Gifts and meals for referring physicians: what the Stark law and the anti-kickback statute allow

A practice that depends on referrals wants the referring offices to remember it. The tools are small: lunch for the front office, a holiday basket, branded pens and notepads, a dinner after a talk. Each of those is something of value given to a person who sends patients your way, and two federal laws look at exactly that. The anti-kickback statute is a criminal law that applies to anyone who offers or pays something to induce referrals of Medicare, Medicaid or other federal program patients. The physician self-referral law, known as the Stark law, applies when the giver furnishes certain designated health services, and it sets a yearly dollar limit on non-cash gifts to each referring physician.

This guide is for physical therapy clinics, imaging centers, labs, specialists, surgery centers and any practice that markets to referring physicians. It covers which law applies to you, the Stark nonmonetary compensation limit and its conditions, what the anti-kickback statute adds, lunch-and-learns, holiday gifts and branded items, and the tracking log that holds it together. The wider map of referral rules is in our patient and physician referrals guide, open house receptions for referring offices in our grand opening guide, and booth giveaways and conference dinners in our trade show marketing guide. For training, badges and marketing support that come from drug and device makers, see our guide to promoting industry ties. For marketing campaigns a hospital pays for or shares with a practice, see our guide to hospital and practice co-branded marketing. Branded pens, mugs and other promotional items get their own guide to promotional items for patients and referral sources. How the liaisons who deliver those gifts and meals are paid is covered in our guide to physician liaison programs.

The short version

• A gift to a referral source is remuneration. OIG says remuneration includes anything of value, and names meals as an example.
• The anti-kickback statute applies to any person in federal program business. Offering or paying anything of value to induce referrals is a felony, and both sides of the gift are covered.
• The Stark law applies if you furnish designated health services. Labs, imaging, physical and occupational therapy, hospitals and the other listed services count.
• The Stark limit for 2026 is 535 dollars per physician per calendar year. Items or services only, no cash or cash equivalents, not tied to referrals and not requested by the physician or the office.
• Keep a log. Date, physician, item, retail value and a running total for each physician are what let you show the limit was kept.

Which law applies to your practice

Start with the anti-kickback statute, because it reaches the widest group. Under 42 USC 1320a-7b(b)(2), whoever knowingly and willfully offers or pays any remuneration, directly or indirectly, overtly or covertly, in cash or in kind, to induce a person to refer an individual for an item or service paid for in whole or in part by a Federal health care program is guilty of a felony. Under 1320a-7b(b)(1), the person who solicits or receives that remuneration is covered too. Section 1320a-7b(h) says a person need not have actual knowledge of the statute or specific intent to violate it.

OIG’s Roadmap for New Physicians says remuneration includes anything of value, and lists free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies. It also says it is illegal for a physician to pay others to refer their Medicare and Medicaid patients to them. OIG’s General Compliance Program Guidance names offering or receiving gifts to reward past or future referrals as conduct the statute prohibits.

The Stark law is narrower. Under 42 CFR 411.351, an entity is a person or organization that furnishes designated health services, and that includes a physician’s practice, though not the referring physician personally. Designated health services are clinical laboratory services; physical therapy, occupational therapy and outpatient speech-language pathology; radiology and certain other imaging; radiation therapy; durable medical equipment; parenteral and enteral nutrients; prosthetics and orthotics; home health; outpatient prescription drugs; and inpatient and outpatient hospital services, when payable by Medicare. OIG’s Roadmap describes Stark as a strict liability statute: proof of specific intent to violate it is not required. If your practice furnishes none of those services, the Stark exceptions below are not the test for your gifts, but the anti-kickback statute still applies.

The Stark nonmonetary compensation limit

The exception at 42 CFR 411.357(k)(1) allows an entity to give a physician items or services, not including cash or cash equivalents, up to an aggregate dollar limit per calendar year. The regulation sets a base of 300 dollars and, under 411.357(k)(2), adjusts it each calendar year by the increase in the Consumer Price Index-Urban All Items (CPI-U) for the 12 months ending the preceding September 30. CMS posts the figure on its CPI-U Updates page. For calendar year 2026, that page lists the limit as 535 dollars. The 2025 figure was 519 dollars. As of October 30, 2026, the page did not yet list a 2027 figure, so check it in January.

Two conditions apply in addition to the dollar limit. Under 411.357(k)(1)(i), the compensation may not be determined in any manner that takes into account the volume or value of referrals or other business generated by the referring physician. Under 411.357(k)(1)(ii), it may not be solicited by the physician or the physician’s practice, including its employees and staff. A referring office that calls to ask when lunch is coming has solicited it.

The rule has a narrow fix for mistakes. Under 411.357(k)(3), if an entity inadvertently gives a physician more than the limit, the excess is deemed within the limit when it is no more than 50 percent of the limit and the physician returns the excess, or its value, by the end of the calendar year or within 180 consecutive days of receiving it, whichever is earlier. An entity may use that fix only once in 3 years for the same physician. A log is how you notice the overage in time.

Under 411.357(k)(4), an entity with a formal medical staff may also hold one local medical staff appreciation event per year for its entire medical staff, but gifts handed out at that event count toward the yearly limit. That provision fits hospitals and other facilities with medical staffs, not an independent practice courting outside offices.

Hospital medical staff benefits are a separate exception

The exception at 42 CFR 411.357(m) covers items or services, not cash or cash equivalents, that a hospital gives members of its own medical staff for use on the hospital campus, such as a meal while a physician is rounding. It requires the benefit to be offered to all members of the medical staff in the same specialty, provided only while they are making rounds or doing other work that benefits the hospital or its patients, related to the delivery of medical services at the hospital, and not determined by referrals. Each occurrence must be of low value. CMS lists that limit for 2026 as less than 46 dollars per occurrence. Under 411.357(m)(8), other facilities and clinics with bona fide medical staffs may use the exception on the same terms. A practice sending lunch to an outside office cannot rely on this exception.

What the anti-kickback statute adds

Fitting the Stark exception does not settle the anti-kickback question. The Stark exceptions are CMS rules under 42 USC 1395nn, and the anti-kickback statute is a separate criminal law with its own safe harbors at 42 CFR 1001.952. We read the list of safe harbors in 1001.952 on October 30, 2026 and found none written for gifts or meals to referral sources. OIG’s Roadmap says an arrangement must fit squarely in a safe harbor and satisfy all of its requirements to be protected by it. Outside a safe harbor, the question turns on intent and the facts.

OIG’s General Compliance Program Guidance lists questions it uses to look at an arrangement. They include whether parties were selected in whole or in part because of their past or anticipated referrals, whether the remuneration takes into account the volume or value of business generated, and whether the arrangement has the potential to interfere with clinical decision making. A gift program that sends the larger basket to the office that sent the largest number of patients last quarter answers those questions badly. Paying or accepting a kickback can also bring civil monetary penalties. Under 42 USC 1320a-7a(a), as amended in 2018 by Public Law 115-123, the penalty for an act described in 1320a-7b(b) is 100,000 dollars for each such act, plus damages of not more than 3 times the total remuneration offered, paid, solicited or received. HHS adjusts the amount each year for inflation under 45 CFR 102.3. OIG’s Roadmap for New Physicians still shows the older 50,000 dollar figure, so use the statute.

Lunch-and-learns and office meals

A meal brought to a referring office is a gift to each person who eats it. No federal rule sets how to value a shared meal. We recommend dividing the full cost, including delivery and tip, by the number of people served, and logging that share against each physician who ate. The Stark limit counts compensation to the physician, and the anti-kickback statute counts anything of value to any person, so food for the referring office’s staff still belongs in the log.

The education part should be real. No federal rule defines a lunch-and-learn. We recommend a written agenda with clinical or referral-process content, a presenter, a sign-in sheet, and modest food that is clearly secondary. Bring lunch on your schedule, not on request, and offer it to referring offices on a schedule that does not track who sent patients last month.

Holiday gifts and branded items

A holiday basket for a referring office is in-kind remuneration under the anti-kickback statute and, for an entity that furnishes designated health services, nonmonetary compensation under 411.357(k). Count it at retail value. No federal rule says how to split a gift shared by a group of physicians. We recommend a written method chosen with counsel and applied the same way each time, for example dividing the value among the physicians in the office.

The (k) exception excludes cash and cash equivalents. The regulation does not list gift cards by name, and we recommend treating them as cash equivalents and leaving them out. Branded pens, notepads and similar items still have value. No federal rule exempts low-cost branded items from the (k) total. We recommend logging them at retail value with the rest.

The tracking log

No federal rule prescribes a form for tracking gifts to referring physicians. A log is the practical way to show that the conditions in 411.357(k) were met and that gifts were not set by referral volume. We recommend one row per gift or meal with: the date; the physician’s name and practice; what was given; the retail value per physician; who suggested it, so you can show it was not solicited; the reason it was chosen; and a running total for that physician for the calendar year against the current CMS limit. Review totals before each new gift, and have one person approve gifts over a set value.

Keep the log apart from referral reports. A sheet that lists gifts next to each office’s referral count invites the question the statute asks.

Questions to ask before a gift or meal goes out

• Does our practice furnish any designated health services listed in 42 CFR 411.351?
• What is this physician’s running total for the calendar year, and what is the current CMS limit?
• Did the physician or anyone in their office ask for this?
• Was this office chosen because of the number of patients it sent us or might send us?
• Is any part of it cash, a gift card or something that spends like cash?
• Is the food secondary to a real educational purpose?
• Would we be comfortable showing the log and the referral numbers side by side to an investigator?
• Has our health care attorney reviewed our written gift policy and the state’s rules?

Use and avoid

• Use: a scheduled lunch-and-learn on how to refer a patient to [Practice name], logged per physician. Avoid: “Send us five patients this month and lunch is on us.”
• Use: the same modest holiday gift to each referring office on the list. Avoid: a larger basket for the office with the highest referral count.
• Use: a running total for each physician checked against the CMS limit before each gift. Avoid: estimating at year end from receipts.
• Use: branded notepads logged at retail value. Avoid: gift cards to the front desk staff who schedule referrals.
• Use: “We bring lunch quarterly to our referring offices.” Avoid: “Just call us whenever you want lunch.”

An illustration

This example is invented. [Practice name], a physical therapy clinic in [Town], plans its referral marketing for the year. Physical therapy is a designated health service, so the clinic is a Stark entity as well as being subject to the anti-kickback statute. The first plan has the marketing coordinator ranking offices by last year’s referrals, sending monthly lunches to the top five, gift cards to their schedulers and holiday baskets sized by rank, with no records beyond credit card receipts.

After review with counsel, the revised plan offers a quarterly lunch-and-learn to each referring office on a fixed rotation, with an agenda on referral forms and home exercise programs. The same holiday gift goes to each office. Gift cards are dropped. The coordinator keeps a log with a per-physician running total checked against the 2026 CMS limit of 535 dollars, notes that no office requested the lunches, and keeps the log in a separate file from the referral reports. The clinic’s attorney reviews the policy each January when CMS posts the new limit.

Checklist

• Decide with counsel whether your practice furnishes designated health services.
• Write a gift and meal policy that covers who may give, what, on what schedule gifts go out and the approval step.
• Look up the current limit on the CMS CPI-U Updates page each January.
• Choose recipients on a fixed list or rotation, not by referral volume.
• Turn down requests from referring offices for meals or gifts.
• Leave out cash, gift cards and anything that spends like cash.
• Value each item at retail and divide shared meals per person.
• Log each gift with date, physician, item, value, reason and running total.
• Keep the gift log separate from referral reports.
• Have a health care attorney review the policy, the log and your state’s rules.

How we help

We build practice websites, local SEO, Google Ads and lead generation and an AI front desk for independent practices. For referral marketing, we build referring-provider pages, referral forms and education content that give offices a reason to send patients your way without a gift attached. Our tools are built with HIPAA in mind. We confirm in writing what a BAA covers before any patient information flows through a tool, and if it is not covered, we do not route patient information through it. We are not a healthcare provider and we do not give legal or medical advice. For the wider rules, see our healthcare marketing rules guide.

Sources

• 42 USC 1320a-7b: Criminal penalties for acts involving Federal health care programs
• 42 USC 1395nn: Limitation on certain physician referrals (Stark law)
• 42 CFR 411.351: Definitions (entity, designated health services)
• 42 CFR 411.357: Exceptions to the referral prohibition related to compensation arrangements
• CMS: CPI-U Updates (nonmonetary compensation and medical staff incidental benefit limits)
• 42 CFR 1001.952: Exceptions (anti-kickback safe harbors)
• HHS OIG: A Roadmap for New Physicians: Fraud and Abuse Laws
• HHS OIG: General Compliance Program Guidance (November 2023)

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