1. Speaker Programs: Still a Persistent, Well-Documented Risk
Payments coded to CMS's two speaker-related categories rose from $633.3 million in 2023 to $786.0 million in 2025, up 24%, outpacing the roughly 18% growth in total industry payments over the same period.
The same manufacturer was the top speaker-fee payer nationally every year; a separate manufacturer tied to a radioligand-therapy product jumped from outside the top 15 in 2023 to roughly $64 million and the #2 spot in both 2024 and 2025. Since September 2022, DOJ has resolved five False Claims Act matters centered on speaker programs, spanning several major manufacturers, totaling more than $1.17 billion, with fact patterns in every case matching HHS-OIG's 2020 Special Fraud Alert almost exactly.
In This Analysis
- 2. Royalty & Consulting Arrangements: Bigger Dollars, Less Visibility
- 3. Ownership & Buyout Payments: Fewer Deals, Much Bigger Checks
- 4. Debt Forgiveness: Small, Fast-Growing, and Easy to Miss
- 5. A Concentration Outlier Worth Flagging on Its Own
- 6. The One Bright Spot
- What This Means for Compliance Programs
2. Royalty & Consulting Arrangements: Bigger Dollars, Less Visibility
Royalty and license payments are the single largest category in the entire dataset by dollar volume, larger than speaker fees, larger than consulting fees. They totaled $1.20 billion in 2023, dropped to $855.1 million in 2024, then rebounded to $1.20 billion in 2025, spread across only 15,000–16,000 transactions each year.
Consulting fees show a steadier but still notable climb: $532.2 million in 2023 to $649.0 million in 2025, up 22% in dollars and 17% in transaction count. Consulting arrangements carry the same fair-market-value and sham-services risk profile as speaker fees: compensation that isn't tied to documented deliverables, that exceeds market rates, or that correlates with prescribing volume gets treated as a kickback dressed up in a services contract.
On May 18, 2026, OIG issued an unfavorable advisory opinion (AO 26-10) on a proposed device-company arrangement that would have paid physician consultants a percentage-of-sales royalty across a broad product line. OIG found the structure could still incentivize physicians to steer other providers toward the company's products, even with safeguards excluding the consultant's own self-referred sales, because the royalty base was tied to overall product-line revenue rather than a documented individual contribution. OIG's guidance: royalties should trace to a specific, documented IP or design contribution, not to sales performance.
3. Ownership & Buyout Payments: Fewer Deals, Much Bigger Checks
CMS's "Acquisitions" category (payments tied to buying out a physician's ownership or investment interest in a manufacturer) jumped from $72.1 million across 624 transactions in 2023 to $266.2 million across just 427 transactions in 2024, before settling at $223.9 million across 405 transactions in 2025.
Physician ownership interests in device and pharmaceutical companies have been an explicit OIG fraud-alert topic since 2013 (physician-owned distributorships), on the theory that ownership stakes can quietly shape device and drug selection even when never disclosed as a "payment" in the traditional sense. A pattern of larger, more concentrated buyouts is worth its own line in any conflict-of-interest review, separate from the speaker and consulting spend that usually gets the attention.
4. Debt Forgiveness: Small, Fast-Growing, and Easy to Miss
This is the category most likely to slip past a monitoring program built around dollar-cap thresholds on fees. Total debt forgiveness payments rose from $13.99 million in 2023 to $40.70 million in 2024 to $48.59 million in 2025, a 247% increase in two years, while transaction counts stayed roughly flat.
The average forgiven amount nearly tripled, from $2,636 to $7,863. Debt forgiveness doesn't look like a fee, an honorarium, or a gift on its face: it's a write-off, which makes it easy to overlook in a review process oriented around invoices and payment requests. Its rapid growth in both total dollars and per-transaction size makes it worth a dedicated look, particularly for accounts where forgiven amounts coincide with other financial relationships with the same provider.
5. A Concentration Outlier Worth Flagging on Its Own
Looking at total general-payment dollars across every category, one manufacturer stands apart. It topped the list of total payers in all three years, ahead of much larger, more prescriber-facing companies, despite reporting only 147 to 201 payment transactions annually, nationwide.
Whatever the underlying compensation form, payments at that scale concentrated among a tiny number of recipients are precisely the kind of relationship that benefits from enhanced disclosure review and conflict management, regardless of which Nature of Payment box it's checked under.
6. The One Bright Spot
Not everything is moving the wrong way. Gift, entertainment, and charitable contribution payments, the categories OIG and industry codes of conduct have targeted longest and most explicitly, all declined from 2023 to 2025.
Their decline suggests the industry does self-correct, just fastest in the categories with the simplest optics and slowest in the structurally complex ones (royalty formulas, consulting scopes of work, ownership buyouts) that have a plausible business rationale attached and are harder to challenge internally.
What This Means for Compliance Programs
The throughline across every category above is the same: spend caps and aggregate-dollar monitoring catch the categories everyone already watches and miss the ones growing fastest underneath.
Speaker programs remain a legitimate and well-documented priority, but a monitoring program built only around them is reviewing last decade's enforcement docket, not this one's.
qordata's Compliance Central and Expense Monitoring & Auditing (EMA) solutions are built to monitor across every Nature of Payment category, not just the ones with the longest enforcement history. Learn more at qordata.com.
