This educational session is designed to take the mystery out of complex immigration rules and provide you with the necessary knowledge, strategies, and training to successfully hire and retain international medical graduates. Learn the the right way to hire H-1B and J-1 physicians FAST so you don’t waste precious time and resources, the legal pitfalls to avoid that can derail your recruitment and cost you time and money, and the little-known tips and tools that will help you eliminate immigration barriers so you can hire the physicians you need. PDF handout

1. 9 Immigration Rules, Tips & ToolsTo Hire IMG Physicians Fast
Presented by Cowles & Thompson
Immigration Practice Group
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Webinar Agenda
Immigration Rules, Tips & Tools for Hiring
•J-1 Physicians
•H-1B Physicians
•E-3 Physicians
Question & Answer

2. International Medical Graduate (IMG) Stats
9 Immigration Rules, Tips & Tools
Physician Immigration Overview

3. Hiring J-1 Physicians
Two Year Foreign Residency Requirement for J-1 Physicians
After residency or fellowship training is completed, all J-1 physicians must return to home country for two years or obtain a waiverof this requirement before he or she can be employed in H-1B status or adjust to permanent residence (“green card”).
Home Country -Country of last citizenship or permanent residence (even if dual citizenship retained) before J-1 visa
1.0
Waiver of Home Residency Rule
Waivers of the Two-Year Foreign Residency Requirement (“J-1 Waivers”)
Interested Government Agency (IGA) –State or Federal Agencies
Hardship –extreme hardship to U.S. citizen/LPR spouse or children
Persecution – likelihood of harm to physician because of politics, religion, etc.

4. Interested Government Agencies (IGA)
Conrad 30 State Program
Department of Veterans Affairs (VA)
United States Department of Health and Human Services (HHS)
Appalachian Regional Commission (ARC)
Delta Regional Authority (DRA)
HPSA/MUA Database
All IGAs require location in or service to underserved areas –Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA)
First step -check Health Resources and Service Administration website to determine HPSA or MUA designation
http://datawarehouse.hrsa.gov/GeoAdvisor/ShortageDesignationAdvisor.aspx
2.0
J-1 Waivers –Conrad 30 State Program
•Varying deadlines and opening dates
•Evaluation process differ
•Unused slots do not rollover
•10 FLEX slots available for non-underserved locations
30 slots per fiscal year –October 1 to September 30
•Must be current –usually within six months.
•Some states have very specific requirements.
•Start early and recruit consistently!
Recruitment efforts
•Priority usually given to primary care
•Hospitalists may be considered specialists
•Some states may restrict number of specialists slots
Primary care or specialty, depending upon state

5. Conrad 30 State Program (cont.)
FLEX 10 Slots
•Check state program requirements
•Determine surrounding HPSA/MUA locations and gather patient data
•Provide evidence of sufficient number of patients for at least one additional physician
3.0
J-1 Waivers –Appalachian Regional Commission (ARC)
Covers Appalachian regionwww.arc.gov and not limit on number of waivers per year
Extensive recruitment required, including notices to medical schools
HPSA and primary outpatient care only (no hospitalist)
$250,000 liquidated damages clause required
J-1 Waivers -U.S. Department of Health and Human Services (DHHS)
Federal agency covers entire United States
•http://www.globalhealth.gov/exchangevisitorprogram/index.html#waiver
Clinical care waiver
•Primary care only in HPSA with 7 score
•Public health center, rural health clinic, or tribal medical facility qualifies
No limit on number of waivers per year but physician cannot have completed residency more than one year before waiver start date

6. J-1 Waivers –Delta Regional Authority (DRA)
Federal agency covering eight state region
•http://www.dra.gov/ for list of eight states
$250,000 liquidated damages in contract
Recruitment required 60 days minimum before application, including notices to medical schools
Primary care or specialty and no limit on number of waivers per year
Contract Requirements for J-1 Waivers
Three year term required (minimum)
Agree to start employment within 90 days of USCIS waiver approval
Non-compete clauses generally prohibited
Employment only –no independent contractor agreements
Liquidated damages permitted (required in some instances, e.g. Georgia, ARC, DRA)
All work locations (addresses) must be included in contract
4.0
J-1 Waiver Employer Obligations
•Annual or semi-annual reporting and notifications to state or federal sponsoring agency
•Apply for H-1B and pay salary that meets the prevailing wage; income guarantees possible
•Employ physician only at agreed locations and/or underserved areas

7. Timeline for the J-1 Waiver to H-1B Process
Employer and Physician apply to IGA
IGA issues recommendation to Department of State (DOS) (1 to 3 months)
DOS issues recommendation to USCIS (1 to 2 months)
USCIS issues final waiver approval I-612 (1 to 3 months)
H-1B petition filed and approved (1 to 4 months)
Total time –4 to 12 months
Six Steps for Hiring J-1 Physicians Fast
Contact immigration attorney early in the process to help develop recruitment plan
Start search for candidates in their 2ndyear of residency or one year before completion of fellowship
Execute employment agreement by early Fall of 3rdyear of residency or final year of fellowship
Document current recruitment efforts, including advertising, recruiters, referrals, etc.
Verify IGA program waiver requirements with attorney and gather data to support waiver application
Plan to present the waiver application on October 1 or first day for acceptance of applications
Hiring H-1B Physicians Fast

8. H-1B Physicians
IMG Physicians who completed residency or fellowship with H-1B visa (no J-1)
J-1 Physicians who returned to home country for two years after residency or fellowship completed
J-1 Physicians who obtained hardship or persecution waiver and seek employment
H-1B Physicians and the H-1B Cap
Limit of 65,000 new H-1B visas per fiscal year (except Free Trade Act (FTA) nationals)
20,000 per fiscal year for persons who hold US Master’s degrees or higher
Fiscal year runs from October 1 to September 30
Employers may apply for H-1B on April 1 with a start date
of October 1
In 2014, over 170,000 new H-1B petitions filed the first week of April
5.0
H-1B Numerical Limitations “H-1B Cap”
Who is subject to the cap?
–First time H-1B beneficiaries (employee)
–Beneficiaries who already hold H-1B status but were employed by cap-exempt employers
–Physicians who maxed out the 6 year H-1B limit, left the U.S. for one year, and wish to return

9. Avoiding the H-1B Cap
Cap-exempt employers
•Universities and non-profit petitioners affiliated with post-secondary educational institutions
•Government research organizations and non- profit petitioners affiliated with government research institutions
•For-profit employers who place physician at a non- profit, university-affiliated facility for at least 50% of work week
Cap-exempt beneficiaries
•Physicians who are beneficiaries of J-1 IGA waivers only (does not include hardship waivers or persecution waivers)
Avoiding the H-1B Cap
Concurrent H-1B Strategy
For profit employer offers part- time employment to the provider (ranges from 5 to 60 hours/week)
The start date of the H-1B must be a date before the physician’s cap-exempt H-1B expires.
Concurrent H-1B petition is filed and approved before current cap-exempt employment ends.
6.0
Employer Obligations for H-1B
•Employer must pay minimum of prevailing wage or actual wage, whichever is higher, for the term of the H-1B
–http://www.flcdatacenter.com/-Department of Labor wage data for prevailing wage –data often missing so prevailing wage request might be required and can delay the H-1B process
–Salary must be guaranteed at prevailing wage or actual wage – productivity bonuses okay after minimum guarantee
–Contracts must offer same benefits and can have same requirements as other physicians but cannot recover H-1B costs or other green card costs
•Employer must pay ACWIA fee of $750 (25 or fewer employees) or $1500 (greater than 25 employees) unless exempt
•Payment of attorneys fees are “safe harbor” from DOL complaints

10. Employer Obligations for H-1B (continued)
•Physician must be on payroll within 30 to 60 days from H-1B approval date, regardless of pending hospital privileges or other credentialing issues
•Physician must be an employee of sponsoring employer; however, independent contractor arrangement is possible if physician forms corporation or LLC (self-employment)
•Employer must pay return transportation costs for physician if employment is terminated
H-1B Facts to Know
•H-1B status can be valid up to 3 years initially, renewable for 3 more years. Physician is eligible for another 6 years after 1 year outside U.S.
•6 year maximum stay with some exceptions -
–1 year extensions available after 6thyear if green card application pending for at least one year
–3 year extension available if green card application is on hold because of limited availability of green cards
•If new H-1B, physician cannot work until visa is approved
•Dependent spouses (H-4) cannot work -2014 proposed rule may grant employment authorization to some H-4 spouses
7.0
H-1B Facts to Know (continued)
•If employee is already in H-1B status and changing employers, new employer must file H-1B petition
•May start new employment upon filing of new H-1B petition –need not wait for final approval
•Extenuating circumstances required for former J-1 physicians completing a J-1 waiver

11. Six Steps for Hiring New H-1B Physicians Fast
Finalize employment by early Fall of 3rdyear of residency or final year of fellowship
Determine whether cap- exempt employer or employment
If competing for non- exempt H- 1B, have contract in place by February so that H-1B petition can be filed on April 1
Encourage early application for medical license and credentials and prevailing wage
Ensure salary and benefits are within prevailing wage requirement for location and that covers the H- 1B term
Contact immigration attorney early in process
8.0
E-3 Visas for Australian Physicians
•Visa category for citizens of Australia for professional positions in the U.S. –10,500 per year available
•Requires certified LCA
•Physician must be licensed in U.S.
•2-year validity; renewable indefinitely
•Dependent spouses can work
9.0

12. THE IMMIGRATION PRESCRIPTION
Step by step, this book will show you how
international medical graduates can legally
practice medicine in the United States. You
will learn:
 The various ways to waive the two-year
foreign residency requirement for
the J-1 visas
 The best paths to permanent residence
(green card) and citizenship
 Your responsibilities as a legal
immigrant
 How to get and maintain legal
immigration status for family members
 And more…!
For your free copy, email
abadmus@cowlesthompson.com
For immigration updates, visit
www.physicianimmigration.com
Legal Notice
Facts of individual situations differ.
The information provided here is general in
nature and should not be relied upon for
specific situations.
Consult with an experienced immigration
attorney to get the right diagnosis and
prescription for your specific situation.