Attending Contract Negotiation: The Financial Basics Beyond Base Salary

Base salary is the easiest number to compare and the least complete one

Attending contracts are compared, informally, almost entirely on base salary — but base salary is often the smallest lever in the actual financial value of an offer. RVU (relative value unit) production thresholds and bonus formulas, signing and relocation bonuses, retirement plan contribution structure, malpractice coverage type, and restrictive covenants each carry real financial weight, and several of them compound over the life of the contract in ways base salary alone does not capture.

RVU thresholds and productivity bonuses

Many employed-physician contracts pay a base salary plus a bonus once the physician's billed RVU production exceeds a specified threshold, with the bonus calculated per RVU above that line. The threshold itself matters enormously: a threshold set unrealistically high relative to typical patient volume, scheduling constraints, or support staffing at that specific practice means the bonus may rarely or never be realized in practice, regardless of the per-RVU rate advertised. Physicians evaluating an offer should ask for the practice's historical RVU production data for physicians in a comparable role, not just the contract's stated threshold and rate, to judge whether the bonus is realistically attainable.

Signing bonuses and their strings

Signing and relocation bonuses are attractive but commonly come with a repayment obligation if the physician leaves before a specified period, often prorated over one to three years. Before accepting, confirm the exact repayment terms, whether the obligation is prorated or due in full regardless of how much of the period has elapsed, and whether it is triggered only by voluntary departure or also by employer-initiated termination without cause — the latter is a meaningfully worse term for the physician and worth negotiating.

Malpractice coverage type: occurrence vs. claims-made

As with attorneys, physicians should understand whether employer-provided malpractice coverage is occurrence-based (covering incidents that happened during the policy period, regardless of when a claim is filed) or claims-made (requiring both the incident and the claim to fall within the active policy period, absent tail coverage). This distinction becomes financially significant at the point of departure — see our companion piece on tail coverage cost planning — and should be clarified and, ideally, negotiated (specifically, who pays for tail coverage if the physician leaves) before signing, not after.

This single clause is worth negotiating as hard as the salary line itself, because the dollar amounts involved at departure can rival a full year of retirement contributions — see our companion piece on tail coverage cost planning for how large that bill can realistically run.

Restrictive covenants and their financial implications

Non-compete clauses, common in physician employment contracts though increasingly limited or banned in some states and under evolving federal regulatory activity, restrict where a physician can practice after leaving an employer, sometimes within a radius of many miles for a period of one to two years. A restrictive covenant that would functionally require relocation to keep practicing has real financial value — it limits your negotiating leverage in future roles and can force a costly move. Physicians should confirm the specific enforceability of non-competes in their state (this varies significantly and has been changing) and negotiate the geographic scope and duration where possible.

A physician evaluating two otherwise similar offers should treat the restrictive covenant as part of the total compensation comparison, not a separate legal footnote. An offer with a slightly lower salary but a narrow, one-year, single-facility non-compete may leave a physician with meaningfully more long-run negotiating leverage than a higher-paying offer carrying a broad, multi-year, county-wide restriction — leverage that translates directly into better terms at the next contract renewal or renegotiation.

A worked example of the RVU threshold problem

Consider an offer with a base salary of $260,000 and a stated bonus of $45 per RVU above a threshold of 6,200 annual RVUs. On paper this sounds generous. But if the practice's actual historical data shows that physicians in this specific role, given realistic patient scheduling and support staffing, typically produce 5,800–6,000 RVUs annually, the bonus is effectively unreachable under normal circumstances — the physician would need to meaningfully exceed typical productivity just to see the first dollar of bonus. A physician who only compared the per-RVU rate and threshold across competing offers, without checking historical production data, could easily rank this offer above a competing offer with a lower per-RVU rate but a threshold set at a level the practice's physicians routinely and comfortably exceed — and end up with meaningfully less real income as a result.

A practical negotiation checklist

• Ask for historical RVU production data before evaluating a productivity bonus threshold.
• Clarify signing bonus repayment terms, including what happens on employer-initiated termination.
• Confirm malpractice coverage type and who pays for tail coverage on departure.
• Understand your state's current enforceability rules for non-compete clauses before accepting broad restrictive covenant language.
• Compare total compensation — base, realistic bonus, retirement contributions, and benefits — not base salary alone.

The takeaway

A strong attending contract negotiation looks past the headline base salary number to the mechanics that actually determine your real financial outcome: whether the bonus threshold is achievable, what departure costs you, and how much flexibility restrictive covenants leave you. Negotiate those terms with the same seriousness as the salary line.