Payment Processing Options¶

Square¶

Website: squareup.com

What it is: All-in-one payment platform with card reader, online payments, invoicing, and subscriptions.

Features: - Free card reader for in-person payments - Online payment links - Recurring billing (subscriptions) - Invoicing - Basic reporting

Costs (Square Free plan, from Square's fee page): - In-person (tap, dip, swipe): 2.6% + 15¢ - Online and payment links: 3.3% + 30¢ - Invoices paid by card: 3.3% + 30¢ - Manually keyed or card on file: 3.5% + 15¢ - Invoices paid by ACH: 1%, $1 minimum ($0 when deposited into Square Checking) - No monthly fee on the Free plan; paid plans lower the in-person rate

Pros: - Easy to start - No monthly fees - Subscription feature built-in - Good for in-person and online

Cons: - Per-transaction fees add up - Not healthcare-specific - Limited practice management features

Best for: Getting started; may continue to work well for established practices.

Stripe¶

Website: stripe.com

What it is: Developer-friendly payment processing platform with powerful features and integrations.

Features: - Online payments - Recurring billing (Stripe Billing) - Invoicing - Extensive integrations - API for custom solutions

Costs (from Stripe's pricing page): - Cards: 2.9% + 30¢ per domestic transaction - ACH Direct Debit: 0.8%, capped at $5 - Stripe Billing (subscriptions): an additional 0.7% of billing volume on pay-as-you-go - Stripe Invoicing: an additional 0.4% per paid invoice, capped at $2 - No monthly fee

Pros: - Powerful and flexible - Excellent for recurring billing - Many integrations available - Can grow with you

Cons: - More technical to set up - May need developer help for customization - Not healthcare-specific

Best for: Tech-savvy practices; practices wanting integration with other tools.

PayPal Business¶

Website: paypal.com/business

What it is: Familiar payment platform with business features.

Features: - Invoicing and payment links - Recurring payments

Costs (from PayPal's pricing page): - Cards through standard checkout: 2.99% + 49¢ - Invoices paid with a PayPal or Venmo balance: 3.49% + 49¢; paid by card: 2.99% + 49¢ - In-person QR code: 2.29% + 9¢

Pros: - Many patients already have accounts - Easy to use - Familiar interface

Cons: - Limited practice management features - Not healthcare-specific - Some patients find it less intuitive than Square

Best for: Practices where patients already prefer PayPal.

Hint Health¶

Website: hint.com

What it is: DPC-specific practice management platform including membership and billing.

Features: - Membership management - Automated recurring billing - Patient enrollment - Reporting and analytics - DPC-specific design

Costs (from Hint's pricing page): - Launch plan from $290/month (one clinician, unlimited members); Pro from $320/month; Scale from $770/month - Payment processing on Launch: cards 3.00% + 30¢ (+1% for American Express); ACH 1.00% + 25¢, capped at $5. Higher plans carry lower rates. - Comparable DPC platforms (Atlas.md, Cerbo and others) publish their own pricing; compare before choosing

Pros: - Built specifically for DPC - Comprehensive membership management - Automated billing and dunning - Integrates with some EMRs

Cons: - Monthly fee (may not justify at small scale) - Another system to learn - May duplicate EMR features

Best for: Established practices wanting streamlined DPC-specific management; larger DPC practices.

ACH / Bank Transfers¶

What it is: Direct bank-to-bank transfers.

Options: - Through your bank - Through payment platforms (Stripe, Square offer ACH) - Through practice management systems

Costs: - Lower than card processing at membership-sized amounts - Usually a percentage with a cap or minimum: Stripe 0.8% capped at $5 (source); Square 1% with a $1 minimum (source); Hint 1% + 25¢ capped at $5 (source) - Square waives the ACH fee when the money is deposited into Square Checking

Pros: - Lower fees than cards - Direct and reliable - Good for recurring payments

Cons: - Takes longer to process (2-5 days) - Failed payments happen (insufficient funds) - Patients must provide bank info

Best for: Cost-conscious practices; patients preferring lower fees.

Checks¶

What it is: Traditional paper checks.

Pros: - No processing fees - Some patients prefer - Simple for occasional use

Cons: - Manual processing - Can bounce - Must deposit (time and travel) - Tracking challenges - Not scalable

Best for: Accommodating patient preferences; not primary payment method.

Recurring Billing Considerations¶

Why Automate¶

Benefits: - Predictable cash flow - Reduced administrative time - Fewer missed payments - Better patient experience (set-and-forget) - Easier accounting

Setting Up Recurring Billing¶

Information needed from patients: - Credit card or bank account details - Billing address - Authorization for recurring charges - Payment date preference

Billing cycles: - Fixed date (e.g., 1^st of month) - easier to manage - Anniversary date (day they enrolled) - more complex to track

Recommendation: Fixed date is simpler. Move all patients to same billing date once established.

Pass-through labs and medications: Bill labs and dispensed medications as separate, itemized charges, never folded into the membership fee, and offer the same pass-through prices to non-members. Under IRS Notice 2026-05 (Q&A-11 and Q&A-12), separately billed items available only to members count as part of the arrangement, and an arrangement that includes non-ambulatory labs or prescription drugs other than vaccines costs members with HSA-qualified high-deductible plans their HSA eligibility.

Failed Payment Handling¶

What happens: - Card declines (expired, limit, fraud block) - ACH fails (insufficient funds) - Account closed

Your process: - Automatic retry (most platforms do this) - Patient notification (automated email/text) - Grace period before membership impact - Personal outreach if not resolved - Clear policy in membership agreement

Fee Comparison¶

Typical Monthly Scenarios¶

Assume: 100 patients, $89/month average = $8,900/month collected (about the $98.64 national average adult fee). Rates are the published ones linked above as of 2026-09-22.

Platform	Fee Structure	Monthly Cost
Square (invoices or online, card)	3.3% + 30¢	~$325
Square (ACH on invoices)	1%, $1 minimum	~$90
Stripe (cards)	2.9% + 30¢	~$290 (about $350 with Stripe Billing's 0.7%)
Stripe (ACH Direct Debit)	0.8% capped at $5	~$70
PayPal (cards)	2.99% + 49¢	~$315
Hint Health Launch (cards)	$290/mo + 3.0% + 30¢	~$590
Hint Health Launch (ACH)	$290/mo + 1% + 25¢	~$405
Checks (your time)	$0 + time	Time cost

Note: At small patient counts, percentage fees are manageable. As you grow, ACH or negotiated rates become more valuable.

Reducing Payment Processing Costs¶

Options: - Encourage ACH (lower fees) - Offer small discount for annual prepayment (reduces transactions) - Negotiate rates with volume (Stripe, etc.) - Pass fees to patients (not recommended for DPC; several states restrict or ban card surcharges, and card networks set rules for them)

Patient Experience¶

Making Payment Easy¶

Best practices: - Multiple payment options - Clear instructions - Automated receipts - Easy to update payment info - Responsive to payment questions

Communication About Payments¶

At enrollment: - Explain payment process - Collect payment information - Set up recurring billing - Confirm first payment

Ongoing: - Receipt for each payment - Advance notice of failed payments - Easy way to update payment method - Clear policies in agreement

Accounting Integration¶

Tracking Payments¶

What to track: - Payment date and amount - Payment method - Patient - Any notes

Tools: - Payment platform reports - Accounting software (QuickBooks, Wave, etc.) - Spreadsheet (early stage)

Bank Reconciliation¶

Payment platforms deposit to your bank
Deposits may batch multiple payments
Reconcile platform reports with bank statements
Track processing fees as expenses

Recommendation: Connect payment platform to accounting software for easier reconciliation.

Security and Compliance¶

PCI Compliance¶

What it is: Payment Card Industry Data Security Standard - requirements for handling card data.

Your responsibility: - Use PCI-compliant processors (Square, Stripe, etc. are compliant) - Don't store card numbers yourself - Keep systems secure - Complete any required PCI questionnaires

Using major platforms: Largely handled by the platform; you're responsible for your account security.

HIPAA and Payment Processing¶

A cash-only DPC practice that sends no HIPAA standard electronic transaction (such as an insurance claim) is not a HIPAA covered entity, but treat HIPAA as the floor for how you handle patient information (see HIPAA Compliance Basics). Card and ACH processing is not a standard transaction, and a bank or card processor handling payments is not your business associate for that activity (HIPAA section 1179; see BAA Requirements), so no BAA is needed for the processor itself.

Payment data is generally not PHI - but be careful about: - What information is visible in payment descriptions and receipts (membership fee, not diagnoses or visit reasons) - How payment issues are communicated - Keeping payment systems separate from clinical systems

Checklist: Payment Processing¶

Setup¶

Choose payment platform(s)
Create business account
Connect to business bank account
Set up recurring billing feature
Configure receipts and notifications
Test payment process

For Each Patient¶

Collect payment information at enrollment
Set up recurring payment
Send welcome/confirmation
Provide receipt for first payment

Ongoing¶

Monitor for failed payments
Follow up on payment issues promptly
Reconcile payments with bank deposits
Track processing fees
Review platform annually (rates, features)

Resources¶

Pricing Your Practice - Setting your membership fees
Membership Agreement Essentials - Payment terms in agreement
Handling Cancellations and Refunds - Payment issues
Current published rates: Square, Stripe, PayPal, Hint Health
IRS Notice 2026-05 - HSA rules, including separately billed labs and medications

Educational Content Only

This is educational content, not legal or financial advice.

Regulations vary by state and change over time
Always consult a healthcare attorney for legal matters
Always consult an accountant for tax and financial matters
Verify current requirements with official sources

Read through and figures checked on 2026-09-22.

Next Steps¶

After setting up payment processing: - Handling Cancellations and Refunds - Patient Onboarding Workflow

Payment Processing Options¶

Table of Contents¶

Overview¶

Prerequisites¶

Starting Lean: Payment Processing by Stage¶

Stage 1: Just Starting (0-25 Patients)¶

Stage 2: Growing (25-75 Patients)¶

Stage 3: Established (75+ Patients)¶