A med spa medical director agreement is supposed to buy a physician's time and judgment. Two phone surveys suggest how often the physician is actually in the building. In Las Vegas, an on-site physician supervised or performed cosmetic procedures at 38.1% of 63 med spas surveyed in 2023. In a Missouri survey published in 2025, 22.52% of spas had a physician present during all cosmetic services, though 94.59% reported a physician affiliation.

Neither figure says anything is illegal. Supervision rules differ by state, and the Las Vegas authors write that in many cases a supervising physician does not need to be on site, only reachable when needed. But the gap between "affiliated" and "present" is the thing regulators have started writing about, and the agreement is where an owner either closes it or papers over it.

What the fee is supposed to pay for

The clearest plain-language account we found is a 2022 article by Patrick O'Brien, writing as legal coordinator of the American Med Spa Association. On how much to pay, he wrote that the "simple but unhelpful answer is 'fair market value.'" The practice is not paying for the use of the physician's license, which O'Brien wrote is prohibited in every state. It is paying for oversight that takes real hours: reviewing charts, assessing patients, reviewing protocols, monitoring providers.

How many hours depends on who is being supervised. A practice staffed with physician assistants and nurse practitioners realistically needs less daily physician time than one that employs nurses and medical assistants, O'Brien wrote.

AmSpa's article gives no dollar range. Neither does any other source we read for this piece, and we found no public survey of medical-director fees. The monthly figures that circulate come from vendor blogs and forums. Treat them as anecdotes.

So fair market value has to be built from the bottom up: the hours the role really takes in your practice, at a rate a physician with those credentials could document for comparable work in your market. I would pay an attorney to put that in writing.

Flat fee, hourly or percentage

A percentage of revenue is the structure most likely to draw legal questions. O'Brien's article says state fee-splitting and kickback rules are often written broadly enough that any commission, bonus or share of a fee tied to influencing a patient's choice of provider can raise the issue. It also says that does not make every percentage or per-patient plan unlawful everywhere. What is allowed depends on the state, the legal structure and the specifics of the plan.

There is a business reason to be wary as well. Here is an illustration with invented numbers; none of them is a benchmark.

Say the oversight genuinely takes 12 hours a month: six on chart review, two on protocols and staff questions, four on site. Under a deal that pays 5% of revenue, a month with $60,000 in revenue pays the physician $3,000, which works out to $250 an hour. A $90,000 month pays $4,500, or $375 an hour, for the same 12 hours.

Nothing about the work changed. That is the difficulty with calling a percentage "fair market value for time": the pay moves with sales, and someone may eventually ask what the extra $1,500 was for. A flat monthly fee tied to a set number of hours, or an hourly rate against a log, is far easier to explain.

In states that follow the corporate practice of medicine doctrine, the question may be upside down. There, O'Brien wrote, the practice has to be owned by a physician or another entity authorized to practice medicine, and the real question becomes "how does the physician pay you?" That is the management services organization model, and it runs on a different contract. Michael Byrd of the law firm ByrdAdatto, writing for AmSpa in March 2025, called it a common misconception that a management services agreement and a medical director agreement are interchangeable. One covers non-clinical administrative services. The other covers clinical oversight.

What Georgia's board said in 2026

In a position statement dated May 7, 2026, the Georgia Composite Medical Board set out a reading that anyone in that state whose practice is owned by an advanced practice registered nurse or a physician assistant should see.

Georgia law makes it unlawful for a physician to be an employee of an APRN the physician is required to supervise, outside certain practice settings (O.C.G.A. § 43-34-25(n); Ga. Comp. R. & Regs. 360-32-.04(5)). The board said it has not generally limited "employee" to the W-2 versus 1099 distinction. It reads the ban to include "a physician receiving compensation of any kind, monetary or non-monetary, from an APRN or an APRN-owned company in exchange for serving as the supervising or delegating physician."

Routing the money through a middleman does not help. The statement names three physician-matching services and says the board would view an arrangement as prohibited where, in substance, the APRN is compensating the delegating physician through the third party. For physician assistants, it says a physician may not be an employee of the PA he or she supervises unless the board approved the arrangement before July 1, 2009.

The same document lists what the delegating physician owes an APRN under Georgia's nurse protocol rules: availability for immediate consultation, documented on-site observation at least annually, and quarterly medical-record review (Ga. Comp. R. & Regs. 360-32-.05). The board said it evaluates these relationships on their "substance & practical effect" and that they "must reflect genuine clinical oversight."

How far this reaches is not settled. Matt Wilmot and Edgar Bueno of HunterMaclean, in an article dated May 21, 2026, wrote that "significant ambiguity remains, including around medical director arrangements." In a follow-up letter dated June 4, 2026, the board said the statement was "not to create new law or policy" and that it is "not terminating any currently active protocols" as a result. It promised further updates. This is Georgia's reading of Georgia law, and it does not apply elsewhere.

What the paperwork should cover

No source we read publishes a model agreement, and yours should come from a health care attorney licensed in your state. Still, the documents above point to the same short list of things a regulator would look for, and I would want each one answered in writing:

  • The specific duties, in the terms your state's rules use (chart or record review and how often, protocol review, on-site time if any)
  • The expected hours, and how they will be logged
  • How staff reach the physician, including after hours, and who covers when the physician is unavailable
  • The compensation basis and how it was arrived at
  • Term, termination and what happens to supervision on the day the agreement ends

The third item is not a formality. In the Las Vegas survey, only 46% of spas said they notify a medical director or supervising physician when a complication occurs.

Where it goes wrong

Two mistakes are the expensive ones. One is signing a percentage deal copied from a practice in another state. The other is an agreement that describes oversight nobody performs. Byrd's article makes the point about management agreements, and it applies here: the form has to match the substance, because absentee physicians expose their own licenses to potential board investigation.

Both surveys cited at the top have limits. Each was a phone survey limited to one city or one state, published in Dermatologic Surgery, and each was funded by the American Society for Dermatologic Surgery, a physician society. Everything legal in this article is general information. Whether your state requires a medical director at all, what supervision it demands and how the physician may be paid are questions for your own counsel.

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