@Bryan Taylor Bryan thanks for sharing this. This is exactly the kind of story the community exists for. And the painful part is your CPA's framing is wrong. "1099 CRNAs don't have enough deductions" is the giveaway. Deductions are usually the smallest lever. The bigger fixes are structural. Three things that almost always matter more than chasing more deductions: 1. Entity structure. If you were taxed as a sole prop on your 1099 income, you paid 15.3% self-employment tax on every dollar of net profit. An S-Corp election splits that into reasonable W-2 wages (subject to FICA) and distributions (no FICA on distributions). For a CRNA at your income level, this single move usually saves more than every deduction combined. 2. Retirement structure. SEP IRA is fine, but Solo 401(k) is usually better for a 1099 CRNA. You can contribute as both employee and employer. Your W-2 403(b) is using up your employee deferral, but the employer-side contribution on your 1099 income (up to 25% of net SE income) stacks on top. Solo 401(k) also opens up Roth, profit sharing, and Mega Backdoor Roth in some plan designs. SEP can't do any of that. 3. State planning. That $7K Missouri pass-through caught my eye. Missouri has a PTE election where the entity pays the state tax and the entity deducts it federally, working around the $10K SALT cap. If your CPA didn't make that election, you paid $7K to Missouri that didn't reduce your federal tax bill the way it should have. May be amendable, definitely fixable for 2026. Two other things worth asking your CPA about. Augusta Rule, section 280A(g), where you rent your personal residence to your S-Corp for up to 14 days a year for legitimate business use. Tax-free income to you, deductible to the entity, usually $5K to $15K a year for a CRNA. And an Accountable Plan, where your S-Corp reimburses you tax-free for home office, mileage, phone, CE, equipment, professional dues. Not a deduction. A reimbursement. Cleaner and much harder to challenge.

OK that simplifies the diagnosis. The S-Corp is in place, so the leak is somewhere downstream of the entity decision. With an S-Corp plus MFJ plus W-2 spouse, the most common gaps I see are: 1. The salary/distribution split. What's your reasonable W-2 salary from the S-Corp versus what gets paid out as distributions? This is the FICA optimization lever. Too high and you're paying FICA you don't need to. Too low and the IRS challenges it, AND your retirement contribution capacity drops because the Solo 401(k) employer-side contribution is capped at 25% of your S-Corp W-2 wages. There's a sweet spot, and most CRNAs miss it in one direction or the other. 2. Accountable Plan. Does your S-Corp reimburse you tax-free for home office, mileage, phone, internet, CE, professional dues, equipment, software? If you're paying those personally without a written Accountable Plan in place, you're missing reimbursements that should be flowing out of S-Corp profit, not your after-tax wallet. 3. Section 199A QBI deduction. CRNAs are usually classified as SSTB (Specified Service Trade or Business). The deduction phases out for MFJ filers in the upper $300K range, roughly $383K to $483K of taxable income depending on the tax year (adjusted for inflation). If your taxable income is under that threshold, you should be getting a 20% deduction on your S-Corp pass-through income. Worth confirming that's actually on your return. 4. Missouri PTE election. Same flag as before. If your CPA didn't elect this for 2024 or 2025, the $7K Missouri tax didn't get the federal deduction it should have via the SALT cap workaround. Possibly amendable depending on the year. 5. Retirement, correction to my earlier note. Since you're S-Corp, the employer-side Solo 401(k) contribution is 25% of your S-Corp W-2 wages, not net SE income. So your salary level directly caps the employer contribution. If your PRN W-2 403(b) is using up your employee deferral, the value of opening a Solo 401(k) is the employer match on top of your S-Corp wages.