  You may not know legalese and the nuances to the contract but if you tell the reviewer generally what you want to do, and what you are looking for, they should help you look for red flags. If you tell the reviewer that you may want to open up your own practice in a few years, then they should be on the lookout for what happens when you want to get out of the contract.

Tip #7 More Vacation!

After money details are worked out, ask for more vacation. At least in the tech world, I have never heard about someone who was is in contract negotiations and was not given at least a little more vacation when they asked for it.  In the doctor world, it can get a little dicey when RVU’s are thrown into the mix, which is why it’s best to leave this for the end of negotiations.

[Editor’s Note: This is a good place to throw in a few extra tips included in the email to me that this author thought were too obvious to mention. I didn’t think they were all that obvious, and I’ve read a few books on negotiation:

  • Ask for a sign on bonus
  • Let them make the first offer and just ask for more of everything
  • For your first offer, ask for just below the price that you think would make them throw you out of the room

If this sort of thing is not obvious to you either, I would suggest some good books on negotiation.]

Tip #8 Restrictive Covenants

Restrictive Covenant is fancy lawyer talk for a non-compete clause.  The terms and legality of this can vary quite a bit from state to state, but you should really think about whether you can live with the terms.  If the terms are that you cannot practice within 100 miles (which was actually the case for one doctor in a different post on this site), that means that if you leave, you are either going to have to move, or you will have a very long commute. [Don’t assume any non-compete is not enforceable. Even if it isn’t, it may cost you something to defend yourself.-ed]

Tip #9 Terminating Employment

Know the results of breaking your contract.  It’s easy to get swept up in the excitement of a lucrative contract with a great bunch of people.  However, sometimes things don’t work out the way you planned. Knowing what happens if things don’t work out gives you options.  If something does happen, then always try to leave on the best possible terms.

Tip #10 Don’t Be Afraid To Walk Away

There are some things that may be non-negotiable to you and others that you could be flexible on. Figure those details out as soon as you can, and certainly before you start looking at the contract.

Well that’s all that I have.  I was just trying to share a few tidbits that my wife and I picked up along the way.  I know that a few of the tips can be expanded into entire posts, but I tried to keep it brief and semi-generic. It seems that anything doctor related can get very specific very quickly.

What do you think? What tips do you have for those negotiating contracts? Comment below!