Although no one is going to do time as a result of thinking that wet sidewalks cause rain, in the case of the federal Anti-Kickback Statute, confusion over correlation can put you in jail.
Take a look at the below images of management services agreements:

Hint: They’re identical. Spoiler Alert: That’s the problem.
The federal Anti-Kickback Statute, commonly referred to as the “AKS”, prohibits the offer of, demand for, payment of, or acceptance of any remuneration for referrals of federally funded healthcare program patients, such as those covered by Medicare or Medicaid.
There are regulatory “safe harbors” that describe certain arrangements not subject to the AKS because they are unlikely to result in fraud or abuse. However, there’s absolutely no requirement that a deal fall within a safe harbor to be legal; rather, the failure to fall within a safe harbor just means that a complete analysis under the statue itself is required.
One of the AKS safe harbors covers management services arrangements. Among the safe harbor’s various requirements, the agreement must be set out in a signed written document.
The problem is that you don’t need a writing to steer clear of an anti-kickback statute violation, although having one is an element of fitting you into a nice-to-have safe harbor.
The common mistake, the one that I implore you to avoid, is correlating a writing with actually being in a safe harbor and therefore, with actually being in compliance with the AKS. After all, anyone can create a writing.
I’d need more than the fingers on three hands to count the times I’ve heard from some physician who fell for a fantastic looking, elegantly drafted agreement presented by some scamster. The unfortunate physician confused a written agreement with compliance. Perhaps he or she was also told that “the deal had been vetted by our lawyers”. Hey, maybe it had been. After all, the AKS is a criminal law and there’s certainly a chance that the lawyers were criminals.
Don’t fall for the same half-baked heuristic. A writing is required, that is, 100% correlated, with being within a safe-harbor, but a writing is no more actually being in compliance than wet sidewalks cause rain.
Take, for example, the December 3, 2024, announcement by the U.S. Attorney’s Office for the District of Massachusetts that Timothy Doyle of Selden, N.Y. was charged and has agreed to plead guilty to one count of conspiracy to violate the AKS. A plea hearing has not yet been scheduled by the Court – so at this point the government’s allegations against him are still just allegations.
According to the government, Doyle allegedly conspired with others, including two managers of a mobile medical diagnostics company, to enter into kickback agreements with several physicians. It’s alleged that Doyle and his co-conspirators agreed to offer and pay doctors kickbacks, some in cash and others by check, based on the number of ultrasounds the doctors ordered.
And, here’s the correlation kicker: Doyle and his co-conspirators allegedly created purported rental and administrative service agreements, which on paper made it appear as if doctors were compensated for the diagnostic company’s use of space and administrative resources of the ordering doctor’s practice based on fair market value and not based on the volume or value of referrals. It is also alleged that these agreements were shams that hid the true nature of the arrangement of paying per test.
Don’t confuse any writing for actual compliance. The image above on the left is from the world’s most correctly structured management services deal. The identical image on the right can land you in prison.
Perhaps a little memory tool will help keep this top of mind:
Wet sidewalks don’t cause rain,
but mistaking a writing for compliance can cause pain.