We help health systems, operators, and investors bring healthcare infrastructure to life. But even the most visionary real estate strategy can unravel if it runs afoul of healthcare regulations.

Compliance isn’t just a legal checkbox, it’s a strategic foundation for long-term value. In this guide, we unpack how three key regulatory frameworks Stark Law, the Anti-Kickback Statute, and Antitrust Law directly shape how healthcare real estate deals should be structured.

Stark Law: When Referrals and Real Estate Collide

The Stark Law is a civil statute that prohibits physicians from referring Medicare or Medicaid patients to entities with which they or their immediate family members have a financial relationship unless specific exceptions apply.

This law is especially relevant in medical office leasing and development deals where physicians have ownership interests or are tenants in the facility. Common pitfalls include:

  • Improper lease rates: If rent is below fair market value (FMV), the arrangement could be seen as an inducement for referrals.
  • Volume-based incentives: Any lease or JV that fluctuates based on patient referrals is prohibited.
  • Missing documentation: Deals must be in writing, signed, and clearly define terms.

We work with healthcare counsel and certified valuation experts to ensure every physician lease is grounded in FMV, commercially reasonable, and built to withstand scrutiny. We proactively identify risk factors and ensure Stark-compliant design in our lease templates and structures, especially in physician-owned hospitals, group practices, and ambulatory centers.

Anti-Kickback Statute (AKS): Drawing the Line Between Incentive and Illegality

Unlike Stark, the Anti-Kickback Statute is criminal in nature. It prohibits knowingly and willfully offering or receiving anything of value to induce referrals for services covered under a federal healthcare program.

Even seemingly benign real estate arrangements can trip AKS violations:

  • Subsidized build-outs: Offering to fund a tenant’s construction or improvements can be seen as a hidden incentive.
  • Space “gifts”: Leasing more space than the provider needs, or giving access to premium locations below market value, raises red flags.
  • Delayed enforcement: Even if rent is fair today, inconsistencies in future payments, use, or incentives can bring violations retroactively.

We go beyond FMV appraisals. Our development and asset management teams ensure all terms from buildout contributions to lease escalations comply with AKS safe harbors. We help clients establish firewalls between business development and provider referrals, and ensure that real estate never becomes a proxy for influence.

Antitrust Law: Growth with Guardrails

As the healthcare market consolidates, antitrust scrutiny has intensified. Mergers, acquisitions, and facility expansions are evaluated not just by their financials but by their impact on market competition.

Here’s where real estate becomes part of the regulatory lens:

  • Market domination: A large health system building in every zip code might face claims of reducing competition or monopolizing care access.
  • Exclusive use clauses: Limiting tenant mix in a building to restrict competitor access can trigger antitrust complaints.
  • Network control through real estate: Strategic acquisitions of real estate assets tied to key referral sources can be interpreted as a method of vertical integration that limits consumer choice.

We structure projects with market optics in mind. Our strategies include community benefit alignment, access planning, and flexible leasing that promotes diverse use not just monopoly-scale expansion. We help clients engage early with antitrust counsel when acquisitions or expansions could change local competitive dynamics.

Where Strategy Meets Compliance

We don’t just deliver buildings we deliver healthcare ecosystems built for sustainability, regulatory soundness, and mission alignment.

Whether we’re structuring a new ambulatory care center, repositioning a behavioral health campus, or supporting a health system JV, we:

  • Ensure FMV-based lease structures
  • Engage legal and valuation partners early in development
  • Avoid volume- or value-based referral entanglements
  • Design for long-term flexibility, not regulatory risk

Because in healthcare real estate, what you build is only as valuable as how you build it.

Let’s Build the Right Way Together

If you’re a provider, operator, or investor exploring a new healthcare real estate opportunity, let’s connect. At ZLD Partners, we combine deep development expertise with a clear-eyed view of the legal landscape to help you grow confidently and compliantly.