The short answer
Visa's Acquirer Monitoring Program, VAMP, replaced the old separate fraud and dispute programs, and on April 1, 2026 its merchant threshold for "excessive" dropped from 2.2% to 1.5%, according to the Merchant Risk Council's summary of the change. The ratio is the sum of reported fraudulent transactions (TC40) and disputes (TC15) divided by settled card-not-present transactions in the month. Merchants over the line are enrolled after a three-month grace period on a first violation, then pay $8 per fraudulent or disputed transaction, and their acquirer, which has its own thresholds of 0.5% and 0.7%, starts asking questions. Whether a minimum monthly count of events applies before enrollment depends on your acquirer's reading of the program, so ask.
For a telehealth brand the exposure is structural rather than exotic. Subscriptions generate recurring card-not-present charges; patients dispute charges they did not expect, could not cancel, or paid before a provider approved treatment; and Stripe's restricted-businesses page (updated May 13, 2026) lists telemedicine and card-not-present prescription products as categories where approval is required and can be withdrawn. The good news is that the disputes are predictable, and most of them are prevented by settings in the billing system rather than by arguing with cardholders afterward.
The math
| Settled CNP transactions per month | Fraud plus disputes that reach 1.5% | What that looks like |
|---|---|---|
| 500 (roughly 250 patients billed twice, or 500 once) | 7 | One confused cohort after a price change |
| 2,000 | 30 | A bad week of "I didn't know it would renew" |
| 10,000 | 150 | A pharmacy delay that hits a whole shipping cycle |
The ratio is monthly, so a program with 500 transactions can be excessive in one month and fine the next, and the grace period exists because Visa knows that. It also means a small brand has less room for error than a large one in absolute terms; seven disputes is a single mishandled email.
Where telehealth disputes come from
We sorted the dispute reasons we see in this category by root cause. Fraud is a small share; the majority are patients who believe, often correctly, that the merchant did something they did not agree to.
| Dispute reason as filed | What actually happened | The fix |
|---|---|---|
| "I did not authorize this charge" (recurring) | Renewal on a date the patient did not expect, or after they thought they had cancelled | Renewal reminder before the charge; one-step online cancellation with email confirmation |
| "Merchandise not received" | Pharmacy delay, out-of-stock, or a shipment with no tracking | Live order status in the portal; proactive delay message; refund or reship before the patient calls the bank |
| "Charged before I got the service" | Card captured at intake before a provider reviewed the case, then treatment declined or delayed | Authorize at checkout, capture on clinical approval; never charge a declined case |
| "Cancelled but still billed" | Cancellation required a phone call or a chat, or took effect a cycle late | Cancellation effective immediately from the account page; final charge shown on screen |
| "Not as described" | Membership fee understood as including the drug, or a dose change that changed the price | Price of the care fee and the drug shown separately, before the card field |
| "Do not recognize" | Descriptor shows the platform's name or a legal entity rather than the brand | Descriptor set to the brand name the patient knows |
Two of those rows are the FTC's allegations against Hims & Hers (July 29, 2026): charging at intake and hiding cancellation. The company denies them and is defending the case, and whatever the court says, the disputes that follow those two patterns are real and countable. The checkout spec is the design answer; this post is the payments consequence.
Ten billing settings that prevent disputes
- Authorize at checkout, capture on approval. A declined case never becomes a charge, so it never becomes a dispute. This one setting removes an entire dispute category.
- Descriptor equals brand. The statement line shows the name on the storefront, plus a phone number that reaches a human.
- Renewal reminder three days before the charge. Email and text, with the amount, the date, and a one-tap way to pause or cancel.
- Cancellation from the account page, effective immediately, confirmed in writing. No calls, no chat scripts.
- Pause and dose-change options on the same screen as cancel. A patient who wanted a lower dose does not cancel and dispute; they change the plan.
- Order status in the portal, tied to the pharmacy. "Merchandise not received" disputes fall when the patient can see the tracking number, and further when a delay triggers a message before they look.
- Refund fast, and refund before the bank does. A refund issued within a day of a complaint closes the matter; a refund issued after the dispute still counts in the ratio.
- Smart retries with a card updater, not blind retries. Failed renewals are involuntary churn, not disputes, but repeated retries on a card the patient replaced generate "do not recognize" calls to the bank.
- Pre-dispute tools where your acquirer offers them. Verifi's Rapid Dispute Resolution and Ethoca alerts resolve some cases before they post as TC15; ask your acquirer which resolved cases are excluded from the count, because the rules have changed more than once.
- A second gateway configured and tested. In a restricted category, approval is revocable; a program that can route to a backup processor survives the month a primary account is paused.
Turbopills' billing engine is built around the first, fourth, sixth, eighth and tenth of those (the subscription starts on the provider's approval, cancellation and order status live in the portal, retries are automatic, multiple gateways with failover are supported), and runs on the founder's own gateway accounts, so the ratio is the brand's own rather than pooled with other merchants. We are in private beta, and the demo is where you should ask to see a declined case, a failed renewal and a refund end to end.
The month you cross the line
First, find out whether you actually did. Your acquirer sees the Visa numbers; your dashboard sees disputes and maybe fraud alerts. Ask for the VAMP ratio by month and the event count. Second, sort the month's events by the reasons in the table above and fix the largest bucket that week, because the grace period is three months and the ratio is recalculated monthly. Third, write to the acquirer before they write to you: what happened, what changed, and the next month's expected ratio. Acquirers keep merchants that communicate; they drop merchants that surprise them. Passing payment processor review covers the underwriting relationship, and the refunds and chargebacks post has the recovery playbook for patients who already called their bank.
FAQ
What is Visa's VAMP threshold for merchants in 2026? Since April 1, 2026, a merchant is "excessive" when fraud reports (TC40) plus disputes (TC15) exceed 1.5% of settled card-not-present transactions in a month, down from 2.2%. Enrolled merchants pay $8 per fraudulent or disputed transaction; first-time violations get a three-month grace period.
How is the VAMP ratio calculated? Fraudulent transactions reported through TC40 plus disputes recorded as TC15, divided by the month's settled card-not-present transactions. Only card-not-present activity counts, which for a telehealth subscription program means all of it.
Why do telehealth subscriptions get so many disputes? Most disputes in the category are unexpected renewals, charges taken before a provider approved treatment, cancellations that did not take effect, and shipments without tracking. Each is prevented by a billing or portal setting rather than by fighting the dispute afterward.
Does a chargeback still count if I refund the patient? A refund issued before the cardholder disputes the charge closes the matter. A refund issued after the dispute is filed does not remove the dispute from the month's count, which is why refund speed matters more than refund policy.
Can Stripe close a telehealth account over disputes? Stripe lists telemedicine and card-not-present prescription products as restricted businesses requiring approval, and approvals can be withdrawn. A rising dispute ratio is the most common trigger, which is why a second gateway should be configured before it is needed.