You will get a start date. You will assume it is the day you start earning. It isn't.
Between your contract and your first collectible dollar sits an administrative gap almost no one warns you about — and it can run three to four months. Two processes have to finish before you can be paid, each on its own clock.
The first is credentialing and privileging. The hospital's medical staff office verifies your training, licenses, and malpractice history with the original sources, then a committee grants you privileges. The second is payer enrollment. Every insurer, starting with Medicare, has to enroll you before it pays a cent. You can be fully credentialed at the hospital and still unable to bill a single commercial plan.
Here is how that gap reaches your bank account. If your pay is tied to productivity (RVUs or collections), you can spend your first months seeing a full panel of patients while the claims sit unbillable. Some contracts carry a base-salary guarantee that covers this window. Some don't. That clause is the difference between a first quarter that pays like a job and one that pays like an unpaid internship.
And not all of the gap comes back. Once Medicare approves you, it lets you bill retroactively, but only up to 30 days before your effective date. Most commercial payers don't allow even that, so the work you do before they enroll you is often lost revenue. The delay isn't only a delay; part of it is money you never collect.
What you control is the calendar and the paperwork. Credentialing can begin months before you finish training, so start the day your employer lets you, often four to six months out. Get your state license moving first: your DEA can't be issued until you hold that license number, so they stack rather than run in parallel. Keep your NPI and CAQH profile complete and attested, since most commercial payers pull from CAQH.
And credentialing stalls on missing signatures and slow document returns far more than on any committee decision — your single biggest lever is being the candidate who returns every form the same day.
Before you sign, ask the one question the salary number won't answer: does my guaranteed pay start on my start date, no matter when credentialing finishes? If the answer is no, you've found the most important thing to negotiate.
Your start date is not your payday. Plan for the gap.