(SHELBY, NORTH CAROLINA) A 30-year-old Indian kidney specialist hired to serve a rural community in North Carolina is stuck in Hyderabad, India, after a new $100,000 fee on fresh H-1B visa petitions left her employer unable to bring her to the United States. The policy has turned a national immigration fight into a local healthcare crisis.
The doctor, nephrologist Dr. Vijaya Chelikani, was recruited by Nephrology Associates of the Carolinas in Shelby, a clinic that serves more than 165,000 people in what federal officials classify as a health-professional shortage area. The practice says it spent months trying to find a U.S.-born nephrologist, advertising in medical journals and on major job sites. The American applicants who did come forward either wanted transplant work (which the Shelby facility does not offer) or had employment records the clinic considered too unstable for a long-term role in a fragile rural system.
Chelikani, who completed a nephrology fellowship in the United States after earlier medical training in India, briefly flew home to see her family in Hyderabad before starting work in North Carolina. That trip, which should have been a short visit, has turned into an open-ended wait because her employer is now caught between a six-figure immigration bill and the risk of leaving thousands of patients without a full-time kidney specialist.
“I want to start my job,” she told the media, explaining that all of her professional plans are on hold while U.S. officials decide whether to excuse her employer from the new fee under a “national interest” waiver.
What changed: the new surcharge
The problem began with a presidential proclamation signed by President Trump on September 19, 2025, which created a $100,000 supplemental fee in addition to existing costs for certain new H‑1B filings. The rule targets new H-1B petitions filed on or after September 21, 2025 for workers who are outside the United States and do not already hold a valid H-1B visa.
Because Chelikani left the country and did not yet have an approved H‑1B to return on, her case falls directly into that category. The surcharge applies based on the filing date of the petition and the worker’s location and visa status at that time, which instantly altered the financial picture for both the clinic and the incoming physician.
Who is affected — quick summary
- Impacted: New H‑1B petitions filed on or after September 21, 2025 for workers who are abroad and do not already hold a valid H‑1B stamp.
- Not impacted:
- H‑1B employees already inside the United States who are simply extending status or changing employers.
- Workers abroad who already have a valid H‑1B visa to reenter on.
| Situation | Is surcharge triggered? |
|---|---|
| New petition filed while worker is abroad with no H‑1B stamp | Yes |
| Extension or change of employer for worker inside U.S. | No |
| Worker abroad with valid existing H‑1B stamp renewing travel | No |
Policy intent vs. real-world effects
The administration framed the fee as a measure to discourage mass hiring of cheaper foreign workers — particularly in information-technology outsourcing firms that bring thousands of Indian engineers to the U.S. each year. Analysis by VisaVerge.com said the measure was widely read as an attempt to squeeze large outsourcing firms that depend heavily on the H‑1B program.
However, the policy makes no distinction between a global tech giant and a small rural clinic, and it contains no automatic carve-out for doctors or hospitals. The result: a rural nephrology practice in Shelby now faces the same $100,000 bill as a multinational software company when it tries to sponsor a foreign worker.
For large firms filing hundreds of petitions, the fee may be absorbed. For a small clinic serving a low-income population, the surcharge can be a make-or-break decision. The new charge also lands on top of existing H‑1B filing, legal, and compliance costs that employers already pay.
The Shelby clinic’s position and waiver request
Nephrology Associates of the Carolinas says it simply does not have the money to pay the surcharge. The practice’s owner, Dr. Muhammad Alam, has warned that paying the fee would threaten the clinic’s financial stability and could force cuts to services for patients in a medically underserved rural area.
The clinic treats chronic kidney disease, high-risk hypertension and dialysis cases for a largely older, low-income population spread across several counties. Facing this dilemma, Alam has asked the government to waive the surcharge.
Under the proclamation, the Department of Homeland Security (DHS) can grant “national interest” waivers in what officials describe as “extraordinarily rare” circumstances. To qualify for a waiver, an employer must show three things:
- Hiring the foreign worker directly serves the U.S. national interest.
- No qualified American worker is available for the position.
- Forcing payment of the $100,000 fee would itself harm U.S. interests (for example, by closing or shrinking essential services).
Alam argues that Chelikani’s role meets all three conditions: the clinic is already designated in a shortage area, it carried out documented recruitment in the U.S., and the fee could undermine its ability to provide kidney care to more than 165,000 residents. A formal waiver request has been filed, but there is no deadline for DHS to decide and no appeal if officials deny the request.
The waiver process — complexity and uncertainty
- Hospitals and clinics preparing waiver requests must provide detailed evidence, such as:
- Recruitment records
- Patient numbers and community health data
- Financial information showing why paying the fee would harm care
- Immigration lawyers say these requests require careful preparation and still depend heavily on the discretion of individual adjudicators.
- There is no automatic list of job types that qualify, even within healthcare. Although a White House spokesperson suggested physicians, medical residents, nurses and care workers could be candidates for exceptions, those comments did not become a broad written exemption. Instead, each case is decided individually, leaving doctors and their employers in prolonged uncertainty.
Broader implications for healthcare and medical trainees
This case illustrates that the H‑1B visa is not just a tech industry tool. It is a primary work visa for professionals in medicine, academic research, university teaching, and specialized science roles.
Foreign-trained doctors — many from India — often complete U.S. residencies or fellowships and then stay on H‑1B visas to work in hospitals and clinics, particularly in rural or inner-city areas where U.S.-trained physicians are scarce. When the cost to sponsor them jumps by $100,000, it affects:
- The physicians and their career plans
- The employers who would sponsor them
- The patients who depend on their services
For Indian medical graduates pursuing a U.S. career, the fee is another barrier on top of already demanding licensing exams, residency matches and fellowship placements. Those who return briefly to cities like Hyderabad to visit family may now think twice, aware that being abroad at the wrong time could trigger a massive surcharge on a new petition.
Students and residents say Chelikani’s case has changed how they think about long-term plans. Immigration lawyers note that some may seek alternative visa paths or prioritize early planning for green card sponsorship if employers hesitate to file new H‑1B petitions subject to the fee.
Practical consequences for rural care
Small hospitals and clinics in rural America fear the fee will make it even harder to recruit specialists, deepening long-running shortages in fields such as nephrology, psychiatry and primary care. These facilities already struggle to match salaries offered by large urban centers. If they must also absorb a $100,000 surcharge for each new foreign doctor who is still abroad, some may stop recruiting internationally and leave positions unfilled.
The Shelby case also highlights planning risks for employers and workers. Nephrology Associates of the Carolinas recruited Chelikani before the fee existed and assumed standard H‑1B costs. The presidential proclamation arrived weeks before she was due to begin work. Because the surcharge is triggered by petition filing date and applicant location/status, it unexpectedly paused her onboarding.
For Chelikani, the impact goes beyond money. Her professional life is frozen: she cannot treat patients who were expecting her in Shelby, and she cannot easily take another specialist job in India while she waits, because she may need to leave at short notice if the waiver is approved. Her U.S. nephrology training is currently unused, even as the sponsoring clinic struggles to cover heavy caseloads with limited staff.
Policy context and resources
Advocates for international medical graduates say her story is a warning about how sweeping immigration reforms can affect real lives in unexpected ways. A rule intended to curb perceived abuse in the tech sector has delayed kidney care for thousands of rural Americans and trapped a trained specialist overseas.
For official guidance about H‑1B eligibility and filing rules, DHS and U.S. Citizenship and Immigration Services offer information on the USCIS H‑1B page at https://www.uscis.gov/working-in-the-united-states/temporary-workers/h-1b-specialty-occupations-dod-cooperative-research-and-development-project-workers-and-fashion-models. That guidance explains which cases count as new petitions and which are extensions or changes of employer — a distinction now carrying life-changing consequences for professionals like Chelikani.
What happens next in Shelby
Everything in Shelby now depends on DHS’s decision about one waiver request. If officials determine that bringing a nephrologist from Hyderabad to a shortage-area clinic in North Carolina serves the national interest and that the clinic should not have to pay the $100,000 H‑1B fee, Chelikani could receive approval, apply for her visa and travel to the U.S.
If DHS denies the waiver, the clinic faces two choices:
- Absorb a charge it says it cannot pay and proceed with sponsorship, or
- Abandon the hire and restart the search for a new nephrologist
In the waiting room at Nephrology Associates of the Carolinas, these policy debates manifest quietly: in longer appointment gaps, rushed follow-ups, and the uncertainty of patients who were told a new kidney doctor was coming and still wonder when — or whether — she will ever arrive.
A presidential proclamation created a $100,000 supplemental fee for new H‑1B petitions filed by workers abroad without valid H‑1B visas. Nephrologist Dr. Vijaya Chelikani, hired by a Shelby, North Carolina clinic serving over 165,000 people in a shortage area, is stuck in Hyderabad while the clinic requests a rare DHS national‑interest waiver. The surcharge treats small rural employers the same as large firms, threatening specialist recruitment and patient care, with waiver outcomes discretionary and potentially lengthy.
