Practice payments, where the balance arrives weeks after the visit.
A practice collects a copay at the desk and a patient balance weeks later after insurance adjudicates. Those are two different transactions at two different costs, and the second one is where the money and the risk both sit.
What this page settles.
Three questions, in the order most people ask them.
Why practices are priced oddly
A practice takes money twice for one visit, and the two transactions behave completely differently.
The copay at the desk. The patient is in front of you, the card is tapped or inserted, and it is card-present at the cheapest available interchange. Small, clean, easy.
The patient balance, weeks later. Insurance adjudicates, a balance remains, and you collect it — by statement, by phone, or against a stored card. Every one of those is card-not-present: higher interchange by roughly 0.3% to 0.5%, more dispute exposure, and the collection risk of a patient who has gone home and lost interest. Card-not-present downgrades.
The second transaction is where almost all the cost and all the risk sit, and most practice quotes are discussed entirely in terms of the first.
So the useful question is not “what is my rate”. It is what proportion of my collections happen after the patient has left, and what each of those costs. Pull a month’s volume and split it card-present against keyed; the ratio usually surprises people.
The card on file question
This is the single highest-value operational change available to a practice, and it addresses cost and collection at the same time.
Taking a card at the visit, with written authorisation to charge the balance remaining after insurance up to a stated limit, means:
the patient is present when the card is collected, which is better evidence in a dispute; collection happens on your schedule rather than theirs; and you stop sending statements to people who have stopped reading them.
It has to be done properly, which means through tokenization: the gateway stores the card and returns a token, and your practice never holds a number. Not a note in the practice software, not a form in a drawer, not a card number in a scheduling comment. Every one of those puts card data in a system you control and gives you something to lose in a breach. Tokenization and P2PE and if card data is breached.
The authorisation has to be written and specific. What you may charge, up to what amount, in what circumstances, and how the patient cancels it. A stored-card charge the patient did not clearly agree to is a dispute you will lose. How to fight a chargeback.
It is still priced as card-not-present, because the card is not being read at the moment of the charge. That cost is small against the balances that otherwise go uncollected.
HSA and FSA cards
Health savings and flexible spending account cards run on the card networks and process like any other card. Three practical points:
Partial approvals happen. The account may cover part of the balance and not the rest, and your terminal or system needs to handle a split tender gracefully. Staff should know what to do before it happens at the desk.
Eligibility is the patient’s problem and your friction. Some services qualify and some do not, and a declined HSA card at the desk is an awkward conversation rather than a processing fault.
Substantiation. Patients may need itemised documentation for their plan administrator. A receipt that shows what was provided, not just an amount, saves a phone call later. Receipt requirements.
None of this changes your cost materially. It changes your front desk workflow, which is worth preparing for.
Payment plans and large balances
Practices carry larger balances than most retail businesses, and at those amounts the method matters more than the rate.
ACH is dramatically cheaper on large balances. Published ACH rates are commonly around 1% capped at $5 to $10, against an uncapped percentage on a card. On a $2,000 treatment plan that is roughly $10 against $58. For practices running orthodontic, implant or elective treatment plans, moving those to ACH is usually the largest single saving available. ACH or card.
In-house payment plans are a credit decision as well as a payment one. If you are charging a stored card monthly, every point in the earlier section about authorisation and account updater applies. Moving recurring billing.
Third-party patient financing moves the credit risk off your books at a cost. Whether that trade is worth it is a practice management question rather than a payments one, and the comparison should be against the realistic collection rate on your own plans rather than against 100%.
Watch your per-transaction limits. A large treatment payment on an account underwritten for small copays gets held. Tell your processor your highest likely ticket at application, and again if it changes. Held funds and reserves.
Data, and keeping it out of the practice
Two separate regimes, frequently conflated.
HIPAA governs patient health information. It is not a card-data standard and does not tell you how to handle card numbers.
PCI governs card data. It applies to you exactly as it applies to a shop. PCI DSS explained.
The practical overlap is that both get easier the less you hold, and practices tend to hold more than they realise. Card numbers accumulate in appointment notes, on paper forms in a drawer, in emails from patients, in a spreadsheet of payment plans, in a voicemail system. All of it is in scope, all of it is a liability, and none of it has any upside once you have a tokenized card on file.
Go looking for it once, deliberately, and destroy what you find. That is the highest-value hour of compliance work available to any practice. Which SAQ do I need.
What to look at on a quote
Your keyed versus card-present split, converted to a blended expectation. A practice collecting 40% of its revenue by phone has a very different cost than one collecting 10%.
Whether the quote is interchange-plus. At practice volumes it almost always beats a flat rate, and it is the only arrangement where you can see what the keyed volume is actually costing.
The gateway and whether you are paying for it twice, particularly if your practice management software includes payment functionality. Gateway fees.
ACH availability and its cap.
Tokenization and account updater, both named explicitly.
The term, the exit cost and whether hardware is bought or leased. A practice management system that bundles processing has made the pricing decision for you, which is worth knowing before you sign the software contract. Agreement red flags.
What we charge
Interchange + 0.50% + 10¢ in person, interchange + 0.75% + 25¢ keyed, with no contract, no monthly fee and no monthly minimum, with ACH on the account.
For a practice the useful first step is the split: how much of your collection happens at the desk and how much happens later. Send us a statement and we will separate them, which usually points at one change worth more than the rate.
While we are on the subject
Can I keep a patient's card on file?
Yes, through proper tokenization, with written authorisation stating what you may charge and when. Never by writing the number down or storing it in the practice software.
Do HSA and FSA cards cost more to accept?
They run on the card networks and are processed like other cards. The practical issues are substantiation and partial approvals rather than cost.
Why are my phone payments so expensive?
Because they are card-not-present. The card was not read, so the issuer carries more fraud risk and charges more interchange — roughly 0.3% to 0.5% more.
Does HIPAA affect how I take payments?
It governs patient health information rather than card data, which is governed by PCI. The practical overlap is that both get easier if you hold less of each.