Locums CRNA: What to Do, What to Avoid, and What to Know Before Your First Gig
The first locums assignment has a learning curve that nobody warns you about. The clinical side you can handle. It's the contract language, the facility red flags, and the financial setup where most CRNAs get burned early. Here's what to pay attention to before you take that first gig.
Facility Red Flags
Not every facility that hires locums is a facility worth working at. Some are chronically understaffed for reasons that will become obvious once you're there. Asking the right questions before you accept an assignment is part of the job now.
Critical medications are unavailable or restricted
Before you accept any assignment, ask specifically about their formulary. Succinylcholine unavailability is a real issue at some facilities, particularly smaller ones with formulary restrictions or supply chain problems. If you cannot manage a can't-intubate can't-oxygenate situation with the drugs and equipment you expect to have, that's not a facility you want to be at solo. Ask about succinylcholine, sugammadex, and lipid emulsion. If any of those answers make you uncomfortable, trust that instinct.
No clear emergency protocols or difficult airway cart
A facility that can't tell you where the difficult airway cart is, or doesn't have a clear malignant hyperthermia protocol posted and stocked, is not ready to support you when something goes wrong. Ask the recruiter or facility contact directly. If they can't answer or say they'll "get back to you," that's an answer in itself.
Vague answers about supervision structure and backup
Some facilities want a locums CRNA because they want anesthesia coverage without paying for it properly. Find out who your backup is if you need a second provider. Find out what the call structure looks like. Find out whether there's a supervising anesthesiologist and what their actual availability is, not just what's on paper. If the honest answer is "you'll mostly be on your own," you need to decide whether that's acceptable before you're standing in an OR at 2am.
Case mix that doesn't match what you were told
Some facilities describe their case load as "routine general" during recruitment and turn out to have a trauma designation, a pediatric population, or complex cardiac cases once you arrive. Get the case mix in writing or at least clearly stated by email before you accept. If what you find on arrival doesn't match what you were told, you have the right to flag it and, depending on your contract, the right to leave.
Contract Traps
The contract is where most of the real risk lives. Read it yourself. All of it. The items below come up constantly and cost CRNAs real money and real freedom when they're ignored.
Broad non-compete clauses, especially with large anesthesia groups
Some of the largest anesthesia management companies include aggressive non-compete language in their locums contracts. These clauses can prevent you from working directly for any facility within a specified radius for one to two years after the contract ends. Read the geographic scope and the time period carefully. A 50-mile radius in a metro area can effectively block you from a large portion of your regional market. These clauses are sometimes negotiable, and in some states they're difficult to enforce against independent contractors, but the safest approach is to get the language removed or narrowed before you sign. Don't assume you can deal with it later.
Signing without confirming malpractice coverage type
Many locums contracts include malpractice coverage, but "included" doesn't tell you what kind. An occurrence-based policy covers you indefinitely for anything that happened during the coverage period. A claims-made policy only covers you while the policy is active. If you leave and a claim is filed six months later, you're exposed unless you have tail coverage. Tail can cost $5,000 to $20,000 depending on specialty and duration. Confirm the policy type before you sign and clarify who pays for tail if the contract ends for any reason.
Accepting verbal assurances about rate, schedule, or case load
If it isn't in the contract, it doesn't exist. A recruiter telling you the facility "usually" runs 40 hours a week, "typically" doesn't require call, or "generally" has straightforward cases is not a binding commitment. Get the specific hours, call expectations, and case type parameters in writing before you sign. The contract is the document that governs what happens when something goes sideways.
Signing a contract with one-sided termination language
Some contracts allow the facility or agency to cancel with 24 to 48 hours notice while requiring you to give 30 days. You could relocate for a 13-week assignment and be sent home after a week with no recourse and a lease you're still paying. Make sure the notice period is the same for both sides, and ask whether there's any compensation if the facility terminates early.
Financial Setup
The financial side of going locums requires actual infrastructure. Not complicated infrastructure, but things you need in place before the money starts moving, not after.
Open a dedicated business checking account before your first paycheck
Your locums income should never touch your personal checking account. Open a separate business account and route all contract payments there. Pay your business expenses from that account. This single habit makes tax time dramatically simpler, protects you in an audit, and forces a clear separation between business and personal finances. It takes about 20 minutes at most banks or credit unions. Do it before you take your first assignment.
Track every business expense from day one
As a 1099 contractor, your legitimate business expenses reduce your taxable income directly. Malpractice premiums, licensing fees, DEA registration, continuing education, professional memberships, scrubs, medical equipment, a dedicated home office, and travel costs related to work are all potentially deductible. If you don't track them, you don't get to deduct them. A simple spreadsheet works. A business credit card used only for work expenses works even better. Don't wait until March to reconstruct a year's worth of receipts.
Set aside taxes from every payment, immediately
Nobody withholds taxes for you as a 1099 contractor. The IRS expects quarterly estimated payments in April, June, September, and January. If you don't plan for this, you'll owe a large bill at tax time plus penalties for underpayment. A reasonable starting point for most CRNAs is 28 to 32 percent of gross income set aside in a separate savings account and left alone. Adjust up if you're in a high-tax state. Your CPA will reconcile the actual amount when you file.
Understand your actual take-home before you accept a rate
Recruiters lead with the gross hourly rate because it's the biggest number. $200/hour sounds significantly better than your staff salary until you subtract self-employment tax, health insurance, malpractice, housing, travel, and unpaid days off. The actual net advantage of a locums contract over a staff position depends on the specific numbers, and those numbers vary a lot by contract, location, and your personal cost structure. Run the actual math before you commit to anything.
Run the actual numbers before you accept
The True Hourly Rate calculator accounts for self-employment tax, malpractice, health insurance, travel time, and unpaid weeks. See what a contract actually nets before you sign.
Open Free CalculatorSet up a Solo 401k as soon as you have 1099 income
As a W-2 CRNA you're capped at $23,500 per year in retirement contributions. As a 1099 contractor with a Solo 401k, that ceiling is $70,000. The employer contribution side, which you fund yourself as both the business owner and the employee, is what creates that gap. The Solo 401k must be established by December 31 of the tax year you want to contribute for. You can't set it up in March and retroactively shelter last year's income. Open it early.
Find a CPA who works with 1099 healthcare providers
A general-practice CPA who has never worked with an independent contractor healthcare provider will miss deductions and may not be familiar with the S-Corp analysis, Solo 401k contribution strategy, or quarterly payment structure that applies to your situation. Ask specifically whether they have clients who are 1099 CRNAs or physicians. If they don't, find one who does. The fee difference is usually small compared to what a knowledgeable CPA can save you.
One More Thing
The first locums assignment is always the hardest logistically. New facility, new EMR, new team, new anesthesia machine layout, new pharmacy workflow. Give yourself a realistic orientation period and don't be afraid to ask questions that might feel basic. Every facility does things differently. The CRNAs who struggle in locums are usually the ones who didn't ask enough questions upfront, either about the facility, the contract, or their own finances.
The ones who do well treat each assignment like a small business decision, because that's what it is.