One Purpose Test: Greber vs. Holland; A discussion with Gabe Imperato with Nelson Mullins

Episode Date: March 8, 2023

In this episode of Stark Integrity, Bob Wade (“Captain Integrity”) is joined by Gabe Imperato, Partner at Nelson Mullins, to discuss the One Purpose Test and its application in key Anti-Kickback Statute cases, including United States v. Greber and United States v. Holland.

Drawing on his extensive experience in healthcare fraud and compliance, Gabe Imperato provides a practical and legal perspective on how intent is evaluated—and why it remains one of the most challenging aspects of compliance.

Understanding the One Purpose Test

Gabe Imperato explains that the One Purpose Test is a legal standard used to evaluate potential violations of the Anti-Kickback Statute (AKS).

Under this test:

• If one purpose of a payment or arrangement is to induce referrals
• Even if there are legitimate business purposes
• The arrangement may still violate the AKS

As Gabe Imperato emphasizes, this creates a broad standard that requires organizations to carefully evaluate not just structure—but intent.

The Greber Case Foundation

Gabe Imperato discusses the Greber case as the foundation for the One Purpose Test.

He explains that the court in Greber held:

• Payments for legitimate services can still be problematic
• If any portion of the intent is tied to referrals
• The arrangement may trigger AKS liability

This established a powerful and far-reaching standard that continues to influence compliance analysis today.

The Holland Decision and Its Significance

The discussion then turns to the more recent Holland case.

Gabe Imperato highlights that:

• The court took a closer look at willful conduct and intent
• It did not automatically apply the One Purpose Test in a rigid manner
• The decision exposed potential limitations and inconsistencies in how the test is applied

This creates an important nuance—while the One Purpose Test remains influential, its application is not always straightforward.

The Role of Evidence and Documentation

A key theme from Gabe Imperato’s insights is the importance of evidence.

He explains that:

• Emails, communications, and internal documents can play a critical role
• Poorly worded statements can create significant risk
• Regulators and prosecutors will closely examine intent through available evidence

Even informal communications can become central in evaluating compliance.

Practical Implications for Healthcare Organizations

Gabe Imperato emphasizes that organizations must go beyond technical compliance.

He notes that:

• Structuring an arrangement correctly is not enough
• Organizations must consider how their actions could be interpreted
• Intent must be clear, legitimate, and defensible

This requires a holistic compliance approach that combines legal, operational, and cultural considerations.

Evaluating Risk Under the One Purpose Test

Gabe Imperato highlights several key factors organizations should consider when evaluating arrangements:

• Whether compensation aligns with fair market value
• Whether services are commercially reasonable
• Whether any aspect of the arrangement could be tied to referrals

This type of analysis helps reduce exposure under the Anti-Kickback Statute.

Practical Takeaways

The key takeaway from Gabe Imperato’s discussion is that the One Purpose Test creates a broad and fact-driven compliance standard. Organizations should:

• Carefully evaluate intent behind all financial arrangements
• Ensure documentation supports legitimate business purposes
• Avoid communications that could suggest referral-based motivations
• Involve legal and compliance teams early in structuring decisions
• Regularly review arrangements for potential risk

Final Thoughts

This episode highlights—through Gabe Imperato’s legal and practical insight—that intent remains one of the most critical and complex aspects of healthcare compliance.

The One Purpose Test demonstrates that even well-structured arrangements can create exposure if not properly evaluated and documented. Organizations must take a proactive, thoughtful approach to ensure their arrangements withstand scrutiny.

Click here to listen to this Stark Integrity Podcast Episode:
https://podcasts.apple.com/us/podcast/one-purpose-test-greber-vs-holland-a-discussion/id1588939373?i=1000603238746&l=fr-FR