Telemedicine, Locums, and Side Gigs: Visa Limits for IMG Physicians

Most of what IMGs hear about side gigs and telemedicine is dangerously incomplete—and sometimes flat-out wrong under U.S. visa law.

You can lose status, get denied future visas, or tank a green card case because you decided to “just pick up a few telehealth shifts from home.” I have watched it happen. More than once.

Let me break this down specifically, visa by visa, gig by gig.

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The Core Rule Everyone Tries to Ignore

Every visa you will realistically touch as an IMG physician in the U.S.—J‑1, H‑1B, O‑1, TN, E‑2, etc.—is employer specific and location specific unless explicitly structured otherwise.

That means:

• You are authorized to work only:
  • For the employer on your petition/DS‑2019
  • In the role described
  • At the location(s) listed
• Anything outside that box is unauthorized employment.
  It does not matter if:
  • It is “remote from my apartment”
  • “My PD said it’s fine”
  • “It is just 2 hours a week”
  • “They are paying my LLC, not me personally”

USCIS and State Department do not care about your side agreements. They care about what is on the approved petition and supporting documents.

Keep that in your head as we walk through telemedicine, locums, and side gigs.

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J‑1 Residents and Fellows: You Basically Have No Side Gig World

If you are in J‑1 graduate medical education status through ECFMG, the answer for 99% of “can I do X?” is: No.

What your J‑1 actually allows

Your J‑1 is for:

• Graduate medical education or training
• In the specific program and specific institution listed on your DS‑2019
• Under ECFMG sponsorship with a clearly defined training plan

That means:

• Your “employer” in immigration terms: the residency/fellowship site listed
• Your “job”: training at that program, period
• Moonlighting is not a “side gig” under immigration law. It is either:
  • Part of your training if built into the program (and permitted per ACGME/ECFMG rules), or
  • A problem

ECFMG guidance is unambiguous: clinical activity outside the approved training program is not allowed unless it fits within strict, prior-approved parameters. And those parameters are narrow.

Telemedicine on J‑1: why it is almost always a violation

Scenario I see constantly:

PGY‑3 internal medicine J‑1 resident, doing evening video visits for an online urgent care company, from his apartment, charting in their EHR, paid as a 1099 contractor.

He tells me: “But I am physically in the U.S. on my valid J‑1, and I am just doing extra medicine, so it should be fine, right?”

No.

Here is why:

• Employer not your training sponsor
  The telemedicine company is a separate employer. Not on your DS‑2019. Not part of the ECFMG-sponsored program.

• Activity not part of training plan
  Your training program isn’t supervising those visits, credentialing you for them, or evaluating you on them.

• Classification mismatch
  Your J‑1 category is “alien physician in graduate medical education.” That is not a generic license to practice medicine anywhere.

So telemedicine shifts for a separate company are unauthorized employment. If discovered, it can:

• Lead to J‑1 termination by ECFMG
• Create unlawful presence or status violations
• Cause major issues at consular renewals
• Sabotage future H‑1B or waiver filings (because you have a documented history of unauthorized work)

The same applies to:

• Teleradiology reads for a private group
• After-hours outpatient tele-psychiatry for another clinic
• Cross-state telemedicine gigs not tied to your training program

Locums on J‑1: essentially off the table

Locums is literally the definition of “different employers, different locations, short term.”

J‑1:

• Employer fixed (training program)
• Locations fixed (training sites, listed on DS‑2019 or supporting docs)
• Purpose fixed (education)

You cannot just pick up a 7‑on/7‑off locums block in another hospital, even if:

• You have the state license
• The hospital credentialed you
• GME office verbally said, “if it is on your own time, that is your business”

Immigration law does not care about “your own time.” It cares about status.

Non-clinical side gigs on J‑1

People get clever:

• “Can I do paid medical consulting for a startup abroad?”
• “What about being paid for an online board review course I help teach?”
• “Paid medical-legal chart review?”

If the activity is work (and if you receive compensation, it almost always is), and it is not part of your J‑1 training program, it is a problem.

ECFMG sometimes approves limited “incidental” scholarly honoraria (e.g., a one-time lecture with small honorarium), but that is not a full consulting contract or ongoing gig. If you are thinking of recurring work, assume the answer is no unless:

• You get explicit ECFMG approval in writing, and
• It clearly fits within the narrow interpretation of allowed incidental honoraria

And even then, be careful. Consular officers have denied visas over patterns of unapproved extra work.

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H‑1B Physicians: You Have Options, But They Are Narrow and Technical

Once you are in H‑1B as an attending—or even occasionally as a senior fellow—your side gig options expand. But this is where people get themselves into trouble with sloppy locums and “remote” assumptions.

Key concept: each employer needs its own H‑1B

Your first mental reset:

H‑1B is employer specific. It does not give you a blanket permission to practice medicine anywhere.

You want to:

• Work full-time at Hospital A, and
• Pick up telemedicine or locums with Group B?

Then Group B needs:

• Its own H‑1B petition for you, usually as “concurrent H‑1B”
• With:
  • Defined hours (part-time allowed)
  • Role and site(s) described
  • LCA (Labor Condition Application) certified for the work locations

Only after USCIS approves that concurrent H‑1B can you legally work for Group B.

Telemedicine on H‑1B: the two big traps

Trap 1: “I am working from home, so no new petition is needed.”

Wrong.

For H‑1B purposes, the worksite is where you are physically located when you perform the work. If you are:

• In Illinois, doing telehealth for a Texas group
• Working from your apartment three nights per week
• Charting in their EHR, billing under their system

Your apartment is the H‑1B worksite for that second employer.

That requires:

• LCA covering that county/metro area
• H‑1B petition acknowledging remote work from that location
• Compliance with wage requirements for that area

Trap 2: “It is 1099, I am an independent contractor, so it does not count as employment.”

USCIS is not impressed by your 1099 label.

They look at:

• Is there a company directing your work?
• Are you providing services in exchange for compensation?
• Is there a continuing relationship?

That is employment. You need an H‑1B for it.

If you create an LLC and route telemedicine income through it, that does not magically solve the problem. The question is still: what is your authorized employment activity under H‑1B? Not “how is the IRS seeing this.”

Locums on H‑1B: possible, but only if structured correctly

Locums assignments involve multiple sites, changing locations, and short contracts. USCIS hates ambiguity here.

To do locums on H‑1B legally, the locums company must:

1. File an H‑1B petition listing:
   • Physician role
   • Anticipated work hours (part-time can be broad, e.g., 5–20 hrs/week)
   • Supervision structure (if any)
2. Attach LCAs that:
   • Cover all anticipated worksites, or
   • Are amended as new sites are added (if “non-commuting distance” from prior sites)
3. Amend the H‑1B if:
   • There is a material change in job duties or primary work location

The reality:

• Many locums firms will not bother for IMG physicians unless you are extremely high value and stable.
• Those that do will insist you keep them updated on every location, schedule shift, and long-term change.

If a locums company says:

“We do not need an H‑1B petition because it’s PRN and 1099; you are just moonlighting…”

Run.

H‑1B and “passive” side income

This category is less dangerous but still misunderstood.

Generally allowed:

• Investing passively in:
  • Index funds
  • Real estate where you are not materially participating in daily operations
  • Startup equity where you are not yet working for the company
• Royalties from:
  • Previously published books
  • Previously created online courses (as long as you are not actively “working” to maintain/teach live under the new visa period)

Gray zones:

• Running a YouTube or social media channel that earns ad revenue
  If you are actively creating and uploading content regularly, that can be characterized as unauthorized self-employment.

• Real estate where you:

  • Screen tenants
  • Manage maintenance
  • Act as landlord day-to-day
    That is not passive in the eyes of immigration authorities.

If your “side gig” needs you to do continuing, active, directed work, assume you either:

• Need it baked into an H‑1B petition, or
• Should not be doing it

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O‑1 Physicians: More Flexible, Still Not a Free-for-All

Some IMG physicians graduate from J‑1 or H‑1B into O‑1 status, especially academic types with strong CVs. O‑1 can be structured to allow more varied work. But structure is the key word.

How O‑1 can help with side gigs

Unlike H‑1B, O‑1 does not require an LCA and can be more flexible if:

• You use an agent or management company as the petitioner
• The petition outlines:
  • Multiple worksites
  • Multiple employers or clients
  • A general scope of “clinical, academic, and consulting work in [specialty]”

This can allow:

• Clinical work at several hospitals
• Speaking gigs
• Consulting for health tech companies
• Limited telemedicine platforms

But only if the O‑1 petition is drafted intentionally that way, with:

• Contracts or deal memos from each anticipated employer/client
• Itineraries of locations and time frames
• Clear evidence you are extraordinary in that field (O‑1 baseline)

Where O‑1 physicians still get burned

Common mistakes:

1. Petition narrowly drafted for one hospital employer
   Then you start doing side telemedicine or additional hospital work “because I have O‑1, that is allowed.” It is not, unless those gigs fall within the itinerary and employer relationships described.

2. Massive expansion beyond original scope
   Original petition: academic cardiology, defined clinical + research role.
   New side gig: heavy tele-ICU across multiple states through a commercial vendor, no contract or mention in original O‑1.
   That can easily be classified as unauthorized work.

3. No updates, no amendments
   O‑1 is more forgiving about amendments than H‑1B, but large changes in employment structure, number of employers, or nature of work still should be documented with USCIS.

O‑1 can be a fantastic platform for diverse work, but only if you have an immigration attorney who understands physicians and builds in your side gig plans from day one.

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Telemedicine Complications: Licensure and Location

Immigration is only half the telemedicine story. The other half is state licensure and where the “practice of medicine” legally occurs.

Two geography layers matter:

1. Immigration geography: where are you physically sitting when you work?
2. Medical law geography: where is the patient located?

Classic telemedicine scenario

You are:

• Sitting in New York
• On H‑1B sponsored by a New York hospital
• Doing tele-psychiatry for patients located in Florida
• Licensed in both NY and FL

Immigration side:

• Your H‑1B must authorize you to work:
  • For that tele-psychiatry employer
  • From your New York location (LCA for your county)

Medical licensing side:

• You must hold a Florida license (because patient is in FL)
• Plus whatever your home state requires; most boards care more about patient location, but some have extra rules

If you move apartments or states and keep doing the same telemedicine gig, you may trigger:

• A need for new H‑1B LCA and possibly an amendment
• New state licenses depending on patient mix

Do not assume “it is telemedicine so location does not matter.” For immigration, it absolutely does.

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Locums Specifics: Visa by Visa Reality Check

Let us be concrete and blunt.

Visa Type	Locums Feasibility	Key Barrier
J-1 (ECFMG)	Nearly impossible	Employer and purpose strictly limited to training
H-1B	Possible with effort	Each locums company needs petition + LCAs for sites
O-1	Moderately flexible	Petition must pre-include multi-site, multi-client structure
TN (for Canadians/Mexicans)	Limited	Employer-specific, each locums company would need its own TN

For each:

• J‑1: Ignore locums. Focus on training, then waiver or home return. Locums will be there later.
• H‑1B: Locums workable if:
  • You have a stable main H‑1B job
  • Locums company is willing to file concurrent H‑1B
  • You are disciplined about not touching any assignment that falls outside the petitioned worksites
• O‑1: If structured with an agent and broad itinerary, you can do locums-like practice more fluidly, but still within the petition framework.

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Green Card Stage: Does Anything Change?

Once you enter the EB‑2 NIW / EB‑1 / PERM / I‑140 / I‑485 world, the rules on side gigs depend on whether you are:

• Still on a nonimmigrant status (J‑1/H‑1B/O‑1) while your green card is pending
  → You must still follow that nonimmigrant status’s employment rules. The I‑485 filing does not magically free you.

• On an EAD (Employment Authorization Document) from a pending I‑485
  → You can, in theory, work for any employer and have multiple gigs.

But two huge caveats:

1. Immigrant intent consistency
   For categories like EB‑2 NIW or EB‑1A, you told USCIS you plan to work in a particular field and usually gave some coherent plan. If your actual work becomes totally fragmented—e.g., half cosmetic tele-dermatology, half random chart reviews, no visible commitment to the national interest project you pitched—USCIS can view that skeptically at the green card adjudication stage.

2. If you are maintaining H‑1B or O‑1 while I‑485 is pending
   Many physicians keep H‑1B active even with an EAD as a safety net.
   In that case:

   • Any work you want to count as H‑1B-compliant must follow H‑1B rules.
   • If you use your EAD to work outside H‑1B scope, you have technically moved off pure H‑1B and are now “in” I‑485-pending status via EAD. That can have implications for travel and fallback options.

Bottom line: The EAD card is more flexible, but do not assume USCIS will not care how scattered your work looks relative to your green card narrative.

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Practical Strategies: What You Can Safely Do at Each Stage

Let me give you a realistic, stage-based mental model.

During J‑1 residency/fellowship

Safest posture:

• No extra clinical work outside the training program
• Scholarly or speaking honoraria only if:
  • One-off or very occasional
  • Pre-cleared with ECFMG and your GME office
  • Directly related to your training/field

Non-clinical, genuinely passive strategies:

• Investment income where you are not actively managing:
  • Index funds
  • Long-term real estate handled by property management companies

Anything that looks like regular, active business or employment → assume forbidden.

Early H‑1B attending years

Priorities:

• Stabilize your primary H‑1B role.
• Use your first 12–18 months to:
  • Build reputation
  • Avoid any hint of status violation
  • Work with an immigration attorney to map out long-term side-gig goals

Side-gig playbook:

• If you want locums or telemedicine:
  • Identify one or two serious secondary employers
  • Have them file concurrent H‑1Bs
  • Start with small, clear time commitments
  • Ensure LCAs cover your actual remote/work locations

Low-risk non-employment activities:

• Passive investments
• Carefully structured royalties (e.g., from a book or course substantially created before current status)

O‑1 / mid-career phase

If you can qualify for O‑1:

• Work with a lawyer who:
  • Understands O‑1 for physicians (not generic O‑1 for artists)
  • Is comfortable using an agent model
• Design an itinerary that:
  • Covers clinical work
  • Anticipates consulting/telemedicine
  • Includes realistic but broad coverage of your intended side gigs

Do not treat O‑1 as “open market.” It is curated flexibility, not chaos.

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A Quick Flow: Should I Take This Side Gig?

Use this mental flow first, then talk to counsel.

Side Gig Eligibility Decision Flow for IMG Physicians

Step	Description
Step 1	Offered Side Gig
Step 2	J-1
Step 3	H-1B
Step 4	O-1
Step 5	Almost certainly no\nunless ECFMG-approved honorarium
Step 6	Yes -> Check duties/location vs petition
Step 7	No -> Needs concurrent H-1B + LCA
Step 8	Yes -> Likely OK within scope
Step 9	No -> Consider amendment/new O-1 structure
Step 10	What is my current status?
Step 11	Is employer on my H-1B?
Step 12	Is gig covered by O-1 petitioner/itinerary?

If you are honest with yourself at each box, you will avoid 80% of the common disasters.

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One More Ugly Reality: “But No One Will Notice…”

I have heard every version:

• “Everyone in my program does telemedicine.”
• “The locums company said they place H‑1B docs like this all the time.”
• “I have been doing this for years and never had an issue.”

Until:

• A consular officer pulls your tax transcripts at a visa renewal and asks,
  “What is this 1099 income from ‘TeleHealthCo LLC’ while you were on J‑1?”
• USCIS issues an RFE on your H‑1B extension:
  “Explain and document all employment activities during prior status, including any 1099 work.”
• An internal HR audit at your hospital flags outside clinical activity not disclosed in credentialing.

I have seen J‑1 waivers denied and green cards cratered over this. Not hypothetical. Real careers.

If a side gig is not legal on paper, do not comfort yourself with “everybody does it.” Everybody is not standing next to you at the visa window in your passport’s most vulnerable moment.

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FAQ (Exactly 5 Questions)

1. Can I do telemedicine for patients in my home country while I am in J‑1 or H‑1B status in the U.S.?

This is one of the thorniest gray areas. Immigration law cares about where you are physically located when you “work.” If you are physically in the U.S., providing medical services—even to patients abroad—can still be treated as U.S. employment. If you are on J‑1, assume this is prohibited unless ECFMG and your program explicitly approve a very narrowly defined academic tele-consulting arrangement. On H‑1B, if you are paid for this work, a conservative reading says you need an H‑1B petition that covers this employment, even if the company is foreign. If the foreign hospital or clinic has no U.S. entity and pays directly in foreign currency, some lawyers treat this as less risky, but it is still not risk-free. Do not do this casually.

2. My J‑1 program allows internal moonlighting. Is that immigration-safe?

Usually yes, if two conditions are met. First, the moonlighting is explicitly approved by your program and allowed under ACGME and ECFMG rules (e.g., not violating duty hour limits, appropriately supervised if needed). Second, the moonlighting is at the same institution(s) and within the training framework already documented for your J‑1. Classic example: a senior resident picking up extra in-house call shifts at the same hospital under the same GME umbrella. Once you start crossing to different hospitals or separate corporate employers, it generally stops being immigration-safe.

3. Can my spouse on H‑4 EAD or J‑2 EAD do telemedicine or locums without all these restrictions?

Yes, your spouse has more freedom than you do. H‑4 with EAD and J‑2 with EAD are employment-authorized “open market” categories. They can work for any employer, in any lawful job, including locums or telemedicine, without separate H‑1B or O‑1 petitions. They still need to comply with state medical licensure and malpractice rules, of course. But from an immigration standpoint, they are not employer-specific the way you are. Do not confuse your own restrictions with theirs.

4. If a hospital pays me a one-time honorarium for giving a Grand Rounds talk, is that unauthorized employment?

One-off honoraria for academic talks are typically low risk, but the details matter. On J‑1, ECFMG has specific policies about incidental lectures and payments; you should clear such activities with ECFMG and your program in advance. On H‑1B or O‑1, a single honorarium from another institution for a lecture closely tied to your field is unlikely to be a problem, especially if it is framed as a speaking fee rather than employment. Problems arise when “one-time” becomes monthly, or when you start doing ongoing teaching, consulting, or clinical work without proper petitions.

5. If my concurrent H‑1B for locums is approved, can I work at any hospital that locums agency sends me to?

No, not “any” hospital. Your concurrent H‑1B must cover the types of assignments and locations you will actually work. That means LCAs and worksite lists for each non-commuting-distance location. If the locums agency later wants to place you in a state or region not covered by the original H‑1B/LCA set, they may need an amended petition before you start there. The safest approach is: do not accept any assignment until you see that the location is within the current approved itinerary/LCA footprint or your attorney has confirmed an amendment is not required.

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If you remember nothing else:

1. Your visa status, not your free time, dictates what work you can do.
2. Telemedicine and locums are not loopholes; they are employment that must be explicitly authorized.
3. A couple of extra dollars now is never worth a denied visa, J‑1 waiver, or green card later.