18 U.S.C. § 220 – Illegal Remunerations for Referrals

Federal EKRA Defense Lawyer

18 U.S. Code § 220, known as the Eliminating Kickbacks in Recovery Act (EKRA), makes it a federal felony to pay or receive remuneration in exchange for referrals to recovery homes, clinical treatment facilities, or laboratories.

Unlike the Anti-Kickback Statute, EKRA applies broadly to both public and private healthcare benefit programs.

If you are under investigation or charged under 18 U.S.C. § 220, you face severe penalties, including up to 10 years in federal prison and fines up to $200,000 per violation.

Immediate legal representation by an experienced federal criminal defense attorney is critical.

Your best hope for a favorable outcome is with an experienced criminal defense attorney at the Hedding Law Firm in Los Angeles. To schedule a consultation, call (866) 986-2092 or use the contact form here.

What Is the Eliminating Kickbacks in Recovery Act?

EKRA was enacted in 2018 as part of the bipartisan SUPPORT Act in response to the opioid crisis.

Its purpose is to eliminate financial incentives that encourage improper patient referrals, especially in the substance abuse treatment industry.

Under 18 U.S.C. § 220, it is illegal to:

Solicit or receive remuneration for referring a patient to a recovery home, clinical treatment facility, or laboratory
Offer or pay remuneration to induce such referrals
Provide payment in exchange for a patient using services at these facilities

Remuneration includes:

Cash payments
Commissions
Consulting fees
Marketing payments
Gifts or non-cash items of value

The statute applies to services covered by any healthcare benefit program, not just federally funded programs.

How EKRA Differs from the Anti-Kickback Statute

The Anti-Kickback Statute under 42 U.S.C. § 1320a-7b applies primarily to federally funded healthcare programs such as Medicare and Medicaid.

EKRA expands liability to include private insurance and other healthcare benefit programs.

Key differences:

EKRA covers private payers
EKRA specifically targets recovery homes and laboratories
EKRA language regarding employee compensation is more restrictive and controversial

Because EKRA is broader in scope, compliance mistakes can expose healthcare providers to federal prosecution even when no federal insurance program is involved.

What Must Prosecutors Prove?

To secure a conviction under 18 U.S.C. § 220, federal prosecutors must prove:

Remuneration was offered, paid, solicited, or received
The payment was tied to patient referrals or service usage
The defendant acted knowingly and willfully
The conduct affected interstate commerce

Intent is a critical element in EKRA cases.

Without proof of knowing and willful misconduct, the government's case may fail.

Exceptions and Safe Harbors

Section 220(b) outlines exceptions to criminal liability.

Exempt arrangements may include:

Certain discounts or price reductions properly disclosed
Legitimate employee compensation arrangements
Payments under qualifying management contracts
Specific remuneration described under 42 U.S.C. § 1320a–7b(b)(3)(I)

However, EKRA safe harbor language is narrower and more ambiguous than under the Anti-Kickback Statute.

Determining whether your compensation structure qualifies for an exception requires careful legal analysis.

Common EKRA Investigation Scenarios

Federal investigations may involve:

Marketing companies paid per patient referral
Commission-based laboratory sales arrangements
Bonuses tied to testing volume
Payments to treatment centers for patient placement
Substance abuse treatment referral networks

Investigations are often conducted by:

Federal Bureau of Investigation
Department of Justice
Department of Health and Human Services

These cases frequently begin with subpoenas, whistleblower complaints, or billing audits.

Penalties Under 18 U.S.C. § 220

A conviction for violating EKRA carries:

Up to 10 years in federal prison per violation
Fines up to $200,000 per occurrence
Potential restitution
Asset forfeiture
Exclusion from healthcare benefit programs

Federal defendants must serve at least 85 percent of any prison sentence imposed.

Professional and licensing consequences may follow a conviction.

Defense Strategies for EKRA Charges

An experienced federal defense attorney may pursue several strategies:

Lack of Intent

Demonstrating no knowing or willful misconduct

Legitimate Business Arrangement

Proving payments were lawful compensation

Safe Harbor Compliance

Showing the arrangement fits within statutory exceptions

No Interstate Commerce Impact

Challenging federal jurisdiction

Insufficient Evidence

Contesting documentation or witness credibility

Early intervention may prevent indictment or allow for mitigation negotiations.

Frequently Asked Questions

What is considered remuneration under EKRA?

Anything of value — including non-cash benefits — tied to referrals or service usage.

Does EKRA apply to private insurance?

Yes. EKRA applies to any healthcare benefit program, not just federally funded programs.

Are employee commissions illegal under EKRA?

Certain commission-based compensation structures may violate EKRA unless they meet statutory exceptions.

Can EKRA charges be reduced or dismissed?

Yes, depending on intent, documentation, and applicability of safe harbor provisions.

Should I speak to federal investigators?

No. Always consult a federal defense attorney before providing statements.

Los Angeles Federal EKRA Defense Attorney

Allegations under 18 U.S.C. § 220 can jeopardize your medical practice, your business, and your freedom.

Hedding Law Firm represents healthcare professionals and business operators throughout:

Los Angeles
Southern California
Federal courts nationwide

Our defense approach includes:

Immediate response to subpoenas
Review of compensation agreements
Compliance analysis
Strategic negotiation
Trial-ready defense

If you are under investigation or charged under the Eliminating Kickbacks in Recovery Act, contact our office immediately at 866-986-2092 for a confidential consultation.

Early legal strategy can significantly impact the outcome of your case.

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