Pay-per-call in healthcare: kickback and telemarketing rules

Pay-per-call offers are pitched to practices and treatment programs in a simple form: a network runs ads, routes the calls to your phone, and bills you for each call that lasts past a set number of seconds. There are no clicks to manage and no landing page to build. For a business that sells to consumers in another industry, that is a normal media buy. In healthcare, a fee that rises with each patient who calls can look like payment for a referral, and the network’s own ads and call handling bring telemarketing and deception rules into play.

This guide explains how a pay-per-call deal is usually built, how the federal Anti-Kickback Statute and the Eliminating Kickbacks in Recovery Act (EKRA) apply, what one state’s patient brokering law adds, where the Telemarketing Sales Rule exempts inbound calls and where it does not, and what to ask before you sign. For per-lead and per-booking fees and the two OIG advisory opinions on them, see our guide to buying patient leads. For the numbers that route the calls, see call tracking for medical practices.

The short version

• A pay-per-call fee is usually set per qualified call, so it varies with the number of people sent to you. Under the Anti-Kickback Statute, paying to induce referrals of people for items or services payable by a Federal health care program is a felony, 42 USC 1320a-7b(b)(2).
• EKRA reaches further for recovery homes, clinical treatment facilities and laboratories: it covers services paid by any health care benefit program, public or private, 18 USC 220(a) and 18 USC 24(b).
• Florida’s patient brokering law applies to any person and to referrals to any licensed provider, with an exception for information services that meet four conditions, including fees not based on the value of a patient, Fla. Stat. 817.505(3)(i).
• The Telemarketing Sales Rule exempts inbound calls made in response to an ad in media other than direct mail, 16 CFR 310.6(b)(5), but not upsells during the call or certain listed offers. Calling back callers who hung up is outbound telemarketing with its own rules.
• Ads that sound like a neutral helpline, or like your practice, but route to whoever paid most can be deceptive under section 5 of the FTC Act, 15 USC 45(a).
• A network that records or screens calls about a caller’s health may be handling protected health information for you. Settle who holds the recordings before calls start.

How a pay-per-call deal is usually built

The parties go by different names, but the roles are similar. A publisher runs the ads: search ads, social ads, TV or radio spots, or websites that list a phone number. A network or broker supplies tracking numbers, routes each call and bills the buyer. The buyer, here a practice, clinic or treatment program, pays for calls that meet the contract’s definition of qualified, which is often a minimum call length and sometimes a screening step first.

The screening step is where health information enters. Some networks use a recorded menu that asks the caller to press keys for insurance type, age or location. Others put a live agent on the line who asks qualifying questions and then transfers the caller to the buyer, often called a warm transfer. Prices in these contracts can vary by the caller’s insurance, location or the service they ask about. Each of those features matters under the laws below.

The Anti-Kickback Statute

Section 1320a-7b(b)(2) makes it a felony to knowingly and willfully offer or pay any remuneration, directly or indirectly, in cash or in kind, to induce a person to refer an individual for, or to arrange for or recommend, any item or service for which payment may be made in whole or in part under a Federal health care program. Section 1320a-7b(b)(1) makes it a felony to solicit or receive such remuneration. Conviction carries up to 10 years in prison. The statute does not exempt marketing companies, and it applies to both the payer and the payee.

A per-call fee is a payment that grows with the number of people sent your way. Whether a particular deal is a problem turns on intent and the facts, and a pay-per-call contract can be built in ways that point either direction. The two published OIG advisory opinions on per-call, per-click and per-booking fees, covered in our guide to buying patient leads, approved arrangements where the seller was not a provider, the fee did not depend on the caller’s insurance or on whether they became a patient, nobody was steered to a practice because it paid more, and callers got nothing for calling. A contract that prices calls higher for Medicare or Medicaid callers, or that pays only when the caller books, is outside what those opinions describe.

EKRA: private insurance counts for treatment programs and labs

EKRA, 18 USC 220, applies to services covered by a health care benefit program. Section 220(a) makes it a crime to knowingly and willfully solicit or receive remuneration in return for referring a patient or patronage to a recovery home, clinical treatment facility or laboratory, or to pay or offer remuneration to induce such a referral or in exchange for an individual using that facility’s services. The penalty is up to 10 years in prison per occurrence.

Two definitions widen it. A health care benefit program, under 18 USC 24(b), is any public or private plan or contract under which a medical benefit, item or service is provided to any individual, so commercial insurance counts. A clinical treatment facility, under 220(e)(2), is a medical setting other than a hospital that provides detoxification, risk reduction, outpatient treatment and care, residential treatment or rehabilitation for substance use under state licensure or certification. Outpatient addiction programs and labs that buy calls should treat EKRA as the starting point, not the Anti-Kickback Statute alone.

EKRA has an exception for payments to an employee or independent contractor with a bona fide relationship, but only if the payment is not determined by and does not vary by the number of individuals referred, the number of tests or procedures performed, or the amount billed or received for them, 220(b)(2). A per-qualified-call fee to an outside network does not look like that exception.

State law: Florida’s patient brokering statute as an example

State laws can reach payments that federal law does not. Florida’s section 817.505(1) makes it unlawful for any person, including a health care provider or facility, to offer or pay a commission, bonus, rebate, kickback or bribe, or engage in a split-fee arrangement in any form, to induce the referral of a patient or patronage to or from a health care provider or facility, and to solicit or receive such payments. The prohibition is not limited to any payer. Violations are felonies, and the degree rises with the number of patients involved, 817.505(4).

The statute’s exception for information services, 817.505(3)(i), reads like a checklist for a lawful call or listing service. It covers payments to a health, mental health or substance abuse information service that gives information on request and without charge to consumers, so they can choose a provider, if the service:

1. Does not steer. It does not try, through its standard questions or any other means, to steer or lead a consumer to a particular provider or facility.
2. Does not diagnose. It does not provide or represent itself as providing diagnostic or counseling services or assessments of illness or injury, and makes no promises of cure or guarantees of treatment.
3. Does not transport. It does not provide or arrange transportation to or from a provider or facility.
4. Charges flat, fair fees. Its fees from participating providers are set in advance, consistent with fair market value for the information service, and not based on the potential value of a patient to the provider or of the services provided.

A network whose agents ask about symptoms and insurance and then transfer the caller to the highest-paying facility fails more than one of those conditions. If you operate in another state, ask your attorney which referral, fee-splitting and patient brokering laws apply there.

The Telemarketing Sales Rule and inbound calls

The Telemarketing Sales Rule defines telemarketing as a plan, program or campaign conducted to induce the purchase of goods or services by use of one or more telephones and involving more than one interstate telephone call, 16 CFR 310.2. A pay-per-call campaign that answers calls across state lines and sells a service fits that definition, so the question is whether an exemption applies.

Section 310.6(b)(5) exempts calls initiated by a customer in response to an advertisement through any medium other than direct mail. The exemption does not apply to calls about investment opportunities, debt relief, technical support and certain other listed offers, to the payment method bans in 310.4(a)(9) and (10), or to any instance of upselling in the call. Calls in response to direct mail, including email and other solicitations sent to specific people, are exempt under 310.6(b)(6) only if the mail piece clearly, conspicuously and truthfully discloses the material information listed in 310.3(a)(1).

Two parts of pay-per-call deals fall outside the inbound exemption. The first is upselling: 310.2 defines it as soliciting the purchase of goods or services following an initial transaction during a single telephone call, and an external upsell is one made by or on behalf of a different seller. A network agent who sells one thing and then transfers the caller to sell another is upselling. The second is callbacks: when the network or the buyer calls back people who hung up or did not reach anyone, that call is outbound. Outbound sales calls fall under the Do Not Call rules, including their limited exceptions for recent inquiries, and the FCC consent rules for autodialed or prerecorded calls, covered in our guide to telemarketing rules for medical practice calls.

What the ad says and who answers

Section 5 of the FTC Act, 15 USC 45(a), declares unfair or deceptive acts or practices in or affecting commerce unlawful. Pay-per-call ads raise deception questions that ordinary practice ads do not. An ad that presents itself as a neutral helpline, a government program or an independent review service, when it actually routes callers to whichever buyer is paying, misleads people about who they are talking to. So does an ad that uses your practice’s name or a competitor’s name when the call goes somewhere else.

Ask to see every ad that will carry calls to you before the campaign starts, and require notice before new ads or new publishers are added. The ad should say who answers or that the service is paid by the providers it refers to. If a live agent answers, the opening should identify the service and say it is not the practice. For ad platform rules on health services and lead collection, see our guide to lead form ads in healthcare.

Recordings and patient information

Networks often record calls to settle billing disputes over which calls qualified, and screening agents may hear a caller’s name, condition and insurance. Under 45 CFR 160.103, a person who creates, receives, maintains or transmits protected health information on behalf of a covered entity for a regulated function, other than as a member of its workforce, is a business associate. Whether a given network fits that definition depends on whom it acts for and what it handles, and that is a question for your counsel. We do not describe any call network as HIPAA compliant.

Decide in the contract who holds recordings and transcripts, how long they are kept, whether the network may use the caller data for other buyers, and what happens to it when the contract ends. State call recording consent laws also apply; see our guide to call recording consent for medical practices.

Questions to ask before you buy calls

• How is the fee set? Is it a flat fee per call, or does it change with the caller’s insurance, age, location or the service requested?
• Do you pay more, or only, when the caller books or becomes a patient?
• Who answers first: a recorded menu, a live agent, or your own staff? What do the agents ask, and is there a script you can read?
• Are callers sent to the highest-paying buyer, or shown or connected to providers by criteria the caller chooses?
• Which publishers and ads carry the calls? Can you see each ad before it runs and stop any you object to?
• Does anyone call back people who hung up or did not connect, and under what consent?
• Are calls recorded? Who keeps the recordings, for how long, and are they used for anyone else?
• Is the network a health care provider, or owned by one?
• Does the network offer callers anything of value for calling, such as gift cards, free transport or free services?

Use and avoid

• Use: a flat, advance-set fee that does not change with the caller’s insurance or what they buy. Avoid: higher prices for Medicare, Medicaid or commercially insured callers, or payment only on booked patients.
• Use: ads that name your practice when calls come to you, or say the service is paid by the providers it lists. Avoid: “free helpline” or “official” wording for a paid referral line.
• Use: callers choosing among providers by their own criteria. Avoid: agents steering callers to whoever pays most.
• Use: a written answer on recordings, retention and reuse of caller data. Avoid: networks that resell caller details to other buyers.
• Use: review by a health care attorney who knows your state. Avoid: relying on a network’s statement that its model is “compliant”.

How we help

We run Google Ads and lead generation for independent practices with ads in the practice’s own name, calls that ring the practice’s own phones, and flat management fees that do not depend on the number of patients. We also build websites, local search and an AI front desk. We do not sell or buy patient calls. We are not a healthcare provider and we do not give legal or medical advice. Our guide to healthcare marketing rules covers the wider picture.

Sources

• 42 USC 1320a-7b(b): Anti-Kickback Statute (Cornell LII, read November 1, 2026)
• 18 USC 220: Eliminating Kickbacks in Recovery Act (Cornell LII, read November 1, 2026)
• 18 USC 24(b): definition of health care benefit program (Cornell LII, read November 1, 2026)
• 15 USC 45(a): unfair or deceptive acts or practices (Cornell LII, read November 1, 2026)
• 16 CFR part 310: Telemarketing Sales Rule, sections 310.2 and 310.6 (eCFR, up to date as of October 29, 2026)
• 45 CFR 160.103: definition of business associate (eCFR, up to date as of October 29, 2026)
• Florida Statutes 817.505: Patient brokering prohibited (2026 Florida Statutes, read November 1, 2026)

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