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        IN THE UNITED STATES COURT OF APPEALS
                 FOR THE FIFTH CIRCUIT  United States Court of Appeals
                                                 Fifth Circuit

                                                                 FILED
                                                            December 18, 2013

                                  11-20805                      Lyle W. Cayce
                                                                     Clerk

UNITED STATES OF AMERICA,

                                          Plaintiff-Appellee,
v.

LIA SAMIRA ST. JUNIUS; DEVON MICHEL SPICER; MARTHA RAMOS,

                                          Defendants-Appellants.



                Appeals from the United States District Court
                     for the Southern District of Texas


Before STEWART, Chief Judge, and KING and PRADO, Circuit Judges.
CARL E. STEWART, Chief Judge:
      The panel issued the original opinion in this case on December 3, 2013.
United States v. St. Junius, 735 F.3d 247 (5th Cir. 2013). We GRANT the
petition for rehearing, withdraw our previous opinion, and substitute the
following.
      This is an appeal by Defendants-Appellants Lia Samira St. Junius (“St.
Junius”), Devon Michel Spicer (“Spicer”), and Martha Ramos (“Ramos”) who
were convicted of various crimes related to their involvement in a health care
fraud conspiracy.     Defendants-Appellants appeal their convictions and
sentences. For the reasons provided herein, we AFFIRM St. Junius and Ramos’s
convictions and sentences. We also AFFIRM Spicer’s convictions. Due to a
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                                     No. 11-20805

Sentencing Guidelines error conceded by the Government, we VACATE Spicer’s
terms of supervised release and REMAND for re-sentencing.
                           FACTUAL BACKGROUND1
        A. The Mobility Store
        James Reese established Arbor Oaks Medical Equipment, Inc. (“Arbor
Oaks”), a durable medical equipment supplier (“DME”), around 2001.2 The
Federal Bureau of Investigation (“FBI”) began investigating Arbor Oaks to
determine whether the company engaged in health care fraud by billing
Medicare for products beneficiaries did not need or receive. Arbor Oaks was
subsequently suspended from the Medicare program. Around 2003, Reese
established a company called The Mobility Store (“TMS”) which also served as
a DME provider. Though Reese created TMS, the company was registered as a
sole proprietorship under St. Junius’s name. Reese is St. Junius’s stepfather
and has been married to St. Junius’s mother since St. Junius was seven years
old.
        In order to receive Medicare funds, DME suppliers must apply for a
Medicare provider number. The National Supplier Clearinghouse (“NSC”)
processes applications and enrolls approved DME suppliers into the Medicare
program. The contents of the application explain the civil and criminal penalties
for furnishing false information to gain enrollment into the Medicare program.
The application also requires the applicant to provide information concerning
any adverse legal history under the DME’s current or former names. An adverse
legal history, including criminal convictions or prior suspensions under any



        1
        This section provides a general factual overview. Supplemental facts are included
throughout this opinion when necessary.
        2
         Reese had been convicted of several felonies at the time he founded Arbor Oaks.
Reese did not list his name as owner when he submitted Arbor Oaks’s provider application to
Medicare. Instead, Reese listed his wife, Lula Reese, as owner.

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Medicare billing number, could result in a DME being excluded from the
Medicare program.         On May 15, 2004, TMS submitted a Medicare initial
enrollment application with St. Junius’s signature affixed as owner/operator.
Reese had an extensive criminal record and previously operated a company
(Arbor Oaks) that was suspended from the Medicare program. These facts made
it unlikely that a company bearing Reese’s name as owner/operator would
successfully obtain a Medicare provider number.
       Consequently, Reese asked St. Junius to sign the enrollment application
and indicate that she owned TMS. By signing this document, St. Junius
certified that she read the contents of the application; that the information
therein was true, correct, and complete; and that her signature legally and
financially bound TMS to the laws, regulations, and Medicare program
instructions applicable to DME suppliers, including the Anti-Kickback Statute.3
St. Junius certified that she understood the criminal, civil, and administrative
penalties for falsifying information in the application.                TMS’s application
indicated that St. Junius was a 5% or greater owner of TMS and a managing
employee who had no adverse legal actions imposed against her.                      No other
individuals were reported as having an ownership or managerial role at TMS.4
Medicare eventually assigned TMS a provider number.5 Despite St. Junius


       3
          42 U.S.C. § 1320a-7b(b)(1)(A) “criminalizes the payment of any funds designed to
encourage an individual to refer another party to a Medicare provider for services to be paid
for by the Medicare program.” United States v. Miles, 360 F.3d 472, 479 (5th Cir. 2004).
Appellants Ramos and Spicer were convicted of violating this statute and it will be hereinafter
referred to as the “Anti-Kickback Statute.”
       4
         Business filings for TMS in Missouri and Texas reflected that St. Junius was the
owner of TMS, either individually or as co-owner with Reese.
       5
         TMS also became a Medicaid provider after joining the Medicare program. TMS’s
application to Medicaid contained the same type of information that was included in the
Medicare application. St. Junius signed TMS’s Medicaid application in the presence of a
notary. In doing so, she certified that she was the only person with an ownership interest in
TMS, and that no one with an ownership interest had been convicted of a crime or terminated

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being listed as the owner/operator of TMS, Reese received the majority of TMS’s
income and managed the company’s operations. Essentially, Reese was the true
owner and operator of the company.
      B. The Reese Group
      Reese also owned and operated a marketing company called The Reese
Group (“TRG”). TRG hired marketers to solicit Medicare beneficiaries to order
TMS products. TRG and TMS ostensibly operated as the same entity, sharing
employees and the same office space in Houston, Texas. Reese was TRG’s
director and Brenda Lopez (“Lopez”) was its office manager.
      C. St. Junius
      According to former TMS officer manager Brenda Lopez, St. Junius knew
that Reese’s name was not included in the documentation provided to Medicare.
At trial, Lopez testified that during the course of her employment, she witnessed
St. Junius sign letters, checks, and other documents as the owner of TMS. Lopez
never signed St. Junius’s name on any document, nor did she witness any other
TMS or TRG employee do so. Lopez further testified that TMS, through St.
Junius, falsely represented to Medicare that its Houston address was used solely
as a warehouse, when in fact it was TMS’s primary office.
      Between May 2005 and October 2007, a NSC representative conducted site
inspections of TMS and had frequent correspondence with St. Junius regarding
TMS’s violations of the “21 Medicare Supplier Standards.” As a result of TMS’s
continuous failure to comply with Medicare standards, NSC revoked TMS’s
supplier number in October 2007.
      D. Ramos and Spicer
      Ramos and Spicer recruited Medicare patients for TRG. They signed
independent contractor agreements stating that in exchange for their



from the Medicare or Medicaid programs.

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“marketing services,” TRG would pay them a 10% commission on the price of
items purchased for patients they referred.6
       While Ramos was an independent contractor for TRG, she also worked
full-time as a “community liaison” for The Four Group Home Care (“Four
Group”). Four Group provides home care services to Medicare patients. Ramos
supplied TRG with patient information she obtained during the course of her
duties as a community liaison for Four Group. TRG often made cash payments
to Ramos for 10% of the amount Medicare paid for items ordered on behalf of
patients she recruited. She also received checks drawn on TMS’s account that
were signed by either St. Junius or Reese.
       At the time Spicer recruited Medicare patients for TRG, he was affiliated
with Elite Care Medical Clinic (“Elite Care”). Elite Care is a comprehensive
health care provider. Spicer supplied TRG with patient information obtained
from Elite Care and TRG paid him commissions from Medicare payments on
claims TMS submitted on these patients’ behalf.                 At trial, a Government
investigator testified that approximately 408 of Elite Care’s patients
corresponded to claims billed by TMS. Medicare and TMS records reflect that
in 2005, Medicare paid TMS over $710,000.00 on claims for patients referred by
Spicer. Spicer received $71,081.00 in commissions in 2005.
       E. Criminal Investigation
       In 2007, authorities executed a search warrant at the Houston TMS/TRG
office and seized 89 boxes of records.7 Among these records, agents found blank
prescription forms; blank prescription pads; completed prescription order forms



       6
         Commissions are the payments prohibited by the Anti-Kickback statute and may be
referred to at times as “kickbacks.” There is no distinction, for the purpose of this opinion,
between a commission and a kickback.
       7
       The agents involved in executing the search warrant were from the United States
Department of Health and Human Serves, FBI and Texas Attorney General’s Office.

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without a physician’s certification or signature; and numerous data sheets
indicating that TMS submitted claims to Medicare without a prescription order.
An investigator testified at trial that she obtained Medicare’s records of TMS’s
claims and compared them with a random selection of 100 TMS patient files.
For sixty-three of the patients, the investigator did not find proof of delivery of
the item(s) billed to Medicare. Many of TMS’s files contained prescription forms
that were unsigned by a doctor, diagnosis codes that did not match what was
billed to Medicare, and items that were billed but did not match anything TMS
had purchased from a DME manufacturer. A large number of the products TMS
purchased had either no approved Healthcare Common Procedures Coding
System (“HCPCS”) code or a different code than what TMS billed to Medicare.8
Additionally, TMS routinely billed for a product that had a higher price than the
product that TMS actually purchased. TMS also billed Medicare for products
patients did not request, need, or receive.
       Between 2005 and 2008, TMS billed Medicare for $19,481,164.00. During
the same period, Medicare paid TMS $5,182,499.84 for products TMS did not
purchase and Medicaid paid TMS $8,931,248.00 on related claims.
                             PROCEDURAL HISTORY
       On February 10, 2011, a federal grand jury returned a 47-count
superseding indictment charging Defendants-Appellants, and others,9 with
health care fraud conspiracy in violation of 18 U.S.C. § 371 (count 1). The

       8
        The HCPCS provides the description and code for items or services that are billed to
Medicare and Medicaid.
       9
         James Reese, Brenda Lopez, and Lily Johnson were also charged in the superseding
indictment with committing health care fraud and conspiracy to commit health care fraud.
Johnson worked for TMS as a medical equipment supplier and for TRG as a
marketer/recruiter. Reese and Lopez were also charged with money laundering and violating
the Anti-Kickback Statute. Reese was also charged with money laundering concealment and
tax evasion. Prior to trial, Lopez and Johnson pleaded guilty to health care fraud conspiracy
and Reese pleaded guilty to health care fraud and tax evasion. Lopez and Johnson testified
on behalf of the Government and Reese testified as a defense witness.

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superseding indictment also charged St. Junius with committing health care
fraud in violation of 18 U.S.C. § 1347 (counts 2–16) and money laundering
conspiracy in violation of 18 U.S.C. § 1956(h) (count 33), and it charged Ramos
and Spicer with receiving kickbacks in violation of 42 U.S.C. § 1320a-7b(b)(1)(A)
(Ramos: counts 17, 19–22; Spicer: counts 18, 23–24).
      A jury trial began on April 11, 2011 and concluded on April 27, 2011. The
jury returned its verdict on April 29, 2011, finding St. Junius guilty of health
care fraud conspiracy (count 1), health care fraud (counts 10–16) and money
laundering conspiracy (count 33). St. Junius was acquitted on counts 2–9
(health care fraud). The district court sentenced St. Junius to a term of 135
months’ imprisonment (60 months on count 1, 120 months on counts 10–16, and
135 months on count 33, to run concurrently). St. Junius was also sentenced to
three years of supervised released, a $900 special assessment, and ordered to
pay $8,651,805.76 restitution.
      Ramos and Spicer were convicted of all Anti-Kickback charges and
acquitted of the conspiracy to commit health care fraud charge. The district
court sentenced Ramos to five concurrent terms of 60 months’ imprisonment
followed by concurrent three year terms of supervised release. The court also
ordered Ramos to pay $53,987.04 restitution, imposed a $4,691.00 fine, and a
$500.00 special assessment.      The district court sentenced Spicer to three
concurrent terms of 60 months’ imprisonment followed by concurrent three year
terms of supervised release. The court also ordered Spicer to pay $794,434.08
restitution, imposed a $71,121.00 fine, and a $300.00 special assessment.
                                 DISCUSSION
      Defendants-Appellants challenge their convictions and sentences on
multiple fronts. We address each party’s claims in turn.
      A. St. Junius
            1. Rebuttal Witness’ Testimony

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      At trial, St. Junius called co-defendant Reese as a defense witness. On
direct examination, Reese testified that he helped St. Junius open TMS with
plans that she would own the store and eventually run it. After St. Junius’s
counsel concluded his examination, counsel for defendant Ramos questioned
Reese. Counsel for Ramos asked Reese about his discussions with Medicare
regarding whether it was proper to pay marketers commissions for Medicare
patient referrals. Reese stated that Medicare told him paying commissions was
“okay,” and he conveyed the same information to his marketers. Reese provided
the same response when Spicer’s attorney questioned him about Medicare’s
instructions on commissions.
      On cross-examination, the Government asked Reese whether anyone from
Medicare visited him while he was operating Arbor Oaks. Reese answered: “I’ve
never talked to Medicare about Arbor Oaks.” The prosecutor asked Reese to
clarify his statement and Reese reiterated that he could not recall speaking to
Medicare when he was operating Arbor Oaks. Reese also denied telling any of
his Arbor Oaks employees that he met with Medicare.            Also on cross-
examination, the prosecutor asked Reese whether St. Junius helped out at Arbor
Oaks from time to time. Reese stated that he did not think so but could not
recall for sure.
      At the conclusion of Reese’s testimony, the defense rested.          The
Government called a rebuttal witness, Lucean Kuykendall, for the purpose of
impeaching Reese based upon his testimony about his conversations with
Medicare during his time at Arbor Oaks, and about whether St. Junius ever
visited Arbor Oaks. Kuykendall began her testimony by stating that she worked
for Arbor Oaks in 2002 or 2003. At the mention of Arbor Oaks, St. Junius’s
attorney immediately objected to Kuykendall’s testimony on the basis of
relevancy. The government responded that the defense called Reese and elicited
information about Arbor Oaks. The court overruled the objection. Kuykendall

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then testified to three key points of fact: 1) While Kuykendall worked for Arbor
Oaks, Reese told her that he met with a Medicare official; 2) after meeting with
the Medicare official, Reese told Kuykendall that Arbor Oaks could no longer pay
marketers commissions for referring Medicare patients; and 3) although St.
Junius did not work for Arbor Oaks, she visited Arbor Oaks on occasion.
       At trial, St. Junius objected to Kuykendall’s testimony on the grounds
that: 1) whether St. Junius visited Arbor Oaks was irrelevant; and 2) Reese’s
conversations about a meeting with Medicare constituted inadmissible hearsay.
The district court overruled the objections. We review the district court’s ruling
on those grounds for abuse of discretion, subject to a harmless error analysis.
United States v. Jackson, 636 F.3d 687, 692 (5th Cir. 2011). “A trial court abuses
its discretion when its ruling is based on an erroneous view of the law or clearly
erroneous assessment of the evidence.” Id. (citation omitted).
                   a. Relevance
      St. Junius argues that Kuykendall’s testimony that St. Junius visited
Arbor Oaks is irrelevant to the crimes charged. This issue is easily resolved.
Before Kuykendall testified, Lily Johnson provided the same information,
without objection, during the Government’s case-in-chief. Even if we concluded
that Kuykendall’s testimony was irrelevant, which we do not, any error that
accrued as a result of its admission is harmless. See United States v. Griffin, 324
F.3d 330, 348 (5th Cir. 2003) (error is harmless where objectionable testimony
is cumulative of other testimony that has not been challenged).
                   b. Hearsay
      St. Junius argues that Kuykendall’s testimony about Reese’s statements
after his meeting with a Medicare official was inadmissible hearsay. Under
Federal Rule of Evidence 801(c), hearsay is a statement, other than one made by
the declarant while testifying at trial or a hearing, offered in evidence to prove
the truth of the matter asserted. Fed. R. Evid. 801(c). The rule against hearsay

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does not apply when an out-of-court statement is offered for some purpose other
than to prove the truth of the matter asserted. See United States v. Watkins, 591
F.3d 780, 786 (5th Cir. 2009). “Using an out-of-court utterance as circumstantial
evidence of the declarant’s knowledge of the existence of some fact, rather than
as testimonial evidence of the truth of the matter asserted, does not offend the
hearsay rule.” Id. (citation omitted). Evidence of a witness’ prior inconsistent
statements may be admitted to impeach that witness. United States v. Sisto,
534 F.2d 616, 622 (5th Cir. 1976). “[T]he making of the previous statement may
be drawn out during cross-examination of the witness himself, or if on cross-
examination the witness has denied making the statement, or has failed to
remember it, the making of the statement may be proved by another witness.”
Id. (citation omitted).

       During his trial testimony, Reese denied meeting with a Medicare official
about Arbor Oaks.         He also denied discussing the propriety of paying
commissions for Medicare patient referrals during the meeting.                      As a
Government rebuttal witness, Kuykendall testified that when she worked for
Arbor Oaks, Reese told her that he met with a Medicare official. He also told her
that Arbor Oaks would have to cease paying commissions to marketers.
Additionally, Kuykendall testified that St. Junius visited Arbor Oaks. The
evidence offered during Kuykendall’s rebuttal testimony directly contradicts
Reese’s testimony. This evidence was offered, not for the truth of the matter
asserted, but rather to impeach Reese’s credibility.10 Accordingly, the district
court did not abuse its discretion by admitting this evidence.

                     c. Character Evidence




       10
          At the conclusion of the trial, the district judge issued verbal and written jury
instructions that included a limiting instruction on impeachment by prior inconsistencies.

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      St. Junius argues for the first time on appeal that Kuykendall’s rebuttal
testimony—that St. Junius visited Arbor Oaks—was improper character
evidence that should have been excluded pursuant to Fed. R. Evid.
404(b)(“404(b)”). St. Junius posits that this evidence was inadmissible because
it suggested that she associated with Reese in a separate, uncharged crime. She
also argues for the first time that the district court committed error by not
issuing a limiting instruction, sua sponte, as to Kuykendall’s testimony.

      Because St. Junius failed to object on these grounds at trial, we review
these claims for plain error. See United States v. Waldrip, 981 F.2d 799, 805
(5th Cir. 1993); see also Fed. R. Evid. 103(a)(1). Plain error is an error “so
obvious that failure to notice it would seriously affect fairness, integrity, or
public reputation of judicial proceedings and result in a miscarriage of justice.”
Waldrip, 981 F.2d at 805.

      Character evidence is inadmissible to show that a person acted in
accordance with that character on a particular occasion. See Fed. R. Evid.
404(a)(1). However, in a criminal case, evidence of other acts is admissible to
prove knowledge. Fed. R. Evid. 404(b)(2). The Fifth Circuit applies a two-prong
test to resolve 404(b) issues: (1) the other crimes, wrongs, or acts must be
relevant to an issue other than the defendant’s character; and (2) the evidence’s
probative value must not be substantially outweighed by its prejudicial effect.
See United States v. Beechum, 582 F.2d. 898, 911 (5th Cir. 1978) (en banc). “In
weighing the probative value and unfair prejudice, this court must make a
‘commonsense assessment of all the circumstances surrounding the extrinsic
offense.’” United States v. Cockrell, 587 F.3d 674, 678 (5th Cir. 2009) (quoting
Beechum, 582 F.2d at 914).

      During Kuykendall’s testimony, she stated that St. Junius did not work
at Arbor Oaks, but sometimes visited the office. Kuykendall did not provide any


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information about what St. Junius did during her visits and her testimony does
not readily suggest that St. Junius engaged in other crimes, wrongs, or acts with
respect to Arbor Oaks. She did not testify that St. Junius reviewed documents,
wrote checks, made phone calls or was otherwise involved in Arbor Oaks’s
operations. The evidence presented at trial did nothing more than suggest that
St. Junius, at some point, had occasion to visit her stepfather’s place of business.
That being the case, we believe it imprecise to categorize this aspect of
Kuykendall’s testimony as 404(b) evidence.

      Nevertheless, even if we assume that the Government elicited the
testimony as 404(b) evidence, which would be odd on rebuttal, the admission of
Kuykendall’s testimony did not result in a “miscarriage of justice” as prescribed
by our plain error standard. Here, evidence that St. Junius visited Arbor Oaks
could have been properly admitted to show that St. Junius had knowledge of
Reese’s pernicious history of committing health care fraud, and not that she was
involved in it. St. Junius’s supposed knowledge of the fraud at Arbor Oaks
would have enlightened her as to Reese’s desire to utilize her name and
unblemished past for the purposes of establishing TMS as a DME recognized
under the Medicare program. See United States v. Madrid, 510 F.2d 554, 555–56
(5th Cir. 1975) (“Admission of such evidence is a matter within the broad
discretion of the trial court and is proper, where, as here, it is introduced not to
show a propensity to commit crime but to show knowledge.”) (citation omitted).
Because 404(b) evidence can be admitted to show knowledge, admission of
evidence showing that St. Junius visited Arbor Oaks would not offend rule 404’s
prohibition against improper character evidence. We also conclude that no
unfair prejudice resulted from the admission of this evidence.

      St. Junius also alleges that the district court committed error by not
issuing a limiting instruction, sua sponte, as to Kuykendall’s testimony. Again,


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we do not conclude that Kuykendall’s testimony necessarily suggested that St.
Junius committed a prior bad act. For that reason, we need not reach the
question of whether it was error to not provide a limiting instruction sua sponte.
Were we to reach this issue, however, it is unlikely that we would find St.
Junius’s argument meritorious. See United States v. Parziale, 947 F.2d 123, 129
(5th Cir. 1991) (failure to give a limiting instruction in this context is generally
held not to be plain error).

       2. Deliberate Ignorance Instruction

       On appeal, St. Junius challenges the district court’s decision to provide
the jury with a deliberate ignorance instruction.

       At trial, St. Junius’s defense centered on the notion that Reese was the
mastermind behind the health care fraud conspiracy and that St. Junius was
nothing more than an unsuspecting pawn in his scheme.11 At the close of the
trial, the Government requested a “deliberate ignorance” instruction to
supplement the “knowingly” section of the jury charge. The court then issued
the following instruction on deliberate ignorance:

       The word “knowingly,” as that term has been used from time to time
       in these instructions, means that the act was done voluntarily and
       intentionally, not because of mistake or accident. You may find that
       defendant, Lia St. Junius, had knowledge of a fact if you find that
       this defendant deliberately closed her eyes to what would otherwise
       have been obvious to her. While knowledge on the part of this
       defendant cannot be established merely by demonstrating that this
       defendant was negligent, careless, or foolish, knowledge can be




       11
          St. Junius’s counsel argued at closing that “for [St. Junius] to be guilty of this fraud,
she has to know about it. She didn’t know about it. Like, if one of you worked for Enron when
there’s a big fraud and you don’t know about it, you’re doing clerical work, you’re not guilty
of the fraud.”

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       inferred if this defendant deliberately blinded herself to the
       existence of a fact.12

       St. Junius challenges the deliberate ignorance instruction on multiple
fronts. First, she reasserts the objection she made at trial that the instruction
improperly altered the “knowing and intentional” standard.                      St. Junius
preserved this issue for review under an abuse of discretion standard.13 See
United States v. Vasquez, 677 F.3d 685, 692 (5th Cir. 2012) (When a defendant
timely objects to a jury instruction, we review the district court’s decision for
abuse of discretion.).

        Secondly, she argues that because the instruction was limited to her, the
district court “exacerbated the detrimental effect” by “singling out” St. Junius.
St. Junius’s written objection to the deliberate ignorance instruction did not
include any argument against the instruction being applied only to her.
Therefore, this issue was not properly preserved for appeal and will be reviewed
for plain error. See Vasquez, 677 F.3d at 692 (stating that a party must inform
the court of the specific objection and the grounds for the objection to preserve
the issue for review under the abuse of discretion and harmless error standard).
              a. Deliberate Ignorance Instruction Generally

       “Appellate review of a deliberate ignorance instruction is necessarily a
fact-intensive endeavor. To determine the validity of the instruction, this Court
must carefully examine the totality of the evidence.” United States v. Lara–
Velasquez, 919 F.2d 946, 952 (5th Cir. 1990). “Even if the district court errs in



       12
          This instruction followed the Fifth Circuit’s pattern jury instructions. See Fifth
Circuit Pattern Jury Instructions: Criminal § 1.37 (2001).
       13
        At trial, St. Junius’s filed a written objection that stated that “[t]he incorporation
of the ‘Willfull Blindness’ instruction into the ‘Knowingly’ instruction reduces the
Government’s burden of proving beyond a reasonable doubt that the Defendant intentionally
and knowingly engaged in a scheme to defraud a health care benefits program.”

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its decision to give the deliberate ignorance instruction, any such error is
harmless where substantial evidence of actual knowledge is presented at trial.”
United States v. Miller, 588 F.3d 897, 906 (5th Cir. 2009) (alteration, citation and
internal quotation marks omitted). The deliberate ignorance instruction should
be given when a “defendant claims a lack of guilty knowledge and the proof at
trial supports a reasonable inference of deliberate ignorance.” United States v.
Scott, 159 F.3d 916, 922 (5th Cir. 1998) (citation omitted). Submission of a
deliberate ignorance “instruction is proper where the evidence shows (1)
subjective awareness of a high probability of the existence of illegal conduct, and
(2) purposeful contrivance to avoid learning of the illegal conduct.” United States
v. Jones, 664 F.3d 966, 979 (5th Cir. 2011) (citation omitted). In reviewing
whether the evidence warranted the submission of the deliberate ignorance
instruction, we view the evidence in the light most favorable to the Government.
Id.

        St. Junius’s defense at trial focused substantially on her alleged lack of
guilty knowledge. St. Junius elicited facts to support her argument that Reese
was the mastermind behind the health care fraud conspiracy and St. Junius had
no idea that TMS, TRG, and Reese were involved in illegal conduct. The
Government presented evidence that St. Junius was a willing participant in the
health care fraud conspiracy. Though Reese was the leader of the organization,
those who worked closely with him testified that they knew that his conduct was
improper. Co-defendants Lopez and Johnson testified that although they did not
familiarize themselves with Medicare regulations, they knew that certain
practices the companies engaged in were wrongful. For example, they knew that
billing without a prescription, billing for one product but providing another,
resubmitting the same claim with a different date of service, or failing to
reimburse Medicare for items that were not received by beneficiaries were all
improper practices. Lopez and Johnson testified that St. Junius handled billing

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                                      No. 11-20805

for TMS and was involved in other operational aspects of the business. St.
Junius also received substantial financial benefits for her role as owner of
TMS.14

       The second part of this analysis requires a finding that the defendant
engaged in purposeful contrivance to avoid learning of the illegal conduct. The
evidence presented at trial demonstrated that the atmosphere at TMS was rife
with signals of illegality. Given that St. Junius worked in the same space and
under the same conditions as Lopez and Johnson, it is reasonable to infer that
she was aware of TMS’s improper and illegal practices.15 As a result, we
conclude that St. Junius was subjectively aware of a “high probability of illegal
conduct.” Inasmuch as St. Junius denies knowledge of the illegalities, the
overwhelming deficiencies in TMS’s operations could only go unnoticed by
someone who purposely avoided them. This type of conduct suggests “purposeful
contrivance to avoid learning of the illegal conduct.” See id.

        As stated previously, a deliberate ignorance instruction is appropriate
when a defendant claims a lack of guilty knowledge and the proof at trial
supports an inference of deliberate ignorance. In this case, St. Junius claimed
at trial, and continues to claim today, that she was unaware of any wrongdoing
that occurred at TMS. Despite her awareness of Medicare’s allegations that
TMS was in violation of numerous Medicare regulations, St. Junius continued
in her role as the signatory of numerous documents that misrepresented facts


       14
          TMS defrauded Medicare/Medicaid of over $8.6 million. The funds were deposited
into accounts bearing various names and used to purchase a variety of expensive vehicles and
a house. The accounts were controlled and operated by Reese and St. Junius.
       15
         Although the instruction is proper where there is “subjective awareness” of illegal
conduct, we believe the evidence in this case supports a finding that St. Junius had actual
knowledge that her conduct was unlawful. Where there is substantial evidence of actual
knowledge, the inclusion of a deliberate ignorance instruction is harmless. Jones, 664 F.3d
at 979.

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                                  No. 11-20805

and helped to defraud the Government. There is no evidence before us that St.
Junius paused to question why Reese’s name could not be included in any
Medicare related documents, why billing codes did not match what TMS ordered
for its patients, or why TMS provided Medicare with volumes of patently false
information. The deliberate ignorance instruction is designed to “inform the jury
that it may consider evidence of the defendant’s charade of ignorance as
circumstantial proof of guilty knowledge.” See Jones, 664 F.3d at 979 (citation
omitted). Viewing the evidence in the light most favorable to the Government,
we conclude that the district court did not abuse its discretion by issuing a
deliberate ignorance instruction under these facts.

            b. “Singling Out” St. Junius

      We also perceive no error in the district court’s decision to instruct the jury
that the deliberate ignorance instruction applied only to St. Junius and not her
co-defendants.    “[I]n a multiple-defendant case where only some of the
defendants justify a deliberate ignorance charge, singling out the defendant who
merits the instruction, based, perhaps, on disputed or equivocal evidence, may
be unfairly prejudicial to that defendant.” United States v. Bieganowski, 313
F.3d 264, 290 (5th Cir. 2002) (citation and internal quotation marks omitted).
“It is equally true, however, that giving the instruction generally, without
naming a specific defendant, may prejudice those co-defendants who do not
merit the instruction.” Id. (citation and internal quotation marks omitted).
“Thus, we have indicated that the better approach in this situation is to give the
instruction and indicate that it may not apply to all of the defendants.” Id.
(alteration, citation, and internal quotation marks omitted).

      Bieganowski is instructive on the quandary district courts face when
deciding whether to issue a deliberate ignorance instruction generally, or
whether to issue the instruction with respect to a single defendant.              In


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                                  No. 11-20805

Bieganowski, four defendants were charged with various crimes arising out of
a scheme to defraud medical insurance companies. Id. at 269. At trial, the
district court issued a deliberate ignorance instruction specific to defendant
Bieganowski. Id. at 290. On appeal, Bieganowski alleged that the instruction
prejudiced him by unfairly singling him out from his co-defendants. Id. We
rejected Bieganowski’s complaints as to the instruction and noted that this type
of decision was one “generally within the discretion of the trial court.” Id. We
noted that “judgments of this kind are primarily entrusted in the trial judge who
inevitably has a superior feel for the dynamics of the trial and the likely reaction
of the jury.” Id. (citation and emphasis omitted).

      St. Junius offers no persuasive argument as to why we should not defer to
the wisdom of the district court who, having observed the entirety of the trial,
decided that this instruction was appropriate. Therefore, we hold that the
district court’s issuance of the deliberate ignorance instruction only as to St.
Junius, and not her co-defendants, did not amount to plain error.

      3. District Court’s Pens

      St. Junius challenges comments made by the district court judge about his
use of different color pens during trial. St. Junius’s trial counsel did not make
a contemporaneous objection to the judge’s comments. During the trial, the
district court judge addressed the jury after a recess and stated the following:

      Please be seated. I’m going to write down what I find humorous, and
      we’ll talk about it at the end of the trial. Okay?
      By the way, I keep track of all sorts of things that go on, including
      when you’re out of the room, so you’ll understand as to what goes on
      maybe with some of these bench conferences or if you have to stay
      in there a little bit longer. So, I take complete notes. Like this one
      point, I find it amusing; but I write it down. I’ll visit with you after
      the case in the jury room. That’s what the red pen is for.
      Counsel, that’s for the good stuff. The other stuff is in black.


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                                  No. 11-20805

At the conclusion of the evidence, the judge provided the following instruction
to the jury:

      [D]o not assume from anything I may have done or said during the
      trial that I have any opinion concerning any of the issues in this
      case. Except for the instruction to you on the law, you should
      disregard anything I may have said during the trial in arriving at
      your own findings as to the facts.

      Because there was no objection to the district court’s comments, the plain
error standard of review applies. United States v. Sanchez, 325 F.3d 600, 603
(5th Cir. 2003).

      “To rise to the level of constitutional error, the district judge’s actions,
viewed as a whole, must amount to intervention that could have led the jury to
a predisposition of guilt by improperly confusing the functions of judge and
prosecutor.” United States v. Achobe, 560 F.3d 259, 272 (5th Cir. 2008) (citation
omitted). While a federal trial judge may manage the pace of a trial, comment
on evidence, and even question witnesses, the judge may not give an appearance
of partiality. See United States v. Hefferon, 314 F.3d 211, 221 (5th Cir. 2002).
Nonetheless, the trial court judge is not required to remain silent and passive
during a criminal prosecution. See United States v. Davis, 752 F.2d 963, 975
(5th Cir. 1985).

      St. Junius urges this court to reverse her convictions because the trial
judge explained that he uses red ink to write down things he finds humorous and
black ink to make other notes. According to St. Junius, the jury could “look to
the Judge to see what color pen he was using” to determine how they should
interpret the evidence. St. Junius does not direct our attention to any particular
moment during the trial when the judge switched pens or caused a certain juror
to be distracted because he did so. St. Junius cites cases as examples of



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                                       No. 11-20805

inappropriate conduct by trial judges to support her position.16 In this case, the
trial judge’s discussion of the pens he uses is a far cry from the conduct of the
judges in the cases St. Junius relies upon. In viewing the totality of the judge’s
conduct, his fairly innocuous and brief commentary about his pens, during the
course of a lengthy trial, does not amount to plain error.
       4. St. Junius’s Challenges to her Sentence
       The district court applied a three-level increase to St. Junius’s base offense
level on the grounds that she held a managerial role in the offense under United
States Sentencing Guideline (“U.S.S.G.”) § 3B1.1(b) and a two-level increase for
abuse of position of trust under U.S.S.G. § 3B1.3. On appeal, St. Junius argues
that both sentencing enhancements were applied in error.17

       The district court’s application of the United States Sentencing Guidelines
(“U.S.S.G”) is reviewed de novo. United States v. Lige, 635 F.3d 668, 670 (5th
Cir. 2011). We accept the findings of fact made in connection with sentencing
unless they are clearly erroneous. Id. We affirm the district court’s application
of the managerial role enhancement if it is plausible in light of the record read


       16
          In United States v. Bray, 546 F.2d 851 (10th Cir. 1976), the trial judge set a
defendant’s bail in front of the jury. In United States v. Lanham, 416 F.2d 1140 (5th Cir.
1969), the trial judge asked a testifying defendant 119 probing questions subsequent to direct
and cross examination. In United States v. Haywood, 411 F.2d 555 (5th Cir. 1969), the trial
judge, in the presence of the jury, twice informed the defendant of his “right to allocution”
before the case was submitted to the jury for its decision.
       17
          The district court adopted the findings in the presentence report (“PSR”). In
describing St. Junius’s relevant conduct, the PSR reported that St. Junius worked in concert
with Reese to acquire the necessary business licenses for TMS to operate. St. Junius
represented in the provider application to Medicare that she was the sole owner and operator
of TMS to avoid disclosing Reese’s involvement. St. Junius’s name on the Medicare application
established the means by which TMS submitted fraudulent medical claims.
       The PSR further reported that St. Junius made significant decisions affecting TMS’s
operations. St. Junius supervised marketers and employees for TMS and TRG. When co-
defendant Brenda Lopez was unavailable, St. Junius was the go-to person who paid the
marketers, ordered products, and supervised the billing. Eleven business accounts relating
to TMS were opened in St. Junius’s name as owner of TMS and she was authorized to use over
forty debit cards opened under the accounts.

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                                  No. 11-20805

as a whole. See United States v. Nava, 624 F.3d 226, 229 (5th Cir. 2010). We
reverse “only if, based on the entire evidence, [we are] left with the definite and
firm conviction that a mistake has been committed.” United States v. Rose, 449
F.3d 627, 633 (5th Cir. 2006) (citation omitted).

            a. Managerial Role Enhancement

      The U.S.S.G. provide for a three-level increase to a defendant’s base-
offense level “[i]f the defendant was a manager or supervisor (but not an
organizer or leader) and the criminal activity involved five or more participants
or was otherwise extensive. . . .” U.S.S.G. § 3B1.1(b). This enhancement may
be appropriate where “a defendant did not organize, lead, manage, or supervise
another participant, but who nevertheless exercised management responsibility
over the property, assets, or activities of a criminal organization.” U.S.S.G. §
3B1.1(b) cmt. n.2; United States v. Delgado, 672 F.3d 320, 345 (5th Cir. 2012).

      Evidence presented at trial by both the Government and defense made
clear that the true leader of the criminal enterprise was James Reese. The
evidence at trial also demonstrated that St. Junius played a significant role in
the functioning of that enterprise and that she profited more from it than any
participant other than Reese. The sentencing enhancement at issue is not
limited to the “true leader” of the criminal enterprise. It also applies to
individuals who “exercised management responsibility over the property, assets,
or activities of a criminal organization.” Id. St. Junius knowingly and willingly
led others to believe that she was the owner of TMS. She signed Medicare
documents, signed and issued paychecks, and sent correspondence as the owner
of TMS.

      Our charge here is to determine whether it was plausible, in light of the
record, that St. Junius’s conduct warranted a role enhancement. See Nava, 624
F.3d at 229. With that in mind, we are satisfied that it is plausible, in light of

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                                  No. 11-20805

the record, that St. Junius exercised some level of management responsibility
over the property, assets, or activities of TMS. Therefore, we affirm the district
court’s application of the managerial role enhancement.

            b. Abuse of Trust Enhancement

      St. Junius also argues on appeal that the district court’s application of an
abuse of trust enhancement was erroneous.

      Section 3B1.3 provides a two-level enhancement for defendants who have
“abused a position of public or private trust . . . in a manner that significantly
facilitated the commission or concealment of the offense.” U.S.S.G. § 3B1.3. The
commentary to U.S.S.G. § 3B1.3 explains that a position of trust is characterized
by professional or managerial discretion and that individuals who occupy these
positions are typically under less supervision than individuals whose
responsibilities are primarily non-discretionary in nature. See U.S.S.G. § 3B1.3
cmt. n.1; United States v. Miller, 607 F.3d 144, 148 (5th Cir. 2010). The
sentencing court should conduct a two-step inquiry when considering whether
to apply U.S.S.G. § 3B1.3. See United States v. Ollison, 555 F.3d 152, 166 (5th
Cir. 2009). “First, the court must determine whether the defendant occupied a
position of trust at all. If not, the inquiry ends and no enhancement accrues. If,
however, this initial inquiry produces an affirmative response, the court must
proceed to ascertain the extent to which the defendant used that position to
facilitate or conceal the offense.” Id. at 165 (citation omitted).

      We hold that as the listed owner of TMS, St. Junius occupied a position of
trust, which satisfies the first prong of this analysis. Her position and authority
as owner of a licensed DME provider, “involved the type of complex, situation-
specific decisionmaking that is given considerable deference precisely because
it cannot be dictated entirely by, or monitored against, established protocol.”
Miller, 607 F.3d at 150 (5th Cir. 2010) (citations omitted). By issuing St. Junius

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                                        No. 11-20805

a license to provide durable medical equipment, Medicare entrusted her to
render a necessary service to some of the most vulnerable members of her
community. Moreover, Medicare authorized St. Junius to render those services
with an attendant expectation that she would submit accurate information in
seeking reimbursement from the Medicare program. See id. (noting that the
functioning of government insurance programs relies heavily upon “the honesty
and forthrightness of the DME provider in its claim submissions”).

       Having decided that St. Junius occupied a position of trust, we must now
determine whether she used her position in a manner that significantly
facilitated the commission of the health care fraud offenses at issue. We are
satisfied that she did. St. Junius signed important documents as owner of TMS,
issued pay checks to employees and contractors, and engaged in numerous other
activities that helped facilitate this health care fraud conspiracy. Without St.
Junius, it would have been extraordinarily difficult, if not impossible, for TMS
to accomplish its criminal pursuits. Given those considerations, we affirm the
district court’s application of the abuse of trust sentencing enhancement.
       B. Ramos
              1. Sufficiency of the Evidence
       Ramos challenges her convictions under the Anti-Kickback Statute solely
on the basis that the Government did not present sufficient evidence to prove
that she “willfully” violated the statute.18


       18
           To sustain a conviction under the Anti-Kickback Statute, the Government must
prove the following elements beyond a reasonable doubt: (1) the defendant solicited or received
any remuneration, including any kickback or bribe, directly or indirectly, overtly or covertly,
in cash or in kind, to any person; (2) that the remuneration was solicited or received to induce
such person to refer an individual to a person for furnishing or arranging of an item or service;
(3) that the item or service was one for which payment may be made in whole or in part under
a federal healthcare program; and (4) that the defendant acted knowingly and willfully. See
42 U.S.C. § 1320a-7b(b)(1)(A). Ramos concedes that the Government satisfied its burden of
proof with respect to elements 1–3. Ramos’s challenge is limited strictly to the assertion that
the Government failed to prove that she acted willfully.

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                                  No. 11-20805

      A procedurally preserved challenge to the sufficiency of evidence is
reviewed de novo. United States v. Grant, 683 F.3d 639, 642 (5th Cir. 2012).
When reviewing the sufficiency of the evidence, we view all evidence “in the light
most favorable to the Government, with all reasonable inferences and credibility
choices made in support of the jury’s verdict. The evidence is sufficient to
support a conviction if a rational trier of fact could have found the essential
elements of the crime beyond a reasonable doubt.” United States v. Ford, 558
F.3d 371, 375 (5th Cir. 2009) (per curiam) (citation omitted).

      Ramos argues on appeal that she could not have willfully violated the
Anti-Kickback Statute because she did not know that engaging in a commission-
based pay arrangement with a Medicare provider was a violation of the law.
Ramos contends that a conviction under the Anti-Kickback Statute requires
proof beyond a reasonable doubt that she knew that being paid on commission
was illegal. We disagree.

      The Anti-Kickback Statute prohibits receiving commissions in return for
referring a Medicare patient to a Medicare provider.                   42 U.S.C.
§ 1320a-7b(b)(1)(A); see United States v. Miles, 360 F.3d 472, 479 (5th Cir. 2004)
(The Anti-Kickback Statute “criminalizes the payment of any funds designed to
encourage an individual to refer another party to a Medicare provider for
services to be paid for by the Medicare program.”). Section 1320a-7b(h) defines
willfulness as it pertains to the Anti-Kickback Statute. In doing so, Section
1320a-7b(h) clarifies that the Government is not required to prove actual
knowledge of the Anti-Kickback Statute or specific intent to violate it. Instead,
the Government must prove that the defendant willfully committed an act that
violated the Anti-Kickback Statute. As applied to Ramos, the Government was
only required to prove that she willfully solicited or received money for referring




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                                       No. 11-20805

Medicare patients to TRG.19 Ramos concedes that the Government proved as
much.

       Furthermore, the Government produced evidence that Ramos had actual
knowledge of the Anti-Kickback Statute and its prohibitions even though such
proof was not required. The Government showed that as part of Ramos’s
employment with Four Group, she signed documents that explained that
receiving commission payments in this context was illegal. By signing these
documents, Ramos affirmed that she understood that such conduct was a
violation of law.20 This evidence, though unnecessary to sustain a conviction,
would satisfy the willfulness element even under Ramos’s erroneous
construction of the Anti-Kickback Statute.

       For the aforementioned reasons, we hold that a rational trier of fact could
have found that the Government proved the willfulness element of the Anti-
Kickback Statute beyond a reasonable doubt.

       2. Prosecutor’s Statement on the Law

       Ramos alleges that the prosecutor misstated the law during his rebuttal
argument. Counsel for Ramos argued in closing that the Government failed to


       19
         Ramos argues that we should adopt the definition of willfulness applied by the Ninth
Circuit in United States v. Dearing, 504 F.3d 897 (9th Cir. 2007). Dearing holds that the
willfulness component of 18 U.S.C. § 1347 (which is not the Anti-Kickback Statute, but rather,
a general health care fraud statute) requires that the government prove that the defendant
acted with knowledge that her conduct was unlawful. Id. at 901. Dearing, however, was
decided prior to a statutory amendment that clarified Congress’ intent with respect to the
willfulness element of § 1347. Section 1347 was amended in 2010 as was 42 U.S.C. § 1320a-
7b, the Anti-Kickback Statute. The § 1347 amendment adds language that mirrors the 2010
amendment to the Anti-Kickback Statute found in § 1320a-7b(h). Section 1320a-7b(h) made
clear that the government need not prove that the defendant had “actual knowledge of the
statute or a specific intent to violate the statute.” In light of the amendment, Dearing is
unpersuasive on this issue.
       20
          “Proof that a document has been signed is sufficient to charge a signatory with its
contents.” United States v. Whittington, 783 F.2d 1210, 1215 (5th Cir. 1986)(citing 7 J.
Wigmore, Evidence § 2134, at 719 n.2 (Chadbourn rev. 1979)).

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                                  No. 11-20805

prove that Ramos knew that receiving commission payments was illegal under
the Anti-Kickback Statute.       The prosecutor stated in rebuttal that the
Government did not have to prove that Ramos knew that receiving commission
payments was illegal. Rather, the prosecutor argued, the Government need only
prove that Ramos knowingly received commission payments. Ramos’s trial
counsel did not object to the prosecutor’s remarks. When no contemporaneous
objection is raised during a prosecutor’s closing remarks, the propriety of those
remarks is reviewed for plain error. United States v. Perez-Solis, 709 F.3d 453,
466–67 (5th Cir. 2013).

      Ramos’s challenge regarding the prosecutor’s comments parrots the
substance of her challenge to the district court’s willfulness instruction. She
claims that the willfulness element of the Anti-Kickback Statute requires that
the Government prove that she knew that receiving commissions for referring
patients was illegal. Again, Ramos’s construction of the Anti-Kickback Statute
is erroneous. The prosecutor correctly explained that the Government need only
prove that Ramos knowingly and willfully received commissions in exchange for
referrals. We perceive no error here, plain or otherwise.

      3. Ramos’s Four Group Personnel File

      Ramos challenges the admission of her Four Group personnel file as a
violation of the district court’s order requiring the parties to exchange all trial
exhibits seven days prior to the start of trial. On the first day of trial, the
Government called Bernadine Njoku, the director of nursing at Four Group.
During her testimony, Njuko produced Ramos’s personnel file which included a
copy of Four Group’s Policies and Procedures. Ramos’s counsel objected on the
grounds that he had not seen the records before and had insufficient time to
review them. The court overruled the objection and admitted the documents.




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                                  No. 11-20805

Ramos’s counsel did not request a continuance or a recess to examine the
personnel file.

      The file included documents entitled “Prohibition of Solicitation of
Patients,” and “Confidentiality Statement/HIPPA Privacy Guideline.” The policy
prohibiting solicitation of patients cited the Anti-Kickback Statute and explained
that receiving commission payments for referring Medicare patients is unlawful.
The documents bore Ramos’s signature which acknowledged that she read and
understood the information contained therein.

      We review the district court’s enforcement of its own scheduling orders for
abuse of discretion. United States v. Hale, 685 F.3d 522, 532 (5th Cir. 2012),
cert. denied, — U.S. —, 133 S. Ct. 559 (2012).

      On appeal, Ramos originally challenged the admission of the personnel file
as a discovery violation pursuant to Fed. R. Crim. P. 16(a)(1)(E) (“Rule 16”). The
Government argued in its brief that Ramos’s challenge under Rule 16 failed
because Ramos did not submit a discovery motion requesting the evidence, as
required by Rule 16. In her reply brief, Ramos conceded that she did not make
an appropriate discovery request. Now, in the alternative, Ramos argues that
the district court abused its discretion by violating its own order that the parties
exchange all trial exhibits seven days prior to the start of trial. Ramos claims
that the personnel file became the “lynchpin” of the Government’s case against
her. According to Ramos, “[t]he personnel file was crucial to the Government’s
case because it was the only evidence that Ramos had knowledge of Medicare
and HIPPA regulations.”

      Even if we found that admitting the personnel file was an abuse of
discretion, which we do not, admission of the file did not prejudice Ramos’s
substantial rights. See United States v. Doucette, 979 F.2d 1042, 1044–45 (5th
Cir. 1992) (an alleged discovery error should result in a new trial only when a

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                                      No. 11-20805

defendant demonstrates prejudice to her substantial rights). The personnel file
was admitted to show that Ramos was familiar with the Anti-Kickback Statute.
Contrary to Ramos’s assertion, the personnel file was not the “lynchpin” of the
Government’s case because the Government was not required to prove that
Ramos had actual knowledge of or a specific intent to violate the Anti-Kickback
Statute. The Government would have sustained its burden of proof without the
admission of the personnel file. We also note that the personnel file was equally
available to Ramos before trial because Ramos had access to, and likely had a
copy of, her own personnel file.          Ramos cites no authority supporting her
argument that reversal is required under these circumstances. Accordingly, we
defer to the wisdom of the district court and hold that it did not abuse its
discretion by admitting Ramos’s personnel file.

              4. Abuse of Trust Enhancement

       Ramos argues that the two-level abuse of trust enhancement should not
apply to her because she did not have a fiduciary relationship with Medicare.
and because “mere access” to Medicare billing information is not sufficient to
support a finding that she occupied a position of trust. With respect to the abuse
of trust enhancement, Ramos’s arguments on appeal differ from her objections
at sentencing. We review these newly raised claims for plain error.21 United
States v. McElwee, 646 F.3d 328, 338 (5th Cir. 2011).

       U.S.S.G. § 3B1.3 Application Note 2(B) explains that § 3B1.3 captures the
conduct of any individual who uses his or her position to obtain, transfer or
unlawfully use any “means of identification” to facilitate the commission of an




       21
         At sentencing, Ramos only challenged the application of the abuse of trust
enhancement on the basis that she did not hold a “position superior to other members” of TRG.


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                                       No. 11-20805

offense.22 “Means of identification,” includes any name, social security number,
date of birth, and a number of other identifiers. U.S.S.G. § 3B.1.3 cmt. n.2(B)(ii).
By way of example, the commentary to § 3B1.3 provides that “a hospital orderly
who exceeds or abuses his or her position by obtaining or misusing patient
identification information from a patient chart” is subject to the application of
an abuse of trust enhancement. Id.

       Ramos cites Ollison in support of her argument that she did not occupy a
position of trust. 555 F.3d at 152. In Ollison, the district court applied the
abuse of trust enhancement to a Texas school district secretary who used the
school district’s credit card to make unauthorized purchases. Id. at 155–56.
Ollison was convicted of theft from an organization receiving federal funds and
sentenced to a term of imprisonment. Id. at 155. She challenged her sentence
on several grounds, one of which was the misapplication of the abuse of trust
enhancement. In reversing the district court, we emphasized the fact that
Ollison’s duties as secretary were clerical in nature and did not grant her the
“substantial discretionary judgment” that generally accompanies a position of
trust. Id. Additionally, we found that her position was not “instrumental in
accomplishing the fraud.” Id. at 169.

       Our decision in Ollison is inapposite to the case sub judice because
defendant Ollison’s conduct did not implicate the circumstances described in the
§ 3B1.3 Application Note 2(B). Here, the commentary to § 3B1.1 speaks directly
to Ramos’s conduct in that she obtained and transferred patients’ “means of
identification” to TRG by using her position as a community liaison for Four


       22
          “[C]ommentary in the Guidelines Manual that interprets or explains a guideline is
authoritative unless it violates the Constitution or a federal statute, or is inconsistent with,
or a plainly erroneous reading of, that guideline.” Stinson v. United States, 508 U.S. 36, 38
(1993); see also United States v. Lipscomb, 619 F.3d 474, 477 (5th Cir. 2010) (quoting Stinson’s
holding that commentary to the guidelines is “treated as an agency’s interpretation of its own
legislative rule.”)

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                                       No. 11-20805

Group. In doing so, she abused a position of trust. Accordingly, the district
court committed no error in its application of this sentencing enhancement.

       C. Spicer

              1. Abuse of Trust Enhancement

       Spicer also challenges the district court’s application of the abuse of trust
enhancement to his sentence. Spicer’s challenge to the enhancement is similar
to Ramos’s challenge supra. Like Ramos, Spicer fails to articulate why his
conduct falls outside of the scope of § 3B1.3 Application Note 2(B).                     The
Government proved at trial that Spicer transferred patients’ “means of
identification” from Elite Care to TRG. Therefore, we conclude that his conduct
falls squarely within the ambit of this sentencing guidelines enhancement.23

              2. Loss Calculation

       Spicer challenges his sentence on the grounds that it is based upon an
improper loss calculation. “We review de novo the district court’s method of
determining loss, while clear error review applies to the background factual
findings that determine whether or not a particular method is appropriate.”
United States v. Isiwele, 635 F.3d 196, 202 (5th Cir. 2011) (citation omitted).

       “The amount of loss resulting from the fraud is a specific offense
characteristic that increases the base offense level under U.S.S.G.


       23
          Subsequent to the submission of his reply brief, Spicer provided this Court with
supplemental authorities pursuant to Fed. R. App. P. 28 (j). Spicer requested that we consider
the Supreme Court’s recent decision in Alleyne v. Unites States, 133 S. Ct. 2151 (2013) and
apply its reasoning to the abuse of trust enhancement. Alleyne held that any fact that
increases the mandatory minimum sentence for a crime is an element of the crime that must
be submitted to the jury. Id. at 2153. Spicer asks that we extend Alleyne’s reasoning to cases
where a defendant’s sentence is enhanced by elements that were not included in the charging
document and not proven at trial beyond a reasonable doubt. Alleyne specifically addressed
mandatory minimum sentences. The abuse of trust enhancement does not give rise to a
mandatory minimum sentence. We therefore decline to extend Alleyne’s holding to the abuse
of trust enhancement.

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                                  No. 11-20805

§ 2B1.1(b)(1)(I).” Id. Loss is defined as “the greater of actual or intended loss.”
Id. Section 2B1.1(b)(1)(I) provides for a 16-level increase if the loss was between
$1,000,000 and $2,500,000. U.S.S.G. § 2B1.1(b)(1)(I). In determining intended
loss in the health care fraud context, we have stated that “the amount
fraudulently billed to Medicare/Medicaid is prima facie evidence of the amount
of loss the defendant intended to cause.” Isiwele 635 F.3d at 203 (alteration,
citation and internal quotation marks omitted).

      Spicer’s PSR indicates that TMS billed Medicare/Medicaid $1,560,249.05
based upon claims for patients Spicer referred to the company. The district
court adopted the PSR’s finding that the intended loss in Spicer’s case amounted
to $1,560,249.05. Spicer asserts that he should only be accountable for the
amount actually paid on those claims as opposed to the amount billed. We
disagree.   Applying the standard we articulated in Isiwele, the amount
fraudulently billed to Medicare in this case was prima facie evidence of Spicer’s
intended loss. Spicer, as permitted by the case law, could have provided
additional evidence to show that the amount billed overstated his intent.
Rather, Spicer provided no evidence to this end. Therefore, we hold that the
district court’s loss calculation was not erroneous.

            3. Restitution Calculation

      Spicer challenges the district court’s restitution order on the grounds that
it was improperly based on conduct outside of the offenses for which Spicer was
convicted. Ramos adopts this argument by reference.

      At sentencing, the Government requested that the district court impose
the payment of restitution as a term of Spicer’s supervised release. The district
court agreed and imposed restitution in the amount of $794.434.08. The
restitution amount was derived from a calculation of the total amount
Medicare/Medicaid paid TMS based on Spicer’s referrals; a figure that grossly

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                                  No. 11-20805

exceeded the amount Medicare/Medicaid paid with respect to the crimes for
which Spicer was convicted. Because Spicer failed to object to the restitution
order in this case, we review this claim for plain error. See United States v.
Howard, 220 F.3d 645, 657 (5th Cir. 2000).

      “The general rule is that a district court can award restitution to victims
of the offense, but the restitution award can encompass only those losses that
resulted directly from the offense for which the defendant was convicted.”
United States v. Maturin 488 F.3d 657, 660–61 (5th Cir. 2007) (citing Hughey v.
United States, 495 U.S. 411, 413 (1990)). Here, the Government concedes that
the district court’s restitution orders exceed the losses derived from the conduct
for which Spicer and Ramos were convicted. Accordingly, we VACATE the
restitution orders with respect to Spicer and Ramos and REMAND for re-
sentencing. If the district court imposes restitution, it should be limited to the
losses suffered as a result of the crimes for which Spicer and Ramos were
convicted.

                                CONCLUSION

      For the foregoing reasons, we wholly AFFIRM St. Junius’s convictions and
sentence. Due to a Sentencing Guidelines error conceded by the Government,
we VACATE Ramos and Spicer’s terms of supervised release and REMAND for
re-sentencing. We otherwise AFFIRM Ramos and Spicer’s convictions and
sentences.




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