The Contract That Pays the Surgeon

(a) Supplement kit with per-kit commission. Paying for referrals is a kickback. Under the federal Anti-Kickback Statute - and Stark where Medicare/Medicaid patients and designated health services are involved - remuneration in exchange for referrals is prohibited regardless of whether the product is any good. Independently: recommending a product because of a commission rather than evidence breaches the duty of loyalty and the prohibition on accepting inducements, and documenting "medically necessary" for a supplement you do not believe is necessary is a misrepresentation and potentially fraud.

(b) Billing 12 visits before they happen. Billing for services not rendered is a false claim. MNT is covered only when delivered face-to-face, ordered by the treating physician, with the patient meeting coverage criteria for a qualifying condition within defined periods, and a new order for subsequent years. Pre-billing invites recoupment, penalties and possible program exclusion.

(c) Two-year, 25-mile non-compete. Often lawful, increasingly restricted by state, but a business and access-to-care question: reasonableness turns on scope, duration, geography and whether it protects a legitimate interest - not on locking out a region's patients.

• Say it once, in writing, neutrally: "I can recommend a supplement for a given patient when the evidence supports it, and I'll document my own clinical rationale. I can't tie my recommendation to a commission, and I can't bill for visits before they happen."
• Offer the lawful version: standard MNT under physician orders, billed per visit as delivered; supplement recommendations driven by documented intake or laboratory deficits, with the food-first alternative named.
• Do not sign the documentation to "get it through." A signature is the act; pressure is not a defense.
• Escalate if pressure continues: administrator in writing, copy retained; then state licensure board guidance, professional liability insurer or a health-law attorney. The professional code of ethics obliges you not to participate in fraud and to use proper reporting channels.
• Decide your walk-away number in advance. This is an ethical floor, not a negotiation. The 60% revenue concentration explains why the ask feels coercive; it does not change the answer.

Analysis: this is concentration risk. Losing the contract removes roughly 60% of revenue overnight, and that vulnerability is precisely what makes the offer feel like it cannot be refused. Fixing the business is part of holding the ethical line, not a separate topic.

12-month plan:

• Legal review before signing - non-compete scope, term, termination, non-solicitation. Negotiate the covenant down: shorter duration, narrower radius, and a carve-out for patients who specifically request you.
• Diversify payers: Medicare MNT provider enrollment, commercial contracts, physician-group referrals for diabetes, CKD and oncology, plus telehealth to widen the catchment.
• Build a second product line: group programs and self-pay offerings that do not depend on a single surgeon.
• Measure it: track revenue by referral source monthly and set a ceiling - no single source above roughly 30-35%.
• If the covenant does take effect: patients may choose to follow you, but you must not solicit in violation of a valid restrictive covenant - get the boundary in writing rather than testing it.