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

                                                                  FILED
                                                                 July 11, 2011

                                 No. 10-30128                    Lyle W. Cayce
                                                                      Clerk

UNITED STATES OF AMERICA

                                          Plaintiff–Appellee
v.

ERNESTINE GIROD; UNA FAVORITE BROWN

                                          Defendants–Appellants



Cons. w/10-30339

UNITED STATES OF AMERICA

                                          Plaintiff–Appellee
v.

MELINDA LANGLEY

                                          Defendant–Appellant



                 Appeals from the United States District Court
                     for the Eastern District of Louisiana


Before HIGGINBOTHAM, DENNIS, and PRADO, Circuit Judges.
EDWARD C. PRADO, Circuit Judge:
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      Ernestine Girod, Una Favorite Brown, and Melinda Langley were each
indicted on one count of conspiracy (18 U.S.C. § 371) and multiple counts of
health care fraud (18 U.S.C. § 1347), and Brown and Girod were charged with
three counts each of making false statements to law enforcement officers (18
U.S.C. § 1001), all in relation to fraudulent Medicaid reimbursement claims
made through A New Beginning of New Orleans (“ANBNO”), a Medicaid Early
Periodic Screening Diagnosis and Treatment (“EPSDT”) organization that
provides minor, disabled Medicaid recipients with Personal Care Services
(“PCS”). A jury convicted the three women on all but three of Langley’s health-
care fraud counts.     Brown, Girod, and Langley separately appeal their
convictions and sentences on various grounds. We affirm.
             I. FACTUAL AND PROCEDURAL BACKGROUND
      Brown and Langley worked for ANBNO, a PCS provider co-owned by
Akasia Lee, a cooperating witness in the case who pleaded guilty to conspiracy.
Specifically, ANBNO provided PCS to disabled children covered under Medicaid,
teaching them activities of daily living (“ADL”) like personal hygiene, light food
preparation, and basic house cleaning. Each child had a specific plan of care
(“POC”) that detailed the activities the PCS provider could provide and Medicare
would reimburse. EPSDT PCS services could only be provided in the child’s
home, and ANBNO employees providing PCS—including Brown and
Langley—underwent training in proper documentation, rules, regulations, and
services provided. A binder of all EPSDT rules, regulations, guidelines, time
sheets, and the POC was placed in the home of each PCS client. Brown and
Langley claimed to provide PCS services to Medicaid recipients, and Girod had
three children on Medicaid who purportedly received PCS from ANBNO
employees.
      From 2001 to 2006, the defendants, among others, engaged in a conspiracy
to defraud Medicaid by creating false documentation that PCS services were

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provided to Medicaid recipients when the services were not provided. Brown and
Langley submitted false PCS time sheets and daily care sheets saying they
provided specific PCS services listed in their clients’ POCs, at specific times,
when these services were not provided. In reality, Brown, Langley, and other
ANBNO PCS providers failed to attend mandatory trainings, transported PCS
clients around in their cars, took clients to social settings like the park, and
babysat them—actions that are all verboten by Medicaid and not Medicaid
reimbursable. Parents of PCS-eligible children, including Girod, signed off on
their children’s PCS time sheets in exchange for kickbacks from Lee and other
ANBNO PCS providers.         In sum, ANBNO defrauded Medicaid out of
approximately four million dollars.
      On June 5, 2008, a grand jury returned an indictment against Girod,
Brown, and Langley, among others. A superceding indictment was issued on
February 12, 2009, charging Girod with conspiracy (Count 1), twenty-five counts
of health care fraud (Counts 15–39), and three counts of false statements to law
enforcement officers (Counts 60–62); Brown with conspiracy (Count 1), ten
counts of health care fraud (Counts 5–14), and three counts of false statements
to law enforcement officers (Counts 63–65); and Langley with conspiracy (Count
1) and thirteen counts of health care fraud (Counts 17–59), among other
defendants.
      Brown filed a motion to dismiss the indictment due to prosecutorial
misconduct in May 2009. After the magistrate judge conducted a hearing, he
recommended that the district court deny the motion.         The district court
conducted two additional days of hearings on Brown’s motion and summarily
denied it on August 24, 2009. A jury trial was held from September 4, 2009, to
September 9, 2009. The jury convicted Brown on Counts 1, 5–14, 63, and 65;
Langley on Counts 1 and 47–56; and Girod on Counts 1, 15–39, and 60–62.
Girod was sentenced to 24 months’ imprisonment, a special assessment, and

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restitution in the amount of $68,140. Brown was sentenced to 21 months’
imprisonment, a special assessment, and restitution in the amount of $33,405.
Langley was sentenced to 15 months’ imprisonment, a special assessment, and
restitution in the amount of $47,717. Each also received a three-year term of
supervised release.
        The defendants separately timely filed their notices of appeal.
                                  II. ANALYSIS
A.      Brown’s Motion To Dismiss the Indictment Due to Prosecutorial
        Misconduct
        The Sixth Amendment guarantees a criminal defendant the right to
present witnesses to “establish his defense without fear of retaliation against the
witness by the government.” United States v. Dupre, 117 F.3d 810, 823 (5th Cir.
1997). “In addition, the Fifth Amendment protects the defendant from improper
governmental interference with his defense.” United States v. Bieganowski, 313
F.3d 264, 291 (5th Cir. 2002) (internal quotation marks and citations omitted).
Thus, “substantial governmental interference with a defense witness’ choice to
testify may violate the due process rights of the defendant.” Dupre, 117 F.3d at
823 (quoting United States v. Whittington, 783 F.2d 1210, 1219 (5th Cir. 1986)).
Whether a defendant has made a showing of substantial interference is a fact
question, and we therefore review a claim of prosecutorial intimidation for clear
error. United States v. Thompson, 130 F.3d 676, 686–87 (5th Cir. 1997). Any
violation is subject to harmless-error analysis, and we “will not reverse unless
the prosecutor’s conduct was sufficiently egregious in nature and degree so as
to deprive [the defendant] of a fair trial.” United States v. Skilling, 554 F.3d 529,
567 (5th Cir. 2009) (internal quotation marks and citation omitted) ( substitution
in Skilling, aff’d in part and vacated on other grounds by Skilling v. United
States, 130 S. Ct. 2896 (2010).



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       Likewise, “as a general rule, ‘[w]itnesses . . . to a crime are the property of
neither the prosecution nor the defense. Both sides have an equal right, and
should have an equal opportunity, to interview them.’” United States v. Soape,
169 F.3d 257, 270 (5th Cir. 1999) (quoting Gregory v. United States, 369 F.2d
185, 188 (D.C. Cir. 1966)) (second alteration in original). Of course, “[n]o right
of a defendant is violated when a potential witness freely chooses not to talk [to
defense counsel].” In re United States, 878 F.2d 153, 157 (5th Cir. 1989).
       1.     The Government’s Visits to Defense Witnesses Allen and
              Randall
       Brown argues that the Government substantially interfered with her right
to present witnesses in her favor when agents visited Semaj Allen and Lakita
Randall—both        identified    as    defense     witnesses     on    Brown’s     pretrial
disclosures—and questioned them regarding the Medicaid fraud at ANBNO.
Allen and Randall subsequently declined to testify on Brown’s behalf. They were
school teachers who worked with Brown at the same school and were PCS
providers with ANBNO. Brown alleges that Allen and Randall would have
testified that Brown spent time with the Morales boys—two children Brown
provided PCS for—before school, at the park, and at football practice.1
       We affirm Brown’s convictions on this ground because the district court did
not clearly err in deciding that the agents’ conduct did not substantially interfere
with Allen’s and Randall’s free choice to testify. Both the prosecution and the
defense have a right to interview witnesses; the fact that Allen and Randall were
interviewed after the Government found out they were on the defense witness
list was not improper, even if the Government previously knew Allen and
Randall were connected with ANBNO. The undisputed testimony was that the



       1
        None of these facts could have exonerated Brown for Medicaid fraud, as the charges
against her were for a failure to provide the specific PCS services claimed on her time sheets
on the dates and times claimed, not a failure to generally spend time with her PCS clients.

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two agents asked to talk with both witnesses about the ANBNO investigation,
informed them that they did not have to speak with them, and told them that
answering questions was voluntary and that they could stop the interview at any
time. The agents did not tell Allen or Randall that they were targets of the
Medicaid fraud investigation nor did they tell Allen or Randall that they had
engaged in wrongdoing or criminal conduct. Nor did the “Martha Stewart”
warning that Allen’s and Randall’s only obligation was to speak truthfully
amount to “substantial interference” in their decision to testify.           See
Bieganowski, 313 F.3d at 291–92 (holding that prosecutor’s comment that a
defense witness could be prosecuted for perjury did not amount to substantial
interference); Thompson, 130 F.3d at 687 (holding that a warning of the
consequences of perjury “even if carried out in a caustic manner, is no cause to
dismiss the indictment against the defendants”) (citation omitted).
      In short, Brown hangs her hat on the correlation between the agents’
interviews and the witnesses’ subsequent decisions not to testify on Brown’s
behalf.   But correlation is not enough; Brown must at a minimum prove
causation. The district court rejected Brown’s causation argument and this
finding was not clearly erroneous. See Skilling, 554 F.3d at 571 (rejecting a
“proof in the pudding” argument that there must have been substantial
interference where many potential witnesses declined to cooperate with the
defense); Thompson, 130 F.3d at 687 (“The defendant bears the burden of
showing that testimony would have been different but for the government’s
actions.”). There are a multitude of reasons why Allen and Randall may have
decided not to testify, neither witness testified to improper conduct on the part
of the agents, and Allen stated in her affidavit that her decision not to testify
was not due to intimidation by the prosecution.
      Even if the information Allen and Randall obtained from the interviews
caused the witnesses to decide not to testify on Brown’s behalf, Brown has

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nevertheless failed to show that the district court committed clear error when
it found that there was no substantial interference with Allen’s and Randall’s
free choice to decide for themselves whether they wished to testify. Presenting
the potential defense witnesses with the facts of the investigation and the crimes
charged does not amount to witness intimidation; there must be evidence of
threats or intimidation. See United States v. Viera, 839 F.2d 1113, 1118 (5th Cir.
1988) (en banc); Bieganowski, 313 F.3d at 291–92. Testimony from the special
hearings on Brown’s motion to dismiss the indictment shows that neither Allen
nor Randall knew the details of the crimes of which Brown was charged before
meeting with the agents, that Allen never felt threatened or intimidated by the
agents and that she subsequently decided she did not want to put her family
through the stress of trial, and that Randall was generally uncooperative and
Brown could only speculate as to the reason why Randall decided not to testify
on Brown’s behalf. The government’s right to interview Allen and Randall did
not disappear simply because they may have been ignorant of Brown’s crimes.
If, after learning the true nature of Brown’s alleged crimes, Allen and Randall
decided not to testify on her behalf for whatever reason, that is their choice.
      2.    The Government’s Phone Call to Prosecution Witness Lee
      Brown also alleges prosecutorial misconduct relating to prosecution
witness Akasia Lee, a co-owner of ANBNO who pled guilty to Count 1 of the
indictment and became a cooperating witness for the Government. At the
evidentiary hearings and in affidavits, the uncontroverted evidence was that Lee
had a meeting with prosecutors on March 25, 2009, at 10:00 a.m., and that she
had also scheduled a meeting with the defense for the same date and time. At
around 10:15 a.m., Lee was sitting in the defense office, and the defense meeting
had not yet started due to an attorney being late. Agent Delanueville called Lee
at 10:15 to remind her of her appointment with the prosecution, and told her she



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should honor her meeting. Lee left the defense office and went to meet with the
prosecution. Thereafter, Lee did not meet with the defense.
        Brown points to evidence that the prosecutor was angry that Lee was
meeting with the defense, and the prosecutor told Lee it was not in Lee’s best
interest to meet with defense counsel without her attorney present. During the
evidentiary hearing, Brown’s attorney Avery Pardee testified that she talked
with Lee’s attorney David Belfield after the March 25 incident, and that he told
her that he did not want Lee meeting with anyone and that the prosecutor
wanted to be present for all meetings with Lee. In his affidavit, however,
Belfield stated that the prosecutor did not demand to be present during defense
interviews with Lee and that the prosecutor did not “shut down” Lee’s March 25
meeting with the defense. As Pardee admitted on cross-examination during the
evidentiary hearing, no witnesses told her that they were told not to cooperate
with the defense, she had no evidence of threats or retribution, and it had been
three months since she had tried to schedule a meeting with Lee.
        Accordingly, we hold that the district court did not clearly err when it
denied Brown’s motion to dismiss the indictment on this ground, and we affirm
Brown’s convictions.
B.      Sufficiency of the Evidence Supporting Girod’s Convictions
        We review a district court’s denial of a motion for judgment of acquittal de
novo. United States v. Myers, 104 F.3d 76, 78 (5th Cir. 1997).2 The jury’s verdict
will be affirmed “if a reasonable trier of fact could conclude from the evidence
that the elements of the offense were established beyond a reasonable doubt.”



        2
         Contrary to the Government’s assertion, Girod’s counsel clearly moved for acquittal
of all charges “for failure to prove the case beyond a reasonable doubt,” and in addition,
specifically challenged Counts 60–62 for listing the incorrect date of Girod’s false statements.
Girod’s appeal challenging the denial of her motion for a judgment of acquittal is therefore
subject to de novo review.


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Id. In assessing the sufficiency of the evidence, we do not evaluate the weight
of the evidence or the credibility of the witnesses, but view the evidence in the
light most favorable to the verdict, drawing all reasonable inferences to support
the verdict. Id. at 78–79.
      1.    Girod’s Ties to the Fraudulent Documents Submitted by Lee
      Girod challenges her convictions first on the ground that there was no
evidence connecting her to the fraudulent PCS forms submitted to Medicaid by
Lee. To prove health care fraud, the Government had to prove that Girod
“knowingly and willfully” executed a scheme “to defraud any health care benefit
program.” 18 U.S.C. § 1347(1). To prove conspiracy, the Government had to
show that she conspired with at least one other person to defraud the United
States and that one conspirator committed “any act to effect the object of the
conspiracy.” 18 U.S.C. § 371.
      Specifically, Girod argues there was no evidence she was “directly involved
or participate[d] in any manner in the conspiracy as there was no proof offered
that [she] actually authored or signed any of the documents filed with Medicaid.”
The Government is not required, however, to show that Girod herself submitted
the forms to Medicaid in order to charge her with Medicaid fraud and conspiracy.
The indictment charged Girod with creating false time sheets and PCS daily
schedules for services she claimed to have witnessed for her children, with being
paid by ANBNO and Lee for “creating fraudulent documentation to support
billings to Medicaid,” and charged that in general false time sheets were made
and ANBNO employees were not providing the PCS services claimed. These
charges were supported at trial with testimony from Connie Smith, who testified
she split her ANBNO check with Girod (for PCS Smith supposedly provided
Girod’s child but did not) in exchange for Girod giving her blank, pre-signed time
sheets. Akasia Lee also testified that Girod filled out false PCS time sheets for
her children and split the Medicaid payment with Smith for the PCS services

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Smith was claiming for Girod’s child, and that Lee gave Girod checks from her
own personal account for one-half the payment amount Medicaid would
reimburse for the services falsely claimed for Girod’s children.
      With respect to Girod’s argument that no one testified to recognizing her
handwriting on any of the PCS documents submitted to Medicaid, Lee testified
that she recognized Girod’s handwriting on several training sign-in sheets where
Girod signed as ANBNO-employee Charvel Steward. Likewise, Audra Scott
testified that Girod signed her name on ANBNO forms. While Lee testified that
the time sheets were falsified to conform to Medicaid requirements, the jury
could have reasonably inferred from Lee’s and Smith’s testimony that Girod
signed the blank PCS forms she gave to Smith.
      In sum, there was substantial evidence from which the jury could have
concluded that Girod was involved in the conspiracy and that she knowingly and
willfully participated in the health care fraud at ANBNO.
      2.    Girod’s Specific Intent To Commit Medicaid Fraud
      Girod also argues she lacked the intellectual capacity to form the specific
intent to commit fraud. Girod points to evidence that she only completed eighth
grade and had difficulty reading, and that Dr. Michael Chafetz (Ph.D.), a
neuropsychologist, determined that she had low verbal comprehension, read at
a fifth-grade level, and had a first- or second-grade level of reading
comprehension. While Girod may have had a low level of education and was low
performing, there was sufficient evidence from which a rational jury could have
determined she had the mental capacity to form the specific intent to commit
health care fraud.
      On cross-examination, Dr. Chafetz testified that Girod is capable of
knowing right from wrong, knowing that stealing is wrong, and telling a lie. He
also testified that Girod has passed a drivers’ test, has raised kids, and can sign
and cash checks. According to Dr. Chafetz, Girod is capable of making decisions,

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and she tested at the nineteenth percentile (81% do better) for daily living skills,
which is adequate. Dr. Chafetz further testified that she is also capable of
fulfilling basic activities of daily living and recognizing when someone else is
doing that for her children. Multiple other witnesses who know Girod testified
that they did not know or suspect she had any mental disabilities or problems.
Christie Coleman, the parent of one of Girod’s PCS clients, testified that, in the
fourteen years she had known Girod, Girod never seemed mentally impaired and
never had any problems communicating with her. Scott testified that she had
no knowledge that Girod had any mental or physical problems. Lee testified
that Girod never showed any difficulty in understanding the material explained
in the training sessions.
      Multiple witnesses testified that, while Girod was never an ANBNO
employee, she posed as Steward at training sessions (sign-ins and taking tests),
picked up Steward’s checks and mail at ANBNO, and signed payroll receipt
forms in Steward’s name. The jury could have concluded based on Dr. Chafetz’s
testimony that Girod could understand that it was wrong to pretend to be
someone else, and that she did it anyways by helping Steward avoid the
mandatory ANBNO training requirements for providing PCS services. Finally,
Scott testified that Girod asked her to put Girod’s checks in Scott’s name to avoid
involving Girod’s social security withholdings. Girod’s purposeful tax fraud is
further proof Girod had the capacity to commit health care fraud.
      Viewing all the evidence in the light most favorable to the verdict, the jury
could have reasonably concluded that Girod knew right from wrong, knew PCS
services were not being provided to her children, and knew she was pre-signing
blank PCS time sheets for services that were not being provided to her children
in exchange for money from Lee and Scott.




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       3.      Whether the Crimes Affected Commerce
       Girod also argues the Government did not show the health care crimes
affected commerce. Specifically, she argues that because the acts all involved
Louisiana businesses and Louisiana residents, interstate commerce was not
affected. We disagree. There was ample evidence from which the jury could
have concluded that the Louisiana Medicaid program is a joint federal–state
program in which ANBNO participated.
       To the extent Girod’s challenge is that the jury instruction was vague and
did not specify how the program must affect commerce, she did not challenge the
instruction at trial, and we therefore review this challenge for plain error.3 See
United States v. Klein, 543 F.3d 206, 212 (5th Cir. 2008). The district court
instructed the jury that the crimes charged must be against a “health care
benefit program,” which, inter alia, is a program “affecting commerce.” Even if
the instruction was erroneously vague, any error did not affect Girod’s conviction
as there was substantial testimonial evidence explaining ANBNO’s ties to
Medicaid, which is a federally funded program that indisputably affects
interstate commerce. See id.; United States v. Hickman, 331 F.3d 439, 443–44
(5th Cir. 2003) (finding no plain error where the district court failed to include
the words “affecting commerce” in the instruction on health care fraud). Nor
does Girod’s conviction on this count seriously affect the fairness or integrity of
the judicial proceedings, as she does not contend that Medicaid is not a “health
care benefit program” under the statute.




       3
         Error is plain only when it is clear or obvious and it affects the defendant’s substantial
rights. A defendant’s substantial rights are only affected if the error “affected the outcome of
the district court proceedings.” United States v. Olano, 507 U.S. 725, 734 (1993). If these
conditions are met, then we will only reverse the error if it seriously affects the “fairness,
integrity, or public reputation of judicial proceedings.” United States v. Cotton, 535 U.S. 625,
631–32 (2002) (citation omitted).

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      Girod also cites to United States v. Chambers, 408 F.3d 237 (5th Cir. 2005),
a case that involved a constructive amendment to an indictment on the
“interstate commerce” element of the crime of a felon in possession of
ammunition. In Chambers, the indictment articulated a specific theory of how
the ammunition affected interstate commerce, and the jury convicted on a
different theory. This Court explained that Chambers’s conviction had to be
overturned because to allow a conviction based on the second theory “would
allow that element to be established on the basis of a set of fact wholly different,
separate and distinct from the one set of facts particularly alleged in the
indictment relevant to that element, and would thus constitute an impermissible
constructive amendment of the indictment.” Id. at 247. Here, there is no
dispute that the “affecting commerce” element of health care fraud has always
been that the fraud was to Medicaid, a federally funded program that affects
commerce.
      4.    The Date Alleged in the Indictment
      Girod also moved for acquittal below based on the failure of the
government to prove the date charged in the indictment beyond a reasonable
doubt. The indictment charged her with making false statements “on or about
August 26, 2006,” but the testimony from trial showed that the false statements
were made on April 26, 2006.        Girod argues this four-month discrepancy
constitutes a material variance from or constructive amendment of the
indictment under Chambers. We disagree.
      “A constructive amendment occurs when the government changes its
theory during trial so as to urge the jury to convict on a basis broader than that
charged in the indictment, or when the government is allowed to prove ‘an
essential element of the crime on an alternative basis permitted by the statute
but not charged in the indictment.’” United States v. Robles–Vertiz, 155 F.3d 725,
728 (5th Cir. 1998) (quoting United States v. Salvatore, 110 F.3d 1131, 1145 (5th

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Cir. 1997)). In this Circuit, “an allegation as to the time of the offense is not an
essential element of the offense charged in the indictment and, ‘within
reasonable limits, proof of any date before the return of the indictment and
within the statute of limitations is sufficient.’” Russell v. United States, 429 F.2d
237, 238 (5th Cir. 1970) (per curiam) (citation omitted); see United States v.
Tunnell, 667 F.2d 1182, 1186 (5th Cir. 1982) (“In this circuit, it is established
that the prosecution is ‘not required to prove the exact date; it suffices if a date
reasonably near is established.’”) (quoting United States v. Grapp, 653 F.2d 189,
195 (5th Cir. 1981)); see also United States v. Valdez, 453 F.3d 252, 259–60 (5th
Cir. 2006) (same). The discrepancy between the indictment and the evidence at
trial therefore is not a constructive amendment, as the date is not an essential
element that was proved on an alternate basis and the Government’s theory of
guilt at trial did not change.
      A variance occurs “when the proof at trial depicts a scenario that differs
materially from the scenario charged in the indictment but does not modify an
essential element of the charged offense.” United States v. Delgado, 401 F.3d
290, 295 (5th Cir. 2005).        We determine whether a variance occurred by
comparing the evidence presented at trial with the language of the indictment.
See United States v. Medina, 161 F.3d 867, 872 (5th Cir. 1998). If a variance did
occur, we reverse only if the variance prejudiced the defendant’s substantial
rights. See Delgado, 401 F.3d at 295; Medina, 161 F.3d at 872. In determining
whether a variance resulted in prejudice, we employ a harmless-error analysis.
United States v. Ramirez, 145 F.3d 345, 351 (5th Cir. 1998); United States v.
Dean, 59 F.3d 1479, 1491 (5th Cir. 1995).
      The discrepancy in dates is not a material variance. “A five-month
variance between the date alleged and the date proved is not unreasonable as
a matter of law as long as the date proven falls within the statute of limitations
and before the return of the indictment.” United States v. Wilson, 116 F.3d 1066,

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1089 (5th Cir. 1997) (citation omitted), vacated on other grounds by United
States v. Brown, 161 F.3d 256 (5th Cir. 1998) (en banc); see Russell v. United
States, 429 F.2d 237, 238 (5th Cir. 1970) (“[W]ithin reasonable limits, proof of
any date before the return of the indictment and within the statute of limitations
is sufficient.”). Because the April 26, 2006 date is only four months apart from
the date charged in the indictment and there is no dispute that it falls within the
statute of limitations, Girod’s argument that this variance warrants overturning
her convictions fails.
        Moreover, a variance between allegations and proof is fatal “only when it
affects the substantial rights of the defendant by failing to sufficiently notify him
so that he can prepare his defense and will not be surprised at trial.” Phillips,
664 F.2d at 1036. The Government used the “on or about” designation in the
indictment, explained the context in which the false statements were made, and
explained the specific statements that were false and made to federal
investigators. Girod’s false statements charged in the indictment were: (1) “that
an employee from ANBNO was present in her house for two hours per day with
each child for a total of 6 hours per day”; (2) “that ANBNO employees came to
her house every day for 6 hours per day, 7 days per week during the entire time
her children were enrolled with ANBNO”; and (3) “that AKASIA LEE did not
pay her $72 per week every two weeks, or pay her any amount, for billing
Medicaid services rendered to GIROD’s children.” This was sufficiently specific
to put Girod on notice of which statements the Government intended to prove
were false. Indeed, Girod has not demonstrated that she was surprised or
prejudiced in any way by the August 26, 2006 date in the indictment.
        In sum, we affirm Girod’s convictions on all grounds.
C.      Girod’s Sentencing Enhancements
        Because Girod did not object to her sentence on the grounds of an incorrect
sentencing enhancement before the district court, our review is for plain error.

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United States v. Jasso, 587 F.3d 706, 709 (5th Cir. 2009). Plain error exists
when: “(1) there was an error; (2) the error was clear and obvious; and (3) the
error affected the defendant’s substantial rights.” Id. (quoting United States v.
Villegas, 404 F.3d 355, 358–59 (5th Cir. 2005)) (internal quotation marks
omitted). “If all three conditions are met an appellate court may then exercise
its discretion to notice a forfeited error but only if (4) the error seriously affects
the fairness, integrity, or public reputation of judicial proceedings.” Id. at 709
n.4 (quoting United States v. Ellis, 564 F.3d 370, 377 (5th Cir. 2009)) (internal
quotation marks omitted). This Court reviews a district court’s interpretation
and application of the guidelines de novo. United States v. Cisneros–Gutierrez,
517 F.3d 751, 764 (5th Cir. 2008).
      1.     Section 3B1.4: Use of Minors To Further the Crimes
      USSG § 3B1.4 provides for a two-level enhancement for using a minor to
commit the offense. The application notes to § 3B1.4 explain that “using”
“includes directing, commanding, encouraging, intimidating, counseling,
training, procuring, recruiting, or soliciting.” USSG § 3B1.4 cmt. n.1. The
district court enhanced Girod’s sentence by two levels under § 3B1.4 for using
her underage children to complete fraudulent Medicaid forms. At sentencing,
the district court stated that it relied on Scott’s testimony that Girod used her
children to create the false PCS time sheets. Girod argues that Scott’s testimony
did not show that Girod directed her children to falsify Medicaid forms but
rather that it was that Scott, Girod, and Girod’s children all sat together and
copied the false forms, and that Scott did not testify that Girod directed her
children to complete the forms.
      Scott testified that she, Girod, and two of Girod’s children were in the
kitchen filling out false PCS forms. Girod and her two children were already
filling the forms out when Scott arrived and sat down to help. She testified that
they all copied off of other forms or old papers. These false PCS forms were then

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                            Nos. 10-30128, 10-30339

submitted to ANBNO. This is more than enough to support the district court’s
finding that Girod “used” her minor children to commit the charged offenses.
See United States v. Mata, 624 F.3d 170, 175–77 (5th Cir. 2010) (explaining the
case law). Scott testified that Girod’s children were much more than mere
passive observers of Girod’s criminal acts; rather, Girod took “some affirmative
action to involve” her minor children in actively creating fraudulent PCS time
sheets. Id. at 176.
      2.    Section 3C1.1: Obstruction of Justice
      Finally, Girod challenges her two-level enhancement under § 3C1.1 for
obstruction of justice for lying to investigators. Girod argues there is no evidence
she impeded the investigation because the agents investigating her had
completed most of their investigation before they interviewed her and they came
to their interview “armed with documentation to confront” her if she made
statements contrary to what the agents believed happened. In essence, Girod
argues “no harm, no foul”: that, by the time she made her (admittedly) false
statements, the investigation had so progressed that her false statements “did
not hamper the investigation.” This argument lacks merit. Section 3C1.1 also
provides for a two-level enhancement for attempted obstruction or impeding
justice.   There does not seem to be any dispute that Girod made false
statements, and that these statements at a minimum reflected her attempt to
impede the investigation.
      Furthermore, the commentary to § 3C1.1 states that “[t]his adjustment
also applies to any other obstructive conduct in respect to the official
investigation, prosecution, or sentencing of the instant offense where there is a
separate count of conviction for such conduct.” USSG § 3C1.1 cmt. n.4. Girod
was convicted of making three false statements to federal investigators
regarding whether ANBNO employees provided PCS services to her children and
whether she received kickbacks for signing-off on the false PCS sheets for her

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                             Nos. 10-30128, 10-30339

children, and these convictions formed the basis for her § 3C1.1 enhancement.
While Girod points to commentary note 4's example of covered conduct (G),
which includes “providing a materially false statement to a law enforcement
officer that significantly obstructed or impeded the official investigation or
prosecution of the instant offense,” note 4 is equally clear that its list of covered
conduct is “non-exhaustive” and that, as explained above, the enhancement also
applies when there are separate convictions for obstructive conduct. USSG
§ 3C1.1 cmt. n.4.
      We accordingly affirm Girod’s sentence.
D.    Testimony of Langley’s Other Acts
      We “review a district court’s evidentiary rulings for abuse of discretion,”
subject to harmless-error analysis. United States v. Cantu, 167 F.3d 198, 203
(5th Cir. 1999). “[F]or any of the evidentiary rulings to be reversible error, the
admission of the evidence in question must have substantially prejudiced [the
defendant’s] rights.” United States v. Sanders, 343 F.3d 511, 519 (5th Cir. 2003).
Langley appeals her convictions on the basis that the district court abused its
discretion when it allowed the Government to present testimony that Langley
provided alcoholic beverages and marijuana to two PCS clients under Federal
Rule of Evidence 404(b) as either intrinsic or extrinsic evidence of health care
fraud.
      Rule 404(b) only limits the admissibility of extrinsic evidence, not intrinsic
evidence. See United States v. Sumlin, 489 F.3d 683, 689 (5th Cir. 2007).
“Evidence of an act is intrinsic when it and evidence of the crime charged are
inextricably intertwined, or both acts are part of a single criminal episode, or it
was a necessary preliminary to the crime charged.” Id. “Intrinsic evidence is
admissible to complete the story of the crime by proving the immediate context
of events in time and place” and to “evaluate all of the circumstances under
which the defendant acted.” United States v. Rice, 607 F.3d 133, 141 (5th Cir.

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                            Nos. 10-30128, 10-30339

2010) (internal quotation marks and citations omitted). If evidence is extrinsic,
Rule 404(b) and United States v. Beechum, 582 F.2d 898 (5th Cir. 1978) (en
banc), require that we first determine “that the extrinsic evidence is relevant to
an issue other than the defendant’s character, i.e., motive, opportunity, intent,
preparation, plan, knowledge, identity, or absence of mistake or accident.”
Sanders, 343 F.3d at 518. “Second ‘the evidence must possess probative value
that is not substantially outweighed by its undue prejudice and must meet the
other requirements of Rule 403.’” Id. (quoting United States v. Anderson, 933
F.2d 1261, 1269 (5th Cir. 1991)).
      Langley was charged with conspiracy and with thirteen counts of health
care fraud for knowingly preparing fraudulent PCS time sheets for Medicaid
reimbursement with the intent to defraud. Langley’s theory of defense was that
she was just doing what she had been told to do when she filled out her time
sheets, and that she did not know it was wrong or fraudulent to record times and
activities she did not actually perform—that is, that she lacked the specific
intent to defraud. At trial, Langley testified that: she “took care” of her PCS
charges; she did not know anything illegal was going on; that she did not know
she was doing anything wrong; and Lee made her change her time sheets so
Medicaid would accept them and they all would get paid. Langley testified that
she “put in the time” with her PCS clients listed on the time sheets and worked
more than the hours claimed, but that the specific times and activities listed
were not always accurate. She testified that she “never questioned Akasia Lee
on anything, I just did my job.” She further testified that she never saw her
clients’ POCs and was never instructed to follow a POC.
      The Government introduced evidence that Langley’s PCS clients smoked
marijuana and drank alcohol in her care. To prove its case, the Government had
Joyce and Jonus Perrier, two of Langley’s former PCS clients who were 13-years
old when Langley committed her crimes, testify. Joyce Perrier testified that

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                           Nos. 10-30128, 10-30339

when Langley was supposed to be providing PCS services in their home, she
brought Joyce and Jonus over to her house where Joyce watched television and
Jonus smoked marijuana with Langley’s boyfriend. She also testified that
Langley gave her alcohol. Jonus testified that Langley brought them over to her
house and that he smoked marijuana and drank alcoholic beverages at her
house. The Government claimed that this evidence was necessary to prove
Langley’s specific intent to commit health care fraud and that she knew that the
“services” she provided could never be mistaken as Medicaid-reimbursable PCS.
After a hearing on the motion (among other motions in limine), the district court
issued a written order that, inter alia, granted the Government’s motion in
limine to admit the testimony without specifying the theory under which it was
allowing the evidence.
      This testimony is not intrinsic to Langley’s crimes.        The “criminal
episodes” charged were Langley’s fraudulent completion and submission of the
PCS time sheets for the children in her care, which occurred separate from when
Joyce and Jonus engaged in the illicit activities at Langley’s home. Evidence of
drug and alcohol use in Langley’s home, therefore, is not part of a “single
criminal episode,” nor does it “complete the story of the crime by proving the
immediate context of events in time and place.” While the Government argues
that the drug and alcohol use is “inextricably intertwined” with the crimes
charged and helpful to “evaluate all of the circumstances under which” Langley
acted, the drug and alcohol use is much more removed in time and space
from—and significantly less similar than—the criminal acts charged in other
cases in which we have found other-acts evidence to be intrinsic. See Rice, 607
F.3d at 141–42 (finding that the defendants’ four unsuccessful robbery attempts
were intrinsic to the crime charged of carjacking the same night); United States
v. Coleman, 78 F.3d 154, 156 (5th Cir. 1996) (holding that evidence that the



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                            Nos. 10-30128, 10-30339

defendants had attempted to carjack two other luxury cars on the same day
before carjacking a Mercedes—the crime charged—was intrinsic).
      Nor does the evidence of drug and alcohol use closely go to the conspiracy
charge, a crime for which we have given greater latitude in classifying evidence
as intrinsic. See United States v. Brown, 399 F. App’x 455, 460 (5th Cir. 2010)
(per curiam) (unpublished) (ruling that the defendants’ drug use was intrinsic
to a conspiracy to steal mail, because the conspiracy’s origin was a desire to
obtain financial information from the mail in order to purchase merchandise
that would later be traded for drugs); United States v. Watkins, 591 F.3d 780,
784–85 (5th Cir. 2009) (finding no plain error where a district court admitted as
intrinsic evidence that the defendant admitted involvement in prior drug runs
to establish how a cocaine conspiracy was structured and operated, and
explaining that other-acts evidence may be admissible in conspiracy cases).
Rather, the evidence relates to Langley’s mental state when she filled out the
PCS time sheets, which is extrinsic to the individual health care fraud counts.
      While we remain skeptical that the Perriers’ testimony would pass a Rule
403 analysis as required for extrinsic evidence under Beechum and Rule 404(b),
we need not decide whether the district court abused its discretion in admitting
the evidence because its admission was nevertheless harmless and did not
substantially prejudice Langley’s rights.       Joyce’s and Jonus’s testimony
regarding drug and alcohol use at Langley’s home was only one portion of their
testimony, which focused on what PCS services Langley did not do for them.
Langley and two of her adult children contradicted the Perriers’ testimony and
testified that no alcohol or drugs were ever served in Langley’s home. In closing,
the Government mentioned Joyce’s and Jonus’s testimony about alcohol and
drug use only very briefly, and emphasized that the case was about Langley
lying on her PCS forms and not about Langley being confused about what
constituted PCS services. Compared to all the evidence presented against

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                           Nos. 10-30128, 10-30339

Langley, Joyce’s and Jonus’s testimony about marijuana and alcohol was given
very little time at trial. Given the relatively small portion of the Government’s
case against Langley that it constituted, its admittance at trial was harmless.
                              III. CONCLUSION
      For the foregoing reasons, Girod’s, Brown’s, and Langley’s convictions
and sentences are affirmed.
      AFFIRMED.




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