Pay per lead, pay per admission or a flat fee: how should a treatment center pay for marketing?
This is the one comparison on the site where the wrong answer can be a crime. The statutes are quoted and linked below, and none of it is legal advice.
- Last reviewed
- 8 primary sources, linked
- No agencies ranked
A flat fee that does not change with the number of patients referred is the structure federal law leaves room for. A fee per admission is tied to the patient by definition, and that is what the Eliminating Kickbacks in Recovery Act (opens in a new tab) targets: it makes it a federal crime to knowingly and willfully pay any remuneration to induce a referral of an individual to a recovery home, clinical treatment facility or laboratory, with a fine of up to $200,000, up to 10 years in prison, or both, for each occurrence. Pay per lead is not automatically illegal, but it is the contract to put in front of a healthcare attorney before you sign.
At a glance
| Factor | Pay per lead or per admission | Flat-fee agency |
|---|---|---|
| What you pay for | Each call, lead or admission delivered | The work itself, at a fixed price |
| EKRA's contractor exception | Does not cover pay that varies with the number of individuals referred | Can fit a fee that does not vary with referrals, tests or amounts billed |
| Florida patient brokering law | A felony to pay a commission, bonus, rebate, kickback or bribe to induce a referral | No payment tied to any patient |
| Ad platform eligibility | LegitScript does not certify lead generators or marketers paid to refer patients | Your center holds its own certification and its own ad accounts |
| Who answers the call | Whoever the vendor routes it to, on the vendor's script | Your admissions staff, under your name |
| FTC exposure | In 2025 the FTC named clinics as defendants alongside the marketer whose call center took the calls | Your ads and pages, under your control |
| What you keep when it ends | Nothing: the calls stop with the contract | Pages, rankings, data and accounts in your name |
| Cost shape | Nothing until a result arrives, then it rises with volume | Fixed, whether the month is good or slow |
Read across a row. Every outside figure in the table is listed with its source at the foot of the page.
Which to choose
Consider a per-lead vendor only if
- A healthcare attorney has reviewed the exact compensation terms against EKRA, the Anti-Kickback Statute if you bill federal programs, and your state's law.
- The fee is never per admission and never a share of what you bill.
- You can hear every call script, and calls are never answered as a hotline or a central admissions office.
- The vendor never bids on other centers' names.
Choose a flat fee if
- You want a fee that does not change with the number of patients referred.
- You want your own LegitScript certification, ad accounts and phone numbers.
- You want the pages, rankings and data to stay yours when the contract ends.
- You can carry a fixed monthly cost while owned channels grow.
What decides it
What federal law actually says
EKRA (opens in a new tab), 18 U.S.C. § 220, was enacted on October 24, 2018. With respect to services covered by a health care benefit program, it punishes whoever knowingly and willfully pays or offers any remuneration, including a kickback, bribe or rebate, to induce a referral of an individual to a recovery home, clinical treatment facility or laboratory, or in exchange for an individual using its services. The penalty is a fine of not more than $200,000, imprisonment of not more than 10 years, or both, for each occurrence.
A health care benefit program (opens in a new tab) means any public or private plan or contract, affecting commerce, under which any medical benefit, item or service is provided. Commercial insurance counts, not only Medicare and Medicaid.
The statute's exception for employees and independent contractors only covers pay that 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 to or received from the health care benefit program. A per-admission fee varies by exactly the first of those.
Where Medicare and Medicaid come in
EKRA does not apply (opens in a new tab) to conduct already prohibited by the federal Anti-Kickback Statute (opens in a new tab), which covers remuneration for referrals of items or services paid for in whole or in part under a federal health care program. That is a felony too, with a fine of up to $100,000, up to 10 years in prison, or both, and it has its own exception for amounts an employer pays a bona fide employee.
State law can reach further
EKRA says it does not occupy the field (opens in a new tab), so state laws on the same subject still apply. Florida's patient brokering statute (opens in a new tab) 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 to split fees, to induce the referral of patients. A violation is a third-degree felony with a $50,000 fine; involving 10 to 19 patients, a second-degree felony and $100,000; involving 20 or more, a first-degree felony and $500,000. Other states have their own rules, so check yours.
The platforms and the FTC have closed the gap
LegitScript, whose certification Google and Meta require for US addiction treatment ads, lists a "lead generator, call center, or marketer referring patients to other providers in exchange for compensation" as not eligible (opens in a new tab). And in June 2025 the FTC sued a marketing company (opens in a new tab), alleging that its search ads displayed the names of clinics it was not affiliated with and routed callers to a call center whose staff posed as the clinic or as a centralized admissions office. Treatment clinics were named as defendants alongside the marketer. Those are allegations, not findings, but they show who ends up in the complaint.
Where pay per result genuinely wins
Cash flow and speed. A per-call vendor often already ranks for searches you do not, and you pay nothing until a call arrives. A flat-fee agency charges whether the month is good or slow, and owned channels take months to carry census. That trade is real. It just has to be weighed against criminal statutes rather than against a marketing budget, which is why the attorney comes before the contract.
Where KhanWork fits
We charge a flat, published monthly fee: Foundation Partner $1,000 a month, Growth Partner $2,500 and Scale Partner $5,000, billed monthly with no minimums, and you can pause or cancel anytime. The fee does not change with calls, leads or admissions, and we are never paid per patient.
Wherever possible we set hosting, the domain connection and analytics up in your own accounts, so the work stays yours when the contract ends. We build websites; we are not a law firm, and nothing here replaces a healthcare attorney's read of your contracts.
Read deeper
- Rehab marketing without buying leads
the long read: EKRA, the FTC cases, certification costs and the owned channels that replace a lead vendor
- How to choose a treatment center marketing agency
including the pay arrangement to refuse
Sources
Every outside fact on this page, about a platform, a law or a market, comes from one of these primary sources, each opened and read on 2026-10-15.
- Legal Information Institute, Cornell Law School18 U.S.C. § 220, Illegal remunerations for referrals to recovery homes, clinical treatment facilities, and laboratories (EKRA) (opens in a new tab)Supports: The offense, the penalty per occurrence, the exception for employees and contractors, the carve-out for conduct covered by the Anti-Kickback Statute, and the statement that EKRA does not occupy the field.
- Legal Information Institute, Cornell Law School18 U.S.C. § 24, Definitions relating to Federal health care offense (opens in a new tab)Supports: The definition of a health care benefit program as any public or private plan or contract, affecting commerce.
- Legal Information Institute, Cornell Law School42 U.S.C. § 1320a-7b, Criminal penalties for acts involving Federal health care programs (Anti-Kickback Statute) (opens in a new tab)Supports: Scope tied to federal health care programs, the felony penalty, and the bona fide employee exception.
- The Florida SenateFlorida Statutes § 817.505, Patient brokering prohibited; exceptions; penalties (2024) (opens in a new tab)Supports: What is unlawful, the felony tiers and fines by number of patients, and the exception for health information services.
- LegitScriptAddiction Treatment Certification (opens in a new tab)Supports: Who is eligible, ongoing monitoring of certified providers, and the exclusion of lead generators, call centers and marketers paid to refer patients.
- Federal Trade CommissionFTC sues to stop Mercury Marketing and others from deceptively advertising substance use disorder treatment (June 24, 2025) (opens in a new tab)Supports: The alleged search ads showing unaffiliated clinic names, calls routed to a call center, and treatment clinics named as defendants (allegations, not findings).
- Google Ads policyHealthcare and medicines: Addiction services (opens in a new tab)Supports: US addiction services ads require LegitScript certification as an addiction services provider and certification with Google.
- Meta Transparency CenterAdvertising Standards: Drug and alcohol addiction treatment (opens in a new tab)Supports: US addiction treatment ads only for advertisers certified with LegitScript who have written permission from Meta.
Last reviewed
KhanWork builds websites and is not a law firm. Nothing on this page is legal advice. If you pay anyone per call, per lead or per admission, talk to a healthcare attorney who works in behavioral health before your next renewal.
Frequently asked questions
Not automatically, and this is not legal advice. EKRA makes it a crime to knowingly and willfully pay any remuneration to induce a referral to a recovery home, clinical treatment facility or laboratory, and its exception for contractors only covers pay that does not vary with the number of individuals referred. Whether a specific per-lead contract crosses that line depends on its terms and your state, so have a healthcare attorney read it before you sign.
Yes. EKRA covers services under any health care benefit program, which federal law defines as any public or private plan or contract, affecting commerce. The separate Anti-Kickback Statute is the one tied to federal health care programs, and EKRA does not apply to conduct that statute already prohibits.
A flat fee to a directory is a different shape from a fee per patient. Florida's patient brokering law expressly excepts payments to a health information service that gives consumers information free of charge, does not steer them, does not diagnose or counsel, does not arrange transport, and charges fees set in advance at fair market value that are not based on the value of a patient. Other states differ, so check yours.
Still deciding? Start with the page you already have.
Send your URL for the free funnel review. Within two business days you get a 3-minute video on the page your traffic lands on, the three places it is losing inquiries, and what ChatGPT and Perplexity say about your center. No call attached.