Alternative Pay

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When looking for a locum tenens assignment, we frequently only think about hourly pay. From my experiences and talking to other traveling nurse practitioners, there can be other monetary incentives.

Some agencies will provide a sign-on bonus for a very high-need site. The sign on bonus can range from several hundred dollars to several thousands of dollars. For example, I know a nurse practitioner that accepted a locums position in South Dakota with a sign-on bonus of $1000. The reason they provided her with a bonus is because it is challenging recruiting someone for that particular state. Typically, the bonus is provided in divided amounts throughout the length of the assignment, to make sure you don’t just accept the bonus and give your 30 days notice.

Moreover, there are agencies that will provide you with a weekly stipend or a daily per diem to cover extra expenses. For instance, to cover the cost of your license indirectly, they may give you $100 a week as a stipend, which in the long run is more than the cost of the license. Or they may give you a $30 per day per diem, to help cover costs of meals and gas. Keep in mind that per diems are tax-free! Imagine having an extra $600 a month at your disposal.

Finally, I have seen a variety of “holiday pay”. If you elect to work on a holiday workday, you are entitled to time and a half. Government focused locum tenens agencies will pay you for federal holidays even when you do not work because the site is closed. This can be pretty substantial.

Some recruiters may laugh at you when you tell them your expected hourly rate or that you need your DEA cost covered. Do not settle for one “no”. One agencies’ “no”, may be another agencies’ “yes”. If the site really wants you, the agency needs you, and they are willing to do whatever it takes to get you out there!

Conflict in Locum Tenens Workplace

For the most part, I have enjoyed my experiences working in locum tenens. However, like any other workplace, there can be some internal conflict. I would like to share a couple of experiences with this and my purpose for sharing them.

During one site I worked for, the scheduling was often irregular, and there would be times that the clinic was over staffed. The patients were only walk-ins so no appointments were made prior. One day, instead of taking turns seeing patients, the other provider assumed that since I was the locums provider, I should be doing the majority of the work.

Each time a new patient came, she had the medical assistant place the patient under my profile. Sometimes she would ask the patient why they were there, and give me a brief overview of the patient, instead of seeing them herself. At first I did not mind since I prefer to be busy than bored. Yet, after seeing 12 patients on my own, and her seeing 0, I decided to confront her.

Instead of asking “why aren’t you seeing any patients?” I jokingly said “Ok you can see the rest of the patients for the day”. She simply said “ok”. And guess what, she saw the remaining 9 patients of the day!

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During another site I worked in, I had a different dilemma. In this instance, I had treated a provider’s patient for sinusitis the week prior. The following week, I had a message waiting for me on my EHR from the nurse practitioner stating: “For your information, the Z-pack is no longer the drug of choice for sinusitis. It is augmentin.” When checking the patient’s chart, I noticed they were allergic to penicillin (this derivative is in augmentin), which reminded me why I chose to treat the patient with the Z-pack. I responded to the provider stating: “Yes, I know. The patient is allergic to penicillin which is why I chose to give the Z-pack over augmentin.” The provider responded with “Ok, I see that now.”

I was super annoyed with that message because 1. I knew what I was doing; 2. The provider should have checked the patient’s chart before messaging me; 3. It was a sinus infection! The treatment isn’t nearly as significant as diabetes or hypertension. 4. I had the utmost respect for this nurse practitioner until he decided to scrutinize my care for his patients; and lastly 5. I have a few more years of experience as a nurse practitioner than he does.

My point is, although most of your coworkers during a locums assignment will be happy to have you there (and the help), some may take advantage. Do not let them abuse you or question your skills! Be confident in who you are as a provider, offer to help as needed, and make sure everyone else is playing fair. Unfortunately, we all know workplace violence is quite common in the medical field. Do not let it go unnoticed and stick up for yourself!

W2 vs 1099 Pay

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I am constantly being asked questions about pay rates for locum tenens nurse practitioners and the difference between W2 and 1099. I decided to write a post about these different pay options.

Everyone’s situation is different so I cannot say one is better than the other regarding W2 vs 1099. I do know that a lot of people automatically think W2 is better because you don’t have to worry about your taxes at the end of the year, and they provide benefits such as health insurance.

Although W2 agencies take out taxes from your paycheck and provide benefits, they tend to pay way lower than 1099 agencies. I have seen the same job being offered by a W2 agency and a 1099 agency with a $10/hour difference. When being offered health insurance, they also tend to deduct another $3/hour from your pay rate to pay for the health insurance. If you choose to pay for health insurance out-of-pocket, you typically are only spending $1/hour of your pay on private insurance, and you get to deduct it at the end of the year when filing your taxes.

Personally, I prefer 1099 because of the higher pay rate. Also, since you are technically self-employed you can deduct a lot of items that will lower your overall taxes. Based off of experience, I think the mixture of working with some W2 agencies and some 1099 agencies is optimal. The reason for this is because the taxes taken out with the W2 position, and owed with the 1099 position will often balance each other out.

I do not choose an agency based off of pay type, instead I choose an agency based off of the job options they can present to me. I usually narrow it down to a handful of agencies, and choose the best job from there, despite them being W2/1099.

Timing

I have had several readers ask me questions about the time frame of searching for an assignment. How soon should we start searching? When should we begin getting worried if we haven’t yet found an assignment?

Sites generally are looking for someone to start as soon as possible. Therefore, I recommend beginning your search process 1-2 months before your ideal start date (if you already have the state license). It may take several weeks for something to become available that meets your criteria. As I have mentioned before, I always recommend working with more than one agency so you can increase your chances of finding the right assignment.

If you are 1 month away from your ideal start date, I recommend expanding your focus. This may mean being open-minded about the location; anywhere in the state vs just one city as an option. Or this may mean being open about the time frame; consider a longer time frame than the typical 3 months. You should also start consulting with other agencies you haven’t connected with yet.

Once you find an assignment you do like, the interview process can range from same-day interviews to 2 weeks. Then the site sometimes needs a second interview, or several days to make a decision (if they have other interviews or need to have a staff meeting about budget etc.).

Always inquire about the credentialing time frame. Each site is different and credentialing may vary from 1 day to 3 months. So if you are 1 month outside of your ideal start date, and the sites credentialing can take up to 2 months, you may want to consider other options.

Definitely, do not wait until the last-minute to find a position unless you are open to anything and anywhere. Sometimes recruiters will tell you that credentialing is quick, so in your mind you think you can start right away. I would definitely factor in about 2 weeks for credentialing for the majority of assignments. I would factor in 1-2 weeks for interviews and 2-4 weeks for the searching process. This is why I recommend searching about 2 months before your ideal start date.

5 Tips to begin Locum Tenens

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  • Do your research: Research which places you would like to practice in. Are you willing to travel? Do you only want to practice locally? Are you interested in working in a state with full practice authority? During your initial conversation with a recruiter, they always want to know where you are interested in working.
  • Identify agencies you would like to work with: Do you prefer to be paid via W2 or 1099? Do you need benefits? Do you need travel and lodging? I suggest searching the agencies current job availabilities to see if they are similar to your needs. For example, one agency may have an abundance of opportunities in your state, while another agency may have more job opportunities in your specialty.
  • Establish a relationship with your recruiter: You should have at least 5 agencies and recruiters that are actively searching for you. A good recruiter will be following up with you and returning your phone calls. It is common for locum tenens providers to bounce back and forth between agencies, depending on what jobs are available.
  • Get organized: Gather all of your licenses, certificates, CEU’s, vaccination records, and other documents you may need to submit. I recommend having them scanned to a computer so you can easily email them to your recruiters and credentialing team.
  • Have several references available: Most agencies and sites will ask for at least three references. Optimally one reference will be a supervisor or physician, and the other two references should be co-workers (other nurse practitioners or physician assistants). You should always have more than three references available, in case the agency cannot reach someone, to keep the process moving along.

Leaving Washington

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My last day at the community health center in Washington was bittersweet. Part of me was looking forward to going back home to the sunshine state from freezing temperatures (28-32 degrees). The other part of me was a little sad to leave because of all of the connections I had made with my co-workers and patients. The adventurous side of me see’s locum tenens opportunities as an exciting escapade. The sensitive side of me sees my sites as the people and relations I form, and reluctance to leave them behind.

The community health center asked me if there was anyway I would go permanent. I think most locum tenens sites that are looking for an ongoing commitment are hoping for a locums to permanent provider. My last day was a light load of seeing patients, with the later half of the day completing documentation. During lunchtime, most of the staff and I went to eat at a local pizza joint. Apparently I had the largest turn out of co-worker attendance :).

My supervisor at the clinic told me that all of the executives are sad to see me go. That they were impressed by my documentation and coding, and that I could teach the billing department a thing or two. They said they received an abundance of patient feedback that was positive about their experience with me, and requests for me to become their primary care provider. They also said that I transitioned really well into the clinic and they were happy to never have had an issue with me or my patient care. The medical director told me that he would be more than happy to be used as a reference or can provide a recommendation letter for future locum tenens positions.

I am truly grateful for my experience at the community health center. Not only did I learn a lot and fine-tune my skills and knowledge, but I also made some life long friends. I would not hesitate to return in the future (of course summer only) to help out with vacation shortages and other needed coverage. Saying good-bye was tough, but I know change is inevitable and can only strengthen a person. It will be difficult finding an upcoming locums opportunity that will match my experience in Washington.

Visiting Portland, Oregon

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Portland, Oregon is only a few hours drive from where I was in Washington. I decided to meet up with some friends in Portland one weekend. It was pretty much everything I expected it to be – interesting, hippie, and weird. I would definitely rather live in Seattle any day over Portland, but it was still a fun experience.

Right off the highway, we got to see the Multnomah Falls. It was a beautiful site with yellow and orange fall colored leaves surrounding it. As we got closer, mists from the falls quickly started covering us. We hiked up a bit to the bridge which brought us closer to the sounds of greatness.

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I have to admit that my favorite part of Portland were the “Powell Book Stores”. It’s incredible how vast a book store can be, with several editions of all types of books, both used and new. It is pretty much a nice book exchange program, where you can sell your lightly used books, and easily purchase other used or new books. There is a book I have been eyeing at Barnes and Nobles that costs almost $20. I bought it at Powell’s Book Store for less than $5. I wish I could have taken this book store with me back home.

We stopped over to the Portland Art Museum which I truly enjoyed. They have a good variety of cultural art such as Native American, Asian, European, and American works. My favorite item was a large Native American canoe that had multiple little canoes in it.

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Food-wise, we lucked out one morning at Voodoo Donuts. We only had to wait in line for 10 minutes compared to the usual 1 hour or so wait. I tried two different donuts that were good, especially the oreo/cookies and cream one. We bought a dozen donuts in between the 3 of us because it seemed like the right thing to do. Yet, we didn’t even finish half of it.

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Overall, I had such a fun weekend! Would I drive through those curvy roads at night on my way to Portland ever again? Probably not. Oregon is a great option for nurse practitioners looking to begin locum tenens work. There is always a need in Oregon and it’s a  pretty cool place.

Guest Blog: Indian Health Services in Arizona

Today’s post is a guest entry from a Traveling Nurse Practitioner, Kate, and her experiences working in Chinle, Arizona with an Indian Health Service facility.

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Why I became a travel nurse practitioner?

After having a permanent nurse practitioner position in a rural area that required me to commute an hour and forty minutes going to work and another hour and forty minutes from work to home, I decided after 10 months of being a brand new nurse practitioner that I might as well get paid to travel and have my accommodations paid for while on an assignment. I have a permanent home in TX and have been living in TX for 20 years. I often daydreamed what it would be like to live and practice in another state or experience and learn about other cultures, societies, and observe how other health care organizations function.

First travel assignment

I am currently finishing up my 3 month assignment. I accepted the job for Flu Nurse Practitioner for my first travel assignment in Chinle, AZ (an Indian Health Service facility). I have one more month left and so far, I have enjoyed every minute of it. My role is to help run the flu clinic and assess patients’ health status prior to administration of the flu vaccine. Flu clinics are held in the outpatient department of the hospital and outreach flu clinics (surrounding places in Chinle like near a grocery store/chapter houses/other surrounding towns). When I am assigned to work at the outreach clinics, I ride with the public health nurses so I don’t have to drive my own vehicle. I felt that the role of the Flu Nurse Practitioner was a unique one. When I am not running the outreach clinics, I am either in the Pediatrics or Family Practice/Internal Medicine department running the flu clinics there. If flu clinic is slow, then I  see regular walk- in patients or same day appointments in between my scheduled patients for the flu clinic. Chinle, AZ is a rural area but a very beautiful one. There is no mall here. No place to get a haircut. Only a few places to eat outside. Only one grocery store. The nearest town/small city with major urban amenities like Walmart/Walgreens is about an hour and a half drive away, in fact, it is in another state!

What Chinle, AZ lacks for in urban/comfortable amenities, Chinle makes up for it in its community and its scenery. I also have been so lucky to have such wonderful support staff at work and be able to work with AMAZING medical providers who have been helpful and have been so welcoming towards me.

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Accommodations in Chinle, AZ

There are only 3 hotels here in Chinle, AZ. There is government housing for permanent staff and some RV trailers for rent. It is better for your recruiters to arrange housing here because it can be hard to find especially during tourist season which is from March through October. Currently I am staying in a hotel chain– my company is paying for this. I have a small fridge and a microwave in my room. I bought kitchen ware and a hot plate which my company gave me reimbursement for. The hotel is nice and I feel secure. Although not having a full kitchen and a big fridge gets old after a while. I don’t have a separate room for cooking other than the bathroom. So I clean my bathroom first and use the sink countertop to put my hot plate on and cook. I don’t like my bedroom smelling like food. A good perk about staying in a hotel chain is that even though you are not the one paying for the hotel room you can still get reward points for a free hotel stay since the hotel room is under your name.

Navajo patients

Most are friendly. Many of the patients that I have seen in the clinic have chronic illness with multiple co-morbidities. Some of the chronic illnesses include: diabetes, hypertension, alcoholism, asthma/COPD, etc. Some of the patients still live in the canyon and places in the desert with no electricity or running water, no street names, and sometimes they have to travel more than 50 miles to get to the clinic or hospital. One thing I don’t like is that some patients jump around from one clinic/hospital to another even if you advise them to stick to one primary care provider which makes it difficult to achieve continuity of care.

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What to do outside work in Chinle, AZ or outside Chinle, AZ ?

Chinle, AZ is located in the Navajo Nation near the northeast corner of Arizona. So more or less than 2 hours of a drive you will be in another state. Below is a list of things to do:

  • Chinle, AZ
    • Visit Canyon De Chelly
    • Do ranger led hikes in the Canyon
    • Go to church if you are spiritual or if you are a church goer
    • Sometimes there are parties and potlucks with the healthcare staff/medical providers – don’t miss out because this is a good way to socialize
  • Flagstaff, AZ
    • Museums/Arbortereum
    • Conconino Forest – hiking
    • Arizona Snowbowl
    • I get my car maintenance here
    • Whole food, natural grocers, other urban amenities are located here.
    • Airport
  • Page, AZ
    • Antelope canyon
    • Horshoebend
    • Glen Canyon Dam
  • Durango, CO
    • Train ride Silverton to Durango
    • Breweries
  • Pagosa Springs, CO
    • Hot Springs – my husband and I are going here for Thanksgiving this year
  • Telluride, CO
    • Skiing
  • Window Rock, AZ
    • Navajo Museum
    • Window Rock
  • Gallup, NM
    • Has the nearest Safeway/Albertson’s/Walmart
    • Has some shops and restaurants
  • Moab, UT
    • Arches National Park – worth visiting
    • Other parks
  • Albuquerque, NM
    • Airport
    • I haven’t explored much of ABQ, NM other than passing through here and getting some stuff
    • Has the nearest Costco

I’m sure that there are other things to do in the towns I have listed above that I haven’t mentioned, but everywhere you go there is always something to explore.

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Applying for a DEA

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If you are currently working in a state that does not allow nurse practitioners to apply and use a DEA certificate, you will need to apply for one before beginning locum tenens. The same applies for those of you that do not have one because your current job does not require it. Applying for a DEA can be tricky depending on the state you are from.

For example, if you are coming from Florida, you cannot apply for a DEA using your Florida license. This means that in order for you to apply for a DEA, you will need to obtain a nurse practitioner license in another state. I would not suggest just applying to just any state. In fact, the first license you apply for out of your home state should be carefully selected.

The reason for this is because you need this state license to help facilitate your DEA application. This means that you should probably choose a state with full practice authority for nurse practitioners. Some states with limited practice authority require physician supervision and a controlled substance permit. You are unable to apply for the controlled substance permit prior to having a supervisory physician. You are unable to apply for the DEA without the controlled substance permit.

This prolongs the process of acquiring a DEA. States to avoid applying for initial DEA certification include Texas, Pennsylvania, and California. I recommend obtaining licenses in states with a quick turnover period and full practice authority if you need to apply for an initial DEA. Some of these states include Washington, Connecticut, Vermont, and Nevada. These states have full practice authority and allow you to obtain free temporary RN/ARNP licenses. This will speed up the process of obtaining a DEA because you can apply for one even with a temporary license.

If you are in a state that allows you to obtain a DEA but you do not have one, I highly recommend going ahead and applying for one with your current position. When you are searching for a job assignment, you are more “attractive” if you already have the DEA certificate. Sites often require their providers to have them, even if you do not end up using it at their facility.

There are two challenging aspects about attaining a DEA. If you are coming from Florida, you already know you need another state license to apply for the DEA. In addition, you need a physical practicing address to include in your DEA application, which should be in the state you are applying for the DEA with.

This means you cannot apply for the DEA until you already have a job assignment. It can be tricky since a lot of sites want someone to start right away and do not want to wait 2-4 weeks for your DEA to come in. On the other hand, some sites are willing to allow you to start prior to obtaining the DEA, while others will wait. The credentialing process in some sites can take 30-60 days. So these places are usually able to wait for you to obtain a DEA, as long as you already have a temporary or permanent license in their state. It is important you quickly realize that your first assignment as a locum tenens nurse practitioner is the most difficult one to obtain. I believe being open-minded to the location and type of facility will help facilitate this process.

The second challenging aspect involving the DEA is getting an agency to pay or reimburse you for it. In my experience, if you ask the agency flat-out if they will pay for your DEA, few will say yes and most will say no. Nonetheless, when it comes down to the negotiating process (remember the best time is after a phone interview when the site confirms that they like you), you can often receive a different response.

For instance, one of the agencies I was speaking with told me they would not cover my DEA, while others said they would. Upon choosing my first assignment, I was leaning towards going with the agency that would not pay for my DEA. Once I told them that my only hesitation was not having my DEA covered, while other agencies would, they quickly agreed to pay for it. Some agencies will provide you with a monthly stipend or sign on bonus that can be used to accommodate the expense instead.

If you prefer a site with an agency that will not pay for your DEA and will not budge, I recommend you go with the agency that will pay for your DEA. You shouldn’t have to pay $731 for a certification their site is requiring you to have. Therefore, I believe it is important that you are honest with your recruiter about your expectations, and to never settle for a NO. Remember you will not get anything that you do not ask for.

License Reimbursement

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Some nurse practitioners prefer obtaining a new state license once they find a job in that state. Often, agencies will apply and pay for your license upon accepting an assignment. However, it is common that sites want someone to start as quickly as possible, so you are more appealing if you already have the license. In this case, you can apply for the state license on your own and expect to be reimbursed for it.

After working with an agency, they may offer to apply for a license for you proactively. This means if you are hoping to work in Wisconsin for your next assignment, they will go ahead and apply (and pay) for your Wisconsin license, as long as you sign an agreement to work with them once the license is obtained. This limits your potential job options since you are limited to working with that one agency, but may be ideal to some travelers.

I personally prefer to apply for licenses in states I see large needs and am interested in traveling to. Then upon choosing my assignment I inquire about license reimburse. Agencies are more likely to reimburse you for your license if you commit to 3 or more months with them.

Make sure to keep receipts of all license application fees if you expect to be reimbursed. Some agencies will reimburse you during your first paycheck. Others may spread it over 2-3 months to make sure you keep your end of the bargain (staying with that site for the requested timeline). Some agencies will say they do not reimburse for license fees, but can pay you $1-2 more hourly to balance out the overall expense. Other agencies may provide you with a monthly stipend instead of a set “license reimbursement”.

When searching for an assignment, be honest with your expectations. Tell your recruiter you are expecting your new license to be covered or reimbursed. Lastly, do not sign your contract until it explicitly states in your agreement how you will be reimbursed for the license. It should state that your license fees will be covered or that you will be given $100 per month worked etc. (whichever form of reimbursement you and the agency agreed upon). I highly recommend applying for licenses on your own before finding an assignment.