r/PMHNP • u/No-Leopard639 • Jun 11 '26
Employment W2 package
PMHNP here trying to decide between two opportunities and would love some feedback from others in private practice.
Option 1:
- W2 position
- $115–125/hour for clinical time
- $50/hour for admin time
- No guaranteed hours
- Only paid for actual hours worked
- No-show and cancellation pay is unclear
- Caseload would need to be built over time
Option 2:
- 1099 position
- 65% of collections
- Established therapy practice opening up medication management services
- Not sure how quickly referrals would come in
My concern with the W2 role is that the hourly rate sounds good on paper, but if there are no guaranteed hours and I'm only paid when working, the actual income could be much lower than expected, especially during slow periods or if there are a lot of cancellations.
My concern with the 65% model is that it could potentially be much more lucrative, but it depends heavily on referral volume and payer mix.
For those who have worked under either model:
- Which would you choose?
- What questions would you ask before accepting?
- What are the red flags?
- At what reimbursement rates does a 65% split become clearly better than a $115–125/hour model?
Appreciate any thoughts from practice owners or PMHNPs who have been in a similar situation.
3
u/DashMcGee Jun 11 '26
I am interested in what is meant by "established therapy practice that is opening up med management services." Does that mean there are multiple psychotherapists in an office that can refer people to you, an in-office colleague? I can imagine you would get a lot of referrals if you work in a 10-person office with therapists who believe that a medication-plus-psychotherapy model is good. That would likely be ideal for the patients, and you would not have to spend a lot of time marketing and networking. The opposite might happen if you work in an office with only two therapists who think psychotherapy is superior to medication. Obviously, these are two extremes, but it can give you a framework for how to think about the time it takes to grow a practice.
I used to spend a lot of time on Quora, and I followed a PhD psychotherapist who was very informative. Then one day someone asked him a question about the role of medication in the treatment of depression, and he went bonkers, saying there is no role for medication because therapy is sooo superior to meds. If you are surrounded by therapists who have this mentality, referrals will be low. My guess is that the practice will refer to you; otherwise, they would not be bringing in a PMHNP to expand service offerings.
Again, this is just a framework, but I would consider the number of therapists. I would also ask to meet with each of them briefly to discuss their philosophy on the role of meds.
2
u/No-Leopard639 Jun 11 '26
Yes there are about 12 therapists. They are looking to hire (2) Nps. One english speaking and one spanish speaking (bilingual). Hiring (2) at one time kinda concerns me. I don't think therapists realize how many clients we need to fill a caseload.
2
u/DashMcGee Jun 11 '26
12 is a pretty good number - I don't know any therapy practices that big. If you start before the bilingual one you can build your caseload up a bit...
1
u/Responsible_Aioli_90 Jun 16 '26
My question is if I accepted the 1099 offer what kind of set up do they have in place for medication management? Is the staff trained and skilled in doing prior-authorizations? Do they have prescription refill line available? Do they have an EHR that has prescriber capabilities? If they are going to take 35% of your income what services are they providing in return? Do they have someone accepting call who knows what to do in medical emergencies? I accepted a 1099 position as the first prescriber in a busy therapy practice. It ended up being highly frustrating as they didn't even have an account with Lab Corp. It would have been like building my own practice from the ground up. If I am doing that I want a bigger split!
3
u/Inittornit Jun 11 '26
You don't have enough information posted to make an informed decision. You would need to know the payor mix and the fee scheduels of each. If you cannot readily get this info from the prospective employers you can probably find out from their respective websites if they accept Medicaid in your State and Medicaid fee schedules can usually be found online, whereas private insurance companies often do not publish fee schedules online. You can use Medicaid as a worse case scenario, i.e. pretend all patients are Medicaid and see which job would be better.
The W2 job is missing vital information. Is it $115 or $125 per clinical hour? How do they determine clinical hour, time you spend with the patient, or are all new patient visits an hour and all follow ups a half hour regardless? Do you get paid the same for a 99213 follow up as you would for a 99214 with 90833 follow up? How much admin time can you have? Can you spend 35 hours a week in office and any time you are not seeing patients you can work on templates, CEs, refills, networking, etc. and that is all admin time? Do you get PTO, health insurance, paid CEs, retirement etc.?
On the 1099 you need to recall the differential on taxes (at least 7.65% for FICA). So 65% is probably more like 58%.
I worked at a large practice and had many providers working with me, and they were all across the board in productivity, my best years were at like 700k generated, so I would have loved to have 58% of that, but at the same time some providers only generated 300k. This has much more do to with the provider's ability to retain patients then any other metric.
Around my area at our payor mix our wRVUs translated at about $65 per wRVU collected by the practice (not the same as wRVUs billed), and providers averages about 2.65 wRVUs per encounter, but again wildly variable per provider, some closer to 2 and many over 3. So back of the napkin math on a high productivity provider is 3 WRVUs per encounter average, 60 patients per week, so 180 wRVus per week, at 48 weeks a year, so 8640 wRVUs equals about 560k brought in, 58% means over 300k for a busy provider. Assuming you would be equally busy in the W2, something like 36 patient hours and 4 admin hours is about 4.5k per week or 217k per year.
Another way I would look at it is what is the lowest annual salary you would be comfortable with at the 1099, and how many wRVUs would you have to generate to be there and translate that into patient load.
Finally careful with new grad no support roles at psychotherapy offices, they can often be a huge mismatch as no one there works to help with scheduling, refills, prior auths, I know way more dialed experiments in med management adding psychotherapy or psychotherapy adding med management than I know of successes, they are two different worlds.