LET'S BE CLEAR ABOUT SURCHARGING (THE 3% CONVERSATION)

If you manage the front desk of a chiropractic practice, you have probably heard the concern before — maybe you have even voiced it yourself. The moment a patient sees a surcharge line on their receipt, they are going to push back. They are going to be annoyed. They might not come back.

That concern is understandable. It comes from a genuine place of caring about the patient relationship and protecting the practice you have worked hard to build. But it may be based on assumptions about consumer behavior that no longer reflect the reality of today’s marketplace — and a few important facts about where that 3% actually goes and why it exists in the first place.

This article is written specifically for the experienced, relationship-minded, patient-first office managers and front desk professionals who are skeptical about surcharging and deserve a clear, complete explanation rather than a corporate talking point. Let’s walk through it together.

[SPECIAL NOTE---Although this white paper was written especially for chiropractic clinics, it fully applies to all medical practitioners.  With respect to non-medical industries, the general concepts and dynamics about credit card surcharging fully apply.]

First, Let’s Talk about What that Fee Actually Is

Every time a patient hands you a credit card, something happens behind the scenes that most patients — and clearly, many practice staff — do not fully realize. The credit card company charges the practice a fee for processing that transaction. That fee is called an interchange fee, and it typically ranges from 1.5% to 3% or more of the transaction amount, depending on the type of card the patient is using and exactly how that card data is entered into the system (chip reader, swipe, manual).

Here is the part that changes the conversation: that fee has always existed. Your practice has always been paying it. The question has never been whether someone pays it — it is a matter of who pays it.

Under the traditional model, the practice absorbs the entire cost silently. It comes out of the practice’s margin on every single visit, from every single patient, regardless of whether that patient paid with a basic debit card (which costs very little to process) or a premium rewards credit card (which can cost the practice considerably more). The patient who pays cash subsidizes the patient who pays with a high-end travel rewards card. Nobody mentions it. Nobody chooses differently. The cost just quietly erodes the practice’s revenue.

A surcharge program does something fundamentally different: it makes the cost visible and assigns it to the person who created it. The patient who chooses to use a credit card — and chooses to earn their airline miles or cash back on that transaction — pays the processing fee associated with that choice. Patients who pay with a debit card, a check, or cash pay nothing extra. That is not a penalty. That is accountability and transparency.

The Market Has Already Made this Decision

One of the most common reasons experienced office managers resist surcharging is the belief that their practice would be the odd one out — that patients would feel singled out or treated unfairly compared to other businesses they patronize. The data tells a very different story.

According to a 2024 survey by J.D. Power among 3,841 small businesses across the United States, 34% of small businesses now add a surcharge when a customer pays with a credit card.¹ That number was somewhere between 1% and 5% just five years ago.¹ The practice has not crept quietly into the marketplace — it has accelerated dramatically, and patients are encountering it routinely at coffee shops, restaurants, service businesses, and healthcare providers alike. Virtually all chiropractors are now demanding a surcharging program from their payment processors.

Credit card surcharging is now legal in 47 of 50 states, with only Massachusetts, Maine, and Connecticut maintaining restrictions.² Your patients have almost certainly paid a surcharge somewhere in the past month without ending a relationship over it. They are more familiar with this practice than the office manager who has been shielding them from it may realize.

In the healthcare setting specifically, the Medical Group Management Association — the professional organization for medical practice administrators — has addressed credit card surcharging directly, noting that the practice is legally permissible in most states and providing guidance for implementation in medical practices.³ The American Association of Professional Coders has similarly documented the practice as an established option for healthcare providers.⁴ This is not fringe territory. It is mainstream healthcare business practice.

What Patients Actually Think — The Nuanced Truth

Let’s be straightforward with the data here rather than only citing figures that support one side. Some surveys do show that consumers express initial frustration with surcharges. A CardRatings survey found that about 31.6% of consumers said they avoid using credit cards when merchants add a surcharge.⁵ A separate survey cited by J.D. Power found that consumer satisfaction scores were modestly lower at businesses that surcharge.¹

Those numbers deserve to be taken seriously — and they also deserve context. Here is what the same data reveals on closer examination.

First, expressed frustration in a survey is not the same as ending a relationship with a provider. Patients choose their chiropractor based on clinical outcomes, trust, location, and relationship — not processing fees. A patient who has been seeing the chiropractor for two years and trusts his care is not going to find a new chiropractor over a 3% fee on a $60 visit. That is $1.80. The decision calculus is entirely different for a commodity transaction at an anonymous coffee shop than it is for an ongoing healthcare relationship.

Second, the same research shows that the way surcharging is communicated makes an enormous difference in how patients receive it. Practices that implement surcharging with advance notice, clear signage, transparent explanations, and a choice to pay differently have meaningfully better patient responses than those that introduce it without preparation. The friction comes from surprise — not from the fee itself.

Third, and perhaps most importantly, consumers are increasingly doing the math on credit card rewards in the context of surcharges. As one industry analysis observed, when a cardholder gets 3% cash back on purchases but pays a 3% surcharge, the rewards program largely cancels itself out.¹ Patients who understand this often choose to pay differently — which is exactly the point. They are making an informed choice rather than an uninformed choice.

What a 3% Surcharge Actually Does to the Practice’s Economics

To understand why a well-run chiropractic practice would implement a surcharge program, it helps to understand what credit card processing costs look like from the inside. This is the side many patients never see or comprehend.

Consider a practice processing $40,000 in monthly credit card volume — a figure that is not unusual for a multi-practitioner chiropractic clinic. At a blended effective processing rate of 2.5% (which is conservative — many practices pay more), that practice is paying $1,000 per month, or $12,000 per year, simply to accept credit cards. That is money that could fund staff salaries, equipment, continuing education, or patient amenities. It goes instead to the issuing bank and card networks, largely to fund the rewards programs that benefit higher-income cardholders disproportionately.

Under a properly implemented 3% surcharge program, the cardholder who chooses to use a credit card covers that cost directly. The practice’s net effective processing cost on credit card transactions drops to near zero. Over the course of a year, that is $12,000 or more returning to the practice rather than flowing out to financial institutions.

One important nuance that should always be communicated clearly: debit cards are not subject to surcharging under federal Durbin Amendment rules and most state laws.⁶ Patients who pay with debit cards pay no surcharge. This is an important distinction because it means patients always have a straightforward zero-surcharge option available to them, and that option should be actively communicated.

How to Talk to Patients about It — The Communication Is Everything

The research is clear on one point that should give every skeptical office manager confidence: the quality of the transition communication is the single largest variable in how patients respond. Practices that handle the introduction thoughtfully report minimal pushback. Those that introduce it without preparation report friction.

Here are the communication principles that work:

• Advance notice: Inform patients before they encounter the surcharge at the payment terminal. A brief letter, email, or in-office announcement a few weeks ahead of implementation sets expectations rather than creating surprises.
• Clear signage: Regulatory-approved patient-facing signage at the front desk and payment terminal is both legally required and practically effective (ChainIT Pay provides this to all our surcharging clients). Patients who see the information before they reach for their wallet have already processed it emotionally.
• A simple, accurate explanation: Something along these lines works well — “We have added a small credit card processing fee to help us keep our service costs stable for all our patients. Patients paying by debit card, check, or cash are not charged this fee.” That is accurate, straightforward, and patient-centered.
• Emphasize the choice: Every patient has the option to avoid the surcharge entirely by paying with a debit card, check, or cash. That choice should be offered genuinely and warmly, not grudgingly.
• Frame it in the context of the practice’s health: Patients who have a genuine relationship with their chiropractor understand that the practice’s sustainability serves their own healthcare continuity. A brief, authentic note about why the practice is making this change — “to continue providing the same level of care without raising our service fees across the board” — resonates with patients who care about the practice.

The AAPC, in its guidance to medical practices, specifically recommends sending patients an informational communication explaining why the practice is considering surcharges before implementation — giving patients a chance to understand the reasoning and adjust their payment habits accordingly.⁴ This proactive approach consistently produces better outcomes than reactive explanation after the fact.

The Ethical Argument — Why Surcharging Is Actually the Fairer Approach

Here is the reframe that often shifts the perspective of office managers who have long believed surcharging is unfair to patients: the current system — where every patient subsidizes the rewards programs of premium cardholders — is arguably the less ethical arrangement.

When a practice absorbs all credit card processing costs silently, two things happen. First, the practice either raises its service prices for everyone to cover those costs, or it accepts a reduced margin that ultimately limits what the practice can invest in staff, equipment, and patient care. Second, every patient — including those who pay by debit card, check, or cash — effectively subsidizes the interchange costs generated by patients who carry premium rewards cards.

Research has documented that credit card rewards programs disproportionately benefit higher-income consumers, while the interchange fees that fund those programs are effectively distributed across all consumers regardless of income level.⁷ A chiropractic practice that absorbs interchange costs silently is, in a very real sense, participating in that wealth transfer — taking from the broad patient base to subsidize the rewards programs of its more affluent cardholders.

A surcharge program reverses that dynamic. The patient who chooses to earn airline miles on a chiropractic visit pays for the cost of that choice. The patient who pays by debit card, check, or cash pays nothing extra. That is not a burden on patients — it is a more transparent and equitable allocation of a cost that has always existed.

People will forgive a practice for adjusting how it handles processing costs — because that is a business reality. What patients find harder to forgive is feeling deceived, or learning that costs were quietly hidden in inflated prices all along. Clarity, is not simply better ethics; it is better business.

A Final Word for the Skeptic

Given your professional role, you likely have spent years building patient relationships and fiercely protecting the culture of a chiropractic practice — your instinct to question anything that could disrupt that culture deserves respect, not dismissal.

The concern about patient pushback is real. Some patients will express frustration. A small number may pay differently going forward. That is all true. But the question worth sitting with is this: in a marketplace where one-third or more of small businesses already surcharge, where patients are encountering these fees routinely across dozens of businesses they patronize, and where a properly communicated transition program gives every patient a clear choice and a clear reason — is the risk of implementing this program actually greater than the financial and operational cost of not implementing it?

The practices that have made this transition thoughtfully — with advance communication, clear signage, a genuine choice offered to patients, and an authentic explanation of why — have largely found that their patient relationships survived intact and their practice finances improved meaningfully.

That is the outcome every good office manager is working toward. Surcharging, done right, is not a threat to the patient relationship. It is a tool for protecting the practice that makes the patient relationship possible.

Sources and References

1 J.D. Power Small Business Payments Study, 2024. Results reported in: Marek, L. (February 3, 2025). “Third of U.S. small businesses add credit card surcharges.” Payments Dive. https://www.paymentsdive.com/news/third-of-us-small-businesses-add-credit-card-surcharges/739018/

2 TRC Insights. (January 6, 2026). “That New and Annoying 3% Credit Card Surcharge: Finding Answers with Pricing Research.” https://trcmarketresearch.com/blog/that-new-and-annoying-3-credit-card-surcharge-finding-answers-with-pricing-research/

3 Medical Group Management Association. (2024). “Ask MGMA: Credit Card Surcharges for Medical Practice Payments.” https://www.mgma.com/podcasts/ask-mgma-credit-card-surcharges-for-medical-practice-payments

4 Dick, M. A. (August 1, 2024). “Don’t Let Credit Card Fees Devour Your Medical Practice’s Profits.” American Association of Professional Coders. https://www.aapc.com/blog/91034-dont-let-credit-card-fees-devour-your-medical-practices-profits/

5 CardRatings Research. (2025). “How Credit Card Surcharges Are Changing Consumer Behavior.” https://www.cardratings.com/research/how-credit-card-surcharges-are-changing-consumer-behavior.html

6 ChiroFutures Malpractice Program. (January 19, 2024). “Risk Management Minute — Navigating Credit Card Processing Fees in Chiropractic Care.” https://chirofutures.org/2024/01/19/risk-management-minute-navigating-credit-card-processing-fees-in-chiropractic-care-a-risk-management-perspective/

7 Clearwave. (June 4, 2025). “The Rise of Surcharging in Healthcare: Trends and Implications.” https://www.clearwaveinc.com/blog/the-rise-of-surcharging-in-healthcare-trends-and-implications/