## Facts

- Angela F. Starks worked as a counselor on a federally funded Florida project that advised pregnant women about drug-abuse treatment options.
- Andrew R. Siegel, through Future Steps, Inc., developed and operated addiction treatment programs and contracted with a hospital to run a chemical dependency unit for pregnant women.
- The hospital received reimbursement through Florida’s Medicaid system for services provided to eligible patients.
- Starks referred patients from her counseling work to Siegel’s treatment program.
- Siegel paid Starks $250 for each referred patient who enrolled in the program.
- Federal prosecutors charged the arrangement as a kickback scheme involving referrals for services paid by a federal health care program, under 42 U.S.C. § 1320a-7b.
- At trial, defendants sought a jury instruction requiring proof that they specifically knew their conduct violated the Anti-Kickback Statute; the court instead instructed on a more general concept of willfulness.
- A jury convicted both defendants; they appealed the willfulness instruction and argued the statute was unconstitutionally vague in light of regulatory “safe harbors.”
- The government cross-appealed aspects of Siegel’s sentence, including acceptance-of-responsibility treatment and the guideline selection.

## Issues

1. Whether “willfully” in the Anti-Kickback Statute requires proof that defendants knew their conduct specifically violated the statute, rather than that they knew the conduct was generally wrongful or unlawful.
2. Whether the Anti-Kickback Statute is unconstitutionally vague as applied to a per-patient referral-payment arrangement, including in light of safe-harbor regulations.
3. Whether the district court erred in aspects of Siegel’s sentencing, including acceptance-of-responsibility treatment and guideline application.

## Decision

- The Eleventh Circuit affirmed the convictions, holding that the requested “specific knowledge of the statute” instruction was not required for willfulness under the Anti-Kickback Statute on these facts.
- The court rejected the vagueness challenge, concluding the statute provided adequate notice that paying and receiving per-patient cash for Medicaid-related referrals is prohibited.
- The court affirmed in part and reversed in part on sentencing issues raised in the government’s cross-appeal and remanded for resentencing consistent with its opinion.

## Legal Principles

- For statutes targeting plainly wrongful conduct, “willfully” may be satisfied by proof that the defendant acted with knowledge the conduct was unlawful in a general sense; the government need not prove the defendant knew the specific statute or its detailed contours.
- The Anti-Kickback Statute’s core prohibition—offering, paying, soliciting, or receiving remuneration to induce referrals for federally reimbursed services—provides sufficient notice when applied to straightforward per-referral cash payments.
- The existence of regulatory safe harbors does not render the statute vague as applied where the challenged conduct falls clearly outside those exceptions.

## Conclusion

The Eleventh Circuit upheld Anti-Kickback convictions arising from cash payments tied to patient referrals into a Medicaid-reimbursed program, ruling that willfulness did not require proof of specific knowledge of the statute and that the statute was not unconstitutionally vague as applied, while remanding for limited sentencing corrections.


United States v. Starks, 157 F.3d 833 (11th Cir. 1998)