A resignation letter arriving before a clinician’s first anniversary always stings. Whether citing “fit,” family needs, or something else, the practice immediately must rework access, rescheduling patients, redistributing call, and stabilizing the care team.  

A quieter problem sits in the offer file: a sizable bonus paid months earlier to recruit the soon-departing clinician. 

Signing and starting bonuses are now common — increasingly for advanced practice providers (APPs) as well as physicians. MGMA continues to track the rise of these incentives and the growing reliance of payback clauses. 

A Feb. 3, 2026, MGMA Stat poll finds that eight in 10 (80%) medical groups use clawback or repayment provisions on signing or starting bonuses if a physician or APP leaves early. Just 16% said they did not, and 4% were unsure. The poll had 304 applicable responses. 

What you told us 

Most respondents said repayment applies to both physicians and APPs, with the majority using prorated schedules based on time worked. A smaller group still requires full repayment. Typical service commitments ranged from one to three years, with a few extending to four or five years depending on specialty or bonus size. 

Among practices that don’t require repayment, leaders said they either avoid signing bonuses, delay or stagger payments, or rely on stronger up-front hiring diligence to mitigate risk. One practice leader disliked clawback clauses entirely, calling them “unhealthy from the start.” 

Repayment clauses can protect the organization’s investment, but they should never be the primary solution. The best outcome is still the one no one enforces: a hiring process and onboarding experience strong enough that the clinician begins building roots well before the repayment window matters. MGMA’s recent workforce research reinforces that retention starts with better recruitment and onboarding, not after-the-fact enforcement.  

Why repayment clauses are becoming standard 

Incentives are a natural response to a tight labor market. Recruitment cycles are long, and the costs of a failed hire compound: lost capacity, disrupted continuity, and the added burden on leaders and clinicians covering the gap. National recruitment benchmarking continues to show lengthy time-to-fill and elevated turnover for physicians and APPs relative to pre-pandemic years. 

Incentive packages also have become more standardized and visible. Recent recruiting incentives data shows sign-on bonuses in a large share of engagements. That transparency cuts both ways: clinicians compare offers more easily, and organizations shoulder greater risk when large, front-loaded incentives don’t translate into longer-term employment. 

Repayment clauses are the natural counterpart. As contract advisors have noted, many agreements now tie sign-on and relocation dollars to one-, two-, or three-year service terms — increasingly prorated rather than “all or nothing.” 

Elements of a well-designed clawback clause 

• Start with definitions: “Signing bonus” and “starting bonus” get used interchangeably at times but they can be operationally different: one may be paid on contract execution, another after start date or after credentialing. Your contract language should match your payroll practice. 
• Use proportional repayment: Monthly proration aligns with how most leaders think about “earned” value. Full repayment late into a multi-year term can feel punitive and increase conflict. 
• Clarify triggers and carve-outs: Specify whether repayment applies to voluntary resignations or terminations for cause. Many advisers recommend waiving repayment when termination is without cause or results from role eliminations, service-line changes, or similar events. 
• Don’t invent repayment mechanics at the end: Spell out how repayment works — lump sum, installments, payroll deduction where permissible. If the bonus is paid in year one and repaid later, tax treatment can become confusing; the contract should state clearly what is owed and how documentation will be provided for repayment. (As always, coordinate with legal counsel and payroll tax advisers.) 
• Make the clause part of a broader incentive philosophy: As our past reporting notes, bonuses with repayment provisions often align with defined commitment periods or orientation milestones. This protects the organization and signals what it values early in the relationship. 

Use the clause to build trust, not to “catch” someone 

If a clinician is surprised by a clawback after deciding to leave, you’ve lost twice: once in turnover, and again in reputation. In a referral-driven talent market, reputational hits travel. 

The better approach is to discuss repayment terms openly and early. Framed well, a repayment clause is a fairness mechanism: incentives represent meaningful investment, and both sides benefit from clear expectations. When clinicians see that the clause is prorated, time-limited, and includes reasonable carve-outs, they usually perceive it as standard. 

Many organizations also reduce enforcement risk by changing how bonuses are paid. Instead of a single upfront payment, consider milestone-based payments (start date, six months, 12 months) or shifting part of the incentive into retention bonuses earned over time. This reduces reliance on clawbacks because less money is unearned at any one point. 

Minimize the odds you’ll ever need the clawback 

Early departures rarely hinge on the bonus itself; it’s normally a mismatch in expectations, workload, support, and belonging. Our workforce reporting repeatedly points to onboarding and engagement as practical levers for retention.  When filling vacancies, begin onboarding immediately after contract signature, provide welcome resources, assign a peer buddy, and schedule structured check-ins across the first year. Those steps matter because many organizations still face physician departures tied to burnout. 

Action steps for practice leaders 

1. Standardize your incentive policy: Define when signing vs. starting bonuses apply, typical ranges by specialty/role, and who approves exceptions. 

2. Use prorated repayment as the default: Keep obligations time-limited (often 12 to 36 months) and avoid full-repayment structures that create unnecessary conflict. 

3. Add fair termination carve-outs: Clarify when repayment doesn’t apply (e.g., termination without cause, service-line closure, disability or death). 

4. Pay incentives in ways that reduce clawback reliance: Consider milestone-based or retention-based structures. 

5. Treat onboarding as a year-long process: Launch pre-start onboarding immediately after signature and use scheduled check-ins to surface early problems. 

A repayment clause helps limit financial exposure when a hire leaves early, but it is not the strategy. The strategy is a hiring and onboarding approach that reduces the risk of mismatch and helps clinicians succeed and stay. In that environment, the clause becomes what it should be: rarely used but reassuring to have.