On July 11, 2025, in United States v. Schena,[1] the Ninth Circuit adopted an expansive interpretation of the Eliminating Kickbacks in Recovery Act (EKRA), applying the law to any payment that could have the effect of inducing a referral, even downstream, regardless of who received the payment. The court affirmed laboratory operator Mark Schena’s convictions for violating EKRA resulting from his percentage-based payments to marketing intermediaries who provided misleading information to referring providers.