Any NPs ever been paid this way?

carachel2 · Dec 30, 2010

It sounds fun, challenging and interesting....but I share your reservations. I work for a solo Family Practice doc and his hours are crazy and he provides *amazing* care and runs his business really well. He also finds the time to sit down and make out individual paychecks that have taxes withheld, etc. IF this guy is known as a rule breaker in regards to traditional bureacratic stuff and how it is done, I wouldn't put it past him to be somehow cheating someone (IRS, etc.) and that is why he is using the whole cash system.

My other concern is that if you DO plan to stay in your community after your DNP, then the reputation of having worked with this doc is bound to follow you. That may put a lot of barriers in your way as you try to find further clinical sites, new jobs, etc.

And finally, it has been my experience that Dr.'s don't readily bail on each other. The good old boy network is alive and well in keeping their bonds among each other strong. It takes something DRASTIC in order for them to turn on a peer. If ALL the other docs in town hate him, there has to be a reason beyond just him thumbing his nose at rules and stuff.

Christen, ANP · Dec 30, 2010

I would make sure I had a written contract in place in addition to all the other NP paperwork you have to do for your state. You'd have to buy your own malpractice insurance, which isn't too bad I guess. I'd talk to an accountant or someone about how to manage being paid in cash to make sure you pay out what you're supposed to and to make this as official as possible.

smkiya, BSN, RN · Dec 30, 2010

It sounds fun, challenging and interesting....but I share your reservations. I work for a solo Family Practice doc and his hours are crazy and he provides *amazing* care and runs his business really well. He also finds the time to sit down and make out individual paychecks that have taxes withheld, etc. IF this guy is known as a rule breaker in regards to traditional bureacratic stuff and how it is done, I wouldn't put it past him to be somehow cheating someone (IRS, etc.) and that is why he is using the whole cash system.
My other concern is that if you DO plan to stay in your community after your DNP, then the reputation of having worked with this doc is bound to follow you. That may put a lot of barriers in your way as you try to find further clinical sites, new jobs, etc.
And finally, it has been my experience that Dr.'s don't readily bail on each other. The good old boy network is alive and well in keeping their bonds among each other strong. It takes something DRASTIC in order for them to turn on a peer. If ALL the other docs in town hate him, there has to be a reason beyond just him thumbing his nose at rules and stuff.

I agree with this. This may not be a good way to start a new career, and may come back to haunt you. If he is mixed up in something controversial that ends up causing scrutiny from the board/state/DEA, you will also be "mixed up" in it by default.

coast2coast · Dec 31, 2010

There are an awful lot of red flags here. Sounds like there is monkey business going on with taxes, and if the IRS arrives on his doorstep, you'll become a part of that chaos.

Add to that his reputation, which makes it sound like a recommendation from him could actually harm your future job applications ...

If you don't need this job I'd seriously think twice before taking it.

Spacklehead, MSN, NP · Dec 31, 2010

Yep, that whole set-up sounds a little odd. Also, even though you state you might not need the benefits now, you have to remember that social security won't be taken out, either, which may affect you down the road a ways when you might need it (if it's even still in existence!). I'm sure there will be better opportunities in the near future if you just hold tight.

I'm also wondering if insurance companies won't credential him (for specific reasons); hence the reason he takes cash only. That could also impact you in the future if you use him as a reference to get credentialed.

core0 · Jan 1, 2011

Yep, that whole set-up sounds a little odd. Also, even though you state you might not need the benefits now, you have to remember that social security won't be taken out, either, which may affect you down the road a ways when you might need it (if it's even still in existence!). I'm sure there will be better opportunities in the near future if you just hold tight.
I'm also wondering if insurance companies won't credential him (for specific reasons); hence the reason he takes cash only. That could also impact you in the future if you use him as a reference to get credentialed.

Umm if you get paid and the employer isn't withholding then its your responsibility to pay social security. To the OP google 1099 employment to get an idea of what you have to do. At a minimum its 15% tax for social security (maybe a little less this year) and quarterly tax withholding. Also with the insurance, depending on the policy you may have to pay a tail (which can be fairly expensive). Most businesses figure 30-50% of an employees salary for additional expenses. So that $50/hr is really like $35-40 or so.

As for the no insurance there are a fair number of practices that do this. If you google concierge medicine you can find some articles on this.

linearthinker, DNP, RN · Jan 1, 2011

Thanks for your thoughts. I am fairly confident that the issues to be concerned about don't involve tax dodging, lol. I have done contract work in the past, and am familiar with the tax issues on my end. I already have enough SS credits to qualify anyway, though I expect to collect my spouses. My spouse is the breadwinner and carries all benefits and has retirement under control. I'm not worried about that.

Dr S has been going the route of concierge medicine for about 3 years now. He says the overhead involved with billing, re-billing, and re-billing insurance companies and medicare outweighed the benefits of accepting them. Patients pay up front and if they are insured, can file their own claims for reimbursement. There are no issues w/ his credentials. He opted not to work with the hospital system anymore due to difficulty billing with his new payment structure, and also because he has a habit of looking for the absolute cheapest way to treat his patients. If it isn't on the $4 list at wal-mart, he doesn't rx it unless there is absolutely NO alternative, lol. He routinely makes house calls and admins IM abx, etc to avoid hospitalization and save the pt money, as well as always having ordered the minimum tests, etc. The hosp admin used to harass him endlessly for not bringing in enough revenue. He also tended to be behind on his charting by about a year, lol.

No, the problem for me is his reputation, which is for being a malcontent (much like myself to nsg admin, he and I are very alike this way). He is a cross between Andrew Weil and Patch Adams. He and his wife live in a yurt and drive these really old cars that they run on vegetable oil -yes, I'm serious. He has a beard and pony tail, both to his waist, and she wears these really odd mumus (she is a very large lady) with outrageous hats. I love her, she is very eccentric to say the least. The "ladies who lunch" etc despise her. Her Dad is a legal big whig here too. Anyway, they are both just square pegs that never fit in with the establishment and don't hesitate to tell establishment types they are hypocrites, posers, etc etc. They don't socialize with the rest of the professional community.

I have not ever heard anyone suggest Dr S isn't competent, but they do scoff at some of his interventions. He likes to use folk remedies, etc when possible. Honey for a cough (not pneumonia obviously, but he isn't going to rx drugs when old timey remidies and OTC stuff will solve the prob). For example, he is famous for using boric acid capsules (health food store here has them) or yogurt tampons for yeast infections, comfrey for rash, net pot irrigation for sinus infections, etc. Other docs are more the metrodiazonale and steroid creme types ;-). People who WANT prescriptions generally don't like him. He will not treat chronic pain and refers those people to pain clinics. He does use schedule IIs for acute episodes but no chronic benzos or narc pains meds. This, and the fact that he doesn't take medicare or caid, effectively dumps the most undesirable patients (i.e the lowest paying visits, fibromyalgia and chronic migraine sufferers and the like, drug seekers and sundry hypochondriacs) on the other area docs, which is another reason they hate him. They don't like him b/c he doesn't look, talk or act like they expect.

I don't know how long I"ll live here or if I'd ever need to work with some of the people that dislike him. I DO socialize within the professional community and with a lot of the people that shun him. That is a concern. I don't want to be in the position of having to constantly defend him, or my choice to work with him. I know people in my social circle would raise an eyebrow, at the very least. Hopefully I would not be ostracized, I doubt it b/c of my spouse's professional standing, but who knows. It might be uncomfortable. He's a good guy, but it's complicated, and very hard to explain.

I am worried about both my social and professional reputation. I don't have any other job prospects, and would not be interested in anything FT under any circumstances. With so few NP jobs here, I seriously doubt as a new grad I could walk in and name my own terms like I could with Dr S.

He has not had a NP in his practice since he went concierge. In the past I gather he's had a typical business arrangement with them, but I don't know how it might be different now. I don't know what questions to ask or guarantees to request be put into place. Thanks for readin all this. YOur additional thoughts are appreciated.

Spacklehead, MSN, NP · Jan 1, 2011

Thanks, David - I do realize that. Some people might forget that, though.

Spacklehead, MSN, NP · Jan 1, 2011

He does sound like a fascinating doc - it's a shame his rep isn't good. I would actually prefer a doc like him to treat me - research has found that buckwheat honey has been found to be as good, if not better, at helping with coughs (due to URIs). Boric acid tampons have also been found to be effective at controlling lady partsl yeast infections; neti pots can do wonders. Too bad more practitioners don't follow his lead and prefer to go for the big guns unnecessarily.

shannons1 · Jan 2, 2011

There is some risk, as mentioned before, but it does sound like a really

interesting opportunity. Since it seems very part time maybe you could give it a try, being very clear with him that you'd like to try it out for "x" amount of time then make a commitment? With the limited amount of NP jobs available there this could be a good thing! Good luck in your decision!!

canchaser, BSN, RN · Jan 2, 2011

Wow, u r describing a holistic doctor. Imagine someone using honey for coughs ect. I am hoping to practice like him some day. I agree to practice with him for x amount of time. I can understand the concern for shunning by the community but it sounds like he can teach u a lot of holistic medicine that likely was not taught in your program. Good luck