In opt-out states, CRNAs can administer anesthesia, bill Medicare and Medicaid directly, and operate their own anesthesia practices without physician supervision. This is one of the highest-earning business opportunities available to any advanced practice provider — independent CRNAs frequently earn $350,000–$500,000+ annually, and those who build group practices or staff rural hospitals can structure income well above that. This guide covers what you need to know to start.
Prerequisite check: This guide assumes you're in an opt-out state. If you're in a non-opt-out state, independent solo practice billing Medicare/Medicaid is not available — but you can still work as an independent contractor to healthcare facilities (they bill, you contract). Check the AANA website for current opt-out state list.
Why Independent CRNA Practice Makes Financial Sense
A hospital-employed CRNA earning $215,000 has their income capped by what the employer pays. An independent CRNA billing directly captures the full anesthesia reimbursement, which in many markets is significantly higher than employment salary. Consider:
Medicare anesthesia reimbursement in many markets: $45–$85 per base unit
A single general surgery case might generate 10–30 base units + 1 unit per 15-minute increment
A 2-hour general surgery case at 20 base units + 8 time units x $65/unit: $1,820 per case
At 6 cases/day, 240 working days/year: $2,620,800 gross revenue
Obviously, overhead (malpractice, billing service, supplies, benefits, licenses) and case mix realities reduce this significantly. But the gap between employment income and practice owner income is real and substantial.
Business Structure: S-Corp vs. LLC
Structure
Best For
Tax Treatment
Complexity
Sole Proprietor
Very early stage, testing market
Schedule C — pays full SE tax
Low
Single-Member LLC
Liability protection without S-Corp overhead
Still Schedule C by default (unless electing S-Corp)
Low-medium
LLC taxed as S-Corp
Income above ~$80,000 net self-employment
Pay yourself "reasonable salary," remainder as distributions (avoids SE tax on distributions)
Medium
Professional Corporation (PC)
Some states require PCs for healthcare providers
Depends on tax election
High
For most independent CRNAs with income above $100,000, the LLC taxed as S-Corp produces meaningful SE tax savings. At $300,000 net income with a $120,000 "reasonable salary," you pay SE tax on $120,000 instead of $300,000 — saving approximately $27,600/year in SE tax. The accounting overhead ($2,000–$4,000/year for a CPA) is easily justified at this income level.
Some states require healthcare professionals to form a Professional Corporation (PC) rather than an LLC — check your state's APRN licensing statutes before forming your entity.
The Setup Checklist
1. Verify opt-out status — Confirm your state has opted out of the CMS physician supervision requirement. Check AANA.com or contact your state CRNA association.
2. Obtain or verify NPI — You need an individual NPI (Type 1) as a CRNA. If starting a group, you'll also need an organizational NPI (Type 2) for your business entity. Apply free at nppes.cms.hhs.gov.
3. Form business entity — LLC or PC, depending on state requirements. File with your state secretary of state. Obtain EIN from IRS.gov (free, instant). Open business bank account.
4. Enroll in Medicare and Medicaid — File CMS-855I (individual enrollment) AND CMS-855B (group enrollment if billing as entity). This process takes 60–90 days. Do this first — you cannot bill until enrollment is approved.
5. Obtain CRNA malpractice insurance — Individual CRNA malpractice for independent practice: $8,000–$25,000/year depending on specialty (obstetric, cardiac, and pediatric cases carry higher premiums). Providers: CRNA-specific coverage through ProAssurance, The Doctors Company, CUNA Mutual. Occurrence policy preferred over claims-made for independent practitioners.
6. Contract with facilities — Approach surgery centers, critical access hospitals, and ambulatory surgical centers in your area. You may work on a fee-for-service basis or negotiate a per-diem or per-case rate. The facility handles OR supplies and equipment; you provide anesthesia.
7. Set up billing — Medical billing for anesthesia is complex. Options: outsource to an anesthesia-specialized billing company (they take 5–8% of collections) or use billing software + hire a medical biller. CRNAs billing independently use CPT anesthesia codes (00100–01999), with units calculated using the American Society of Anesthesiologists relative value guide.
8. Credentialing at facilities — Each facility requires credentialing — submit your CRNA license, NBCRNA certification, DEA registration, malpractice certificate of insurance, and privileges application. Allow 60–90 days per facility. Start this process in parallel with Medicare enrollment.
Income Potential: Real Scenarios
Practice Model
Annual Revenue Estimate
After Overhead (~35%)
Solo CRNA, rural critical access hospital, 4 days/week
$350,000–$500,000
$227,500–$325,000
Solo CRNA, ambulatory surgery center, 5 days/week
$400,000–$600,000
$260,000–$390,000
CRNA group (2–3 CRNAs), covering hospital OR
$1.2M–$2.0M total
$400,000–$700,000 per owner (after expenses + associate pay)
The Rural CRNA Opportunity
Rural and critical access hospitals (CAHs) often cannot recruit or afford employed anesthesiologists. They desperately need CRNAs willing to staff their ORs. Many pay CRNAs a daily or per-case facility fee on top of independent billing, effectively double-compensating them — the facility pays a staffing fee AND the CRNA bills insurance independently. This "rural CRNA" model consistently produces $350,000–$500,000+ in annual income for CRNAs willing to serve rural markets, often with significant scheduling flexibility (work 3–4 days/week, 200 days/year, earn $400,000).
Before you start: New CRNAs without 3–5 years of clinical experience should not rush into independent practice. The experience base matters for patient safety and for your confidence handling unexpected intraoperative events without backup. Most successful independent CRNAs spent several years in high-acuity hospital settings (cardiac, trauma, obstetric) before going independent. The income ceiling is high — but so is the responsibility.
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