                                                                                      Michigan Supreme Court
                                                                                            Lansing, Michigan
                                                             Chief Justice:               Justices:



Syllabus                                                      Bridget M. McCormack
                                                             Chief Justice Pro Tem:
                                                              David F. Viviano
                                                                                          Stephen J. Markman
                                                                                          Brian K. Zahra
                                                                                          Richard H. Bernstein
                                                                                          Elizabeth T. Clement
                                                                                          Megan K. Cavanagh

This syllabus constitutes no part of the opinion of the Court but has been                Reporter of Decisions:
prepared by the Reporter of Decisions for the convenience of the reader.                  Kathryn L. Loomis



                                              PEOPLE v WANG

            Docket No. 158013. Argued on application for leave to appeal November 7, 2019.
      Decided May 13, 2020.

               Xun Wang was convicted following a bench trial in the Ingham Circuit Court, Rosemarie
      E. Aquilina, J., of two counts of Medicaid fraud under MCL 400.607 of the Medicaid False
      Claim Act (MFCA), 400.601 et seq., and one count of unauthorized practice of a health
      profession under MCL 333.16294 of the Public Health Code, 333.1101 et seq. Defendant was
      from China, where she had previously earned a medical degree and completed two years of a
      three-year residency program. She moved to the United States in 2001, after which she earned a
      Ph.D. in basic medical science. In 2013, defendant began a two-month student rotation through
      the AmeriClerkships program working in the Livernois Family Clinic, which was owned by Dr.
      Murtaza Hussain. After completing her student rotation, defendant volunteered at the clinic
      before eventually becoming a part-time employee. Notwithstanding her education in the United
      States and abroad, defendant was never licensed to practice in a health profession in this country.
      The Michigan Department of the Attorney General’s Health Care Fraud Division discovered that
      a high volume of narcotics prescriptions were being written at the clinic, and in 2014, the
      department conducted an investigation, during which Drew Macon and Lorrie Bates, special
      agents with the department, separately went to the clinic while posing as patients with Medicaid
      benefits. Defendant saw both agents when they posed as patients, identified herself as Hussain’s
      assistant, and took written notes of their medical histories. Defendant also performed physical
      examinations, answered their questions, and wrote prescriptions for both agents on a prescription
      pad that Hussain had previously signed, including a prescription for Ambien, a Schedule 4
      controlled substance. The patients’ notes were entered into the clinic’s computer system and
      were electronically signed by Hussain; the notes indicated that both defendant and Hussain had
      seen the agents. The Medicaid processing system reflected that claims were submitted for both
      agents’ treatment and were paid to Hussain for a total of $260. Defendant was charged with two
      counts of Medicaid fraud under MCL 400.607 and one count of unauthorized practice of a health
      profession under MCL 333.16294. The trial court sentenced her to concurrent terms of 365 days
      in jail for each conviction, which was suspended upon the successful completion of five years’
      probation and the payment of $106,454 in fines and costs. Defendant appealed. In an
      unpublished per curiam opinion issued on May 10, 2018 (Docket No. 336673), the Court of
      Appeals, METER, P.J., and GADOLA and TUKEL, JJ., affirmed defendant’s convictions but
      vacated the trial court’s imposition of fines and remanded for resentencing to allow the trial court
      to articulate why the amount assessed in fines was proportionate. Defendant sought leave to
appeal in the Supreme Court, and the Supreme Court ordered and heard oral argument on
whether to grant the application or take other action. 503 Mich 987 (2019).

        In an opinion by Justice ZAHRA, joined by Chief Justice MCCORMACK and Justices
VIVIANO, BERNSTEIN, CLEMENT, and CAVANAGH, the Supreme Court, in lieu of granting leave to
appeal, held:

        Defendant was not a licensed health professional and therefore was categorically not
authorized to dispense prescriptions to patients; accordingly, the lower courts did not err by
determining that there was sufficient evidence to convict defendant of the unauthorized practice
of a health profession under MCL 333.16294. However, the evidence presented in this case did
not establish that defendant was aware or should have been aware that the patients at issue were
Medicaid beneficiaries and that their treatment was substantially certain to cause the payment of
a Medicaid benefit under MCL 400.607; therefore, defendant’s convictions of Medicaid fraud
were reversed.

        1. MCL 333.16294 provides, in pertinent part, that except as provided in MCL
333.16215 (the delegation exception), an individual who practices or holds himself or herself out
as practicing a health profession regulated by Article 15 of the Public Health Code without a
license or registration is guilty of a felony. The practice of medicine is a “health profession”
within the meaning of MCL 333.16294 because it is regulated and licensed under Article 15.
The delegation exception outlined in MCL 333.16215(1) provides that a licensee who holds a
license other than a health profession subfield license may delegate to a licensed or unlicensed
individual who is otherwise qualified by education, training, or experience the performance of
selected acts, tasks, or functions when the acts, tasks, or functions fall within the scope of
practice of the licensee’s profession and will be performed under the licensee’s supervision.
MCL 333.16215(1) further provides that a licensee shall not delegate an act, task, or function
under MCL 333.16215 if the act, task, or function, under standards of acceptable and prevailing
practice, requires the level of education, skill, and judgment required of the licensee. In this
case, defendant argued that the delegation exception permitted her conduct. However, the
delegation exception had no application because defendant engaged in the performance of
functions that could not be delegated. Specifically, the delegation exception did not countenance
defendant’s issuance of prescriptions for controlled substances. Under MCL 333.17708(3), a
prescription generally means an order by a prescriber to fill, compound, or dispense a drug or
device, and MCL 333.17708(2) defines “prescriber,” in pertinent part, as a licensed health
professional. Defendant stipulated that she was not licensed to practice a health profession;
therefore, defendant was categorically not authorized to dispense prescriptions to patients.
Accordingly, the lower courts did not err by determining that there was sufficient evidence to
convict defendant of the unauthorized practice of a health profession.

        2. Under MCL 400.607(1), a person shall not make or present or cause to be made or
presented to an employee or officer of this state a claim under the Social Welfare Act, MCL
400.1 et seq., upon or against the state, knowing the claim to be false. To sustain a conviction
for Medicaid fraud, the prosecution must therefore prove (1) the existence of a claim, (2) that the
accused makes, presents, or causes to be made or presented to the state or its agent, (3) the claim
is made under the Social Welfare Act, (4) the claim is false, and (5) the accused knows the claim
is false. MCL 400.602(f) provides that “knowing” and “knowingly” mean that a person is in
possession of facts under which he or she is aware or should be aware of the nature of his or her
conduct and that his or her conduct is substantially certain to cause the payment of a Medicaid
benefit. “Knowing” and “knowingly” include acting in deliberate ignorance of the truth or
falsity of facts or acting in reckless disregard of the truth or falsity of facts. Proof of specific
intent to defraud is not required. Additionally, intent and knowledge can be inferred from one’s
actions, and when knowledge is an element of an offense, it includes both actual and constructive
knowledge. The actual- or constructive-knowledge element requires knowledge of both the
falseness of a claim and that the claim is substantially certain to cause payment of a benefit. In
this case, a defense witness who was an employee of the clinic involved in Medicaid billing
testified that defendant had no involvement in the billing process. Defendant testified that she
was aware that some of the patients at the clinic were Medicaid patients but that she did not pay
attention to her patients’ insurance coverage. Furthermore, the prosecution presented no
evidence that defendant was trained in or otherwise possessed knowledge of the clinic’s billing
practices. Hussain also testified that billing was not discussed with individuals who came to the
clinic through the AmeriClerkships program. Therefore, the evidence in this case did not
demonstrate actual or constructive knowledge that defendant’s conduct was substantially certain
to cause the payment of a Medicaid benefit. There was no evidence that defendant had
possession of a paper chart with the patients’ Medicaid status or that defendant was aware of any
particular patient’s insurance status. The trial court improperly imputed knowledge to defendant
with regard to Medicaid billing. The critical inquiry was whether defendant had knowledge from
which she was aware or should have been aware that her conduct in treating Macon and Bates
was substantially certain to cause the payment of a Medicaid benefit; general knowledge that
some source of insurance will be billed is simply not enough. Accordingly, the trial court’s
findings were speculative and not reasonably drawn inferences from the evidence that the trial
court found determinative. The Court of Appeals likewise erred in its determination that
defendant’s general knowledge of the American healthcare system or her general knowledge that
the clinic was not a free clinic provided evidence that defendant had satisfied the “knowing”
element of a Medicaid fraud conviction. The evidence presented in this case did not establish
that defendant was aware or should have been aware that the patients at issue, i.e., the agents,
were Medicaid beneficiaries and that their treatment was substantially certain to cause the
payment of a Medicaid benefit. Finally, there was no evidence presented that defendant should
have familiarized herself with the insurance status of clinic patients. Therefore, the evidence did
not support a finding that defendant acted in deliberate ignorance of the truth or falsity of facts or
acted in reckless disregard of the truth or falsity of facts.

        Defendant’s conviction for the unauthorized practice of a health profession affirmed,
defendant’s convictions of Medicaid fraud reversed, and case remanded to the Ingham Circuit
Court in accordance with the Court of Appeals’ previous judgment to analyze the proportionality
of the fines assessed against defendant.

       Justice VIVIANO, concurring, agreed with the majority’s decision to affirm defendant’s
conviction for unauthorized practice of a health profession and to reverse defendant’s
convictions for Medicaid fraud but wrote separately to raise some concerns regarding the
MFCA’s criminal-liability provisions. Consideration of how the MFCA developed over time,
and comparison of its provisions to a somewhat analogous federal statute, the False Claims Act,
31 USC 3729(a)(1)(B), revealed a number of problematic aspects of the MFCA. The Michigan
Legislature engrafted civil-liability concepts from the federal act onto preexisting language in the
MFCA without, it seems, careful thought about how and whether those concepts fit in the
criminal-liability context. Justice VIVIANO therefore wrote to encourage the Legislature to
consider amending the MFCA to clarify its meaning.

        Justice MARKMAN, concurring in part and dissenting in part, agreed that defendant’s
conviction of the unlawful practice of medicine should be affirmed and that defendant did not
possess actual knowledge that the agents were purporting to be Medicaid patients, but he would
have affirmed defendant’s convictions of Medicaid fraud in view of the definition of “knowing”
set forth in MCL 400.602(f) and the appellate standard of review governing defendant’s
sufficiency-of-the-evidence challenge.        When considering a sufficiency-of-the-evidence
challenge, a reviewing court is required to draw all reasonable inferences and make credibility
choices in support of the verdict, and because it can be difficult to prove a defendant’s state of
mind on issues such as knowledge and intent, minimal circumstantial evidence suffices to
establish the defendant’s state of mind, which can be inferred from all the evidence presented.
The definition of “knowing” and “knowingly” in MCL 400.602(f) mirrors the federal definition
of those terms within the context of false claims against the government and includes acting in
“deliberate ignorance of the truth or falsity of facts.” “Deliberate ignorance” exists when the
evidence indicates that the defendant, knowing or suspecting that he or she is involved in “shady
dealings,” takes steps to make sure that he or she does not acquire full or exact knowledge of the
nature and extent of those dealings. Defendant in this case had seven years of medical training in
China and studied and worked in medical-related fields since she entered the United States in
2001, including spending nine months at the Livernois Family Clinic prior to the conduct
underlying her criminal conviction. Moreover, she knew of, but had not satisfied, the
requirements for obtaining a license to lawfully practice medicine so as to allow billing for her
services. Given her experience and her efforts to obtain a license, defendant was or should have
been aware of four facts such that a reasonable trier of fact could conclude that defendant acted
with deliberate ignorance of the ultimate fact that a false claim would be submitted to Medicaid
as a result of her services: (1) that it was unlawful for her to practice medicine; (2) that a bill
would be generated for her services, even when Dr. Hussain was not present; (3) that it was
unlawful and fraudulent to bill Medicaid for her services; and (4) that a significant percentage of
the clinic’s patients were Medicaid recipients, such that the clinic would bill the government for
her services. From these facts, a reasonable trier of fact could conclude that defendant knew that
her employment at the clinic was an integral part of some illicit scheme. Defendant then avoided
three readily available means of determining whether a given patient was a Medicaid patient: (1)
defendant could have asked the clinic receptionist whether a patient was a Medicaid recipient,
(2) defendant could have reviewed the patients’ paper charts, which contained insurance
information and a photocopy of their Medicaid cards, and (3) defendant could have expressly
asked the patients themselves whether they were Medicaid patients. Therefore, Justice
MARKMAN would have affirmed defendant’s convictions of Medicaid fraud.




                                    ©2020 State of Michigan
                                                                           Michigan Supreme Court
                                                                                 Lansing, Michigan



OPINION
                                                  Chief Justice:                 Justices:
                                                   Bridget M. McCormack          Stephen J. Markman
                                                                                 Brian K. Zahra
                                                  Chief Justice Pro Tem:         Richard H. Bernstein
                                                   David F. Viviano              Elizabeth T. Clement
                                                                                 Megan K. Cavanagh


                                                                    FILED May 13, 2020



                            STATE OF MICHIGAN

                                    SUPREME COURT


 PEOPLE OF THE STATE OF MICHIGAN,

              Plaintiff-Appellee,

 v                                                                 No. 158013

 XUN WANG,

              Defendant-Appellant.


 BEFORE THE ENTIRE BENCH

 ZAHRA, J.

       Defendant was convicted after a bench trial of two counts of Medicaid fraud under

 MCL 400.607 and one count of unauthorized practice of a health profession under MCL

 333.16294. The Court of Appeals affirmed the convictions but vacated the imposition of

 fines and remanded for resentencing to allow the trial court to articulate why the amount
assessed in fines was proportionate.1 Defendant now appeals in this Court, challenging

the sufficiency of the evidence.      We affirm defendant’s conviction of unauthorized

practice of a health profession because defendant engaged in the nondelegable task of

prescribing controlled substances. We reverse defendant’s convictions of Medicaid fraud

because the evidence presented at trial and relied upon by the trial court did not support

the conclusion that defendant knew or should have known that the nature of her conduct

was substantially certain to cause the payment of a Medicaid benefit.2 Lastly, we remand

this matter to the trial court for further proceedings consistent with this opinion.

                       I. FACTS AND PROCEDURAL HISTORY

        Defendant is from China, where she previously earned a medical degree and

completed a two-year residency. She moved to the United States in 2001, after which she

earned a Ph.D. in basic medical science from Purdue University’s veterinary school and

began work as a medical researcher at the University of Michigan’s medical school. In

2013, she began a two-month student rotation through the AmeriClerkships program

working in the Livernois Family Clinic, which was owned by Dr. Murtaza Hussain.

After completing her student rotation, defendant volunteered at the clinic before

eventually becoming a part-time employee. Notwithstanding her education in the United

States and abroad, defendant has never been licensed to practice in a health profession in

this country.


1
 People v Wang, unpublished per curiam opinion of the Court of Appeals, issued
May 10, 2018 (Docket No. 336673), p 9.
2
    MCL 400.607(1); MCL 400.602(f).



                                              2
      The Michigan Department of the Attorney General’s Health Care Fraud Division

discovered that a high volume of narcotics prescriptions were being written at the clinic.

In 2014, the department conducted an investigation of the clinic, during which Drew

Macon and Lorrie Bates, special agents with the department, separately went to the clinic

while posing as patients with Medicaid benefits.

      Macon went to the clinic in August 2014, posing as a new patient. He presented a

Medicaid insurance card during the check-in process. When defendant called Macon into

a patient room, she weighed him, took his blood pressure, and obtained information

regarding the reason for his visit and his medical history. Macon informed defendant that

he had attention deficit disorder and asthma, and Macon requested prescriptions for

vitamin D, an inhaler, Klonopin,3 and Adderall.4          Defendant left the room for

approximately eight minutes. When she returned, she stated that Macon would need to

forward his out-of-state medical records to the office to receive Adderall and gave Macon

a release form and instructions. Defendant then gave Macon prescriptions for vitamin D,

Klonopin, and the inhaler. The signature on the prescriptions was Hussain’s.

      In December 2014, Bates went to the clinic, also posing as a new patient. A

medical technician accompanied Bates into an exam room and noted Bates’s complaints

of headaches and insomnia. The medical technician took Bates’s blood pressure, medical

history, and made some written notes on a piece of paper attached to a clipboard. Taking

3
 Klonopin is the trade name of clonazepam, a Schedule 4 controlled substance. See
MCL 333.7218(1)(a).
4
 Adderall is an amphetamine, a Schedule 1 controlled substance.                See MCL
333.7212(1)(c).



                                            3
the clipboard, the medical technician left after informing Bates that the doctor would be

in shortly. Defendant, wearing a stethoscope and a long, white lab coat, was the next

person to enter the exam room. Defendant stated that she was Hussain’s assistant and

asked about the reason for Bates’s visit. When Bates responded that she was having

difficulty sleeping and combating headaches, defendant obtained further information

about these complaints. Defendant also took written notes of Bates’s medical history.

Defendant then asked Bates if she had taken medication for the headaches and stated that

medication could be provided to help. Bates declined a Pap smear, and at that point,

defendant left the room for approximately six minutes. When defendant returned, she

inquired as to Bates’s pharmacy preference. Bates responded, and defendant typed

something into her cellular phone before informing Bates that a prescription had been

sent to a pharmacy. A physical examination was then performed, in which defendant

shined a flashlight into Bates’s eyes and had Bates alternate standing and sitting down.

When Bates asked whether defendant was a doctor, defendant responded, “No, I’m just

his assistant. He’s not here today.” At this point, defendant gave some details about the

headache medication that had just been prescribed.       Defendant asked if there was

“anything else,” and Bates called attention to her insomnia, to which defendant replied

with recommendations of taking melatonin, drinking milk before going to sleep, and

spending time relaxing. Defendant added that if these techniques were unsuccessful,

Bates could use a low dose of a “controlled medication.”         Defendant produced a

prescription pad, which had been previously signed by Hussain, and wrote a prescription




                                           4
for Ambien.5 Before the interaction concluded, Bates asked how long defendant had

been a doctor. Defendant responded that she had been a doctor for “one year.” Lastly,

defendant offered Bates advice regarding “sleep hygiene.”

      Both agents’ patient progress notes were entered into the clinic’s computer system

and were electronically signed by Hussain. The notes indicated that both defendant and

Hussain had seen the agents. The Medicaid processing system reflected that claims were

submitted for both agents’ treatment and were paid to Hussain for a total of $260.

      A search warrant was executed at the clinic. There, agents found prescription pads

that were presigned by Hussain. Defendant was not present during the search, and so

Bates went to defendant’s home. There, defendant agreed to speak with agents. She

stated that she was not a doctor and that she only worked under Hussain’s guidance. She

added that if she saw a patient when Hussain was not in the office, she would contact him

via phone so that he could make final decisions.

      Defendant was charged with two counts of Medicaid fraud under MCL 400.607

and one count of unauthorized practice of a health profession under MCL 333.16294.

Defendant waived her right to a trial by jury, and a bench trial followed. The parties

stipulated that defendant had no license to practice in a health profession in 2014 or 2015

and that Hussain was not present at the clinic when Macon and Bates visited. Defendant

was found guilty of all charges.     In January 2017, the trial court sentenced her to

concurrent terms of 365 days in jail for each conviction, which was suspended upon the

5
 Ambien, which is a brand name for Zolpidem, is a Schedule 4 controlled substance.
Mich Admin Code, R 338.3123(1)(hhh); Bloomfield Twp v Kane, 302 Mich App 170,
184; 839 NW2d 505 (2013).



                                            5
successful completion of five years’ probation and the payment of $106,454 in fines and

costs.

         In her appeal of right, defendant challenged the sufficiency of the evidence

supporting her convictions as well as the proportionality of her fines. In an unpublished

per curiam opinion, the Court of Appeals affirmed her convictions but vacated the trial

court’s imposition of fines and remanded for resentencing to allow the trial court to

articulate why the amount assessed in fines was proportionate.6 Defendant now seeks

leave to appeal in this Court, and on March 27, 2019, this Court entered an order

directing oral argument on the application and requiring the parties to address:

         (1) whether the statutory exception in MCL 333.16294 is an element of the
         offense for which the prosecutor has the burden of proof, see People v Rios,
         386 Mich 172[; 191 NW2d 297] (1971); but see People v Langlois, 325
         Mich App 236[; 924 NW2d 904] (2018);[7] (2) if the statutory exception is
         an element of the offense, whether the Court of Appeals erred in holding
         that the evidence was sufficient to sustain the defendant’s conviction under
         MCL 333.16294 and specifically, whether the Court of Appeals erred in
         concluding that the defendant’s actions were consistent with the practice of
         medicine and therefore could not be delegated to her under MCL
         333.16215; and (3) if the statutory exception is not an element of the
         offense, whether defense counsel was ineffective for failing to raise a
         delegation defense and bring the relevant statutory provisions to the trial
         court’s attention. In addition, the appellant shall address whether the
         evidence was sufficient to sustain the defendant’s convictions under MCL
         400.607(1), and specifically whether the evidence was sufficient to show
         that the defendant was in possession of facts under which she was aware or


6
    Wang, unpub op at 9.
7
  We need not address this question now because defendant engaged in the performance
of tasks that simply could not be delegated at all. Thus, whether the delegation exception
is an element of the unauthorized practice of a health profession has no bearing on our
opinion.



                                              6
         should have been aware that her conduct was substantially certain to cause
         the payment of a Medicaid benefit. See MCL 400.602(f).[8]

                                       II. ANALYSIS

                               A. STANDARD OF REVIEW

         Defendant opted for a bench trial, waiving her right to a trial by jury. Bench trials

stand in sharp contrast to jury trials. A jury is required to consider all the evidence and to

render a unanimous verdict, without the need for explanation.9 In a bench trial, however,

the trial court is obligated to “find the facts specially, state separately its conclusions of

law, and direct entry of the appropriate judgment. The court must state its findings and

conclusions on the record or in a written opinion made a part of the record.”10 Because of

this, reviewing courts are provided greater insight into the specific evidence found by the

trial court to support verdicts in bench trials.

         Defendant contends that the evidence presented at trial was insufficient to sustain

her convictions. Challenges to the sufficiency of the evidence are reviewed de novo.11

“In evaluating defendant’s claim regarding the sufficiency of the evidence, this Court

reviews the evidence in a light most favorable to the prosecutor to determine whether any

trier of fact could find the essential elements of the crime were proven beyond a

reasonable doubt.”12 The prosecution submits that defendant’s convictions are largely

8
    People v Wang, 503 Mich 987, 987 (2019).
9
    See MCR 6.410(B).
10
     MCR 6.403. See also People v Legg, 197 Mich App 131, 134; 494 NW2d 797 (1992).
11
     People v Meissner, 294 Mich App 438, 452; 812 NW2d 37 (2011).
12
     People v Robinson, 475 Mich 1, 5; 715 NW2d 44 (2006).



                                               7
supported by circumstantial evidence. “Circumstantial . . . evidence is evidence of a fact,

or a chain of facts or circumstances, that, by indirection or inference, carries conviction to

the mind and logically or reasonably establishes the fact to be proved.”13 Circumstantial

evidence may sustain criminal convictions, but “the circumstantial proof must facilitate

reasonable inferences of causation, not mere speculation.”14

              B. UNAUTHORIZED PRACTICE OF A HEALTH PROFESSION

          Under MCL 333.16294, “[e]xcept as provided in section 16215 [known as the

delegation exception], an individual who practices or holds himself or herself out as

practicing a health profession regulated by this article without a license or

registration . . . is guilty of a felony.”15 The practice of medicine is a “health profession”

within the meaning of MCL 333.16294 because it is regulated and licensed under the

Public Health Code.16 The delegation exception outlined in MCL 333.16215(1) provides

that

          a licensee who holds a license other than a health profession subfield
          license may delegate to a licensed or unlicensed individual who is
          otherwise qualified by education, training, or experience the performance of
          selected acts, tasks, or functions where the acts, tasks, or functions fall

13
     4 Michigan Pleading & Practice (2d ed), § 36:313, pp 69-70 (citations omitted).
14
     Id. at 70.
15
     Emphasis added.
16
   MCL 333.1101 et seq. The “practice of medicine” is defined as “the diagnosis,
treatment, prevention, cure, or relieving of a human disease, ailment, defect, complaint,
or other physical or mental condition, by attendance, advice, device, diagnostic test, or
other means, or offering, undertaking, attempting to do, or holding oneself out as able to
do, any of these acts.” MCL 333.17001(1)(j).



                                               8
         within the scope of practice of the licensee’s profession and will be
         performed under the licensee’s supervision. A licensee shall not delegate
         an act, task, or function under this section if the act, task, or function, under
         standards of acceptable and prevailing practice, requires the level of
         education, skill, and judgment required of the licensee under this article.

Defendant argues that the delegation exception permitted her conduct in this case. But

the delegation exception has no application here because defendant engaged in the

performance of functions that could not be delegated.             Specifically, the delegation

exception does not countenance defendant’s issuance of prescriptions for controlled

substances.

         Simply stated, defendant’s act of prescribing Ambien, a Schedule 4 controlled

substance,17 to Bates was a nondelegable action as a matter of law. Michigan statutory

authority, while sometimes difficult to parse, supports this conclusion. A “prescription”

in this state generally “means an order by a prescriber to fill, compound, or dispense a

drug or device . . . .”18 A prescriber, critically, means

         a licensed dentist, a licensed doctor of medicine, a licensed doctor of
         osteopathic medicine and surgery, a licensed doctor of podiatric medicine
         and surgery, a licensed physician’s assistant, a licensed optometrist . . . , an
         advanced practice registered nurse . . . , a licensed veterinarian, or another
         licensed health professional acting under the delegation and using,
         recording, or otherwise indicating the name of the delegating licensed
         doctor of medicine or licensed doctor of osteopathic medicine and
         surgery.[19]



17
     Mich Admin Code, R 338.3123(1)(hhh); Bloomfield Twp, 302 Mich App at 184.
18
     MCL 333.17708(3) (emphasis added).
19
     MCL 333.17708(2).



                                                9
Defendant stipulated that she was not licensed to practice a health profession in 2014 or

2015.20     Thus, under Michigan law, defendant was categorically not authorized to

dispense prescriptions to patients. When she prescribed Ambien to treat Bates’s reported

difficulty sleeping, she attempted to perform a task that “requires the level of education,

skill, and judgment required of” a licensed physician.21 Such tasks are nondelegable, and

the lower courts therefore did not err by determining that there was sufficient evidence to

convict defendant of the unauthorized practice of a health profession.22

                                 C. MEDICAID FRAUD

         Defendant next claims that the evidence was insufficient “to show that the

defendant was in possession of facts under which she was aware or should have been

aware that her conduct was substantially certain to cause the payment of a Medicaid

benefit.”23 The Medicaid False Claim Act24 provides that “[a] person shall not make or

20
   Although defendant introduced herself to Bates as Hussain’s “assistant,” defendant
takes care to note, in her supplemental brief, that she did not say that she was a
“physician assistant,” which is among the types of professionals that, if licensed, may
qualify as a “prescriber” under MCL 333.17708(2).
21
     See MCL 333.16215(1); MCL 333.17708(2).
22
   See MCL 333.16215(1). Defendant also raised the issue of ineffective assistance of
trial counsel for failure to call the delegation exception to the trial court’s attention. Of
course, because defendant could not prevail under the delegation exception, trial counsel
cannot have been ineffective for failing to call it to the trial court’s attention. People v
Ericksen, 288 Mich App 192, 201; 793 NW2d 120 (2010) (“Failing to advance a
meritless argument or raise a futile objection does not constitute ineffective assistance of
counsel.”).
23
     Wang, 503 Mich at 987.
24
     MCL 400.601 et seq.



                                             10
present or cause to be made or presented to an employee or officer of this state a claim

under the social welfare act, 1939 PA 280, MCL 400.1 to 400.119b, upon or against the

state, knowing the claim to be false.”25 To sustain a conviction for Medicaid fraud, the

prosecution must therefore prove:

         (1) the existence of a claim, (2) that the accused makes, presents, or causes
         to be made or presented to the state or its agent, (3) the claim is made under
         the Social Welfare Act . . . , (4) the claim is false . . . , and (5) the accused
         knows the claim is false . . . .[26]

MCL 400.602(f) provides:



25
     MCL 400.607(1) (emphasis added).
26
   People v Orzame, 224 Mich App 551, 558; 570 NW2d 118 (1997), citing In re Wayne
Co Prosecutor, 121 Mich App 798, 801-802; 329 NW2d 510 (1982). Notably, the fourth
and fifth elements of Medicaid fraud as outlined by Orzame initially required that a claim
be “false, fictitious, or fraudulent, and . . . [that] the accused knows the claim is false,
fictitious, or fraudulent.” Orzame, 224 Mich App at 558 (emphasis added). The
emphasized language stems from the original version of MCL 400.607 as enacted in
1977. See 1977 PA 72, effective July 27, 1977; People v American Med Ctrs of Mich,
Ltd, 118 Mich App 135, 144; 324 NW2d 782 (1982). That language was removed,
however, when MCL 400.607 was amended in 1984. See 1984 PA 333, effective
December 26, 1984; Orzame, 224 Mich App at 558. Even now, after a second
amendment to the statute, see 2008 PA 421, effective January 6, 2009, all that the statute
requires is that a claim be “false” and that the defendant have knowledge of that falsity,
without a distinction for claims that are “fictitious” or “fraudulent,” as opposed to “false.”
Nevertheless, Michigan courts continue to refer to the “fictitious, or fraudulent”
language, which has not been a part of MCL 400.607(1) for over 30 years. See, e.g.,
People v Kanaan, 278 Mich App 594, 619; 751 NW2d 57 (2008), quoting Orzame, 224
Mich App at 558; Wang, unpub op at 7. We take this opportunity to clarify that MCL
400.607(1) now requires, as the fourth and fifth elements of a viable Medicaid fraud
conviction, sufficient evidence that the claim at issue was false as defined under the
Medicaid False Claim Act, MCL 400.602(d), and that the defendant possessed the
requisite knowledge of that falsity. The Legislature has indicated that there is no longer a
distinction for claims that are “fictitious” or “fraudulent.”



                                                11
                 “Knowing” and “knowingly” means that a person is in possession of
         facts under which he or she is aware or should be aware of the nature of his
         or her conduct and that his or her conduct is substantially certain to cause
         the payment of a medicaid benefit. Knowing or knowingly includes acting
         in deliberate ignorance of the truth or falsity of facts or acting in reckless
         disregard of the truth or falsity of facts. Proof of specific intent to defraud
         is not required.

With regard to the knowledge element of MCL 400.607(1) and MCL 400.602(f), the

Court of Appeals has explained:

         “Intent and knowledge can be inferred from one’s actions and, when
         knowledge is an element of an offense, it includes both actual and
         constructive knowledge.”        People v American Medical Centers of
         Michigan, Limited, 118 Mich App 135, 154; 324 NW2d 782 (1982).
         Therefore, it is not problematic that these statutes define “knowing” to
         include “should be aware.” Contrary to defendants’ contention, this actual
         or constructive knowledge element does not relate solely to knowledge that
         a claim is filed. The knowledge element relates to both “the nature of his or
         her conduct and that his or her conduct is substantially certain to cause the
         payment of a [Medicaid or] health care benefit.” . . . Accordingly, the
         actual or constructive knowledge element of these offenses appropriately
         requires knowledge of both the falseness of a claim and that the claim is
         substantially certain to cause payment of a benefit.[27]

         Defense witness Darius Baty was an employee of the clinic who was involved in

Medicaid billing. He testified that a patient’s insurance status was known to the front

desk staff, the clinical manager, and the billing staff and that a copy of a patient’s

Medicaid card would be included in the paper chart and could be seen if one “flipped

through the paper chart.” He further testified that “a good 50 percent” of the clinic’s




27
     People v Perez-DeLeon, 224 Mich App 43, 48-49; 568 NW2d 324 (1997).



                                               12
patients were Medicaid patients.        Importantly, Baty added that defendant had no

involvement in the billing process.28

       Defendant testified that she was aware that some of the patients at the clinic were

Medicaid patients, but she “never paid attention for their insurance . . . .” Defendant

explained, “I have this piece of paper,[29] there’s no Medicaid card on it.” Defendant said

that she thought that insurance information was included in the clinic’s electronic medical

record system but that she never looked at the medical insurance and did not know how it

would be billed. Macon testified that he did not know whether defendant had any

knowledge of Medicaid procedures or Medicaid billing and, significantly, the prosecution

presented no evidence that defendant was trained in or otherwise possessed knowledge of

the clinic’s billing practices. To the contrary, defendant testified that she was never

trained in billing procedures. Further, Macon could not recall seeing at any time during

the investigation any documents pertaining to Medicaid procedures or billing that were

signed by defendant. Bates likewise did not identify anyone who claimed that defendant

was involved in the Medicaid process at all.

       Hussain stated that billing was not discussed with individuals who came to the

clinic through AmeriClerkships. Indeed, during the 22 years in which Hussain owned the

clinic, he never trained foreign doctors like defendant in billing. Hussain explained that

28
   Unsurprisingly, Baty conceded that everyone, including defendant, who had contact
with a patient “knew that a bill was going to be generated and sent to somebody so that
the clinic could be paid for that patient visit . . . .”
29
   Defendant appears to refer to a piece of paper on which she took notes during
interactions with patients. The other side of this paper contained billing codes, but
defendant testified that she was unfamiliar with this side of the form.



                                            13
he was not required to train individuals like defendant in billing, and so it was “never”

done.     Even when defendant became a paid employee—as opposed to a clerk or

volunteer—she was not expected to be involved in Medicaid billing at all, and nothing

presented at trial suggests that defendant was knowledgeable or in any way involved in

the billing practices of her employer.

         The evidence presented in this case simply does not demonstrate actual or

constructive knowledge that defendant’s “conduct [was] substantially certain to cause the

payment of a medicaid benefit.”30 As to actual knowledge, the prosecution relies on

evidence that clinic patients’ charts contained their Medicaid status and copies of their

cards. Nevertheless, there is no evidence that defendant had possession of the paper

chart, much less that she flipped through it to find the Medicaid information.

Significantly, the trial court found defendant to be credible and that she possessed a

“truthful nature.” Defendant’s recitation of the evidence is consistent with the other

evidence offered at trial—the video in particular—which appears to show that defendant

had single sheets of paper on the clipboard with her in the examination room, not a

multipage chart. Moreover, defendant testified that she was not aware of any particular

patient’s insurance status. When reviewing the sufficiency of the evidence, appellate

courts must not interfere with the fact-finder’s role of deciding credibility.31

         Notwithstanding the trial court’s finding that defendant was truthful and credible,

the court nonetheless imputed knowledge to defendant with regard to Medicaid billing.

30
     See MCL 400.602(f).
31
     People v Wolfe, 440 Mich 508, 514; 489 NW2d 748 (1992).



                                              14
The trial court on two occasions declared that “ignorance of the law” is not an excuse.

But the critical question is not whether defendant knew the law. Instead, it is whether

reasonable inferences can be drawn from the circumstantial evidence to conclude that

defendant knew or should have known that a false claim would be submitted to the state

under the Social Welfare Act. On this point the trial court found:

                There is evidence that at least half of the money—and it doesn’t
         matter if it’s half or any other portion, but I believe the testimony is or was
         that Livernois Family Medical Services received about half of their income
         from Medicaid.

         This is insufficient evidence to sustain defendant’s convictions. Even assuming

that this statistic is accurate and that defendant was aware of it, a high percentage of

Medicaid patients at the clinic does not establish that defendant had knowledge under

which she was aware or should have been aware that her conduct in treating Macon and

Bates was substantially certain to cause the payment of a Medicaid benefit.32

         The trial court also placed great emphasis on the fact that defendant knew that the

clinic would be billing an insurance company for medical care:

         [T]he form that defendant used, this encounter form, Exhibit B, is not the
         full form, the other side is the billing form, so defendant clearly knew that
         there was billing going on to insurance. That there are multiple forms of
         insurance. This was not her only job. She had multiple experiences. She
         testified to that. And she clearly knew that her paycheck was derived from
         insurance, that insurance was going to be billed, that that’s what her
         paycheck was coming from, at least in part—at least in part from Medicaid.




32
     See MCL 400.602(f).



                                               15
It is unremarkable that any person employed in the healthcare industry would know that a

variety of insurance companies will be billed for services rendered.           It is equally

unremarkable that such person may infer that his or her employment is funded in part by

the revenue generated by insurance billing. But such inferred knowledge does not sustain

a claim for Medicaid fraud.       Again, the critical inquiry is whether defendant had

knowledge from which she was aware or should have been aware that her conduct in

treating Macon and Bates was substantially certain to cause the payment of a Medicaid

benefit. General knowledge that some source of insurance will be billed is simply not

enough. The trial court’s findings are speculative and not reasonably drawn inferences

from the evidence that the trial court found determinative.

       Likewise, the Court of Appeals erred in its determination that defendant’s general

knowledge of the American healthcare system—as a student, employee, and patient—or

her general knowledge that the clinic was not a free clinic and that she was a paid

employee provided evidence that defendant had satisfied the “knowing” element of a

Medicaid fraud conviction. Defendant was charged with two counts of Medicaid fraud

related to claims for two specific individuals. She cannot be held liable on the basis of

the Medicaid status of other individuals treated at the clinic in its day-to-day operation.33

Even viewed in the light most favorable to the prosecution, the evidence presented does

not appear to establish that defendant was aware or should have been aware that the


33
  See People v Schilling, 110 Mich 412, 414; 68 NW 233 (1896) (a defendant cannot be
convicted for crimes other than those charged in the complaint); MCL 768.32(1) (a
defendant may be found guilty of an offense upon which an indictment was based or of
an inferior offense to the one charged).



                                             16
patients at issue were Medicaid beneficiaries and that their treatment was substantially

certain to cause the payment of a Medicaid benefit.

         Finally, we also conclude that there was no evidence presented that defendant

should have familiarized herself with the insurance status of clinic patients. Thus, the

evidence did not support a finding that defendant acted “in deliberate ignorance of the

truth or falsity of facts or acting in reckless disregard of the truth or falsity of facts.”34

Although the prosecution’s expert testified that defendant could be expected to be aware

of the American healthcare model, the expert did not testify that defendant should have

obtained the patients’ Medicaid status before, during, or after her encounter with them.

Because defendant was never trained to examine or alter billing information, and because

her employer did not expect her to become familiar with this process, it cannot be said

that the ignorance of Medicaid billing procedures was “deliberate” or due to “reckless

disregard of the truth or falsity of facts.”35 From the evidence presented, it appears that

34
     MCL 400.602(f).
35
   In his partial dissent, Justice MARKMAN relies on federal caselaw to support his belief
that defendant acted in deliberate ignorance of whether claims under the Social Welfare
Act were false. But these cases require, for a finding of deliberate ignorance in the
context of federal healthcare fraud, that the defendant be made aware of a high
probability of illegal conduct and take active steps to avoid learning of it. See United
States v Delgado, 668 F3d 219, 227 (CA 5, 2012); United States v Lennartz, 948 F2d
363, 369 (CA 7, 1991); United States v Nazon, 940 F2d 255, 259-260 (CA 7, 1991);
United States v Walter-Eze, 869 F3d 891, 909-910 (CA 9, 2017). The same appears to be
true in other contexts requiring an assessment of deliberate ignorance under federal law.
See, e.g., United States v Lara-Velasquez, 919 F2d 946, 952-953 (CA 5, 1990); United
States v Nicholson, 677 F2d 706, 710-711 (CA 9, 1982); United States v Heredia
(Amended Opinion), 483 F3d 913, 917 (CA 9, 2007). Because the evidence did not
establish that defendant was required to participate in the billing process, trained in
billing procedures, or lawfully required to make herself aware of individual patients’
insurance information, there is no indication that defendant actively sought to remain


                                             17
defendant was not expected to know or become aware of a patient’s insurance status in

the course of her duties at the clinic. We therefore hold that defendant’s failure to

become generally versed in billing procedures did not establish criminal culpability in

this case.36



ignorant of information she knew to be likely to reveal illegal conduct. To hold
otherwise would, in our view, impose a daunting standard not only on licensed healthcare
professionals but also on those seeking to become licensed healthcare professionals while
working under the lawful supervision of licensed doctors.

       Justice MARKMAN also opines that “[w]hen defendant performed her services, the
only fact unknown to [her] was whether a private insurance company or the state of
Michigan would be the victim of a false claim for her unlicensed services.” But Justice
MARKMAN points to no evidence in support of the notion that defendant knew, at any
point, that the services she provided were not lawful (whether by function of the
delegation exception under MCL 333.16215(1) or otherwise). This, of course, does not
shield her from her conviction for the unauthorized practice of a health profession.
People v Motor City Hosp & Surgical Supply, Inc, 227 Mich App 209, 215; 575 NW2d
95 (1997), citing Cheek v United States, 498 US 192, 199; 111 S Ct 604; 112 L Ed 2d
617 (1991) (ignorance of the law is no defense from a criminal prosecution). Even so,
that we affirm defendant’s conviction for the unauthorized practice of a health profession
does not inherently equate with a determination that she knew of some “ ‘shady dealings’
that were certain to result in the generation of false bills.”
36
   Justice MARKMAN offers three means by which defendant might have made herself
aware of Macon’s and Bates’s Medicaid status: (1) she could have asked the clinic
receptionist about the agents’ Medicaid status, (2) she could have reviewed their paper
charts, and (3) she could have asked Macon and Bates themselves whether they were
Medicaid recipients. Nevertheless, the evidence in this case did not establish that
defendant should have inquired as to patients’ insurance status with the clinic receptionist
or with the patients themselves. Thus, the mere fact that defendant could have asked is
irrelevant. Justice MARKMAN’s point about the Medicaid information in each patients’
chart is well-taken, but it does not acknowledge that the evidence in this case did not
show that defendant was ever in possession of paper charts when providing care for
Macon and Bates. Additionally, the evidence did not show that, if defendant had those
charts, she would have been required to flip through the charts to examine each patients’
Medicaid information.



                                            18
                                  III. CONCLUSION

      For the reasons outlined in this opinion, we affirm the conviction for the

unauthorized practice of a health profession but reverse the convictions for Medicaid

fraud. The case shall be remanded to the Ingham Circuit Court in accordance with the

Court of Appeals’ previous judgment to analyze the proportionality of the fines assessed

against defendant. We do not retain jurisdiction.


                                                      Brian K. Zahra
                                                      Bridget M. McCormack
                                                      David F. Viviano
                                                      Richard H. Bernstein
                                                      Elizabeth T. Clement
                                                      Megan K. Cavanagh




                                           19
                             STATE OF MICHIGAN

                                     SUPREME COURT


    PEOPLE OF THE STATE OF MICHIGAN,

               Plaintiff-Appellee,

    v                                                           No. 158013

    XUN WANG,

               Defendant-Appellant.


VIVIANO, J. (concurring).
        I agree with the majority’s decision to affirm defendant’s conviction for

unauthorized practice of a health profession under MCL 333.16294 and to reverse

defendant’s convictions for Medicaid fraud under MCL 400.607 of the Medicaid False

Claim Act (MFCA). I write separately to raise some concerns regarding the latter statute.

For defendant’s conduct to fall within the fraud provisions of the MFCA, the prosecution

must prove that it was “knowing,”1 which the act defines as meaning, among other things,

that the defendant possesses “facts under which he or she is aware or should be aware of

the nature of his or her conduct and that his or her conduct is substantially certain to cause

the payment of a medicaid benefit.”2        As the majority explains, the evidence was

insufficient to show that defendant knew or should have known a Medicaid payment was

substantially certain to result from her conduct.       At most, in my view, the record


1
    MCL 400.607(1).
2
    MCL 400.602(f).
demonstrates that defendant, by recording her treatment notes and entering them into the

clinic’s computer system, made false records that were material to a false claim. That

evidence would appear to be sufficient to establish civil liability under a provision in a

somewhat analogous federal statute, the False Claims Act (Federal Act), 31 USC

3729(a)(1)(B).        However, the MFCA—under which defendant was criminally

prosecuted—contains no provision prohibiting the making or use of a false record that is

“material to a false or fraudulent claim.” Thus, the majority properly reverses defendant’s

Medicaid fraud convictions.

          Given the scope of the parties’ arguments and the evidence in the record, the result

in this case is relatively clear. But in analyzing the criminal-liability provisions of the

MFCA, a number of problematic aspects of the statute have become evident to me.

Although they need not be resolved to dispose of this case, I write to highlight these

problems and encourage the Legislature to address them in order to clarify the statute’s

meaning.

          The problems with the MFCA result, in large part, from how the statutory language

developed over time. When the MFCA was enacted in 1977 PA 72, the substantive

criminal offense in MCL 400.607(1) was nearly identical to the current version. It required

the defendant to have submitted a claim “knowing” it to be false.3 “Knowing” and


3
    It stated:

          A person shall not make or present or cause to be made or presented to an
          employee or officer of the state a claim under Act No. 280 of the Public Acts
          of 1939, as amended, upon or against the state, knowing the claim to be false,
          fictitious, or fraudulent. [MCL 400.607(1), as enacted by 1977 PA 72.]



                                                2
“knowingly,” in turn, were defined to mean “that a person is aware of the nature of his

conduct and that his conduct is substantially certain to cause the intended result.”4 The

Legislature made minor changes to MCL 400.607 in 1984 PA 333, but that act significantly

amended the definition of “knowing” and “knowingly” in MCL 400.602. After the 1984

amendment, the full definition read:

                “Knowing” and “knowingly” means that a person is in possession of
         facts under which he or she is aware or should be aware of the nature of his
         or her conduct and that his or her conduct is substantially certain to cause the
         payment of a medicaid benefit. Knowing or knowingly does not include
         conduct which is an error or mistake unless the person’s course of conduct
         indicates a systematic or persistent tendency to cause inaccuracies to be
         present.[5]

         Under the first sentence of this section, which remains in the current version, courts

have held that either actual knowledge (“is aware”) or constructive knowledge (“should be

aware”) suffices.6 Courts have also interpreted the section as requiring knowledge that the

claim would cause payment of benefits.7 When read in conjunction with MCL 400.607(1),

“the actual or constructive knowledge element . . . requires knowledge of both the


4
    MCL 400.602(c), as enacted by 1977 PA 72.
5
    MCL 400.602(f), as amended by 1984 PA 333.
6
  People v Perez-DeLeon, 224 Mich App 43, 48-49; 568 NW2d 324 (1997), citing People
v American Med Ctrs of Mich, Ltd, 118 Mich App 135, 154; 324 NW2d 782 (1982); see
also People v Kanaan, 278 Mich App 594, 603; 751 NW2d 57 (2008) (“[A]ctual
knowledge that a Medicaid claim is false is not required to support a conviction. Rather, a
conviction can be sustained on the basis of evidence showing that a defendant should have
been aware that the nature of his or her conduct constituted a false claim for Medicaid
benefits, akin to constructive knowledge.”).
7
    Perez-DeLeon, 224 Mich App at 49.



                                                3
falseness of a claim and that the claim is substantially certain to cause payment of a

benefit.”8

          Understanding the next round of amendments to the MFCA requires some

background about the Federal Act and how it compares to the MFCA. Under the Federal

Act, private parties can bring qui tam actions on behalf of the government for civil penalties

and damages, which the party and the government split.9 The MFCA, by contrast,

originally relied on criminal penalties and a civil penalty (plus damages) in actions brought




8
    Id.
9
  31 USC 3730. A qui tam action is one “brought under a statute that allows a private
person to sue for a penalty, part of which the government or some specified public
institution will receive.” Black’s Law Dictionary (10th ed).

        The Federal Act had a criminal penalty, codified in 18 USC 287, that was derived
from the original Federal Act passed in 1863. See United States v Bornstein, 423 US 303,
305 n 1; 96 S Ct 523; 46 L Ed 2d 514 (1976) (describing the history of 18 USC 287).
Section 287 criminalizes making or presenting a claim knowing the claim to be false,
fictitious, or fraudulent. In 1986, when Congress amended the Federal Act to define
“knowing,” it also amended 18 USC 287 to provide criminal penalties for making the same
false claims as described in 31 USC 3729. PL 99-562, § 7; 100 Stat 3153, amending 18
USC 287. Federal courts now generally refer to 18 USC 287 as the “criminal provisions”
of the Federal Act. See, e.g., United States v Glaub, 910 F3d 1334, 1336 (CA 10, 2018).
In addition to 18 USC 287, a number of other federal statutes provide criminal penalties
for healthcare fraud or related offenses. See, e.g., 18 USC 1035 (prohibiting knowingly
falsifying a material fact or making a materially false statement in connection with the
delivery of or payment for healthcare benefits); 18 USC 1347 (prohibiting knowingly
executing or attempting to execute a scheme to defraud a healthcare benefit program or to
obtain money or property owned by a healthcare benefit program by means of false
pretenses, in connection with the delivery of or payment for healthcare benefits).



                                              4
by the government.10 Not until 2005 did the MFCA allow for qui tam actions akin to those

in the Federal Act.11

         Another difference is that the Federal Act contains a broader liability provision in

31 USC 3729(a)(1)(B), which prohibits “knowingly mak[ing], us[ing], or caus[ing] to be

made or used, a false record or statement material to a false or fraudulent claim[.]”

“Material” is defined as “having a natural tendency to influence, or be capable of

influencing, the payment or receipt of money or property.”12 As noted above, the MFCA

does not contain a similar provision.

         Like MCL 400.607(1), many of the provisions in the Federal Act contain a scienter

requirement under which the defendant must act “knowingly.”13 The Federal Act left this

term undefined prior to 1986, leading many courts to require specific intent to defraud the

government or actual knowledge of falsity, while others held that the knowledge element

was satisfied by extreme carelessness.14 To bring some order to the subject, Congress

enacted a definition of “knowing” and “knowingly,” which still stands today.15 Under this

new definition, no specific intent to defraud is required and knowledge can be proven in


10
     1977 PA 72.
11
     2005 PA 337; see MCL 400.610a.
12
     31 USC 3729(b)(4).
13
     See, e.g., 31 USC 3729(a)(1)(A), (B), (F), and (G).
14
   See Boese, Civil False Claims and Qui Tam Actions (4th ed, 2019 update), § 2.06
(explaining the history and caselaw).
15
     PL 99-562, § 2, 100 Stat 3153, amending 31 USC 3729(b).



                                               5
three different ways: by showing that a person “has actual knowledge of the information,”

“acts in deliberate ignorance of the truth or falsity of the information,” or “acts in reckless

disregard of the truth or falsity of the information[.]”16

         Thus, compared to the more open-ended “constructive knowledge” standard in

MCL 400.602(f), the Federal Act contains two specifically defined forms of constructive

or imputed knowledge.       The MFCA’s constructive-knowledge standard represents a

potentially broader concept, embracing “[k]nowledge that one using reasonable care or

diligence should have . . . .”17 By contrast, “reckless disregard” as used in the Federal Act

has been described as a “constructive knowledge standard” requiring “aggravated gross

negligence, gross negligence-plus, or conduct that runs an unjustifiable risk of harm.”18

And “deliberate ignorance”—again in the context of the Federal Act—has been thought to

suggest “willful blindness.”19

         Our definition of “knowing” and “knowingly” became much more opaque when the

MFCA was amended in an apparent effort to qualify for financial incentives crafted by




16
     31 USC 3729(b)(1).
17
  Black’s Law Dictionary (10th ed), p 1004; see also Echelon Homes, LLC v Carter
Lumber Co, 472 Mich 192, 197; 694 NW2d 544 (2005) (defining constructive knowledge
“as ‘[k]nowledge that one using reasonable care or diligence should have”), quoting
Black’s Law Dictionary (8th ed) (alteration in original).
18
     See Boese, § 2.06.
19
   Id. (“[T]he [Federal Act]’s ‘deliberate ignorance’ standard of intent and ‘willful
blindness’ are virtually identical concepts.”).



                                               6
Congress in the Deficit Reduction Act of 2005.20 Under that act, if a state has a false-

claims act that “establishes liability . . . for false or fraudulent claims described in” the

Federal Act, then the state can keep 10% more of the recoveries under its own false-claims

act—the additional funds coming from the share of the recovery to which the federal

government would have been entitled.21 In other words, a state could receive 10% more

from shared false-claims judgments if its false-claims act is as broad as the Federal Act.

The Deficit Reduction Act charged the Inspector General of the Department of Health and

Human Services with determining whether the state statute qualified.22 The Inspector

General set out various standards it would use in this determination, including whether the

state law had provisions analogous both to the federal definition of “knowing” and

“knowingly” and also to the provision creating liability for false records set forth in 31

USC 3729(a)(1)(B).23

         In 2008, in an apparent effort to satisfy the federal civil-liability standard and

thereby qualify for the additional reimbursement share, our Legislature amended the intent

requirement in MCL 400.602(f).24 But instead of adopting the Federal Act’s coherent

20
  See generally Office of Inspector General, Dep’t of Health & Human Servs, Publication
of OIG’s Guidelines for Evaluating State False Claims Acts, 71 Fed Reg 48552 (August
21, 2006).
21
     42 USC 1396h.
22
     42 USC 1396h(b).
23
     OIG Guidelines, 71 Fed Reg at 48553.
24
   2008 PA 421; House Legislative Analysis, SB 1622 (December 11, 2008), pp 1-2
(recommending that the House of Representatives revise the definition of “knowing” and
“knowingly” in MCL 400.602(f) to include “deliberate ignorance” and “reckless
disregard,” as defined in the Federal Act, so that the state of Michigan would be eligible


                                             7
tripartite structure—i.e., actual knowledge, deliberate ignorance, and reckless disregard—

the Legislature simply patched the latter two forms of constructive knowledge onto our

existing statute (along with the disclaimer that specific intent need not be shown) and struck

the language concerning errors.25 These changes, however, failed to satisfy the Inspector

General that the MFCA contained the same breadth of civil liability as the Federal Act.26


for additional federal funding). According to the legislative analysis, Michigan had already
“missed out” on the extra funds because federal officials had concluded that the MFCA
failed to comply with the Federal Act. Id. at 1. The bases for rejecting the MFCA were
that it lacked a provision creating liability for false records used to decrease or avoid paying
obligations to the government and that it did not allow civil penalties for each false claim.
OIG Evaluates 10 State False Claims Acts Under DRA; Three Statutes Meet Requirements
for Incentive Allowing Increased Share of Fraud Recoveries, 15 No. 12 FDA Enforcement
Manual Newsletter 7 (2007).

       Noting the legislative history here is not the same as using it to interpret the statute.
If anything, the legislative analysis shows the perils of relying on these types of materials:
it expressed a view of the Legislature’s purpose that does not appear to be reflected in the
statutory text, at least according to the Inspector General. This disjunction between the
text and the legislative history is why we examine what the statute says rather than what
the legislators intended it to say as evidenced by extrinsic documents. See Scalia & Garner,
Reading Law: The Interpretation of Legal Texts (St. Paul: Thomson/West, 2012), p 375
(“[T]he use of legislative history poses a major theoretical problem: It assumes that what
we are looking for is the intent of the legislature rather than the meaning of the statutory
text. That puts things backwards. To be ‘a government of laws, not of men’ is to be
governed by what the laws say, and not by what the people who drafted the laws
intended.”); Easterbrook, The Role of Original Intent in Statutory Construction, 11 Harv J
L & Pub Pol’y 59, 61 (1988) (“Original meaning is derived from words and structure . . . .
What any member of Congress thought his words would do is irrelevant. We do not care
about his mental processes.”).
25
     2008 PA 421.
26
   Letter from Office of Inspector General to Attorney General Mike Cox (March 21,
2011), available at <https://oig.hhs.gov/fraud/docs/falseclaimsact/Michigan.pdf>
[https://perma.cc/V56Y-BB57]. Michigan received supplemental letters, one in 2011 and
another in 2016, offering additional reasons why the MFCA was not certified. See Letter
from Office of Inspector General to Attorney General Bill Schuette (December 28, 2016),


                                               8
While few details were given in the Inspector General’s 2011 official letter notifying the

Michigan Attorney General that the state was ineligible for the additional reimbursement

share under the Deficit Reduction Act, it did cite the Federal Act’s broad definition of

“material” as contrasting with the MFCA.27

         In sum, civil-liability concepts from the Federal Act have been engrafted onto

preexisting language in the MFCA without, it seems, careful thought about how and

whether those concepts fit in the criminal-liability context. To make matters worse, the

MFCA’s old language already created a number of interpretive puzzles. The combined

product is even more difficult to parse.

         First, the initial sentence of MCL 400.602(f), defining “knowing” and “knowingly,”

is incomplete. It refers to knowledge of the “nature of [an individual’s] conduct” without

clearly expressing what the “nature” of the “conduct” relates to. Only by reading it together

with MCL 400.607(1)—when that offense is at issue—can the terms in the first sentence

be linked to the falsity of the claim, i.e., knowledge that the claim is false.28 Certainly it

seems that the Legislature intended such a reading. But incorporating the full definition of

“knowing” into MCL 400.607(1)—“knowing the claim to be false”—makes the statute


available at <https://oig.hhs.gov/fraud/docs/falseclaimsact/Michigan-supplement2.pdf>
[https://perma.cc/RWL4-WXBM] (explaining that the MFCA did not provide for the
same increased civil penalties as the Federal Act); Letter from Office of Inspector
General to Attorney General Bill Schuette (August 31, 2011), available at
<https://oig.hhs.gov/fraud/docs/falseclaimsact/Michigan-supplement.pdf> [https://perma.cc/H7EG-
HMDL] (noting differences in the statutes of limitations).
27
     Letter from Office of Inspector General to Attorney General Mike Cox (March 21, 2011).
28
     See Perez-DeLeon, 224 Mich App at 49.



                                              9
difficult to comprehend, to say the least.29 As one example, the critical element here—

certainty about the Medicaid payment—becomes an element of the offense despite lacking

any clear grammatical or logical connection to the phrasing of MCL 400.607(1).

       Second, a related question is whether the first sentence of MCL 400.602(f)

encompasses the full breadth of the actual- and constructive-knowledge standards. The

phrasing—“is aware” or “should be aware”—suggests that it does. But again, these phrases

refer to awareness regarding the “nature” of the individual’s “conduct,” not specifically the

falsity of the individual’s Medicaid claim. In this respect, the Federal Act’s clarity in

establishing three ways to demonstrate knowledge contrasts with the MFCA’s less direct

language. Moreover, if the first sentence covers constructive knowledge—what the

individual should have known in the exercise of reasonable diligence—then it is not

apparent what meaning is added by the second sentence introducing “reckless disregard”

and “deliberate ignorance.” Those two standards would already seem to fall within the

broader concept of constructive knowledge in the first sentence.

       Third, in defining “reckless disregard” and “deliberate ignorance,” it is unclear what

role is played by the existence of both criminal and civil provisions in the MFCA, as

compared to the civil provisions in the Federal Act. If “reckless disregard” bears a meaning



29
  Consider substituting in just a portion of the term’s definition: “A person shall not make
or present or cause to be made or presented to an employee or officer of this state a claim
under the social welfare act . . . [a person is in possession of facts under which he or she is
aware or should be aware of the nature of his or her conduct and that his or her conduct is
substantially certain to cause the payment of a medicaid benefit] the claim to be false.”
MCL 400.602(f); MCL 400.607(1). That the definition was not written to fit the syntax of
the sentence is one of the more obvious problems with the definition.



                                              10
similar to that in the Federal Act, and thus focuses on disregard of a substantial or

unjustified risk, how does this meaning work with the phrase “substantial certainty”?30

Does “reckless disregard” mean reckless disregard of a substantial and unjustified risk that

a defendant’s conduct will result in payment of a false claim, or does it mean reckless

disregard (i.e., disregard of a substantial risk) of a substantial certainty that the conduct will

result in payment of a false claim? If the latter, what sort of probabilistic assessment would

be required, diluted by two layers of “substantial” risks or certainties? For that matter,

what degree of certainty is signified by the phrase “substantial certainty”?

         Fourth, with regard to MCL 400.607(1), what does it mean to “cause” a false claim

to be made or presented?        Does this term incorporate a common-law definition of

causation?31 And if “cause” is modified by “knowing,” how does the definition of

“knowing” in MCL 400.602(f), which already contains its own causal requirement linked

to actual payment, fit into MCL 400.607(1)? Compounding this issue is the definition of

“deceptive,” which also contains language concerning causation. That term comes into

play through the definition of “false,” which “means wholly or partially untrue or

deceptive.”32 “Deceptive,” in turn, “means making a claim or causing a claim to be made

under the social welfare act” containing statements or omissions that mislead the

government into thinking “the represented or suggested state of affair to be other than it

30
     See Boese, § 2.06.
31
   Cf. Ray v Swager, 501 Mich 52, 63-69; 903 NW2d 366 (2017) (holding that the
Legislature used “proximate cause” as a legal term of art, borrowing its lengthy background
in the caselaw).
32
     MCL 400.602(d).



                                               11
actually is.”33 Thus, in the context of MCL 400.607(1), three potentially different causal

requirements might apply at the same time. In this respect, a comparison to 31 USC

3729(a)(1)(B) demonstrates the issues with our statute. That provision of the Federal Act

includes nearly identical phrasing—“causes to be made or used”—but does not again refer

to causation in the definitions of other pertinent terms. Instead, 31 USC 3729(a)(1)(B)

employs the term “material,” which, as noted before, “means having a natural tendency to

influence, or be capable of influencing, the payment or receipt of money or property.”34

         These are hard interpretive questions that could arise in future MFCA cases and may

lead to a vagueness challenge or rule-of-lenity argument. I offer no view on them here,

except to say that they are best resolved by the Legislature. For these reasons, I concur in

the judgment and encourage the lawmaking branch to consider amending the statute to

clarify its meaning.


                                                         David F. Viviano




33
     MCL 400.602(c).
34
     31 USC 3729(b)(4).


                                             12
                            STATE OF MICHIGAN

                                    SUPREME COURT


PEOPLE OF THE STATE OF MICHIGAN,

              Plaintiff-Appellee,

v                                                            No. 158013

XUN WANG,

              Defendant-Appellant.


MARKMAN, J. (concurring in part and dissenting in part).
       I concur with the majority to affirm defendant’s conviction of the unlawful

practice of medicine. I further concur with its conclusion that defendant here did not

possess actual knowledge that Special Agents Macon and Bates were purporting to be

Medicaid patients. Where I respectfully depart from my colleagues concerns whether

there was sufficient evidence to allow a reasonable trier of fact to conclude that defendant

here acted in “deliberate ignorance” of the special agents’ putative Medicaid status in

providing unlicensed services for which no bill could lawfully be generated. In view of

the distinctive definition of “knowing” set forth in MCL 400.602(f) and the appellate

standard of review governing defendant’s sufficiency-of-the-evidence challenge, I would

affirm defendant’s convictions under the Medicaid False Claim Act (MFCA), MCL

400.601 et seq.
                                   I. BACKGROUND

       I adopt the majority’s recitation of the factual and procedural history of this case.

As defendant’s experience within the healthcare field is relevant to the knowledge

element of her convictions under the MFCA, I briefly summarize that experience.

       Before moving to the United States in 2001, defendant completed a five-year

medical-school program in China as well as two of three years of a residency program in

internal medicine. Defendant then entered the United States to pursue studies at Purdue

University, earning a Ph.D. in Basic Medical Science. Upon completing her studies,

defendant worked as a medical researcher at the University of Michigan Medical School

and then at William Beaumont Hospital. In 2013, through the AmeriClerkships program,

defendant rotated through four primary-care clinics. Thereafter, AmeriClerkships placed

defendant at the Livernois Family Medical Clinic (LFMC), run by Dr. Murtaza Hussain.

Defendant then rotated through all five clinics as an unpaid volunteer, doing so to gain

experience and additional personal references in support of her applications to United

States medical-residency programs. During her two-month rotation at LFMC, defendant

performed the functions of a medical student on an outpatient rotation, including taking

patient histories and performing initial physical examinations. Defendant performed

these basic tasks while Dr. Hussain was present in the clinic.

       In early 2014, defendant failed to obtain a United States residency placement. She

did, however, continue to work at LFMC, first as a volunteer and then as a part-time and

paid employee. When Special Agent Macon purported to be an LFMC patient, defendant

had spent a total of nine months at the clinic, was working there 10 to 15 hours a week,

and was earning between $20 and $30 an hour. Defendant saw 10 to 15 patients a day


                                             2
when Dr. Hussain was absent from the clinic. Finally, defendant saw patients even while

Dr. Hussain was vacationing abroad.

                             II. STANDARD OF REVIEW

       The standard of review for evaluating sufficiency-of-the-evidence challenges

following jury trials and bench trials are one and the same. People v Petrella, 424 Mich

221, 268-269; 380 NW2d 11 (1985). Thus, the fact that defendant’s convictions arise

from a bench trial does not alter the basic legal framework governing our review of her

sufficiency-of-the-evidence challenge. Id.

       When considering a sufficiency-of-the-evidence challenge, “this Court reviews the

evidence in a light most favorable to the prosecutor to determine whether any trier of fact

could find the essential elements of the crime were proven beyond a reasonable doubt.”

People v Robinson, 475 Mich 1, 5; 715 NW2d 44 (2006). “[I]mportantly, the standard of

review is deferential: a reviewing court is required to draw all reasonable inferences and

make credibility choices in support of the . . . verdict. People v Oros, 502 Mich 229, 239;

917 NW2d 559 (2018) (brackets, quotation marks, and citation omitted). “It is for the

trier of fact, not the appellate court, to determine what inferences may be fairly drawn

from the evidence and to determine the weight to be accorded those inferences.” People

v Hardiman, 466 Mich 417, 428; 646 NW2d 158 (2002). “The scope of review is the

same whether the evidence is direct or circumstantial. Circumstantial evidence and

reasonable inferences arising from that evidence can constitute satisfactory proof of the

elements of a crime.” Oros, 502 Mich at 239 (quotation marks and citation omitted).

“[B]ecause it can be difficult to prove a defendant’s state of mind on issues such as




                                             3
knowledge and intent, minimal circumstantial evidence will suffice to establish the

defendant’s state of mind, which can be inferred from all the evidence presented.”

People v Kanaan, 278 Mich App 594, 622; 751 NW2d 57 (2008) (emphasis added).

                                   III. DISCUSSION

      Under the MFCA, “[a] person shall not make or present or cause to be made or

presented to an employee or officer of this state a claim under the social welfare

act . . . upon or against the state, knowing the claim to be false.” MCL 400.607(1). In

order to sustain a conviction under MCL 400.607(1), the prosecutor must prove five

elements:

      “(1) the existence of a claim, (2) that the accused makes, presents, or causes
      to be made or presented to the state or its agent, (3) the claim is made under
      the Social Welfare Act . . . , (4) the claim is false . . . , and (5) the accused
      knows the claim is false . . . .” [Kanaan, 278 Mich App at 619, quoting
      People v Orzame, 224 Mich App 551, 558; 570 NW2d 118 (1997).]

Defendant’s sufficiency-of-the-evidence challenge centers on whether the prosecutor

established the fifth element-- knowledge that the claim is “false.” This element pertains

to “both the nature of [defendant’s] conduct and that [defendant’s] conduct is

substantially certain to cause the payment of a [false Medicaid or] health care benefit.”

People v Perez-DeLeon, 224 Mich App 43, 49; 568 NW2d 324 (1997) (emphasis and

quotation marks omitted). The MFCA provides the following specific definition for

“knowing” and “knowingly”:

      [A] person is in possession of facts under which he or she is aware or
      should be aware of the nature of his or her conduct and that his or her
      conduct is substantially certain to cause the payment of a medicaid benefit.
      Knowing or knowingly includes acting in deliberate ignorance of the truth
      or falsity of facts or acting in reckless disregard of the truth or falsity of


                                             4
         facts. Proof of specific intent to defraud is not required. [MCL 400.602(f)
         (emphasis added).]

         In my judgment, the highlighted aspects of this definition emphasize that an

individual may not disregard readily ascertainable facts that would otherwise cause that

individual, in light of other facts of which he or she is aware, or should be aware, to

recognize that a claim made upon the government under the Social Welfare Act is false.1

To be sure, the MFCA does not define “deliberate ignorance.” See MCL 400.602.

However, the definitions of “knowing” and “knowingly” are modeled after and mirror the

federal definitions of those terms within the context of false claims against the

government. Compare, e.g., MCL 400.602(f) with 31 USC 3729(b)(1).2 And, under

federal law, a finding of “deliberate ignorance” is appropriate when (1) the defendant

claims a lack of guilty knowledge; (2) “the defendant was subjectively aware of a high



1
  I emphasize “government” because the victims of defendant’s actions were not only the
patients at LFMC who had every reason to believe they were receiving care from a
licensed medical professional, see note 5 infra, but also the taxpayers of this state.
2
    The federal statute, 31 USC 3729(b)(1), states:

                (1) the terms “knowing” and knowingly”—

                (A) mean that a person, with respect to information—

                (i) has actual knowledge of the information;

               (ii) acts in deliberate ignorance of the truth or falsity of the
         information; or

               (iii) acts in reckless disregard of the truth or falsity of the
         information; and

                (B) require no proof of specific intent to defraud[.]



                                               5
probability of the existence of the illegal conduct”; and (3) “the defendant purposely

contrived to avoid learning of the illegal conduct.” United States v Delgado, 668 F3d

219, 227-228 (CA 5, 2012) (quotation marks and citation omitted); see also United States

v Walter-Eze, 869 F3d 891, 910 (CA 9, 2017) (describing “deliberate ignorance” as

existing “where the defendant remained willfully ignorant of the nature of his activity

after the circumstances would ‘have put any reasonable person on notice that there was a

“high probability” that the conduct was illegal’ ”), quoting United States v Nicholson,

677 F2d 706, 710 (CA 9, 1982) (brackets omitted). A defendant acts with “deliberate

ignorance” when the defendant has a reasonable basis to suspect that her actions run afoul

of the law but does not know the precise nature of the criminal conduct. United States v

Lara-Velasquez, 919 F2d 946, 952-953 (CA 5, 1990) (finding sufficient evidence to

establish that the defendant acted with deliberate ignorance when he had reason to

suspect he was transporting illicit cargo but avoided inspecting the vehicle he drove).

Equating “deliberate ignorance” to “conscious avoidance” has also gained widespread

approval in the federal circuit courts. United States v Nazon, 940 F2d 255, 259 (CA 7,

1991).   A defendant acts with “deliberate ignorance” when she intentionally takes

“actions to avoid confirming suspicions of criminality.” United States v Heredia, 483

F3d 913, 917 (CA 9, 2007). The Seventh Circuit has arguably summed up “deliberate

ignorance” in a manner most relevant to this case, stating that “[d]eliberate ignorance

exists when the evidence indicates that the defendant, knowing or suspecting that he is

involved in shady dealings, takes steps to make sure that he does not acquire full or exact

knowledge of the nature and extent of those dealings.” United States v Lennartz, 948 F2d

363, 369 (CA 7, 1991) (quotation marks and citation omitted).


                                            6
       Given that defendant was, or should have been, aware of the following four facts,

a reasonable trier of fact could conclude that defendant acted with “deliberate ignorance”

of the ultimate fact that a false claim would be submitted to Medicaid as a result of her

services. First, based on defendant’s experience in the healthcare field and her efforts to

obtain a residency placement and an accompanying medical license, defendant was

aware, or should have been aware, that it was unlawful for her to practice medicine. This

is particularly true given that defendant provided medical services even while Dr.

Hussain was more than 5000 miles away in Greece.3 Second, as acknowledged by the

majority, Darius Baty, an employee in LFMC’s billing department, testified that everyone

at LFMC “knew that a bill was going to be generated [for each patient visit] and sent to

somebody so that the clinic could be paid for that patient visit . . . .” And defendant’s

knowledge of this specific point is lent further support by the fact that she was receiving

compensation for her work at LFMC. For when defendant was the sole person seeing a

patient-- as was the case, for example, with Special Agent Bates-- and LFMC was paying

her, it follows that defendant knew that LFMC would prepare and submit a bill for the

visit. Third, based on her considerable history in the healthcare field, defendant was


3
  The majority asserts that I have not identified any “evidence in support of the notion
that defendant knew, at any point, that the services she provided were not lawful . . . .”
But as the above discussion reflects, her experience in the medical field in combination
with her unsuccessful efforts to obtain a medical license provided a trier of fact with a
reasonable basis to conclude that she was cognizant that she could not practice medicine
and write prescriptions while Dr. Hussain was not at LFMC. This is particularly true
given that this Court must view the evidence in the light most favorable to the prosecutor
and given that defendant’s criminal state of mind is subject to the specific standards of
MCL 400.602(f).



                                            7
aware, or should have been aware, that a bill could not be sent to Medicaid or any

insurance company for services rendered by an individual who lacked any type of

professional medical license and thus could not lawfully practice in the field.4 Fourth,

defendant was aware, or should have been aware, that a high percentage of the patients

specifically seeking treatment at LFMC were Medicaid beneficiaries. From her nine

months of experience at LFMC, she possessed at least a basic understanding of the

clinic’s patient population. Indeed, defendant acknowledged during cross-examination

that she was cognizant that at least some of the patients at LFMC were Medicaid patients.

Furthermore, Baty quantified the percentage of patient visits resulting in bills to

Medicaid, estimating that “a good 50 percent” of LFMC’s patients were Medicaid

recipients.

       To summarize, a reasonable trier of fact could have concluded that defendant was

aware, or should have been aware: (1) that it was unlawful for her to practice medicine;

4
  The majority states that “[b]ecause the evidence did not establish that defendant was
required to participate in the billing process, trained in billing procedures, or lawfully
required to make herself aware of individual patients’ insurance information, there is no
indication that defendant actively sought to remain ignorant of information she knew to
be likely to reveal illegal conduct.” One need not, however, partake in the billing process
or be trained in billing procedures to know that it is fraudulent to bill for services that the
majority, in upholding defendant’s unlawful-practice-of-medicine conviction, correctly
concludes defendant could not legally perform. When defendant performed her services,
the only fact unknown to defendant was whether a private insurance company or the state
of Michigan would be the victim of a false claim for her unlicensed services. Thus, by
knowing that she could not practice medicine and that a bill would be generated for her
services, defendant knew or should have known that she was engaged in “shady dealings”
that were certain to result in the generation of false bills. This is perhaps made most
apparent by her decision to treat patients even while Dr. Hussain was vacationing in
Greece. And as discussed in point four infra, defendant knew or should have known that
there was a high probability that the state of Michigan specifically would be the victim.



                                              8
(2) that a bill would be generated for her services, even when Dr. Hussain was not

present; (3) that it was unlawful and fraudulent to bill Medicaid for her services; and (4)

that a significant percentage of LFMC patients were Medicaid recipients, such that

LFMC would bill the government for her services. From these facts, a reasonable trier of

fact could conclude that defendant knew that her employment at LFMC was an integral

part of an illicit scheme. Further, such a reasonable trier of fact could also conclude that

defendant knew that on the occasions on which Special Agents Macon and Bates visited,

there was approximately-- arguably at least-- a one-in-two chance that her “treatment” of

any given patient would cause LFMC to submit a false claim to Medicaid. Put another

way, because defendant testified that she saw 10 to 15 patients on days when Dr. Hussain

was not present at LFMC, her services on those days caused, on average, the submission

of five to eight false bills to Medicaid.5

       Despite this high probability and volume of false bills to Medicaid resulting from

defendant’s “treatment” of patients, defendant avoided three readily available means of

determining whether a given patient, such as Special Agents Macon or Bates, was a

Medicaid patient. First, she could have asked the clinic receptionist, who was cognizant

of a given patient’s insurance information, whether a patient was a Medicaid recipient.

Second, she could have reviewed their paper charts, which contained insurance

information, including a photocopy of their Medicaid cards. Third, she could have


5
  Quantified differently, if 50% of LFMC patients were Medicaid recipients and Wang
saw 10 patients on a day when Dr. Hussain was not at LFMC, there was a greater than
99.9% chance that her work at LFMC on that day would have resulted in the clinic
sending a false Medicaid bill to the government.



                                             9
expressly inquired whether they were Medicaid recipients. Rather than determining

whether a patient was or was not a Medicaid recipient, defendant simply closed her eyes

to this information, all the while knowing that bills would be generated and submitted to

the government for the unlawful services that she had provided.6 In my judgment, the

four facts of which defendant was aware, or should have been aware, combined with her

avoidance of readily ascertainable information regarding a patient’s Medicaid status,

amount to “deliberate ignorance” of the ultimate fact that her “treatment” of the special

agents would cause the submission of false claims to Medicaid.7

6
  Apart from the requirement placed upon defendant by the MFCA, knowing a patient’s
insurance status, particularly when treating a patient of limited financial means who is on
Medicaid, is relevant to devising a treatment plan and selecting a prescription-medication
regimen. See Schneider & Hall, The Patient Life: Can Consumers Direct Health Care?,
35 Am J L & Med 7, 33-34 & nn 130, 132 (2009) (discussing studies showing that
doctors “routinely consider [an] insured patient’s out-of-pocket costs in some clinical
situations, especially when prescribing drugs” and observing that knowing a patient’s
insurance status and financial limitations influenced treatment plans and what specific
medications doctors prescribed). Thus, defendant’s decision to avoid learning of a
patient’s Medicaid status not only caused a false claim to be submitted to Medicaid but
also arguably impacted the specific care received by patients at LFMC. For this latter
reason, I respectfully disagree with the majority that because defendant was not herself
involved in billing procedures, she had no particular need or reason to learn of a patient’s
insurance status.
7
  The majority contends that while defendant could have asked about a patient’s
insurance status, nothing shows that defendant either possessed a patient’s paper chart or
would have looked through the paper chart to determine a patient’s insurance status had
she possessed one. But it is not a question of what defendant did or would have done.
Rather it is a question of what the law required of her in light of the facts that she knew or
should have known. Because defendant knowingly involved herself in “shady dealings”
that were certain to result in some type of false billing, a trier of fact could rely on the
“deliberate ignorance” standard for establishing knowledge and return a guilty verdict by
reasonably inferring that defendant intentionally avoided learning a given patient’s
insurance status and, in turn, that her treatment of that patient would result in Medicaid
fraud. Certainly, as evidenced from the three ways by which defendant could have


                                             10
                                  IV. CONCLUSION

      Defendant was aware that a large percentage of patients at LFMC were Medicaid

patients such that her actions would cause the submission of false bills to Medicaid but

acted with “deliberate ignorance” of the readily ascertainable fact that Special Agents

Macon and Bates were Medicaid patients and thus that false governmental claims were

being generated under the Social Welfare Act. Therefore, I respectfully dissent from the

portion of the majority’s opinion vacating defendant’s convictions under the MFCA.


                                                       Stephen J. Markman




learned a patient’s Medicaid status, the information was readily accessible. But, of
course, had defendant taken the few moments necessary to learn a patient’s Medicaid
status and then declined to provide services to the patient, there is a reasonable question
whether she would have been able to maintain her employment at LFMC, and it is not
inappropriate that this also be considered by the trier of fact.



                                            11
