A decision by the U.S. Circuit Court of Appeals for the Third Circuit finding that a longstanding agreement between a physician group and a hospital was insufficient to protect them from Stark Law violations underscores the need for providers to review and, where necessary, update the written contracts and fair market value determinations used to document compliance with the personal services exception to the federal Ethics in Patient Referrals Act of 1989 (the Stark Law) and the safe harbor to the Medicare and Medicaid Anti-Kickback Statute (the Anti-Kickback Statute). U.S. ex rel. Kosenske v. Carlisle HMA Inc. – noteworthy because of the limited number of court rulings in this area – highlights the risks where operating relationships under long-standing service agreements between hospitals and physician practice groups have changed over time and no longer resemble the circumstances of the original agreements (e.g., hospital ownership, new facility development, scope of services). It also serves as a reminder that (1) in-kind remuneration, and not just cash payments, can serve as the basis for a finding of violation under the Stark Law; and (2) anesthesiologists who provide pain management services can make referrals as defined by the Stark Law. The case also shows that the False Claims Act may be the means through which Stark Law and Anti-Kickback Statute violations may be prosecuted – and that disgruntled former partners and employees remain a key source of these qui tam actions.