On April 23, 2026, the HHS Office of Inspector General updated its "General Questions Regarding Certain Fraud and Abuse Authorities" FAQ page for the first time since July 2024. It revised FAQ 4 and added a new FAQ 17. The updates changed no law. They sent a message — and for compliance programs that lean on fair market value as the centerpiece of their defense, it is a pointed one.
The message, in one line: Stark Law compliance and fair market value alone do not shield an arrangement from the Anti-Kickback Statute. Liability turns on intent.
This post is for compliance officers and healthcare counsel who own physician-arrangement risk. It walks through what the two FAQs actually say, why they expose a blind spot in how most programs are built, and what a defensible posture looks like now.
What revised FAQ 4 says: Stark fit is not AKS protection
The OIG reiterated that compliance with a Stark Law exception under 42 U.S.C. §1395nn does not, by itself, insulate a financial arrangement from liability under the Anti-Kickback Statute. These are two different laws doing two different things. Stark is a strict-liability self-referral statute: if a financial relationship exists and no exception is met, the referral is prohibited regardless of intent. The AKS is an intent-based criminal statute: it punishes remuneration offered or received to induce referrals of federal healthcare program business.
The practical consequence is that the two analyses do not collapse into one. A program that has carefully mapped each arrangement to a Stark exception — personal services, fair market value, rental of office space — has done necessary work. It has not, by that fact, addressed the AKS. The exception checklist answers a different question than the one a kickback investigation asks.
This is not a new legal theory — it is settled law the OIG chose to restate. But restatement matters: it removes the "we reasonably believed Stark compliance was enough" posture. After April 2026, a program that documented exception fit and stopped there has, on the record, addressed one statute and left the intent-based one unexamined.
What new FAQ 17 adds: FMV is not dispositive
FAQ 17 is the part that should reorganize a few compliance budgets. The OIG states that fair market value is not a dispositive defense to AKS liability. FMV is necessary — an above-market payment is a classic red flag — but it is not sufficient. A payment set precisely at market can still be unlawful if intent to induce or reward referrals is present.
That inverts a common mental model. Many programs treat the FMV opinion as the keystone: secure a current valuation, and the arrangement is "clean." The OIG is saying the keystone load-bears less than assumed. The dollar figure can be right and the arrangement can still be a kickback — because the AKS does not ask how much, it asks why. An FMV opinion, by construction, never answers the second question: it benchmarks a rate, it does not interrogate the purpose of the relationship.
The blind spot: programs built around the wrong question
Walk the typical physician-arrangement file. It contains an executed contract, an FMV opinion with a valuation date, and an exception-element checklist. Every artifact answers "is the payment defensible as priced and structured?" Almost none of it answers "could a prosecutor argue that one purpose of this arrangement is to secure referrals?"
That gap is not negligence; it is the natural shape of tooling and habit built around FMV and Stark exceptions. But the OIG has now stated, in writing, that the gap is where the liability lives. The same April 2026 guidance notes that arrangements involving compensation, marketing activities, gifts, and other remuneration should be evaluated under both statutes, with attention to how they operate in practice and the intent of the parties.
The "one purpose" test, in practice
Courts have long held that the AKS is violated if even one purpose of a payment is to induce referrals — even when the payment also serves legitimate ends and sits at fair market value. So the intent inquiry is concrete. The signals an investigator looks for are not exotic:
Compensation that moves with the volume or value of referrals, even indirectly. Remuneration that travels alongside the contract but off the FMV ledger — marketing support, gifts, free goods or services, below-cost items. Compensation that remains at the high end of the market with no commercial-reasonableness rationale for why the services are needed at all. Agreements whose written terms no longer match how the parties actually behave. The Tuomey Healthcare matter ($72.4M, on a 21,730 false-claims jury finding) turned in large part on compensation that the government argued tracked referrals — an intent question, not a pricing one.
What a defensible program documents now
The fix is not to discard FMV and Stark work — it is to pair it with an explicit Anti-Kickback intent analysis, captured contemporaneously. A defensible file adds, alongside the valuation and the exception checklist: a written commercial-reasonableness rationale (why this arrangement, why these services, why now); affirmative documentation that compensation is not tied to referral volume or value; evidence that the services are actually performed as the contract describes; and a clean answer to whether any off-record remuneration accompanies the deal.
None of this requires a valuation firm or outside counsel for every arrangement — it requires that the intent rationale be captured where the arrangement lives, in structured, contemporaneous form, rather than reconstructed from memory under deadline. The programs that struggle after April 2026 won't be the ones missing FMV opinions; they'll be the ones that can produce a price but not a purpose.
The discipline is the same one that separates a program that tracked compliance from one that can prove it: the intent analysis has to exist at the time the arrangement is active, not get assembled after a subpoena. The Community Health Network settlement ($345M, the largest Stark resolution in ArrowISE's enforcement library) is a reminder that documentation integrity — what existed, when — is itself part of the defense.
The takeaway
The April 2026 update doesn't change the law, but it removes an excuse. A program can no longer treat a current FMV opinion and a satisfied Stark exception as the end of the analysis; the OIG has said plainly that they are the beginning. The arrangements most exposed are the ones that look cleanest on a pricing basis and have never been examined on an intent basis.
ArrowISE is built for both halves of that analysis: FMV currency and element-by-element Stark exception validation, and — the part the April 2026 guidance puts front and center — an explicit Anti-Kickback intent lens on every arrangement, captured as tamper-evident, audit-ready evidence.