How to Choose a Locum Tenens Agency (a Neutral Checklist)

You choose by evaluating every agency against the same neutral, non-ranked criteria and getting the answers in writing — not by trusting a "top 10" list. Six criteria predict a good experience more reliably than reputation: (1) NALTO membership plus Code of Ethics adherence; (2) markup/rate transparency; (3) malpractice and tail coverage; (4) payment timing; (5) recruiter conduct — CV-permission and no double-submitting; and (6) credentialing/licensing support.

The criteria are identical whether you are a physician (MD/DO), a CRNA, or an Anesthesiologist Assistant (AA). The point of a checklist is that it is agency-agnostic: you ask each recruiter the same questions and compare the written answers, rather than ranking firms by marketing polish.

locu.ms deliberately does not publish a "best agencies" ranking, take placement fees, or sell your contact information. Its agency directory mirrors NALTO's own published Agency Members list (and adds a few curated major non-member firms, clearly labeled) so you can verify membership yourself. That is the whole reason this checklist exists: to give you objective, verifiable criteria instead of a conflicted leaderboard. Use the comparison table below as your call-by-call worksheet, and treat any answer a recruiter won't put in writing as a finding in itself.

NALTO — the National Association of Locum Tenens Organizations, founded in 2001 — is the industry's self-regulatory body. Its members agree to a binding written Code of Ethics and are subject to an Ethics Committee complaint process. Membership is a meaningful baseline, not a guarantee: it gives you a written standard to hold a recruiter to, but it does not audit pay rates or certify tail coverage.

Important caveat: several large national firms are not NALTO members, so non-membership alone is not disqualifying. (locu.ms's directory reflects this — it syncs NALTO's Agency Members list and separately includes major non-member firms labeled as "curated.") The value of NALTO is the enforceable conduct standard, not the badge.

Key Code provisions worth quoting back to a recruiter (Article III, Ethical Rules): - Art. III.A.4 — the agency must possess a signed written contract from the client clearly stating all fee conditions before submitting a CV (excepting government contracts). - Art. III.A.5 — the agency shall not present or refer a candidate (in person, by CV, or by name) except at the client's request and only with the candidate's knowledge and permission; Art. III.B.4 independently bars presenting your name or CV without your prior consent. - Art. III.B.5 — when requesting permission to present you, the agency must disclose, at a minimum, the client name, facility name and worksite location, assignment time frame, and clinical requirements (the citable anti-blind-submission standard). - Art. III.B.3 — must describe the responsibilities, compensation, hours, and other pertinent information as accurately as possible. - Art. III.A.7 / III.B.10 — must comply with independent-contractor classification law; candidates contract as ICs, with revenue reported on the IRS Form 1099. - Art. III.E (Cooperation) / III.F (Advertising) — agencies must cooperate with Ethics Committee investigations and must not make false or misleading marketing statements (relevant to "best of" claims).

Scope note: the Code is physician-worded — it defines "Candidate" as "A physician who provides personal medical services" (with a parallel clause for any "individual who provides personal medical services"). Member agencies place CRNAs and AAs under the same conduct standards, but the written Code does not separately name CRNAs or AAs. The Code also does not contain a blanket ban on two agencies submitting the same candidate to the same client; your protection is the permission requirement, which keeps each submission under your control.

A transparency-first agency will at least discuss how your pay rate relates to the bill rate; an opaque one treats it as a black box. There is no legal requirement for an agency to disclose its markup, so the real test is willingness, not a specific number.

Industry reality: agency margin/markup commonly runs about 30–50% of the bill rate, with the full observed range roughly 15–60% (and higher in some specialties). These are industry observations from clinician and agency sources, not regulated or audited figures. That spread is wide because the markup bundles real costs — malpractice, credentialing, housing and travel, and the recruiter's compensation — alongside profit.

Good signs: the recruiter will tell you whether the rate is itemized or bundled, explain what the markup actually covers, and commit that there are no surprise post-hoc "administrative fees." Bad signs: a flat refusal to discuss the relationship between your pay and the bill rate, or fees that appear after you've signed.

This is exactly why locu.ms exists: it crowd-sources real, clinician-reported rates so you can sanity-check what you're offered against what peers in your specialty and region actually receive. You don't need the agency to disclose an exact margin — you need a market benchmark and a recruiter who won't dodge the question.

Through an agency, malpractice is typically agency-paid for the duration of the assignment — but the genuine danger is the tail, and this is the single highest-stakes clause in your contract.

The distinction that matters: an occurrence policy covers an incident that happened during the policy period no matter when the claim is later filed, so no tail is needed. A claims-made policy only covers claims filed while the policy is active — once it ends, you need a tail (an extended reporting endorsement) or you are exposed for years, because malpractice claims often surface long after the care was delivered.

Get these answers in writing before you sign: - Is the coverage occurrence or claims-made? - If claims-made, who buys the tail, what is its duration, and does it survive the agency's insolvency?

That last question is not hypothetical. After the financial collapse of major staffing firms — Envision and American Physician Partners (APP) filed Chapter 11 in 2023, and NES Health filed Chapter 7 in February 2025 — some emergency physicians were left exposed without coverage when the entity that was supposed to provide their tail no longer existed or could no longer fund the premiums. A tail that depends on the agency staying solvent is not real protection.

The length of coverage you need is tied to your state's malpractice statute of limitations, which is state-dependent — varies by state. Confirm the required tail duration, and the contract language, with a healthcare attorney licensed where you work.

Most locum clinicians are paid weekly or biweekly by direct deposit after an approved timesheet, as 1099 independent contractors paid by the agency (not the facility). Because you invoice through the agency, the mechanics — and the failure modes — are worth pinning down before you sign.

The neutral criteria to confirm in writing: - Pay frequency (weekly vs. biweekly) and the cutoff/submission schedule. - Whether pay is gated on the facility's timesheet approval, and what happens if the facility is slow to approve. - Net terms — how many days from approval to deposit. - Any stop-payment or clawback provisions, and the conditions that trigger them.

Ask for the written pay schedule and net terms up front. An agency that won't commit to a schedule, or that buries clawback terms, is telling you something. Because you're a 1099 contractor, no taxes are withheld — set aside for quarterly estimated taxes and self-employment tax yourself, and confirm the specifics with your CPA.

The brightest line is CV permission and submission control — who decides where your name and resume go, and when. A good recruiter never sends your CV anywhere without asking first.

Green flags: - Asks your permission before each CV submission. - Names the client, facility, location, and timeframe up front (this mirrors NALTO Art. III.B.5). - Confirms you haven't already been submitted to that facility by another agency. - Describes the role, compensation, and hours accurately (NALTO Art. III.B.3).

Red flags: - Blind submission — sending your CV without permission, or refusing to name the facility. - Pressuring same-day commitments. - Double-submission — presenting you to a facility you've already been submitted to. This can get you blocked at that facility by *both* agencies, because facilities typically honor only the first submission and will sidestep the conflict by declining both.

You can work with several agencies at once — many clinicians do — but you have to manage submissions actively: tell each recruiter where you've already been put forward. NALTO's permission requirement (Art. III.A.5 / III.B.4) is the mechanism that keeps you in control of every submission.

A full-service agency should run credentialing and licensing largely for you and at its cost — application, primary-source verification, and delivery fees — leveraging established board and facility relationships. If a recruiter is pushing the paperwork and the fees onto you, that's a downgrade from what the market offers.

Set expectations with ranges, not promises (these are typical industry timelines, not guarantees): - Credentialing/privileging: roughly 60–120 days (occasionally a few weeks for clinic-only identity and license verification). - State licensure: anywhere from about 1 week to 6 months — plan on roughly 90 days. - IMLC (Interstate Medical Licensure Compact): can produce additional-state licenses in days once your State of Principal License issues a Letter of Qualification.

Know the two distinct steps: credentialing asks *are you qualified* (license, training, malpractice history verified), while privileging defines *what you may do at that specific facility*. Both must finish before you see a single patient.

Scope caveat: IMLC eligibility is physician-specific and varies by state. CRNAs and AAs license through their own state boards and professional pathways, not the IMLC. Treat any "we'll have you working next week" promise skeptically — fast is possible for compact-state physicians, but it is the exception, not the baseline.

Because almost every "best of" locum list is published by an agency, a lead-generation site that sells your contact information, or an affiliate that earns a commission on referrals. The ranking is a marketing asset, not a neutral evaluation — and "#1" usually means "highest bidder" or "our own brand," not "best for you."

This is also a consumer-protection issue. Under the FTC's Rule on the Use of Consumer Reviews and Testimonials (16 CFR Part 465, effective Oct 21, 2024) and the FTC Endorsement Guides, undisclosed material connections, fake or incentivized reviews, and insider endorsements without clear disclosure are deceptive practices, carrying civil penalties up to $53,088 per violation. That cap is the FTC's inflation-adjusted maximum effective since January 2025; for 2026 the federal government did not issue an annual inflation adjustment (OMB Memorandum M-26-11, April 2026, citing missing October 2025 CPI data), so the $53,088 figure remains in effect. A ranking that doesn't disclose its financial ties is exactly the kind of content the rule targets.

The neutral alternative is to use objective, verifiable criteria — this checklist — and to verify NALTO membership against NALTO's own directory rather than a third party's list. locu.ms's directory is the worked example: it mirrors NALTO's published Agency Members list and does not rank agencies or sell placement, so there is no "pay to be #1." The schema has no ranking field and no placement-fee field by design; agencies are tagged only by source ("nalto," "curated," or "manual"), with NALTO vendor members excluded.