Medical tourism agencies are paid by the provider that treats the patient, through one of six commission models: a percentage of the package price, a fixed fee per case, a tiered percentage that rises with monthly volume, a net rate plus the agency’s own markup, a success fee paid after the patient arrives or completes treatment, or a commission split across stages. No audited public benchmark gives a market rate; the only official figures we found are South Korea’s ceilings of 30%, 20% and 15% of the medical fee, by type of provider. Where statutes protect commercial agents, commission is earned when the provider performs the deal (Directive 86/653/EEC Art. 10; German HGB § 87a; Spanish Ley 12/1992 Art. 14; Turkish Commercial Code Art. 114) and is returned if the customer never pays. If a clinic does not pay, escalate in order: reminder, formal notice, mediation, then arbitration or court. This guide is planning information, not legal, tax or financial advice; the signed contract and the governing law decide.
Updated: 2026-10-17 · Reading time: 32 min · Guide
Commission is the part of a medical tourism package that pays for bringing the patient. The clinic, hospital or hotel pays the agency or facilitator once the patient books and is treated; the patient normally sees one package price. What the agency earns is a share of that price, a fixed fee, or the margin between a net rate and its own selling price. Three questions decide every deal: how the fee is calculated, which event makes it payable, and what happens to it when the case goes wrong.
The ledger at the top of this page shows the arithmetic; it runs in your browser and nothing is sent. The sections below explain each model, when commission is earned, how clawbacks and leakage work, who invoices whom, and what to do when payment does not arrive. Terms such as commission, net rate and escrow link to the health tourism glossary.
Models differ in two ways: how the amount is set and which event pays it. The table lists the six forms that agencies and providers describe. Real contracts often combine two, for example a fixed fee as a floor with a percentage above a price threshold. See commission, referral fee, net rate and markup in the glossary.
Agencies join Health onMESSE free, with no booth fee or subscription: meet clinics, hospitals and hotels and ask for their commission model and payment term before you refer a patient.
The right to commission arises at an event. Choose the event on purpose, because it fixes when the agency can invoice, how much it can lose to a cancellation and how long it waits.
Statutes that protect commercial agents follow the same logic: the right arises when the provider performs, not when the lead is passed. Directive 86/653/EEC Article 10(2) makes commission due at the latest when the third party has performed its part; Germany’s HGB § 87a(1) gives the claim as soon as and to the extent the principal has executed the transaction; Spain’s Ley 12/1992 Article 14 and Türkiye’s Commercial Code Article 114(1) read alike. These rules apply only to relationships that qualify as agency. For a case-by-case facilitator the contract decides, so write the trigger down.
The numbers here are illustrative. A patient books a package priced at USD 4,000. The patient pays a 30% deposit (USD 1,200) on day 0 and the balance (USD 2,800) on arrival on day 21; treatment ends on day 28. The agency’s base rate is 12%, it sends 8 cases a month, and each commission is paid 30 days after its trigger. The five models are set so that each earns the same USD 480 on a completed case. That isolates what really differs between them: timing and risk. It is not a market rate. Change any number in the ledger to run your own case.
The sixth model, a success fee, is any of these with a later trigger: in the ledger it is the fixed-fee or tiered row, paid after arrival or completion. Now change the outcome. Two things can go wrong after the deposit. The patient cancels before arriving (the table assumes day 14, with the deposit refunded in full), or the clinic refunds 25% of the price (USD 1,000) after treatment on day 35.
Read the table like this. Commission that follows the money follows the refund: with a 25% refund the percentage, tiered, net and staged models fall to USD 360, while the fixed fee stays at USD 480 unless the contract says it can be reduced. With a 30-day payment term nothing has been paid before a cancellation on day 14, so the percentage, fixed, tiered and staged models end at zero without any repayment. The net-rate model has already moved money: the agency held the deposit, and its share of it (USD 144) goes back with the refund. Shorten the payment term to a few days in the ledger and the percentage and staged models show repayment lines too, because they pay on the deposit: the sooner the agency is paid, the more it may have to return.
A clawback is the clause that returns commission when the money behind it goes back to the patient. Three events trigger it in practice: the patient cancels or does not arrive, the clinic refunds part or all of the price, and a complication or revision changes who pays for what. The statutes agree on the principle and differ on the detail. Directive 86/653/EEC Article 11 lets the right to commission fall away only when it is established that the customer’s contract will not be executed and the principal is not to blame, and requires amounts already received to be repaid; Germany’s HGB § 87a(2) and Türkiye’s Commercial Code Article 114(2) say the same for sums received. The contract should settle the rest.
Deposits deserve a separate sentence. A deposit is paid before anything else happens, so it is the money most exposed to a refund, and a trigger set at the deposit has the highest clawback exposure; see deposit, escrow and cancellation policy in the glossary.
Clinics, hospitals and hotels exhibit at Health onMESSE: present your treatments, packages and agency terms to agencies that are looking for partners.
Leakage is a patient the agency introduced who later books the clinic directly, brings a relative, or returns for a second procedure, and the agency is not paid. It is a commission risk that needs its own clause. The remedies are contractual and practical. The contract carries a non-circumvention clause: for a defined period after the introduction the clinic pays the agreed commission on that patient’s treatment, including return visits and family members the agency introduced (see exclusivity). The agency keeps a case ledger with the patient reference, the date of the first introduction, the quotation sent and the clinic’s acknowledgement. The clinic gives each introduction a case ID at the start, so that both sides count the same patients. No public statistic measures leakage, so this page quotes none; the clinic contract checklist shows how to set the non-circumvention period.
Three invoice structures exist in practice, and they decide which tax questions arise.
Cross-border tax can quietly take a share of the margin. In the EU, services supplied to a business customer are generally taxed where the customer is established (Directive 2006/112/EC Article 44), and a customer in another Member State accounts for the VAT itself under the reverse charge (Article 196). An agency in the EU that invoices a clinic outside the EU therefore usually charges no EU VAT on that invoice. Other countries, including Türkiye, the Gulf states, India and Mexico, apply their own rules on VAT or GST, withholding tax and foreign-currency receipts. Ask a tax adviser in both countries before the first invoice: this guide gives no tax advice.
Currency and payment channel are commercial terms, so fix them in the contract: the invoice currency (the clinic’s list currency, the patient’s, or a third such as USD or EUR); which exchange rate applies (invoice date, payment date, or a named bank’s published rate) and who bears conversion differences, see FX rate; who pays bank charges (a payment instruction can carry OUR, SHA or BEN charge codes); the payment channel (bank transfer, card, or a payment-service provider); and the language of the statement. Use the case economics calculator to see what commission leaves per case once costs are in, and the package price calculator to see how a hospital builds the package price the commission is calculated on.
Four instruments reduce the risk that commission is paid late or has to be repaid. A deposit commits the patient and shows that the booking is real; its amount, refund conditions and holder belong in the quotation. An escrow account holds money with a neutral third party until agreed conditions are met, for example the clinic’s final payment or the agency’s commission after discharge; it protects whoever would otherwise pay first, at the price of fees and set-up time. A bank guarantee issued by the clinic’s bank gives the agency a claim against the bank if the clinic does not pay, which suits large, recurring flows. Set-off lets the parties net what they owe each other; say in writing whether it is allowed. Each of these needs drafting under the contract’s governing law.
A late commission can have ordinary causes before it has bad ones: a statement is stuck, a case ID does not match, or the finance team is waiting for the patient’s last payment. The ladder starts friendly and ends in the forum your contract names. The days count from the due date and are practice, not law: your contract’s notice and cure periods decide what you may do and when. Enter the due date to see calendar dates, and the late-interest rate from your contract to see what interest adds.
Keep an evidence file from day 0: the signed contract and its annexes, the case ledger (patient reference, introduction date, quotation, clinic acknowledgement), every statement and invoice, proof of delivery of each notice, and the messages in which the clinic confirms a case. In every forum the side with the cleaner file moves faster. State the late-interest rate in the contract; where it is silent, the law of the governing jurisdiction supplies one. Under Turkish law, for example, a contractual default-interest rate cannot exceed the statutory rate by more than 100% (Turkish Code of Obligations Art. 120).
Settle the terms before the first referral: meet clinics and hospitals at Health onMESSE and agree the model, the trigger and the payment term in writing.
Only a lawyer can tell you whether your relationship is a statutory commercial agency, and the answer depends on facts: whether you hold continuing authority or send case-by-case introductions, whether you negotiate or only introduce, whether services as well as goods are covered, and which law the contract chooses. The texts below show what the statutes say, so you know which questions to ask. Where they apply they give the agent rights that a contract cannot always remove.
Three patterns repeat across these texts. Commission follows performance, not introduction. A terminated agent can claim a capped goodwill indemnity, the cap being one year of average pay in each text, and must claim it within a year in Germany and Türkiye. And the protective rules cannot be removed to the agent’s detriment by contract: Directive 86/653/EEC Arts. 10(4) and 11(3), HGB § 87a(5) and § 89b(4), and Turkish Commercial Code Arts. 116(3) and 122(4) say so. Whether they reach a medical tourism facilitator is the question to put to a lawyer.
No audited public benchmark of agency commission in medical tourism exists, and this page does not invent one. Rates are set deal by deal and rarely published. What can be cited: South Korea publishes ceilings. Under Article 9(2) of its Act on Support for Overseas Expansion of Medical Services and Attraction of International Patients the Minister announces an appropriate fee rate; in 2017 the Ministry of Health and Welfare set the maximum fee for registered attraction agencies at 30% of the medical fee for clinics, 20% for hospitals and general hospitals and 15% for tertiary general hospitals, and a 2025 study by the Korea Legislation Research Institute still describes these caps. They are legal ceilings in one country, not market averages elsewhere. Trade commentary gives lower figures without a method: Medical Tourism Magazine, in an undated article by Renée-Marie Stephano of Global Healthcare Accreditation, says facilitators “can usually profit 10-20 percent of the total cost of a procedure”. Treat such figures as opinion.
What moves the rate in a given deal is easier to name than to price. Each of these comes up in negotiations; none is a formula.
The clinic contract checklist expands these into 18 clauses with sample wording. The patient acquisition cost calculator puts the commission next to your other costs of winning a patient, and the patient journey guide shows where in the journey each commission trigger falls.
Legal texts were read on 17 October 2026 in the official or consolidated versions below. Statutes change, so check the current text before you rely on one. The figures in the ledger are examples, not data.
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