Of all the states where it’s possible for commission-only pay schedules to go wrong, Washington tops the list. Washington minimum wage is currently $17.13 per hour, and many cities are even higher. Tukwila takes the prize for the highest minimum wage in the entire country at $21.65 per hour, for employers with 15+ employees. Seattle’s a close second at $21.30 for all employers. So if you have a per-patient, percent production, or commission-based pay structure at your practice, your employees can fall below that minimum… and suddenly, you’re out of compliance.
It’s not unusual for dental hygienists, med spa staff, associate doctors, veterinarians, audiologists, and some nursing professionals to work on commission. We’re not opposed to bonuses and percent collection pay structures. It’s a tried-and-true way to encourage quality work and keep high-value patients coming through your doors. But we are opposed to straight commission pay structures. They’re just way too legally risky.
What’s the Deal with Washington State?
Federally, minimum wage hasn’t changed in about 17 years. Yep, it’s still $7.25 in 20 states, but like many states, Washington minimum wage has been rising in the meantime. As of 2026, it’s $17.13, which makes it the highest in the United States. That’s right, it’s even higher than California, which is famously employee-friendly. Some cities within Washington go even higher than that.
But this is not news. States have been setting their own minimum wages for years, and Washington has long been a leader of the pack. There are plenty of other worker-friendly laws there too, like paid sick leave, PFML, and better healthcare workplace violence prevention. It’s a good place to work, but since the Washington minimum wage is so high now, it’s getting riskier and riskier to use a per-patient pay structure without that safety net.
How to Do Per-Patient Pay Structures the Legal Way
The main thing you’ve got to remember is that your employees can’t dip below the minimum wage. Not even for one paycheck. That means paying solely on commissions, percent production, or per-patient schedules is playing with fire.
You can still pay your hygienists, associate doctors, and other patient care professionals per patient or percent collections. It could even be the bulk of their income. But only if you do it compliantly. Here’s what we’d recommend:
- Start with an hourly rate at whatever your minimum wage is. Double check your city’s laws, because some are quite a bit higher than the rest of the state.
- Make sure your employee tracks all of their working hours in your timekeeping system. Be sure to pay overtime, since they’ll probably be non-exempt.
- Layer a separate commission or bonus structure on top of that hourly pay. Here’s where you can pay based on production, patients, or whatever other metrics you like. As long as you’ve got that minimum wage baseline, you have a good deal of flexibility here. That said, non-discretionary bonuses (bonuses earned with specific eligibility and criteria) can change an employee’s regular rate of pay for the period that they are earned. This usually increases their rate of pay for the purposes of calculating overtime, so it’s something to keep in mind.
- Document it! Put this all down in writing in your employee handbook and your employment details.
Here’s an example.
Let’s say you’re in Seattle and you have a hygienist who’s on a (non-compliant) per-patient commission. For the sake of math, imagine they earn $100 per patient and typically see 5 patients daily, for a total of $500 per day. It’s a pretty nice paycheck, but if there was a sudden change in patient flow or somehow everyone no-showed one day, that hygienist could dip below minimum wage. And you could be on the hook for a wage and hour claim.
But! If you paid your hygienist Seattle’s minimum wage of $21.30 per hour, that would cover $170.40 per 8-hour workday. You could adjust the $100 commission to $65.92, and the hygienist would still take home that $500 for the same amount of work. This one change would ensure that your hygienist met the most relevant Washington minimum wage for your area, and it would keep your practice legally compliant, even on slow days.
So long as you have this policy well-defined in your employee handbook, your employees are tracking all their hours, and you’re covering overtime as needed, it is possible to have a compliant per-patient pay structure.
It’s Already Set Up for You in HR for Health
Are all these numbers stressing you out? If you tried to create this setup in another HR and payroll solution, you’d probably end up with a patchwork system that only works most of the time. And you’d still have to do a lot of the hard math yourself.
We created HR for Health knowing full well that most practices don’t have “easy” pay structures. We also know that each state has its own set of quirks, and non-compliance with those quirks can come with costly fines or even lawsuits. We’ll help you through all of it.
Start by downloading your state’s employment law updates here.
