With a signed contract in hand and your new practice location decided, it is tempting to kick back and relax while you finish those last few months of training or wind up your old practice. Unfortunately, there is still much to do prior to hanging out your new shingle, so keep your nose to the grindstone a bit longer.

In this chapter, we will touch on a few checklist items you should get taken care of long before you arrive with a white coat pressed and stethoscope in hand.

State Licensure

A surefire way to start off on the wrong foot with your new practice is to show up without your state medical license in order— this is not only an inconvenience for the practice that planned for you to hit the ground running, but is also a source of embarrassment for you (reflects poorly on your organizational skills and competence with practical matters), as well as a financial hit— most practices will not start paying you until you start seeing patients, and you cannot see patients without a valid state license.

Many young clinicians fail to realize that it may take two to six months to obtain a new state license after the application is made. Advance preparation is critical. In our modern era where fraud cases make daily headlines, state licensing boards have become much more stringent about licensure, and the practice of reciprocity between states is now uncommon. These boards will not take your word for it that you sailed through college, medical school, internship, and residency—they will want independent verification from each of those sites of your attendance and records. Gather the names and addresses of the attendance offices and current contact persons at each of these sites and programs in advance; indeed, it would be a good idea to ensure that they have all your records dusted off and ready to go before you even nail down your job. If you know from the beginning which state you intend to practice in, you should go ahead and apply for the license even before you land a job; indeed, already having a state license in the state to which you are applying for a position may give you a leg up on the competition, as it indicates to a potential practice partner your sincere desire to come.

The biggest delays we have seen in license application processing revolve around incorrect addresses or outdated contact information at prior training programs that prevent documentation from ever being sent to the state board. Remember—the state will NOT remind you of the delinquency. It is up to YOU to keep on top of the record-gathering process and act quickly if a particular item is not forthcoming in a timely manner. To make matters worse, some states will discard your entire application and make you start over if they do not get all the items requested within a certain time period. They will NOT necessarily warn you about this policy, so be sure to ask if delays become apparent.

Did you spend some time with Uncle Sam in the past? The licensure boards will want copies of your DD-214 documents. The states will also perform criminal background checks, and you will need to obtain and submit fingerprint records in many states. If you have had any run-ins with the law, you will need to gather information and documents pertaining to those to submit as well.

Speaking of state licenses, what should you do about the license(s) you already have from your prior residency or practice state? My advice would be to keep it (them) for several years. We all hope for a rosy outcome in your new practice position, but in the real world, sometimes things just don’t work out. Having other state licenses up your sleeve gives you many more options if you need to look elsewhere down the road. Keeping the licenses active in other states is relatively inexpensive compared to having to reapply for them later. Be sure, however, that you apprise your old state licensure boards of any new address changes for their records.

Medicare and Medicaid Provider Numbers and Tax Identification Number

For those of you just coming out of training, this might be an item you are unfamiliar with: for a practice to be able to bill the federal government for your services, you need to have a specific Medicare and Medicaid provider number. These numbers often take several weeks to obtain, so as soon as you sign on the dotted line, ask your new practice to start the application process for you. They will be impressed that you are thinking ahead, and this will avoid your having to limit the scope of your practice when you first arrive. Similarly, the practice administrator can get your unique provider identification number (UPIN) ahead of your arrival. The UPIN is now your standard identifier in the world of insurance reimbursement, as is the even newer identifier known as your NPI (National Practitioner Identifier) number. Also, if you decide to incorporate yourself into a professional association (PA) or professional corporation (PC) depending upon your state, you will need to obtain a federal tax identification number (EIN) that your employer will use rather than your personal social security number when distributing your monthly income to you. Your community or state may require a local business license, and your employer can help you obtain that.

Drug Enforcement Administration (DEA) Number

You will probably have already obtained this in Residency or your private practice, but remember that you must notify the DEA of your change of address.

Hospital Privileges

Once you sign up with your new practice, ask the practice administrator to begin preparing hospital privilege packages on your behalf for all hospitals in which you are to practice or see consultations. These privileges take several weeks to obtain, and hospitals will often ask for the same credentialing material the state obtained, independently. Thus there may be delays, so get the packages moving—most hospitals will let the process begin even before your state license is approved, although final hospital privileges will not be granted until after the state license is awarded. In addition, hospitals often require personal interviews by medical staff leaders as well, so call the medical staff office of each hospital to which you are applying to see if you can schedule those interviews ahead of time while you are already in town on another errand, such as a house-hunting trip.

Insurance Company Credentialing

As if there is not enough paper flying around your head by now, please realize that even insurance companies will often have specific credentialing criteria that you need to meet. Your practice administrator should begin working on this at least two months before your arrival, but once again, many of the final credentials cannot be granted until state licensure is secured.

Malpractice Insurance (MI)

MI needs to be looked at in a couple of different ways. First, your new group will want to get you on their policy effective the date you start working for them, so be sure their administrator is on top of this. Be sure to clarify in your contract whether you or the practice is to pay your malpractice premiums. Second, let’s talk for a minute about so-called “tail” insurance. If a lawsuit is filed in the first couple of years after you leave residency or private practice to join your new group regarding your involvement in a case at your prior work site, your malpractice policy with your new group is NOT responsible for covering that lawsuit. To be covered, your old malpractice coverage from your prior work site must provide “tail” insurance for prior acts. Tail insurance usually involves a one-time premium and, in many cases, is covered by your residency training program, but often NOT in effect if you are leaving another practice unless you specifically ask and pay for it.

Health Insurance

Speaking of insurance, don’t forget to provide for yourself and your family. Most new recruits are covered under health insurance programs under their training program institution or prior practice, but often forget that that coverage is usually terminated when you walk out the door. Health insurance coverage with your new group will probably not start until you begin work. What happens during that interval between jobs? You may well be totally exposed and without any coverage.

This gap can be an expensive window of vulnerability. Let’s face it, after many years of a grueling residency, the tendency is to take some vacation before starting a new job. A fellow resident of ours took the three-month window between jobs to get married and travel to Bali for a nice long honeymoon—nice, that is, until he came down with hepatitis A while overseas and wound up being air-evacuated back to the United States and spending six weeks in the hospital with liver failure. To add insult to injury, he was in the “no coverage” gap for the entire treatment course and was personally responsible for the entire bill.

You should make every attempt to avoid this gap. One option is to discuss continuing interim health insurance coverage with your health benefits advisor at your residency institution or prior practice to see how you can continue to pay for your premium out of pocket until your new insurance begins (one form of this is called COBRA insurance). Alternatively, you can negotiate with your new practice to start your coverage early (you might need to pay for these premiums out of pocket as well). Both of these options are cheaper than going out on the open market to get a full-fledged short-interval individual health insurance policy.

Your practice may offer you a menu of different options for health insurance coverage. Indemnity coverage (carrier pays whatever is billed) gives the broadest coverage but is fairly rare anymore and, even if available, is the most costly option. Much more common are preferred-provider organization (PPO) options that have fairly broad coverage panels, prenegotiated rates with network providers, and require some type of co-pay by the insured (80 percent/20 percent is fairly common for panel providers, with higher co-pays for use of providers outside the PPO network). This option is of intermediate cost. The cheapest option is often a health maintenance organization (HMO) in terms of the least out-of-pocket expenses for the employees but is also the most restrictive option in terms of access to providers of your choosing. A newer low-cost option is the so-called health savings account (HSA). The HSA allows you to set aside pretax dollars into a special savings account (check with your advisor for current allowable amounts). The insurer providing the HSA product will provide a lower-cost PPO or similar arrangement, but will make you responsible for a higher deductible for charged services— these payments can be made straight from your HSA account. The attempt here is to shift a larger portion of the responsibility for using health care services directly to the consumer—if you have to pay out the initial amount directly from your account, you might think twice before seeking care for trivial problems. On the positive side, any funds you don’t use from your HSA  account during the year roll over tax-free into the next year. Thus, if you remain healthy for many years, the unused funds in the HSA account can accumulate. When you reach Medicare age, you can roll the extra funds into your Individual Retirement Account, tax-free.

Other Benefits

Other items to discuss with your new employer might include the availability and cost of dental insurance coverage and retirement plans, such as a 401k. A word of advice—contribute the maximum you can every year to this and the earlier you start, the healthier your retirement will be later. Life insurance may or may not be available from the practice, but nevertheless will be readily available from a variety of sources including the American Medical Association, state or county medical societies, etc. If you are just starting out in practice, a good rule of thumb is to insure yourself for 3–5 times your annual salary. We only recommend term insurance, rather than whole life or flexible life, as the term is by far the cheapest alternative.

Moving and Housing

Perhaps you are a free-spirited bachelor/bachelorette who owns few worldly possessions, is in touch with the universe, and can load all your meager belongings in your 1960s Volkswagen Microbus. Peace be with you. For the rest of you, listen up.

Most folks gather enough “stuff” during or after training that a formal moving company will be required to haul it to your new locale. This can be an expensive proposition and often engenders sticker shock for the uninitiated: it is not unusual for household moving costs to range from $5,000–$20,000, depending upon the size of your load and the distance you are moving. Explore options by contacting several companies in your area, and even asking for personal references for smaller companies. The experiences of friends and neighbors can sometimes be helpful as well. Unfortunately, the moving industry is fluid, and experiences often reflect the luck of the draw of packers and movers assigned to you that day. It is probably best for you to hand carry any particularly valuable items with you personally during the move (jewelry, passports, cameras, and the like). If you have any priceless antiques or artwork, make special moving arrangements for those individually with specialty carriers.

Make arrangements well in advance, especially if you are traveling in the busy summer months, and be sure to have an expected delivery date on the receiving end. The least risk of damage to your household goods occurs if the truck is loaded at your old residence, travels to your new home, and unloads directly into your new residence. Even with the best of movers, some breakage will occur—shift happens. If you cannot race ahead to meet the truck on the receiving end, the shipper will offload the goods in a warehouse and later reload the same items (you hope) on another truck to be carried to your new home. In our experience, much more breakage and loss of items occurs when this interim step is required. Try to avoid this interim step—take your vacation either before or after the move, but not in the middle.

Housing in your new locale represents both a new opportunity and a source of major consternation: Now you will finally be able to afford a mortgage on a spectacular new condo or home, yet at the same time you might be afraid to lock into a major purchase if you are unfamiliar with the area or unsure of how the new job will go. Questions you will consider: Where will I be working, and how long is the commute? Will I be traveling to several hospitals or work sites? What is the traffic like at different times of day to and from different areas of the town or city? What are the schools like? How close to shopping? How close to the airport? How close to recreational opportunities? Do I want a condominium or a detached home? Do I want to be in the city, on the river, against the mountain, or overlooking the ocean?

Most cities have different microenvironments that can be fairly subtle to the new arrival, but can take on importance with familiarity. For this reason, many new job hires are now electing to rent an apartment or home for the first 6–12 months after they arrive, rather than buy. On the downside, temporary lodging implies yet another move down the road once you find the home of your dreams, with the attendant cost and risks of breakage or loss outlined above. This is certainly an individual choice. In general, the less you know about an area or your new practice, the more you should favor temporary accommodations until you get educated, rather than gambling on a huge purchase you might not be happy with down the road.

You will read elsewhere in this text about the importance of setting up a relationship with a personal banker. This is one reason why—the personal banker in many markets can waive or minimize some loan fees on known long-standing customers, which in turn may save you big dollars down the road.

Other Miscellaneous Items

Once you arrive in your new community, some other items will need attention. First, get yourself a LOCAL cell phone number. Most states require that you get a state driver’s license within 30–90 days of arrival. While you are at it, don’t forget to register to vote in your new community. Also, don’t forget to join your local medical societies—these are a great way to get your name out to potential referral sources and will be a great source of networking contacts as you grow your practice. You will want to get a personal banker, an accountant (don’t even THINK of doing your own taxes if you incorporate), and an attorney who can help you with real estate and estate planning services. Your group can usually get you pointed in the right direction here. Discuss with your accountant and attorney whether it would be best for you to be employed as an individual or independent contractor, whether or not it makes sense for you to incorporate, and if so which structure corporation makes best sense for you (LLC, subchapter S, or subchapter-C, for example).