Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca7-14-02607/USCOURTS-ca7-14-02607-0/pdf.json

Parties Involved:
Kamal Patel
Appellant
United States of America
Appellee

Document Text:

In the

United States Court of Appeals

For the Seventh Circuit ____________________

No. 14-2607

UNITED STATES OF AMERICA,

Plaintiff-Appellee,

v.

KAMAL PATEL,

Defendant-Appellant.

____________________

Appeal from the United States District Court for the

Northern District of Illinois, Eastern Division.

No. 12 CR 491-5 — Robert M. Dow, Jr., Judge.

____________________

ARGUED DECEMBER 5, 2014 — DECIDED FEBRUARY 10, 2015

____________________

Before FLAUM, EASTERBROOK, and KANNE, Circuit Judges.

FLAUM, Circuit Judge. Dr. Kamal Patel is a Chicago-area 

physician who commonly prescribes home health care services for his patients. After federal investigators learned that 

Patel had been receiving undisclosed payments from Grand 

Home Health Care (“Grand”), a home care provider used by

some of his patients, Patel was charged with six counts of 

violating—and one count of conspiring to violate—42 U.S.C. 

§ 1320a-7b, otherwise known as the Anti-Kickback Statute. 

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In relevant part, the Statute makes it illegal to “knowingly 

and willfully solicit[] or receive[] any remuneration (including any kickback, bribe, or rebate) ... in return for referring 

an individual to a person for the furnishing” of health care 

services paid for, in whole or in part, by a federal health care 

program. Id. § 1320a-7b(b)(1)(A).

During his bench trial, at the close of the government’s 

evidence, Patel moved for a judgment of acquittal, arguing 

that he had not “referred” any patients to Grand because 

there was no evidence that he steered or directed his patients 

to Grand; rather, the patients independently chose Grand as 

their provider after Patel prescribed home health care. The 

district court rejected Patel’s argument, holding that, even if 

a patient had initially chosen Grand, Patel “referred” the patient to Grand when he certified or recertified that the patient needed care, that the care would be provided by Grand, 

and that Grand could be reimbursed by Medicare for services provided. This certification and recertification occurred 

each time Patel signed a standardized Medicare form, Form 

485, for one of his patients.

On appeal, Patel argues that the district court erred by 

holding that the certification and recertification, via Form 

485, of patients for treatment constitutes a “referral” under 

the Anti-Kickback Statute. He also argues that even if those 

certifications were referrals, there was insufficient evidence 

to conclude that Patel was paid “in return for” certifications, 

as required by the statute. We affirm.

I. Background

Patel is an internal medicine specialist who treats approximately twenty elderly patients per day and prescribes home 

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health care services to about ten patients per month. One of 

the approximately 10–20 home health care providers used by 

Patel’s patients is Grand, a Chicago-based company. Around 

95% of Grand’s patients are Medicare beneficiaries; Medicare, the parties have stipulated, is a federal health care program as defined in the Anti-Kickback Statute. In 2002 or 

2003, Grand experienced a significant decline in business 

when some of its partners left to form a competing company, 

taking most of Grand’s patients with them. Prior to that time, 

Grand had received patients from Patel, but this ceased following the partners’ departure. To counteract this downturn, 

Grand’s owners, Nixon Encinares and Maria Buendia, initially tried introducing themselves to numerous doctors in the 

area, including Patel, in an effort to attract business. After 

this approach proved unsuccessful, the Grand owners begin 

offering to pay doctors for referrals of Medicare patients. 

Encinares approached Patel, specifically offering to pay 

him for “referrals.” According to Patel, he did not say anything in response to the proposal and “didn’t agree with” 

Encinares. Buendia and Encinares, on the other hand, testified that Patel said something to the extent of “okay” or 

“yeah” in response to their offer.1 During a second meeting 

with Patel, Encinares and Buendia offered to pay Patel for 

referrals on a per-patient basis. After making this offer, 

1 The district court, acting as trier of fact, concluded that it was unnecessary to resolve this factual dispute. The dispute was immaterial to Patel’s

guilt on the six counts of violating the Anti-Kickback Statute. And, even 

if Patel did not verbally agree to the arrangement, the district court concluded that he was also guilty of conspiracy because he later manifested 

his involvement in the conspiracy by accepting payments from Encinares 

while certifying and recertifying patients to Grand.

 

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Grand began providing home health care services to about 

2–4 of Patel’s patients per month; a majority of Patel’s patients continued to use other providers.

To qualify for Medicare-reimbursed home health care 

services, a patient must be homebound and suffer from a 

medical condition or constellation of medical conditions that 

requires skilled nursing care or therapeutic services. A doctor or nursing facility must initially determine that a patient 

needs these services. Once this determination is made, the 

patient or his caregiver must select a provider to furnish the 

necessary services. Often, a treating physician or nurse will 

discuss the merits of particular providers with patients. Patients who have previously received home health care services often reselect their previous provider. After a provider 

is selected, the patient or his doctor contacts the provider 

and supplies important information, including the patient’s 

name, his diagnosis, and his Medicare number. The provider 

then assesses the patient’s condition and needs, and formulates a treatment plan. To be reimbursed by Medicare for the 

treatment, the provider must complete and submit to Medicare a Form 485 for each patient; Form 485 is a standardized 

Medicare form that certifies that home care is medically necessary and outlines a patient’s diagnosis, medications, treatment plans, and goals. After filling out this information, 

providers must procure the signature of the patient’s primary care physician on each Form 485 before the provider can 

bill Medicare. A signed recertification form is necessary for 

home care that lasts longer than the initial 60-day certification period. Home health care providers can—and often 

do—treat patients prior to receiving a signed Form 485, but 

they cannot be reimbursed by Medicare until the Form has 

been signed. By signing a Form 485, a physician certifies that 

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“the patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech 

therapy or continues to need occupational therapy,” and that 

the physician has “authorized the services on this plan of 

care and will periodically review the plan.”

Both before and after Grand began offering Patel kickbacks, Patel used the following process when prescribing 

home health care for a patient. First, Patel made the initial 

determination that the patient required home health care 

services. This initial decision is not at issue in this case—it is 

undisputed that all of Patel’s patients who were treated by 

Grand needed home health care. After this initial determination was made, a provider needed to be chosen. Patel did not 

personally discuss the selection of providers with patients or 

their family members, either as an initial matter or as part of 

recertification. Rather, his patients discussed home health 

care options with Patel’s medical assistant, Jeanette 

Sungvoom. Patel did not tell Sungvoom which provider to 

recommend. Sungvoom gave patients an array of 10–20 brochures from various providers. The brochures were given to 

Patel’s office by the providers, but it is unclear whether 

Sungvoom and Patel included every brochure that they were 

offered. One of the brochures provided by Sungvoom was 

Grand’s, but the government does not contend that it was 

included in the array because Grand had offered Patel kickbacks. Each patient independently chose a provider from 

those in the array. After a provider was selected, Sungvoom 

called or faxed the provider with the name of the patient, his 

diagnosis, and his Medicare number. The fax cover pages 

from Patel’s office bore the subject line “new referral” and 

the body of the faxes contained prescriptions for home 

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health care signed by Patel or by Sungvoom, with Patel’s authorization. 

If the patient selected Grand as his home health care provider, Grand would then send one of its nurses to assess the 

patient and complete an “OASIS” form to document the assessment. Grand would devise a treatment plan and fill out 

most of a Form 485 for that patient. Grand often began 

providing the proposed services before Patel signed the 

Form 485. Encinares met with Patel on a monthly basis to 

have him sign Form 485s. During these meetings, Encinares 

paid Patel cash. The amount of cash was equivalent to $400 

for each signed Form 485 representing a new admission to 

Grand and $300 for each signed recertification. The district 

court found that Patel would have signed the Form 485s for 

each of these patients even if they had not selected Grand. It 

noted, however, that on at least one occasion Patel indicated 

over the phone that he was not ready to sign the forms for 

patients who selected Grand until Encinares was able to 

bring cash along with the forms. In her office, Buendia kept 

handwritten notebooks keeping track of Patel’s patients being treated by Grand, as well as Grand’s payments to Patel. 

Buendia and Encinares would refer to these notebooks each 

month to determine how much money Patel was due. The 

notebooks contain entries reflecting multiple payments of 

over $1,000 to “Dr. Patel” or “Dr. P.” In addition to normal 

cash payments, Patel was also at times compensated by 

Grand in the form of incremental loan forgiveness for an 

$8,000 loan Patel previously received from Grand.

The government began investigating Grand for health 

care fraud in the spring of 2011. Encinares and Buendia 

quickly agreed to cooperate in the government’s investigaCase: 14-2607 Document: 26 Filed: 02/10/2015 Pages: 24
No. 14-2607 7

tion of others taking part in their scheme by recording telephone calls and meetings with those individuals. Encinares 

recorded several phone conversations and three meetings 

with Patel, which Encinares testified were typical of their 

prior meetings. During these interactions, Patel frequently 

sounded nervous. In their recorded meetings, Patel signed 

Form 485s and Encinares gave Patel cash. During one recorded phone call, on May 10, 2011, Patel said, “I was wondering if we could meet for paperwork today.” Encinares replied by stating that money was “tight” for Grand, to which 

Patel responded, “So you’re not ready for the paperwork 

right now.”

On November 13, 2012, the government filed a 42-count 

indictment against Patel, Encinares, Buendia, and others alleging violations of the Anti-Kickback Statute. Patel was 

charged with six counts of violating the Statute and one 

count of conspiracy to violate the Statute. A three-day bench 

trial began on June 10, 2013. The next day, at the close of the 

government’s case in chief, Patel filed a motion for a judgment of acquittal on all counts, arguing that he had not 

made any “referrals” to Grand. The district court took the 

motion under advisement and continued with the trial.

On February 19, 2014, the district court denied Patel’s 

motion for judgment of acquittal and found him guilty on all 

counts. Patel was sentenced to serve eight months’ imprisonment and 200 hours of community service, and was required to forfeit $31,900 of kickback payments. After sentencing, the district court granted Patel’s motion for bond 

pending appeal.

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II. Discussion

A. Definition of “Referring”

The Anti-Kickback Statue is designed to prevent Medicare and Medicaid fraud. According to the Health Resources 

and Services Administration, the Statute was enacted to 

“protect the Medicare and Medicaid programs from increased costs and abusive practices resulting from provider 

decisions that are based on self-interest rather than cost, 

quality of care or necessity of services.” Health Res. & Serv. 

Admin., Program Assistance Letter 1995-10, Guidance on the 

Federal Anti-Kickback Law, available at 

http://bphc.hrsa.gov/policiesregulations/policies/pal199510.h

tml (last visited February 2, 2015); see also United States v. 

Borrasi, 639 F.3d 774, 781 (7th Cir. 2011) (explaining that the 

Anti-Kickback Statute was “designed to help combat health 

care fraud”). The Statute has another purpose as well—to 

protect patients from doctors whose medical judgments 

might be clouded by improper financial considerations. See 

Health Res. & Serv. Admin., supra (“The law seeks to ... preserve freedom of choice and preserve competition.”). 

The provision of the Anti-Kickback Statute at issue in this 

case states:

whoever knowingly and willfully solicits or receives any remuneration (including any kickback, bribe, or rebate) directly or indirectly, 

overtly or covertly, in cash or in kind—in return for referring an individual to a person for 

the furnishing or arranging for the furnishing 

of any item or service for which payment may 

be made in whole or in part under a Federal 

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No. 14-2607 9

health care program [shall be guilty of a felony].

42 U.S.C. § 1320a-7b(b)(1)(A). This appeal requires us to interpret the meaning of the term “referring”—which is not 

defined in the statute—and specifically to decide whether 

Patel referred his patients to Grand each time he signed 

Form 485 certifications and recertifications, thereby allowing 

Grand to be reimbursed by Medicare for services provided 

to those patients.

Patel argues that, in the context of the Anti-Kickback 

Statute, the word “refer” means to personally recommend to 

a patient that he seek care from a particular entity. In Patel’s

view, a physician does not refer a patient when the patient, 

with no input from the physician, independently chooses a 

provider. Therefore, because there is no evidence that Patel 

ever urged any of his patients to use Grand, he argues that 

he cannot be guilty of violating the Statute.2 The government, in contrast, argues for a broader reading of the term 

2 Under this theory, Patel would also be innocent of conspiracy to violate 

the Anti-Kickback Statute even if he had agreed to be paid in return for 

certifications and recertifications, as this would not be a conspiracy to be 

paid in return for referrals. However, under Patel’s theory, Patel could

still be guilty of conspiracy if he agreed to be paid in return for recommending his patients to Grand, but never actually carried out this plan. 

The district court did not determine whether Patel entered into such an 

agreement because the court found Patel guilty of conspiracy for a different reason: certifications and recertifications are referrals, meaning 

that Patel manifested his agreement to an illegal conspiracy by accepting 

payments in exchange for these certifications. Because we ultimately 

agree with the district court’s legal determination, as well as its factual 

conclusion that Patel was paid in return for referring patients, we also 

agree with the district court’s conclusion on the conspiracy count.

 

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“refer,” which includes not only a doctor’s recommendation 

of a provider, but also a doctor’s authorization of care by a 

particular provider. Under this reading, Patel referred his 

patients to Grand by signing Form 485 certifications and 

recertifications. We agree with the government’s interpretation.

We review issues of statutory construction de novo. United States v. Berkos, 543 F.3d 392, 396 (7th Cir. 2008). When interpreting the meaning of undefined statutory terms, the 

“cardinal rule is that words used in statutes must be given 

their ordinary and plain meaning.” Sanders v. Jackson, 209 

F.3d 998, 1000 (7th Cir. 2000). To determine the plain meaning of words, we frequently look to dictionary definitions. Id. 

We also consider the construction of similar terms in other 

statutes, id., as well as the purpose of the statute being interpreted. Id. at 1002. 

Patel’s central argument is that the most common usage 

of “refer” in the medical context is a doctor’s recommendation that a patient see a particular specialist or provider, and 

that this is the behavior that Congress targeted when it enacted the Anti-Kickback Statute. Indeed, one dictionary defines “referral”3 as “the process of directing or redirecting 

(as a medical case or a patient) to an appropriate specialist or 

agency for definitive treatment.” MERRIAM-WEBSTER 

DICTIONARY ONLINE, available at http://www.merriamwebster.com/medical/referral (last visited February 2, 2015).

3 The Statute uses the word “referring,” but both parties frequently discuss the base form of that verb, “refer,” as well the noun form, “referral.” 

We agree with the parties that these terms are interchangeable for the 

purposes of our analysis.

 

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Another defines it as “the directing of a patient, usually by a 

general practitioner, to a consultant or institution for specialist treatment.” OXFORD ENGLISH DICTIONARY ONLINE, available at http://www.oed.com/view/Entry/160858 (last visited 

February 2, 2015).

But although Patel’s proposed definition of “referral” is a 

common usage of the term, it is not the only common usage. 

Often, people use the word “referral” to describe a doctor’s 

authorization to receive medical care, even when the doctor 

is not the one choosing the provider of that care. For example, in Illinois, a physical therapist cannot provide treatment 

without a physician’s “referral.” 225 Ill. Comp. Stat.

90/17(1)(V). A “referral,” in turn, is defined as “a written or 

oral authorization for physical therapy services for patient by 

a physician.” Id. 90/1(6) (emphasis added). Presumably, 

many patients in Illinois visit their doctors seeking physical 

therapy and with a specific therapist already in mind. In 

such a case, the patient does not need a recommendation 

from his physician, but still needs a referral—that is, an authorization—before he can be treated by his chosen therapist.

This more expansive definition of “referral” is frequently

used in the medical context. Indeed, in this case, Patel’s own 

office often identified a patient as a “new referral” when faxing new patient information to Grand, even though Patel 

had played no part in the patient’s selection of Grand. 

Courts, including our own, often employ this usage of the 

word. See, e.g., Moran v. Rush Prudential HMO, Inc., 230 F.3d 

959, 963 (7th Cir. 2000) (ERISA plaintiff sued HMO after 

HMO-affiliated primary care physician denied her “request 

for [an] out-of-network referral to consult with” a specific 

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surgeon chosen by the plaintiff); McElhone v. Sebelius, No. C 

12-06090, 2014 WL 1048583, at *2 (N.D. Cal. Mar. 14, 2014) 

(“Plaintiff also requested an out-of-network referral to Physiatrist Sherman Tran at Stanford Medical Center.”); Nealy v. 

U.S. Healthcare HMO, 711 N.E.2d 621, 622–23 (N.Y. 1999) 

(“When Dr. Yung informed him during one or both of these 

visits that he should see a cardiologist, Mr. Nealy requested 

a referral to Dr. Green ... . Dr. Yung allegedly assured his patient that he would submit a request to U.S. Healthcare to 

approve an out-of-plan referral ... .”). Patel contends that 

these cases4 do not support the government’s position be4 The government argues that our decision in United States v. Polin, 194 

F.3d 863 (7th Cir. 1999), forecloses Patel’s proposed definition of “referring,” but we disagree. According to the government, the word “refer” 

should be interpreted broadly because, in Polin, we agreed with the government’s statement that “refer is to recommend, is to turn over, is to 

make a selection, is to give the business away.” Id. at 866. For multiple 

reasons, we are unpersuaded. First, no part of this expanded definition 

clearly encompasses Patel’s actions in this case; rather, they mostly have 

to do with recommending that a patient see a particular provider. Second, we did not adopt this definition in Polin—we merely said that the 

government’s counsel had “aptly summarized” the term. Id. Finally, this 

language is taken out of context. In Polin, the defendants had paid money to a pacemaker sales representative—a non-physician—in return for 

the representative’s referral of patients. Id. at 864. The indictment reflected the language of § 1320a-7b(b)(2)(A), which criminalizes paying kickbacks for certain “referrals.” The defendants claimed that they had been 

charged under the wrong subsection of the Statute, arguing that only 

physicians can make “referrals.” Instead, they argued that they should 

have been charged under subsection (B) of the same statute, which criminalizes “recommendations,” which non-doctors can make. We held that 

these subsections were not “separate subsections that address ‘different 

and non-overlapping’ types of conduct,” and thus that both subsections 

could apply to doctors or non-doctors. Id. at 866. In referencing the government’s suggested definition of “referring,” we were merely stating 

 

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cause, in each of them, the physician was involved in the selection of a specific provider prior to treatment, regardless of 

who identified the specialist in the first instance. That is factually incorrect. In each of these cases, the doctor was not 

involved in the selection of a provider—the patient independently chose a specific provider. All the physician did 

was authorize care by the patient’s chosen provider. Patel is 

correct that it does not matter who first identifies the care 

provider; what matters is whether the doctor facilitates or 

authorizes that choice. In each of the above cited cases, the 

doctor acted as a gatekeeper—without his approval, the patient could not receive treatment from the provider the patient had selected. Exercising this gatekeeping role is one 

way that doctors refer their patients to a specific provider.

Both parties point to the definition of “referral” in a related federal statute, the Stark Act, 42 U.S.C. § 1395nn, for 

support. The Stark Act is a civil statute that prohibits referrals of health services for Medicare and Medicaid patients to 

entities in which the physician or a member of his family has 

a financial interest. It defines “referral” to include “the request by a physician for a consultation with another physician” and “the request or establishment of a plan of care by a 

physician which includes the provision of [health services].” 

Id. § 1395nn(h)(5)(A)–(B). Regulations interpreting that definition, in turn, define “referral” to include “the request by a 

physician for, or ordering of, or the certifying or recertifying of

the need for, any designated health service for which payment 

may be made under Medicare Part B.” 42 C.F.R. § 411.351 

(emphasis added). Under this definition, Patel’s certifying 

that “refer” and “recommend” are synonyms—precisely what Patel argues in this case.

 

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and recertifying of patients by signing Form 485s would 

seem to constitute referrals. Patel argues, in contrast, that the 

Stark Act definition provides support for his reading of the

Anti-Kickback Statute. First, he argues that Congress needed 

to expressly define “referral” so broadly in the Stark Act because the ordinary meaning of the term is much narrower. In 

contrast, according to Patel, Congress intended the word to 

have its “ordinary,” narrower meaning in the Anti-Kickback 

Statute, and therefore did not feel a need to further define 

the term. But it is equally possible that Congress defined “referral” in the Stark Act as it did because Congress believes 

that is what the word means. At the very least, the Stark Act 

definition suggests that Congress considers the government’s broad reading of the term “referral” to be a permissible one. Patel’s second argument regarding the Stark Act is 

that the purpose of that Act supports a broader definition of 

“referral,” while the purposes of the Anti-Kickback Statute

do not. He argues that in the context of a self-referral (the 

target of the Stark Act), an expansive definition of “referral” 

is necessary because a self-referring physician has an ongoing financial interest in the health care provider that treats 

the patient. But Patel also had an ongoing financial interest in 

the treatment of his patients by Grand—he received a kickback for every recertification he signed. 

Dictionary definitions and the construction of a related

statute leave us with two plausible readings of the AntiKickback Statute. Upon considering the Statute’s main purposes, however, we are convinced that Congress intended 

the Statute to extend to the certification and recertification of 

patients for government-reimbursed care. The central purpose of the Statute is to prevent Medicare and Medicaid 

fraud. Patel contends that there was no harm to the Medicare 

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No. 14-2607 15

system in this case, as the government concedes that every 

one of his patients that went to Grand actually needed home 

health care services. But this is irrelevant5 to our legal interpretation of the meaning of the statute, because even if the 

Medicare system suffered no losses in this instance, the danger of fraud at the certification and recertification stages is 

quite clear. At the certification stage, a physician could refuse to certify a patient to a patient-chosen provider unless 

the provider paid the physician a kickback. This behavior 

could increase the cost of care. It could also contravene the 

second purpose of the Anti-Kickback Statute—protection of 

patient choice—by interfering with the patient’s choice if the 

selected provider refused to pay. 

Or, consider a patient who goes to his physician seeking 

authorization to visit a certain provider. If that physician will 

receive a kickback for a certification to that provider, he will 

have an incentive to certify the patient even if he thinks that 

the care is unnecessary or believes that the patient-chosen 

provider is substandard. All of these same concerns arise at 

the recertification stage as well: a doctor being paid for each 

recertification will be incentivized to authorize unnecessary 

further care and to ensure that the patient continues to use

the same provider, even if that provider gives poor care.

Additionally, as the district court noted, if Patel is correct 

that only steering a patient to a particular provider constitutes a referral, a physician would be free to accept a kickback each time he recertified a patient for treatment by a 

5 There is no allegation in this case that Grand provided subpar treatment to any patients certified by Patel or that those patients suffered any 

tangible harm. This is also irrelevant to our legal determination.

 

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previously selected home health care provider. This outcome 

was recently rejected by the Eleventh Circuit in United States 

v. Vernon, 723 F.3d 1234 (11th Cir. 2013). In Vernon, the defendant argued that a patient could not be “referred” to a 

provider within the meaning of the Anti-Kickback Statute if 

he was already a patient of that provider. The court rejected 

this argument, stating that it “would lead to the absurd result that the first kickback payment for a referral is unlawful, 

but future kickback payments for the same patient are lawful because they are not for an initial ‘referral.’” Id. at 1256. 

Such a result is undesirable because the possibility of a kickback for each recertification incentivizes the physician to 

keep recertifying, even if further treatment is unnecessary or 

if treatment by a different provider would be in the patient’s 

best interest. Patel argues that Vernon is distinguishable from

this case because the patients in Vernon did not choose or 

even know the identity of their provider. Thus it was the defendant, a “patient advocate,” who continued to choose 

where to fill her clients’ prescriptions whenever she filled a 

prescription at the pharmacy paying her kickbacks. Patel argues that he, in contrast, played no role in his patients’ initial 

selection of Grand or their decision to continue using Grand.

True, but Patel chose whether his patients could go to Grand 

at all, which we think is just as important. Patel acted as a 

gatekeeper to federally-reimbursed care. Without his permission, his patients’ independent choices were meaningless. 

Regardless, Patel’s proposed distinction from Vernon does 

not eliminate the absurdity that can result from his proposed 

definition. Even if the patient makes the initial choice of a 

provider, a physician could take advantage of his power to 

veto that choice at the certification or recertification stage, 

harming Medicare, the patient, or both.

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These concerns persuade us that, in passing the AntiKickback Statute, Congress intended to criminalize the receipt of kickbacks in return for a physician’s certification or 

recertification, through a signed Form 485, that a patient requires Medicare-reimbursed care. The word “referral” is 

commonly used—including by Congress in the Stark Act—

in a way that extends to such authorizations. Moreover, a 

narrow definition of the term would defeat the central purposes of the Anti-Kickback Statute.

Patel offers a number of other arguments in favor of his 

proposed reading of the Statute, none of which we find convincing. First, he points out that the word “referring” must 

be read in the context of the rest of the statutory subsection, 

which criminalizes the solicitation or receipt of a bribe in return for “referring [a patient] to a person” for medical care. 42 

U.S.C. § 1320a-7b(b)(1)(A) (emphasis added). This, he argues, indicates that Congress meant to address only situations in which a doctor recommends a specific provider, not 

a situation where the patient independently chooses a provider after the physician issues a generic order for treatment. 

But this is beside the point—Patel was not convicted for 

writing a generic order. Rather, he was convicted because he 

authorized his patients’ treatment by a specific provider—the 

Form 485s signed by Patel specified Grand as his patients’

caregiver and recipient of Medicare funds. Whether these 

actions were referrals is a separate question from whether 

they were referrals to a person. And the fact that Patel’s patients independently chose the “person” from whom they 

wanted services does not mean that Patel’s subsequent certifications, assuming they were referrals, were not referrals to 

that person.

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Patel’s next argument is that it makes no sense to call a 

certification a “referral” when it is made weeks after the patient began receiving treatment from the selected provider, 

as occurred in this case. This scenario, however, makes sense

once one considers the main purpose of the Anti-Kickback 

Statute—to prevent kickbacks from influencing the provision of services that are charged to Medicare. It stands to reason that the Statute should apply to the actions—certification 

and recertification—which directly allow Medicare to be 

charged. Even if treatment has begun, a doctor deciding 

whether to sign a Form 485 wields just as much power over 

Medicare costs and his patients’ health as a doctor deciding 

where to direct his patient.

As the district court noted, Patel “was a financial gatekeeper as well as a medical one”:

Defendant’s patients could not initiate or continue treatment from Grand on their own; 

without Defendant’s authorization and certification, the patients could not receive treatment 

from Grand, regardless of their preferences. 

Even if Defendant had nothing to do with a patient’s decision to choose Grand in the first instance, his signature on the Medicare-required 

forms not only confirmed the patient’s decision 

to go to Grand but also placed his imprimatur 

on the need for services that would be billed to 

and paid for by Medicare.

United States v. Patel, 17 F. Supp. 3d 814, 827 (N.D. Ill. 2014). 

Given these considerations, it is irrelevant that Patel’s patients received treatment from Grand before he signed their 

Form 485s. Even though care had begun, Grand could not 

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No. 14-2607 19

have charged Medicare for that care prior to receiving a 

signed Form. The referral process, as far as Medicare is concerned, continues until the Form is signed. Patel could have 

withheld his signature in an attempt to extort larger payments from Grand. In fact, it seems that Patel once threatened to do just that when Encinares lacked the money to pay 

him. If Patel had decided not to sign the forms, Grand could 

not have billed Medicare. In other words, the prospect of a 

kickback gave Patel an increased incentive to charge Medicare for these services—exactly the type of incentive that 

Congress sought to eliminate by passing the Anti-Kickback 

Statute.

Patel also argues that the government’s broad definition 

of “referring” would effectively eliminate the word from the 

Statute. Under the government’s interpretation, he argues, it 

would be illegal for a physician to receive any remuneration 

from a person who treats the physician’s patients because the 

government’s interpretation allows a doctor to be prosecuted 

even when he does not direct a patient to go to the provider 

making the payment. For example, Patel claims, a doctor 

could be convicted if he is paid to give a speech at a hospital

and some of his patients are later treated by that hospital.6

6 In Patel’s example, the doctor also “compliments the hospital in the 

speech.” We assume Patel included this detail to suggest that the patients in the hypothetical choose to go to the hospital because of the doctor’s compliments—in other words, because the doctor, in a way, recommended the hospital to his patients. However, Patel’s argument is 

that we are reading the word “referring” out of the Statute completely. If 

he is right, it should not matter whether the doctor recommends the 

hospital to his patients or not. As we explain above, the doctor in Patel’s 

hypothetical cannot be convicted whether he affirmatively directs his 

 

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20 No. 14-2607

This argument, however, completely overlooks the Statute’s

requirement that a kickback be paid “in return for” a referral. § 1320a-7b(b)(1)(A). Payments made for legitimate services (such as giving a speech) cannot be construed as an illegal kickback. Borrasi, 639 F.3d at 780–81. Patel’s argument 

simply has nothing to do with the scope of the term “referring.” The doctor in Patel’s hypothetical neither recommended the hospital to his patients nor acted as a gatekeeper for 

his patients’ care there. The construction of “referring” that 

we adopt here, in contrast, requires the doctor to do something that either directs a patient to a particular provider or 

allows the patient to receive care from that provider. And 

even if the doctor in Patel’s hypothetical had steered his patients to the hospital, the doctor could not be prosecuted because he was not paid “in return for” referrals.

Patel’s final argument is that the meaning of “referring” 

in the Anti-Kickback Statute is ambiguous, and thus should 

be interpreted in his favor under the rule of lenity. The Supreme Court has recently stated that the rule of lenity applies only if, “after considering text, structure, history, and 

purpose, there remains a grievous ambiguity or uncertainty 

in the statute such that the Court must simply guess as to 

what Congress intended.” Maracich v. Spears, 133 S. Ct. 2191, 

2209 (2013) (citation and internal quotation marks omitted).

The rule does not apply merely because a “statute’s text, taken alone, permits a narrower construction.” Abramski v. United States, 134 S. Ct. 2259, 2272 n.10 (2014). No grievous ambiguity exists here. The definition of “referral” put forth by the 

government is in common usage, including by Congress itpatients to the hospital, merely compliments the hospital in a speech, or 

does nothing at all that causes his patients to use the hospital.

 

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No. 14-2607 21

self. Most importantly, we think that Congress intended for 

the Statute to apply to certifications and recertifications for 

Medicare-reimbursed care. To hold otherwise would defeat 

Congress’s purpose in passing the statute.

Moreover, the purposes underlying the rule of lenity do 

not justify the rule’s application here. “Application of the 

rule of lenity ensures that criminal statutes will provide fair 

warning concerning conduct rendered illegal ... .” Liparota v. 

United States, 471 U.S. 419, 427 (1985). Patel argues that 

adopting the government’s definition of “referral” will lead 

to the prosecution of many unsuspecting physicians and will 

lead others to fear that their actions are possibly illegal. This 

argument, though, is tied up with Patel’s mistaken belief

that, if we affirm, doctors will be exposed to prosecution 

when their patients use a provider from whom the physician 

has previously received a legitimate payment. As described 

above, however, this concern is overblown. In fact, the government’s definition only exposes doctors to liability for a 

clearly delineated set of actions—receiving or soliciting 

kickbacks in return for directing a patient to a provider, or

for certifying or recertifying patients for Medicarereimbursed care. Patel’s nervous behavior suggests he knew 

that these actions were illegal. Other doctors should know 

that this behavior is illegal as well—the Department of 

Health and Human Services issued a Special Fraud Alert to 

the health care provider community twenty years ago stating 

that “[p]ayment of a fee to a physician for each plan of care 

certified by the physician on behalf of the home health agency” is a form of illegal kickback. Home Health Fraud, and 

Fraud and Abuse in the Provision of Medical Supplies to 

Nursing Facilities, 60 Fed. Reg. 40,847, 40,848 (Aug. 10, 

1995). The Department noted that such kickbacks threaten 

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22 No. 14-2607

patients’ freedom of choice and increase the cost of care—

precisely the reasons that we hold certifications and recertifications are “referrals” under the Anti-Kickback Statute.

B. Sufficiency of the Evidence

Finally, Patel argues that, even if he “referred” his patients to Grand when he signed their Form 485s, there was 

insufficient evidence to demonstrate that he received money 

from Grand in return for signing those forms, as required by 

the statute. Rather, Patel argues, Grand paid Patel to induce 

him to recommend to his patients that they choose Grand as 

their home health care provider. In other words, Patel says 

that he was paid for one type of referral (a recommendation), 

but gave Grand an entirely different type (a certification); he 

thus was not paid “in return for” the referral he actually

gave. According to Patel, the government needed to prove 

beyond a reasonable doubt that Patel was paid in return for 

his signature on the Form 485s, and it has failed to do so. 

And although Patel admits he was paid at the same time that 

he gave the signed forms to Encinares, and the payment 

amount was perfectly correlated with the number and type 

of forms, he claims that this was a mere convenience—the 

forms functioned as a proxy for actual recommendations 

made by Patel to his patients.

In reviewing the sufficiency of the evidence, we consider 

the evidence “in the light most favorable to the government, 

drawing all reasonable inferences in the government’s favor.” United States v. Lee, 558 F.3d 638, 641 (7th Cir. 2009). We 

overturn a conviction based on insufficient evidence “only if 

the record is devoid of evidence from which a reasonable 

jury could find guilt beyond a reasonable doubt.” United 

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No. 14-2607 23

States v. Johnson, 729 F.3d 710, 714 (7th Cir. 2013) (citation and 

internal quotation marks omitted).

Even accepting Patel’s premise that the government had 

to prove he was paid specifically for his signatures, there 

was sufficient evidence such that a reasonable factfinder 

could conclude that Grand paid him for that reason. The 

payments were literally exchanged for these signatures and

the payment amount was calculated based on the number

and type of Patel’s authorizations. Based on this evidence, a

reasonable factfinder could conclude that the payments were 

made in return for the signatures. More importantly, the fact 

that Patel was paid for recertifications—in addition to initial 

certifications—strongly suggests that Grand was paying him 

for his signatures, not for patient recommendations. If Grand 

wanted to pay Patel for recommendations, why pay him for 

both certifications and recertifications? Any payment due for 

a recommendation could be fully paid upon certification; 

recertified patients, by definition, were not new patients that 

Patel had recommended to Grand. Presumably, Grand paid 

Patel for recertifications because his signatures on those 

forms were an added bonus to the company—Grand paid 

Patel so that he would allow his patients to continue using 

Grand.

Patel also suggests that he should not have been convicted because he would have signed the certification forms 

with or without the promise of kickbacks. This, however, is 

irrelevant. The Anti-Kickback Statute prohibits a doctor from 

receiving kickbacks that are made in return for a referral. It 

does not require that the referral be made in return for a 

kickback. A reasonable factfinder could conclude that Patel 

“willfully and knowingly” received a kickback paid by 

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24 No. 14-2607

Grand because Patel gave Grand referrals; that was all the 

government needed to prove. 

III. Conclusion

We AFFIRM the judgment of the district court.

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