How to negotiate a PA or NP job offer

The strongest thing you can bring to a negotiation is a number you can defend. For PAs, NPs and CRNAs, the best free benchmark is the BLS Occupational Employment and Wage Statistics (OEWS) survey, which publishes wage percentiles nationally, by state and by metro area.

A percentile is a boundary, not an average. BLS explains that the median (50th percentile) is the boundary between the highest paid 50 percent and the lowest paid 50 percent of workers in that occupation. So the 75th percentile is the pay level that 75 percent of workers in that occupation earn less than. That makes percentiles a useful way to place yourself: a new graduate and a clinician with eight years in a procedural specialty should not be anchoring to the same row.

National figures are a starting point. Pull the numbers for the state and metro where the job is: physician assistant salary by state, nurse practitioner salary by state and CRNA salary by state. In Texas, for example, the PA median is $134,550 and the NP median is $131,670, both slightly below the national medians (Texas PA data, Texas NP data).

One caution when you compare an offer to these numbers: OEWS wage estimates do not include nonproduction bonuses or employer costs of benefits such as health insurance and retirement contributions. Compare the guaranteed base (and, if you can estimate it honestly, expected productivity pay) to the percentile. Do not count a sign-on bonus or a retirement match as if it were salary.

An APP offer can have more moving parts than the offer letter shows. Here is the full list, with the question to ask for each one.

You will not win every item, and you should not try to. Pick the three that matter most to your life and your money, and make those the center of your counter.

Some APP offers pair a base salary with a bonus tied to work relative value units (wRVUs). The scale behind wRVUs is the resource-based relative value scale (RBRVS). According to the AMA, the RBRVS is the physician payment system used by CMS and most other payers, and each service is divided into three components: physician work, practice expense and professional liability insurance. The work component reflects the time, technical skill, physical effort, mental effort and judgment, and stress involved in a service.

A wRVU bonus can be generous or nearly impossible to earn, depending on details that rarely appear in the offer letter. Ask these before you accept a lower base in exchange for upside:

• What is the dollar rate per wRVU, and what is the threshold before the bonus starts?
• Is the threshold realistic for this clinic's current volume and my schedule? Ask what the APPs already in the role produced last year.
• Are shared or split visits credited to me or to the physician? Do procedures I assist with count toward my wRVUs?
• Is the bonus paid quarterly or annually, and is there a reconciliation that can take money back?
• Is there a guarantee period while my panel builds, and how long is it?
• Will I get a monthly report of my wRVUs so I can check the math?

1. Get the full offer in writing. Ask for the offer letter and the draft employment agreement together, so you can see the productivity formula, malpractice terms and non-compete before you negotiate pay.
2. Ask your questions before you counter. Use the table above. Missing answers change what you should ask for.
3. Set your anchor. Choose the percentile that fits your experience in this specialty and setting, using state or metro data where the job is.
4. Rank your priorities. Decide your top three items and the ones you will concede.
5. Make one consolidated counter. Put every request in a single email. Asking for one item, agreeing, then asking for another erodes trust.
6. Trade, do not just ask. If the base is fixed, move to sign-on, CME, schedule, start date or tail coverage.
7. Get the revised terms in writing. A verbal yes is not a term until it is in the agreement.
8. Have an attorney review the final contract before you sign, especially the termination, non-compete and malpractice sections.

If you are working with a recruiter, they can carry your counter to the employer and tell you which items the employer has moved on before. See recruiter vs career coach for how that relationship works and who pays for it.

Keep the tone collaborative. You are trying to start a job on good terms, not win a debate. Replace the brackets with your own facts.

• When they ask your salary expectation first: "I'd like to understand the full package before I name a number. Can you share the range budgeted for this role and how productivity pay works?"
• Anchoring with data: "BLS data for [state] puts the [75th] percentile for [PAs] at [$X]. With [n] years in [specialty] and [specific skill, such as first assisting or a procedure you perform independently], I'm asking for a base of [$Y]."
• When the base is fixed: "I understand the base is set. Could we look at the sign-on bonus, an extra week of PTO, or a higher CME allowance instead?"
• On productivity: "Before I can weigh the bonus, could you send the wRVU rate, the threshold, and how shared visits are credited? I want to compare offers fairly."
• On malpractice: "Is the policy claims-made or occurrence? If it's claims-made, I'd like the agreement to state that the practice covers tail coverage if I leave."
• On start date: "I need to give my current employer [x] weeks' notice. Could we set the start date for [date], or tie it to the date my credentialing is complete?"
• Closing: "If we can agree on [item 1] and [item 2], I'm ready to accept. Could you send a revised agreement reflecting those changes?"

This term is easy to skip, and it can cost you money after you leave. HPSO explains that claims-made policies cover claims that occur and are reported while the policy is in force, and once the policy expires, coverage expires. Occurrence policies cover claims for incidents that happened while the policy was active, even if the claim is reported after the policy ends.

If your employer's policy is claims-made, a claim filed after you leave for care you gave while employed needs either tail coverage, which extends the time incidents may be reported on a claims-made policy, or prior acts coverage from your next insurer. Ask in writing: who pays for tail if I resign, if I am terminated without cause, and if I am terminated for cause? Those can be three different answers.

• Base pay and how future raises are decided
• The complete productivity formula, including what counts as your wRVU
• Sign-on and relocation amounts, payment dates and repayment terms
• CME dollars and days, and which license and certification fees are covered
• PTO, holidays, schedule and call expectations
• Malpractice type, limits and who pays tail
• Non-compete radius, duration, scope and any buyout
• Termination notice periods for both sides, with and without cause
• Start date and what happens if credentialing is delayed

When the final version arrives, read it against your notes line by line. Then have an attorney who reviews healthcare employment agreements look at it before you sign. Our PA and NP employment contract checklist goes clause by clause.