Solo practitioner uses solo 401(k) with after-tax contributions + in-plan Roth conversion = $69K/yr into Roth (2024).
For solo owner-only practices (no employees other than spouse), Solo 401(k) plans can be customized to allow after-tax contributions above the $23K (2024) elective deferral, up to the $69K total annual addition limit ($76,500 with catch-up). Then convert those after-tax dollars to Roth (in-plan Roth rollover) immediately — zero tax on conversion since dollars were already after-tax. Net: $45K+/yr into Roth for future tax-free growth. Off-the-shelf Solo 401(k)s from Vanguard/Fidelity/Schwab typically DON'T allow this — use customized providers (mysolo401k, Nabers, RocketDollar).
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Practice pays $2.85M/yr premium to owner-controlled captive; captive receives tax-free (small insurance co election).
Combine a defined-benefit cash balance plan with 401(k)+profit share — total deductible contributions $400K+/yr for older owners.
Professional practice (PLLC) contracts with owner's Management LLC for admin, IP, real estate — shifts income to lower-rate entity.
Practice rents from professional's own real estate LLC — rent flows to owner tax-favored, building appreciates outside practice.
At sale, allocate purchase price to professional's PERSONAL goodwill (patient/client relationships) — capital gain, one level of tax.
MSO owned by non-professionals contracts with PC for management — recapitalize practice with outside capital legally.
Pass-Through Entity Tax lets practice deduct 100% of state income tax federally, bypassing $10K SALT cap.
C-corp (or spouse-hired setup) can reimburse 100% of family medical expenses tax-free — bypasses 7.5% AGI floor.