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Parties Involved:
Nelly Anderson
Appellant
United States of America
Appellee

Document Text:

[DO NOT PUBLISH]

In the

United States Court of Appeals

For the Eleventh Circuit

____________________

No. 24-10059

Non-Argument Calendar

____________________

UNITED STATES OF AMERICA, 

Plaintiff-Appellee,

versus

NELLY ANDERSON, 

Defendant-Appellant.

____________________

Appeal from the United States District Court

for the Southern District of Florida

D.C. Docket No. 1:23-cr-20124-CMA-1

____________________

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2 Opinion of the Court 24-10059

Before WILSON, ANDERSON, and HULL, Circuit Judges.

PER CURIAM:

Following a jury trial, Nelly Anderson appeals her 

convictions for conspiring to defraud the United States and paying 

kickbacks for referrals of Medicare patients. On appeal, Anderson 

challenges the sufficiency of the evidence supporting her three 

convictions. After careful review, we conclude that ample 

evidence supported Anderson’s convictions. Accordingly, we 

affirm Anderson’s convictions.

I. TRIAL EVIDENCE

A federal grand jury indicted Anderson on one count of 

conspiracy to defraud the United States and to pay health care 

kickbacks, in violation of 18 U.S.C. § 371 (Count 1); two counts of 

payment of kickbacks in connection with a federal health care 

program, in violation of the Anti-Kickback statute, 42 U.S.C. 

§ 1320a-7b(b)(2)(A) (Counts 2 and 3); and two counts of 

destruction, alteration, and falsification of records in a federal 

investigation, in violation of 18 U.S.C. § 1519 (Counts 4 and 5).

Anderson pled not guilty and proceeded to trial. We 

recount the trial evidence relevant to the sufficiency-of-evidence

issues presented on appeal.

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24-10059 Opinion of the Court 3

A. Dial 4 Care

Anderson was one of four owners of Dial 4 Care Inc. (“Dial 

4 Care”), a home health services company that provided services 

to Medicare patients. To serve Medicare patients, a health care 

provider must enroll as a Medicare provider. As part of the 

enrollment process, the provider must certify compliance with the 

Anti-Kickback statute, which prohibits payments between two or 

more parties that induce a person “to refer” an individual to a 

health care provider for a service payable under Medicare. See 42 

U.S.C. § 1320a-7b(b).

Dial 4 Care enrolled as a Medicare provider. On its

enrollment application, Dial 4 Care certified that it would comply 

with the Anti-Kickback statute, abide by Medicare laws and 

regulations, and not pay kickbacks. As Dial 4 Care’s authorized 

official, Anderson signed the certification.

Between 2017 and 2021, Medicare paid Dial 4 Care over $8 

million. Medicare, however, would not have paid Dial 4 Care for 

its Medicare patients’ claims if it knew that Dial 4 Care paid for the 

patient’s referral because that would violate the Anti-Kickback 

statute.

B. Dial 4 Care’s Use of Marketers

Anderson hired marketers to recruit patients to Dial 4 Care. 

One such marketer was Denisse Hanley, who testified at trial. 

From 2015 to 2021, Hanley worked for Dial 4 Care and reported 

directly to Anderson. Hanley learned of the job opportunity with 

Dial 4 Care through a meeting at the nursing home where she 

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4 Opinion of the Court 24-10059

worked. At the meeting, one of Dial 4 Care’s owners told the 

nursing home employees that they could earn $300 to $350 by 

referring patients to Dial 4 Care. 

As a Dial 4 Care marketer, Hanley went to hospitals and 

medical offices to introduce Dial 4 Care to patients. Hanley 

recruited only Medicare patients for Dial 4 Care.

Hanley signed a contract with Dial 4 Care that provided that 

she would be paid $50 per hour. But the $50 hourly rate was a “lie” 

because Hanley was actually paid for each patient that she brought 

to Dial 4 Care, not per hour. If a patient refused service, Dial 4 

Care did not pay Hanley regardless of how many hours Hanley 

spent recruiting the Medicare patient. If a Medicare patient 

terminated Dial 4 Care’s services early, Dial 4 Care deducted 

money from Hanley’s paychecks.

Dial 4 Care’s payment to Hanley fluctuated between $300 

and $350 for each patient referral but increased to $400 or $500 per 

patient depending on the services that the patient needed. If a 

patient needed treatment for just one condition, Hanley’s referral

payment would be within a range of $300 to $350. But if the patient 

“was getting all the services,” then the referral payment would be 

within a range of $400 to $500.

When Hanley successfully referred a Medicare patient to 

Dial 4 Care, she submitted invoices to get paid for the referral. 

Anderson directed Hanley to write on the invoices a number of 

hours that “match[ed]” her referral fee. In other words, Anderson 

directed Hanley to take the $50 contractual hourly rate and 

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24-10059 Opinion of the Court 5

multiply it by the number of hours necessary to match the actual 

per-patient payment amount. Anderson also directed Hanley not 

to log her hours in whole numbers so as not to “call attention to 

it.”

Although multiple people ran Dial 4 Care’s operations, 

Anderson was the “number one” person. Anderson signed 

Hanley’s checks. If Hanley had a problem with her check, she 

spoke to Anderson because Anderson was “the person in control” 

and “had the power to be able to resolve the problem.” 

Dial 4 Care’s checks contained invoice numbers, dates, and 

names of patients. The government identified two specific invoices 

and corresponding checks. In August 2019, Hanley submitted 

invoice number 89, billing Dial 4 Care $500 for referring a Medicare

patient. Dial 4 Care then wrote a $500 check, dated August 23, 

2019, that was payable to Hanley. The check listed invoice number 

89, the date, and the patient’s name on the memo line. This check 

formed the basis of Count 2 of the indictment.

In October 2021, Hanley submitted invoice number 09, 

billing Dial 4 Care $400. Dial 4 Care then wrote a $400 check, dated 

October 29, 2021, that was payable to Hanley. The check listed 

invoice number 21-09 and the date in the memo line. This check 

formed the basis of Count 3 of the indictment.

Between 2017 and 2021, Dial 4 Care paid Hanley a total of 

$36,355. Dial 4 Care’s checks were generally written for amounts 

in $100 increments, including $300 and $500 amounts.

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6 Opinion of the Court 24-10059

In addition to Hanley, Dial 4 Care employed other 

marketers such as Celeste Brens. Brens and the other marketers 

signed the same marketing contract that Hanley signed. Like 

Hanley, Brens submitted invoices in the amount of $500 for each

patient referral, and Dial 4 Care subsequently sent Brens checks 

that corresponded to the invoice amounts. 

C. Investigation and Revised Invoices

In April 2021, federal agents visited Hanley to discuss her 

employment with Dial 4 Care and review several invoices and 

checks. Hanley eventually stopped working at Dial 4 Care because 

she thought “things weren’t being done correctly.” 

In November 2021, Anderson asked Hanley to come to Dial 

4 Care’s office to “correct” some of her invoices. Specifically, 

Anderson showed Hanley invoices that did not match pay stubs for 

the corresponding checks and asked Hanley to change the invoices. 

To make the invoices match, Hanley changed the number of hours 

worked and the descriptions of the work performed.

For example, Hanley changed a $1000 invoice to $600 

because she had been paid only $600 via the check that 

corresponded to the $1000 invoice. In another instance, Hanley 

changed a $525 invoice to $400—the amount paid to her in the 

corresponding check. The mismatches between the invoices and 

the checks occurred when Dial 4 Care did not pay the full invoice 

amount because the Medicare patient declined certain services or 

terminated services early. 

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24-10059 Opinion of the Court 7

Hanley did not initially think there was anything wrong with 

correcting the invoices, but she reconsidered after remembering

her visit with federal agents. When Hanley realized there could be 

a problem, she began photographing the invoices. Hanley 

eventually turned the photographs over to federal agents.

D. Verdict and Sentence

At the conclusion of the government’s case-in-chief, 

Anderson moved for a judgment of acquittal. Anderson 

contended, in relevant part, that the government presented 

insufficient evidence to establish a conspiracy and that the 

payments to Hanley were not kickbacks for referrals. The district 

court denied the motion. Anderson did not testify or present 

evidence.

The jury found Anderson guilty of Counts 1, 2, and 3 and 

acquitted Anderson of Counts 4 and 5. Anderson renewed her 

motion for a judgment of acquittal and moved for a new trial. The 

district court denied both motions. The district court sentenced 

Anderson to 38 months’ imprisonment followed by 3 years of 

supervised release. Anderson timely appealed.1

II. SUFFICIENCY OF THE EVIDENCE

On appeal, Anderson argues that the evidence was 

insufficient to support her three convictions.

1 On appeal, Anderson does not challenge her sentence. Anderson challenges 

only the sufficiency of the evidence to support her three convictions.

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8 Opinion of the Court 24-10059

We review de novo challenges to the sufficiency of evidence, 

viewing “the evidence in the light most favorable to the 

government and draw[ing] all reasonable inferences and credibility 

choices in favor of the jury’s verdict.” United States v. Wilson, 788 

F.3d 1298, 1308 (11th Cir. 2015). The jury’s verdict “cannot be 

overturned if any reasonable construction of the evidence would 

have allowed the jury to find the defendant guilty beyond a 

reasonable doubt.” Id. (quotation marks omitted).

A. Conspiracy Conviction

We first address Anderson’s conspiracy conviction in 

Count 1. Anderson argues that the government did not present

direct or circumstantial evidence that (1) a kickback scheme 

existed, and (2) she participated in an agreement to pay kickbacks. 

To sustain a conspiracy conviction under 18 U.S.C. § 371, 

the government must prove “(1) an agreement among two or more 

persons to achieve an unlawful objective; (2) knowing and 

voluntary participation in the agreement; and (3) an overt act by a 

conspirator in furtherance of the agreement.” United States v. 

Gonzalez, 834 F.3d 1206, 1214 (11th Cir. 2016) (quotation marks 

omitted).

To obtain a conviction, “the government need not 

demonstrate the existence of a formal agreement, but may instead 

demonstrate by circumstantial evidence a meeting of the minds to 

commit an unlawful act.” United States v. Toler, 144 F.3d 1423, 1426 

(11th Cir. 1998) (internal quotation marks and citation omitted). 

Additionally, “the government need not prove that the defendant 

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knew all of the details or participated in every aspect of the 

conspiracy. Rather the government must only prove that the 

defendant knew the essential nature of the conspiracy.” United 

States v. Sosa, 777 F.3d 1279, 1290 (11th Cir. 2015).

Here, more than enough evidence presented at trial 

supported Anderson’s conspiracy conviction under § 371. 

First, a reasonable jury could find that there existed an

agreement to pay kickbacks to marketers for referring Medicare 

patients to Dial 4 Care. Hanley’s testimony established that 

Anderson and Hanley had an agreement for Anderson to pay 

Hanley on a per-patient basis, with the payment amount 

depending on the type of services the patient received. Although 

the official marketing contract stated that Hanley would be paid 

per hour, Hanley testified that the contract was a “lie,” as she was 

paid per patient that she referred to Dial 4 Care instead.

Second, ample evidence established that Anderson knew of 

the agreement and participated in it. Anderson hired the 

marketers. She explained to Hanley how to fill out her invoices to 

“match” the number of hours worked multiplied by the $50 hourly 

rate with the referral fee. She also directed Hanley not to log her 

hours in whole numbers so as not to “call attention to it.” 

Anderson was the “person in control” who signed Hanley’s 

checks. The checks contained invoice numbers and the names of 

patients. The checks reflected the ranges of per-patient referral 

amounts that depended on the type of services the patient received. 

And if a patient terminated services early, Dial 4 Care deducted 

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10 Opinion of the Court 24-10059

money from Hanley’s checks. When federal agents began 

investigating Dial 4 Care, Anderson asked Hanley to “correct” her 

invoices so that the hours worked, at $50 per hour, matched the 

payment amounts when those payments were reduced because a 

patient terminated Dial 4 Care’s services early.

This evidence is more than sufficient for the jury to infer (1) 

Anderson and the marketers had an agreement to pay kickbacks for 

referrals, (2) Anderson knowingly and voluntarily participated in 

the agreement, and (3) the existence of an overt act by her. See 

Gonzalez, 834 F.3d at 1214. The government did not need to 

demonstrate the existence of a formal agreement; the 

circumstantial evidence it presented was sufficient to show a 

meeting of the minds to pay kickbacks. See Toler, 144 F.3d at 1426. 

Further, the evidence established that Anderson “knew the 

essential nature of the conspiracy.” See Sosa, 777 F.3d at 1290. 

Accordingly, we affirm Anderson’s conspiracy conviction in Count 

1.

B. Payment-of-Kickbacks Convictions

Anderson also contends that the evidence was insufficient to 

support her substantive convictions in Counts 2 and 3 for violating 

the Anti-Kickback statute. Anderson argues that there is no 

evidence in the record of an actual kickback, an offer to pay a 

kickback, or the receipt of a kickback or offer.

The Anti-Kickback statute makes it illegal to: 

[K]nowingly and willfully offer[] or pay[] any 

remuneration (including any kickback, bribe, or rebate) 

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24-10059 Opinion of the Court 11

directly or indirectly, overtly or covertly, in cash or in 

kind to any person to induce such person . . . to refer 

an individual to a person for the furnishing or 

arranging for the furnishing of any item or service for 

which payment may be made in whole or in part 

under a Federal health care program.

42 U.S.C. § 1320a-7b(b)(2)(A) (emphasis added). The AntiKickback statute “speaks broadly to ‘whoever knowingly and 

willfully . . . pays any remuneration’ to ‘any person to induce such 

person . . . to refer an individual’” for a service paid by Medicare. 

United States v. Vernon, 723 F.3d 1234, 1254 (11th Cir. 2013)

(omissions in original) (quoting 42 U.S.C. § 1320a-7b(b)(2)(A)). 

The Anti-Kickback statute criminalizes “commission-based 

arrangements between health care providers and third parties.” Id.

at 1256.

To prove a substantive violation of the Anti-Kickback 

statute, the government must establish that the defendant 

(1) knowingly and willfully (2) paid money, directly or indirectly,

(3) to induce the referral of individuals to a health care provider for 

the furnishing of services (4) to be paid by Medicare. Id. at 1252.

Here, the record contains sufficient evidence by which a 

reasonable jury could find that Anderson violated the 

Anti-Kickback statute. As discussed above, the evidence showed 

that (1) Anderson explained to Hanley how to fill out invoices to 

“match” her hours, at the $50 hourly rate, to the fixed per-patient 

amount for referrals; (2) Anderson signed the checks to Hanley in 

amounts corresponding to the per-patient ranges based on the 

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12 Opinion of the Court 24-10059

services the patient received; and (3) Dial 4 Care deducted the 

money from the checks if the patient declined or terminated Dial 4 

Care’s services. 

Regarding Count 2, the government showed that, in August 

2019, Hanley submitted an invoice billing Dial 4 Care $500, and 

Dial 4 Care subsequently wrote a $500 check to Hanley with the 

invoice number and the Medicare patient’s name on the memo 

line. Regarding Count 3, the government showed that, in October 

2021, Hanley submitted an invoice for $400, and Dial 4 Care then 

wrote Hanley a $400 check with the invoice number on the memo 

line. 

These invoices and corresponding checks, together with 

Hanley’s testimony that she was paid for each patient referral and 

not by the hour, support the jury’s findings that (1) the payments 

were kickbacks to induce the marketers to refer Medicare patients

to Dial 4 Care, and (2) Anderson made the payments knowingly 

and willfully. See 42 U.S.C. § 1320a-7b(b)(2)(A); Vernon, 723 F.3d at 

1254; Nerey, 877 F.3d at 968. As with Anderson’s conspiracy 

conviction, the absence of direct evidence of a formal payment or 

offer of a kickback does not preclude the jury from inferring, in 

light of the overwhelming circumstantial evidence described 

above, that Anderson knowingly and willfully paid Hanley for 

patient referrals. And it is undisputed that Hanley recruited only 

Medicare patients for Dial 4 Care.

Anderson argues that the Anti-Kickback statute proscribes 

only paying kickbacks to health care providers, and because Hanley 

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is not a health care provider, the Anti-Kickback statute does not 

apply. But the Anti-Kickback statute prohibits paying 

remuneration to “any person” to induce that person to refer an 

individual for a service payable by Medicare. 42 U.S.C.

§ 1320a-7b(b)(2)(A) (emphasis added); Vernon, 723 F.3d at 1252. 

The Anti-Kickback statute is interpreted “broadly,” and a nonphysician such as Hanley can still “refer” patients under the statute. 

Vernon, 723 F.3d at 1254 (“[T]he plain language of the statute is not 

limited to payments to physicians who prescribe medication.”); see 

also Sosa, 777 F.3d at 1288, 1293-94 (sufficient evidence showed that 

the defendant violated the Anti-Kickback statute by paying a 

recruiter to refer patients to a clinic); United States v. Young, 108 

F.4th 1307, 1318-19 (11th Cir. 2024) (“Even if de la Cruz could not 

and did not write or sign the prescriptions herself, she was in a 

position to ensure that the prescriptions were sent.”).2

We thus conclude that a reasonable jury could find that the 

evidence sufficiently established that Anderson knowingly and 

willfully furnished kickbacks to marketers for referring patients to 

Dial 4 Care. See Vernon, 723 F.3d at 1252.

2 Anderson did not assert, either below or on appeal, any rights under the “safe 

harbor” provision of the Anti-Kickback statute. See 42 U.S.C. 

§ 1320a-7b(b)(3)(B).

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14 Opinion of the Court 24-10059

III. CONCLUSION

We affirm Anderson’s convictions for conspiring to defraud 

the United States and making payments in violation of the AntiKickback statute.

AFFIRMED.

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