EKRA Explained: Marketing Rules for Treatment Centers

Why EKRA Belongs at the Top of Your Marketing Plan

You found a marketing partner who will send you admissions and only wants to get paid per patient who walks through the door. It sounds fair. You only pay for results. For an addiction treatment center, that single arrangement can be a federal felony.

The Eliminating Kickbacks in Recovery Act, known as EKRA, changed the rules for how treatment centers, recovery homes, and labs can pay for marketing and referrals. It carries criminal penalties of up to $200,000 in fines and up to ten years in prison for each violation. Owners who treat patient acquisition like an ordinary lead-buying business are the ones who get caught.

This is a business problem before it is a legal one. Your census depends on a steady flow of admissions, and the channels that fill beds are exactly the ones EKRA polices. Learning the law is not about fear. It is about building a patient acquisition system that brings in admissions and still survives a federal audit. The owners who understand the rules tend to compete with more confidence, not less, because they are not worried about which of their referral deals might unravel.

What EKRA Actually Says

Congress passed EKRA in 2018 as part of the SUPPORT Act, the federal response to the opioid crisis. The statute lives at 18 U.S.C. § 220. In plain English, it makes it a crime to knowingly and willfully pay, offer, solicit, or receive any payment in return for referring a patient to a recovery home, a clinical treatment facility, or a laboratory.

One feature makes EKRA broader than the older Anti-Kickback Statute. The Anti-Kickback Statute reaches only federal health care programs like Medicare and Medicaid. EKRA reaches all payers. A cash-pay client or a client covered by private insurance falls under EKRA just the same. For a treatment center that bills commercial insurance or takes private pay, that covers most of the business.

The word that does the work in the statute is remuneration, and it is read broadly. It covers cash, but also free rent, gifts, inflated salaries, paid travel, or anything of value handed over to induce a referral. The law also requires that the act be knowing and willful, so an honest mistake is treated differently from a deliberate scheme. That distinction is small comfort in practice, because prosecutors point to per-patient pay structures as evidence of intent.

The penalties attach per occurrence. Five improper referral payments can be charged as five separate counts. That is how a marketing arrangement that felt routine turns into a sentence measured in decades. The U.S. Department of Justice has made health care kickbacks an enforcement priority through its Health Care Fraud Unit.

Marketing Payments That Cross the Line

EKRA does not ban marketing. It bans paying for referrals in ways that tie compensation to the patient. A few common arrangements are the usual sources of trouble:

• Per-admit or per-head fees. Paying a marketer, interventionist, or call center a set amount for each admitted patient is the textbook violation.
• Percentage-of-revenue deals with outside marketers. Paying an outside marketing company a cut of the revenue each referred patient generates ties the payment directly to referrals.
• Per-lead fees from lead vendors. Buying treatment leads priced per lead or per admission is a high-risk arrangement when those leads are patients headed to your facility.
• Head-count bonuses for staff. Even employees on payroll can create exposure when their pay rises with the number of patients they bring in.

The thread running through all of these is the same. When the dollar amount moves with the patient, EKRA is in play. When you pay for honest work at a fair fixed rate, you stand on much safer ground.

The Schena Decision and Percentage Pay

The biggest recent development came in 2025. In United States v. Schena, the Ninth Circuit Court of Appeals affirmed a lab operator’s EKRA conviction and clarified how percentage-based marketing pay is treated. The court held that a percentage-based payment to a marketer is not automatically illegal under EKRA. On its face, that reads like good news for marketers who work on commission.

The catch is what came next. The court upheld the conviction because the operator paid marketers to sway referrals through false and misleading claims about the services. The percentage structure was legal on its own. The fraud layered on top is what made it criminal. The same day, the court walked back an earlier ruling that some had read as a safe harbor for commission pay.

The lesson for an owner is not that commissions are suddenly fine. It is that pay structure and conduct are judged together. A clean compensation formula does not rescue a dishonest referral scheme, and federal enforcement against treatment and sober home marketing has been climbing, with several 2025 indictments built on exactly these arrangements.

For owners, the practical response is to stop relying on how a deal is labeled. Calling someone an employee, or calling a payment a flat marketing fee, does not settle the question. What a court examines is whether the money was meant to buy referrals, and whether anyone misled patients or providers along the way. Substance over label is the standard.

State Patient Brokering Laws Stack on Top

EKRA is federal. Many states run their own patient brokering laws at the same time, and Florida’s is among the most aggressive in the country. The Florida Patient Brokering Act, Florida Statutes § 817.505, makes it a crime to pay or receive any commission, benefit, or kickback in exchange for patient referrals. Florida prosecutors have used it heavily against treatment centers and sober homes.

State and federal charges can both be brought for the same conduct. One per-admit deal could expose an operator to an EKRA count and a state patient brokering count at once. If you operate in Florida, or you send or receive referrals across state lines, assume both layers apply and build to the stricter of the two. The safest design is one that needs no exception to survive.

HIPAA and Privacy in Your Marketing

Patient acquisition also runs into privacy law. HIPAA protects patient health information, and substance use records carry an extra federal layer under 42 CFR Part 2. That shapes what your marketing is allowed to do.

• Client testimonials and success stories need signed, specific authorization before you publish them.
• Photos, first names, or any detail that could identify a former client require documented consent.
• Handing a prospective client’s information to a third-party marketer or call center can create a privacy problem on its own when the right agreements are not in place.

The reputational damage from a privacy complaint often outlasts the fine. Treat every client story as protected until you hold written permission that says otherwise.

Build consent into your intake and alumni process from the start. A short, specific release that a client signs knowingly is worth far more than a rushed signature collected after you already want to use the story. When in doubt, keep identifying details out of public marketing entirely and speak in general terms about the care you provide.

Ad Platforms Add Their Own Gate

Beyond the law, the major advertising platforms set their own requirements for addiction treatment advertisers. Google and other networks require treatment providers to pass a third-party certification before they can run ads for these services. The review looks at licensing, staffing, and business practices. Plan for it early. An ad account can sit idle for weeks when an operator starts certification after launching a campaign instead of before.

Marketing That Stays Fully Legal

It is easy to read EKRA and conclude that all marketing is dangerous. It is not. The law targets payments tied to referrals, not the work of attracting patients. A treatment center has a wide set of channels that carry no per-referral risk at all.

• Search and content. A website that answers the real questions families ask, paired with strong organic search, brings in admissions without paying anyone per patient.
• Paid advertising at fixed cost. Running certified Google or social campaigns and paying an agency a flat monthly fee for the work is a normal, compliant arrangement.
• Alumni and family programs. Former clients and their families are a durable referral source, and unpaid word of mouth raises no EKRA concern.
• Professional reputation. Relationships with clinicians, hospitals, and courts that refer because they trust your outcomes are legal, as long as no money changes hands for the referral itself.

None of these depend on a per-admit deal. They take longer to build than buying leads, and they are far harder for a competitor or a prosecutor to attack. The owners who invest here early are the ones who end up with an admissions pipeline they actually own, instead of one they rent from a lead vendor.

Building a Compliant Patient Acquisition System

Compliance and growth are not opposites. The centers that fill beds reliably are usually the ones that built clean systems early. A practical framework looks like this:

1. Pay for work, not for patients. Compensate marketers, agencies, and staff at fixed rates for defined work such as ad management, content, web, and call handling. Keep the dollar amount independent of how many patients result.
2. Handle in-house marketers carefully. EKRA has an employee exception, but courts read it narrowly. Avoid pay that climbs with admission counts even for staff on payroll.
3. Get every marketing contract reviewed. A health care attorney should read any agreement involving referrals, leads, or commissions before you sign it.
4. Build referral relationships on trust, not money. Alumni, clinicians, and community partners refer because they trust your outcomes. That is legal and durable. Paying for those referrals is neither.
5. Own your inbound channels. A strong website, a real organic search presence, and a well-run admissions phone line bring in patients without per-referral payments.
6. Document everything. Written scopes, fixed fees, and clean records are exactly what an audit looks for.

This is where outside help earns its keep. Knowing how to fill beds, and how to do it within EKRA, state law, and platform rules, is a specific skill set. It is not one a vendor selling per-admit leads will ever hand you. Small business owners can also find plain-English guidance on advertising rules from the Federal Trade Commission.

Where Marketing Meets Compliance

The treatment centers that grow without legal trouble share one habit. They check the marketing math against the law before the money moves, not after a subpoena arrives. A pay-per-patient deal that looks like a bargain on Monday can cost far more than an empty bed by Friday.

At MJI Consulting Group, we work with treatment center owners on patient acquisition that is built to be both effective and compliant, from intake performance to marketing that keeps you on the right side of EKRA. If your admissions pipeline has stalled, or you are not certain your current marketing arrangements would survive scrutiny, that is a solvable problem.

Every business is different, and this article is general information, not legal, financial, or compliance advice for your specific situation. EKRA enforcement and case law are developing quickly. Consult a qualified health care attorney before you sign or change any marketing or referral arrangement.