The Med Spa Practice That's Crossing Legal and Ethical Lines

You've just finished your laser treatment. You're checking out, and suddenly a tip screen appears asking for 20%.

You hesitate. Should you tip? It feels weird, but you don't want to seem cheap.

Here's what's really happening behind that screen.

The Low Wage Problem Nobody's Talking About

"This company is using tips so that they can underpay their nurses and in addition the structure with a very low hourly wage and a high dependence on tips and commission that incentivizes the nurses potentially anyway, to sell you services that you do not need or want." — Dr. Kate Dee, Medspa Confidential Podcast

National med spa chains have figured out a way to cut costs that should make you uncomfortable. They're paying nurses as little as $28 an hour and expecting tips and commission to make up the difference. In California, where the cost of living is sky high, that's barely enough to get by.

When businesses underpay nurses and rely on tips and commissions to fill the gap, it creates a potentially dangerous incentive. That system gives your provider a financial incentive to push treatments you don't actually need.

Imagine walking into a medspa for one simple treatment only to feel pressured into buying more. The nurse isn’t being pushy for fun; she needs that commission. In medicine, that kind of pressure crosses a line that should never be blurred.

Why Medicine and Money Don't Mix

"So if you're going to have heart surgery and you bring your doctor an extra big tip, does that bump you up in line above somebody who maybe needs it more but doesn't have as much money? So there are a lot of laws to prevent money from influencing medical procedures." — Dr. Kate Dee, Medspa Confidential Podcast

The American Medical Association is clear about this. Their code of ethics states that physicians shouldn't let gifts influence patient care. A large tip counts as a gift. And yes, it has the potential to change how you're treated.

Some medical boards go further. They consider tipping for medical procedures as fee splitting, which is flat out illegal in many states. For doctors, practicing unethically can mean losing their license. That's serious.

What This Reveals About Your Med Spa

"Every med spa should have a doctor in charge. They're supposed to have a medical director. I can tell you I really care because the unethical practice of medicine can be grounds to lose your license." — Dr. Kate Dee, Medspa Confidential Podcast

A tip screen for medical procedures is often the visible sign of a bigger problem. If your med spa doesn't understand the ethical line here, what else are they getting wrong?

Do they have a real medical director who's actually involved in patient care? Or just a name on paper? Are they using FDA-approved products or gray market supplies? Do their providers have proper training and licensing?

One red flag usually means there are others.

When Tipping Makes Sense

Not all med spa services fall into the same category. Some are spa treatments where tipping is totally fine. How do you know which is which?

Dr. Kate Dee breaks down the specific criteria that separate a spa service from a medical procedure in the full episode of Medspa Confidential.

She explains exactly what makes Botox different from a facial, and why that difference matters more than you think. You'll learn which treatments should never have a tip screen and what to look for when you're not sure.

Listen to the complete episode to learn when it’s okay to tip and what questions to ask before you do.

The transcript

[00:00:00] Dr. Kate Dee: have you ever been asked to tip your Botox or laser provider? Hi, I'm Dr. Kate d and today I'm gonna talk a little bit about tipping and tip screens at med spas. There's a video that Helen XO put out [00:00:15] recently that complains that toxic tip culture in the US has spread to med spas.

[00:00:21] Dr. Kate Dee: And in it, she makes some really great points about toxic tip culture. But I think the situation's even worse than she's pointing out, [00:00:30] and I'm gonna tell you why.

[00:00:31] Helen: I recently had a laser facial done at the National Med Spa Chain Skin Laundry with a registered nurse. At the end, I was asked to tip up to $30 for the service valued at $275.

[00:00:44] Dr. Kate Dee: So first of [00:00:45] all, she describes going into a national chain of med spas. She was in California. this national chain was called Skin Laundry.

[00:00:53] Dr. Kate Dee: And at that place they hire nurses to perform laser procedures and other medical treatments. [00:01:00] Now the company posts job openings in California saying that it pays, uh, nurses $28 an hour. Plus tips and commission. Now that's a really low wage for this kind of service. [00:01:15] It'd be low for nurses kind of anywhere, but especially low in the med spa space.

[00:01:20] Dr. Kate Dee: So what's the result of that? I mean, this company is using tips so that they can underpay their nurses and in addition the [00:01:30] structure with a very low hourly wage and a high. Dependence on tips and commission that incentivizes the nurses potentially anyway, to sell you services that you do not need or want.

[00:01:44] Dr. Kate Dee: [00:01:45] Okay. And then Helen in the video describes how this happened to her at Skin Laundry. Now, you know, upselling, you know, that is legal in business, but in medicine. It's really unethical. Okay, so let's dive into that. Tip [00:02:00] screens are everywhere. Takeout. You're now paying a tip.

[00:02:04] Dr. Kate Dee: Fast casual restaurants, you're paying a tip. Even just counter sales where you go up and you literally just pay at the register for. You know, a thing at the counter, whether it's lip [00:02:15] balm or whatever, a tip screen tends to pop up these days. Now, ever since COVID, I think this has become the norm, and you now have to decide whether you're gonna tip all these workers or not.

[00:02:25] Dr. Kate Dee: They're really, you know, appealing to our sense of duty. Like, you know, people [00:02:30] don't make enough money. That's okay, right? But don't you think that these places should be paying their workers adequately to start with? My biggest pet peeve about the toxic tip culture now is that those tip [00:02:45] screens, whether it gives you percentage options, like 18 20, 20 2%, that percentage is based on the post tax amount of the bill.

[00:02:55] Dr. Kate Dee: Okay? And I don't know about where you live, but where I live in Seattle, [00:03:00] our sales tax is already 10.25%. We are now being asked to tip 20% on top tax. Okay. That's my pet peeve. But anyway. What about med spas and other cosmetic medical practices? Why are they doing this? Well, [00:03:15] I think most of them, it's a money grab, mostly from unethical spas that you know this because this shady practice predates the recent tip screen epidemic, which I would date to COVID [00:03:30] in 2020.

[00:03:31] Dr. Kate Dee: So. Why is it illegal or unethical or both at Med Spas? Well. In general, money is not supposed to influence medical treatment. Okay? So if you're going to have [00:03:45] heart surgery and you bring your doctor, you know, an extra big tip, does that bump you up in line above somebody who maybe needs it more but doesn't have as much money, that kind of thing, right?

[00:03:57] Dr. Kate Dee: So there are a lot of laws to [00:04:00] prevent money from influencing medical, procedures, but what about elective procedures? Well. There's two big problems with it. So first of all, tipping may be considered fee splitting by the medical boards, and that's illegal. , And [00:04:15] then if you ask the a MA, they would say it's completely unethical.

[00:04:19] Dr. Kate Dee: And I'll read from the a MA code of ethics here. It states that physicians to whom a patient offers a gift should not allow the gift or offer of a [00:04:30] gift to influence this patient's medical care. Okay? Could a large tip be construed as a gift? Absolutely. And that has the potential to influence the patient's care.

[00:04:40] Dr. Kate Dee: But hey, the a MA doesn't know specifically anything about med spas, right? [00:04:45] So we do have tipping in med spas because many med spas have non-medical treatments like facials and derma plating. Okay? So those passive tip screens will pop up, but they should only pop up for [00:05:00] the non-medical treatments. Is that what happens?

[00:05:03] Dr. Kate Dee: Well, I think there is, a little bit of a businessy software component to this problem. Okay. Because, all these different med spas are using different kinds of software and some just have an automatic [00:05:15] tip scream that you have to get rid of for the medical ones and keep for the non-medical ones, in my opinion, they shouldn't be using that kind of simple software because that will unduly influence people to tip on medical procedures and they shouldn't be.

[00:05:29] Dr. Kate Dee: [00:05:30] So at my med spa, we use a pretty complicated, spa software that actually allows us to control that. And so it should only offer a tip screen for facials and, and things like that. Now, I will tell you that we have gone [00:05:45] through iterations of this software where it automatically upgrades and. It affects a lot of the defaults and suddenly the tip screens change.

[00:05:53] Dr. Kate Dee: I have had it happen where I've been scrambling around to get rid of the tip screen for the medical procedures because something got [00:06:00] undone. But in general, these offices should not be asking for tips on Botox or laser. Okay. So hopefully. It was an honest mistake, but my, guess is that most of the time these places are just looking [00:06:15] to increase their bottom line, so it's a little bit murky.

[00:06:19] Dr. Kate Dee: Is it completely illegal or merely unethical? Does that matter? I mean, it should definitely matter to the doctor in charge. And of course, every med [00:06:30] spa should have a doctor in charge. They're supposed to have a medical director. I can tell you I really care because the unethical practice of medicine. Can be grounds to lose your license.

[00:06:42] Dr. Kate Dee: Okay? So for most doctors, it's the [00:06:45] equivalent of being illegal, even if the lawyers might quibble about whether it's fee splitting or not. But what if your provider is not a doctor? What if they don't even have any license at all? They have no [00:07:00] license to lose, so they don't care. Adding a tip screen could boost their bottom line by 20%.

[00:07:05] Dr. Kate Dee: So. Beware of the tip screen in your medical spa. If you had a facial, it's fair game. But if you just had Botox or laser and you see a tip [00:07:15] screen, don't be afraid to pass and let the manager know it could possibly have been a mistake. So if you've had this happen to you, drop me a line and tell me about it.

[00:07:25] Dr. Kate Dee: Your story could end up featured in a future episode of Med Spa Confidential. And until [00:07:30] next week, thanks so much for being here.