The shifts are worked, the notes are signed, and the money still hasn’t arrived. A fellow on Reddit described a “mandatory” moonlighting rotation that was still unpaid months later, and then an email saying an individual DEA registration had been required all along, even though the written guidance the fellows were given said it wasn’t. Other fellows were in the same spot. Moonlighting is one of the few ways to raise income during training, as our guide to surviving residency notes, but the gap between doing paid work and getting paid for it is mostly paperwork, and most of that paperwork has to exist before the first shift.
We covered withholding and resident cash flow in an earlier post. This one is about eligibility, collecting money you’re owed, and the clawbacks and contract clauses that follow you into your first attending job. It’s general education, not legal or tax advice. When real money is in dispute, an hour with an employment attorney or a physician-savvy tax preparer costs less than guessing.
Five things to have in writing before your first shift
- Written permission from your program director. ACGME’s Common Program Requirements say PGY-1 residents are not permitted to moonlight, and that internal and external moonlighting hours count toward the 80-hour weekly limit. Institutional policies, such as this one from Arizona, cite the ACGME requirement for written PD permission and make you renew it every academic year. If you’re an intern who needs side income, the answer for now is no.
- Whose DEA registration and license you’re working under. The institutional DEA number with your resident suffix covers program activities. Some GME policies, like Dartmouth Health’s, say outright that it can never be used for moonlighting. External shifts usually require your own unrestricted license and your own DEA registration.
- A malpractice certificate naming you and this work. “You’re covered” in a hallway conversation isn’t a certificate.
- Your visa status, cleared with your GME office. Cleveland Clinic’s policy is typical: J-1 physicians can’t do independent practice outside the program, and an H-1B physician moonlighting for a different employer needs that employer to file a concurrent H-1B petition first.
- The rate, the classification and the pay date, in an email. W-2 or 1099, hourly or per shift, and who to contact when a check is late.
When the money doesn’t arrive: an escalation ladder
Start with an itemized record of dates, hours, site and the email that set the rate. Then send one short written request to the person who scheduled you, copying whoever runs payroll for that site: “I worked the shifts listed below between [dates] at the agreed rate of [rate]. I haven’t been paid for them. Please confirm when payment will be issued.”
If two weeks pass with no answer, go up one level. For internal moonlighting, that means the GME office and, if needed, the DIO, since the program approved the arrangement. If several fellows are owed money, send one joint letter. A group claim reads as a systems failure, not one person’s paperwork mix-up, and is harder to slow-walk.
Know which outside door is actually open. Under federal overtime law, the salary tests don’t apply to practicing physicians, and residents in training are covered by the same exemption, so a federal overtime claim isn’t your tool. Earned but unpaid wages are a different question, usually handled under state wage-payment law through your state labor department or small claims court. Check your state’s filing deadline before waiting another quarter.
A requirement that shows up after the work is done
If you’re told after the fact that you needed an individual DEA registration or some other credential, reply in writing and quote the guidance you were originally given. Ask two specific questions: is payment for hours already worked being withheld because of this, and what exactly is required for future shifts? Don’t agree to anything that trades away pay for completed work. Fix the credential going forward, treat the past shifts as a separate issue, and call an employment attorney if the pay is still withheld.
Signing-bonus clawbacks: silence isn’t a release
A hospitalist who left a few months short of a bonus commitment described offering to repay it and hearing nothing back from HR. That silence isn’t forgiveness. Clawback language can be enforced long after you’ve left. Ask for a written payoff figure, pay it, and get a signed release that says the obligation is satisfied.
The tax treatment depends on timing. According to this breakdown of repaid signing bonuses, repaying in the same calendar year lets the employer take the bonus off your W-2. Repaying in a later year means paying back the gross amount. Above $3,000, Section 1341 lets you take either a deduction or a credit for the earlier tax, whichever is better. At $3,000 or less, the same source says there’s no federal deduction, because the 2025 tax law made the suspension of miscellaneous itemized deductions permanent. Ask a tax preparer before you pick a repayment date.
The non-compete that caps your side income
A new attending found that the non-compete in an otherwise comfortable job barred all moonlighting, capping income for the life of the contract. A Texas court blocked the FTC’s rule in 2024, and the agency dropped its appeal in September 2025. Protection now depends on your state, and several, including Massachusetts, Indiana and Oregon, restrict physician non-competes to varying degrees. Before signing a first contract, ask for a carve-out: “I’d like the restrictive covenant to exclude per diem or locum work outside [the employer’s service area or specialty line]. Can we add that?” The worst answer is no, and the question is far easier to ask before signing than after.
The resident who gets paid isn’t necessarily working the most shifts. It’s the one who has the permission letter, the coverage certificate and the rate email in a folder before day one, and who sends a polite, dated written request the first week a check is late.