Overtime Rules for Nurses and Medical Assistants

Brittney Simpson
5 days ago
6 min read

Let me start with a conversation I have more often than you might expect.

A practice owner is walking me through how payroll works at their clinic. Good team. Busy schedule. Growing patient volume. About twenty minutes in, they bring up something important. Their nurses and MAs sometimes work more than 40 hours a week. When that happens, they still pay the same hourly rate for all those extra hours.

Then they ask: "Is that a problem?"

Yes. That is a problem.

They didn’t do anything with bad intent. Most people don’t. But over time, the practice grew. The hours got longer. And no one stopped to check if the payroll setup was keeping up.

This is something I see often in healthcare settings. And it is one of those issues that can be quiet for a long time before it becomes very loud, very fast.

Let's walk through what is actually happening here.

Why This Comes Up So Often in Medical Practices

Most practices set up their payroll early. The team is small. The hours remain manageable.

Overtime rarely shows up, so it never sparks a question.

As your practice grows, you see more patients, longer days, and extra shifts. You might even open a second location. Soon, your staff work over 40 hours a week. But the payroll setup is still the same one from three years ago.

Healthcare founders often assume that licensed clinical staff follow different rules. In reality, nurses must follow the same overtime rules as other employees.

They usually do not.

Consultant aside: This is usually the moment practice owners realize something important. Being a licensed professional does not mean she is exempt from overtime. Licensing and exemption are two separate issues.

The Core Issue: Most Nurses and MAs Are Non-Exempt

The Fair Labor Standards Act splits employees into two groups: exempt and non-exempt. Non-exempt workers get one and a half times their regular pay for every hour over 40 each week.

Nurses, including RNs and LPNs, and medical assistants are almost always non-exempt. Employers must pay them overtime whenever they work more than 40 hours in a week.

The FLSA has a 'learned professional' exemption that some practices try to use. On paper, it seems like a fit. In reality, it usually doesn’t work for two reasons.

First, the law requires employers to pay the employee a set salary that meets the threshold. Many hourly clinical staff don’t earn enough to qualify. This keeps them from getting the exemption, no matter their credentials.

Second, courts are skeptical about applying this exemption to salaried nurses. The exemption applies to jobs that need independent judgment. Nurses follow clinical protocols and take direction from physicians. Because of this, they usually don’t qualify.

Medical assistants face an even bigger challenge. Most medical assistants lack advanced degrees and earn hourly wages. Medical assistants perform skilled work but follow set procedures most of the time. Almost all medical assistants are non-exempt.

The Consultant Lens

After reviewing payroll setups for a lot of healthcare organizations, small solo practices, multi-provider groups, urgent care clinics, specialty offices, one pattern shows up consistently.

The practices spending the most time cleaning up payroll problems are rarely the ones that made careless decisions. They are the ones where the payroll infrastructure was built for an earlier version of the business, and nobody went back to look at it after the team grew.

The moment most practices realize there is an issue is usually one of three things: a payroll audit flag, an employee complaint, or a Department of Labor inquiry. By that point, the back-pay exposure can stretch two or three years.

That is not a compliance failure. It is a systems problem. The structure just did not keep up.

What You Actually Need to Know

Let's take a closer look at the specific rules that tend to catch practices off guard.

Overtime is calculated by workweek, not pay period.

This is one of the most common structural mistakes I see. Overtime is owed based on hours worked in a defined seven-day workweek, not across a biweekly pay period. If a nurse works 50 hours one week and 30 hours the next, she is owed overtime for week one, even if her two-week total is 80 hours. You cannot average the two weeks together.

The overtime rate is based on the "regular rate," not just the base wage.

This one trips up even experienced payroll teams. The regular rate of pay under the FLSA includes most additional compensation, shift differentials, on-call pay, and certain bonuses blended into the calculation for that week. If a nurse earns a shift differential for working evenings or weekends, that differential factors into her overtime rate. If your payroll system is not accounting for this, the overtime being paid is likely understated.

State law may require more than federal law.

The FLSA sets a federal floor. Many states go further. California, for example, requires overtime after eight hours in a single workday, not just after 40 hours in a week. If your practice operates in more than one state or has recently expanded, confirming compliance with each state's specific rules is worth the time.

On-call time and travel between locations can count as hours worked.

Depending on how your on-call policy is structured, those hours may need to be counted toward overtime. The key factors are how restricted the employee is during that time and what the response requirement looks like. Similarly, if an MA travels between your main clinic and a satellite location during their shift, that travel time is generally compensable.

This is usually the moment when practice owners pause and realize they have never actually sat down to review this in any structured way. Payroll runs. Checks go out. Nobody is complaining. So it is easy to assume everything is fine.

Most practices do not surface this kind of issue until something forces the question.

The good news is that it is a much easier conversation to have before that happens.

Payroll for a medical practice should feel predictable. Quiet. Almost routine.

When overtime questions start surfacing from staff, from auditors, or from your own review, it is usually a signal that the infrastructure around how people are paid has not kept up with how the practice actually operates.

The practices that handle this well are not the ones with the most complex systems. They are the ones that took the time to get the basics right, correct classification, accurate rate calculations, state-specific rules built in, and a workweek structure that reflects how the team actually works.

The goal is a payroll setup that is defensible, accurate, and quiet. One that is not going to surface at the worst possible moment as a liability you did not know you were carrying.

What I'd Recommend if This Sounds Familiar

If you are reading this and realizing that your payroll setup for clinical staff may not fully reflect how your practice operates today, that is very common.

It does not mean something went wrong. It usually just means the practice grew faster than the systems did.

A good place to start is a straightforward review of how your overtime is currently being handled, how your workweek is defined, whether shift differentials are factored into the regular rate, and whether state-specific rules are built into your payroll system. On-call policies and inter-location travel are worth looking at, too, if those apply to you.

Every practice's situation is a little different.

If you would like a second set of eyes on it, you can schedule a call with me, and we can walk through your specific circumstances together.

Sometimes it just needs a few adjustments. Sometimes it needs a bigger rethink. Either way, it is a lot easier to figure out when you are actually looking at it clearly.

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