Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca6-15-01528/USCOURTS-ca6-15-01528-0/pdf.json

Parties Involved:
Jamella Al-Jumail
Appellant
United States of America
Appellee

Document Text:

NOT RECOMMENDED FOR FULL-TEXT PUBLICATION

File Name: 16a0579n.06

Case Nos. 15-1527, 15-1528, 15-1529

UNITED STATES COURT OF APPEALS

FOR THE SIXTH CIRCUIT

UNITED STATES OF AMERICA,

Plaintiff-Appellee,

v.

FELICAR WILLIAMS (15-1527); JAMELLA 

Al-JUMAIL (15-1528); ABDUL MALIK ALJUMAIL (15-1529),

Defendants-Appellants.

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ON APPEAL FROM THE UNITED 

STATES DISTRICT COURT FOR 

THE EASTERN DISTRICT OF 

MICHIGAN

Before: MERRITT, ROGERS, and KETHLEDGE, Circuit Judges

MERRITT, Circuit Judge. Felicar Williams, Jamella Al-Jumail (“Ms. Al-Jumail”), and 

Abdul Malik Al-Jumail (“Mr. Al-Jumail”) each appeal from their jury convictions for offenses 

related to a complicated scheme to defraud Medicare.

The defendants on appeal (“Defendants”)1 were each found to have been involved with 

the management and operation of businesses that existed primarily—and in some cases, 

exclusively—as tools to defraud Medicare. Following a lengthy joint trial, a jury convicted each 

of the Defendants of conspiracy to commit health care fraud in violation of 18 U.S.C. § 1349. 

 

1

A fourth defendant, Dr. Carey Vigor, was tried alongside Ms. Williams, Ms. Al-Jumail, and Mr. Al-Jumail in the 

district court. Dr. Vigor was found not guilty on all counts and, as such, does not seek this Court’s review on 

appeal.

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Ms. Williams and Mr. Al-Jumail were also convicted of conspiracy to pay and receive health 

care kickbacks in violation of 18 U.S.C. § 371. Ms. Al-Jumail was also convicted of destroying 

records in a federal investigation in violation of 18 U.S.C. § 1519.

Ms. Williams now raises several arguments on appeal that she claims require either 

reversal of her conviction or resentencing. First, she argues that the United States failed to 

produce sufficient evidence to support her conviction and that the district court’s denial of her 

Rule 29 and Rule 33 motions for judgment of acquittal amounts to reversible error. She also 

argues that the trial court erroneously admitted certain evidence in violation of the Federal Rules 

and her rights under the Sixth Amendment. Finally, she contends that the district court erred by 

failing to grant her a downward variance under the Sentencing Guidelines’ “aberrant behavior” 

provision.

Ms. Al-Jumail also raises several issues on appeal. Like Ms. Williams, Ms. Al-Jumail 

seeks reversal on the basis of the sufficiency of the evidence produced against her at trial. Next, 

she argues that certain statements within the prosecution’s closing arguments amounted to 

unconstitutional “burden-shifting” entitling her to a new trial. Ms. Al-Jumail also attacks her 

sentence because she contends that it was based upon an insufficiently individualized 

determination of the loss attributable to her actions. Finally, she contends that the district court’s 

criminal restitution order violates her rights under the Sixth Amendment because it was not 

based upon a jury’s determination of the amount of loss attributable to her specifically.

Mr. Al-Jumail’s only argument on appeal is that the prejudice from being tried alongside 

his daughter caused by the district court’s denial of his motion to sever entitles him to a new 

trial.

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Because we find no merit in any of the Defendants’ arguments on appeal, we AFFIRM

the judgments of the district court in their entirety.

I. Facts

This case involves a number of health care businesses which operated largely 

independently of one another, except for the involvement of Sachin Sharma.2 Mr. Sharma was 

the architect of a scheme through which he was able to bill Medicare for services that were either 

worthless in quality or never provided at all. The success of Mr. Sharma’s scheme depended 

upon fraud of the most egregious kind: He hired individuals to pose as patients. He issued staff 

members badges falsely indicating that they had professional credentials. He acquired Medicare 

patient referrals by paying illegal kickbacks and then billed Medicare for services that were 

never provided by using falsified patient documentation. In order to avoid detection, Sharma 

replicated this fraud at several independently operated business entities that are the subject of this 

litigation.

A. Abdul Malik & Jamella Al-Jumail

Abdul Malik Al-Jumail and his partner, Firas Alky, purchased one of Mr. Sharma’s 

fraudulent enterprises—ABC Home Care—in 2009. Mr. Sharma testified that he and Mr. AlJumail discussed the fraudulent nature of ABC’s business activities at the time of purchase. Mr. 

Sharma further testified that he and Mr. Al-Jumail discussed various strategies to prevent 

Medicare from discovering ABC’s fraud, that Mr. Al-Jumail followed that advice after assuming 

control of the company, and that Mr. Al-Jumail shared a portion the profits of the fraud with Mr. 

Sharma. Upon being informed of an upcoming Medicare audit, Mr. Sharma connected Mr. Al-

 

2

Sharma entered into a plea agreement with the United States conditioned upon his agreement to testify truthfully at 

the Defendants’ trial.

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Jumail with an individual who—with the help of Mr. Al-Jumail’s daughter and co-defendant, 

Jamella—proceeded to fabricate patient documents in order to pass the inspection.

In addition to ABC, Mr. Al-Jumail owned several more home health agencies, one of 

which was called Accessible Home Health. Mr. Al-Jumail placed his daughter, Ms. Al-Jumail,

in charge of the day-to-day operations at Accessible. Upon Mr. Al-Jumail’s request, Mr. Sharma 

provided Ms. Al-Jumail with a flash drive filled with template documents in order to allow 

Accessible to execute the same fraud upon Medicare as he had at ABC. After Accessible was 

approved to bill Medicare, Ms. Al-Jumail directed and oversaw an elaborate records falsification 

process in order to produce the documents that would form the basis of Accessible’s Medicare 

claims. When certain Accessible staff members began discussing the appropriateness of 

Accessible’s billing practices among themselves, Ms. Al-Jumail instructed them that they were 

not to discuss their concerns with anyone but herself or her father.

Mr. Al-Jumail was eventually arrested for his involvement with ABC and Accessible, 

among other businesses. Upon learning of her father’s arrest, Ms. Al-Jumail coordinated the 

incineration of several binders full of patient documentation.

B. Felicar Williams

Felicar Williams and Mr. Sharma were co-owners of Haven Adult Daycare. The Haven 

partnership between Ms. Williams and Mr. Sharma was the product of an introduction arranged 

by Mr. Al-Jumail in response to Mr. Sharma’s desire to expand his portfolio of health care 

companies beyond home health agencies. Haven’s origin story is tied inextricably with the 

dissolution of TGW, another adult day care facility in which Ms. Williams held an ownership 

interest. Indeed, TGW shut down on a Friday, and Haven opened for business on the following 

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Monday. Many of Haven’s initial clients were passed on from TGW.

3

 Haven’s staff was also 

peppered with individuals who formerly worked for TGW. Finally, Haven’s clinical and billing 

practices were substantially the same as those employed at TGW.

Haven provided various services to adults who required supervision or care during the 

day. Specifically, Haven conducted individual and group “therapy” sessions with its clients. 

Haven staff conducted group sessions with all of their clients on a daily basis. These sessions 

included anywhere from twelve to twenty individuals and were essentially freeform discussions 

about general interest topics—health, hygiene, current events—guided only by cursory Internet 

searches by the staff member assigned to lead the sessions. Haven’s staff also conducted 

individual therapy sessions with clients on a less predictable basis.

The overwhelming majority of “psychotherapy” services provided to Haven’s clients fell 

far short of the relevant Medicare requirements. Haven’s staff often led group therapy sessions 

with as many as twenty participants despite the fact that Medicare reimbursement for such 

services is limited to groups of less than twelve patients. Patients with profound intellectual 

disabilities were made to sit in group sessions despite their inability to meaningfully participate.4

Therapy sessions were almost always conducted by unsupervised, unlicensed staff members 

without any formal training in providing psychotherapy.

In addition to overseeing the provision of these worthless services, Ms. Williams also

orchestrated and oversaw an intentionally fraudulent system of documentation and billing. Ms. 

Williams directed her staff to document “progress notes” for two sessions of individual therapy 

per client per week, even if no individual services were actually provided to a patient in a given 

 

3

In addition to the patients brought from TGW, Haven obtained Medicare-eligible clients by paying money to the 

owners of adult foster homes in exchange for sending their charges to Haven for the day.

4

Out of its recognition that group therapy is not effective for beneficiaries with profound intellectual disabilities, 

Medicare will not reimburse providers for group therapy provided to such beneficiaries. 

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week. In order to conceal this fraud from Medicare, she instructed Haven staff not to date their 

sometimes-fabricated progress notes so that another Haven employee could ensure that the 

services were billed on nonconsecutive days in order to comply with the relevant Medicare 

regulations.

II. Procedural Background

Following nearly two years of volleying indictments and plea negotiations, a grand jury 

returned a Third Superseding Indictment charging Ms. Williams, Ms. Al-Jumail, and Mr. AlJumail—among others—as follows: Ms. Williams and Mr. Al-Jumail were both charged with 

conspiracy to commit health care fraud in violation of 18 U.S.C. § 1349 and conspiracy to pay 

and receive health care kickbacks in violation of 18 U.S.C. § 371. Ms. Al-Jumail was charged 

with conspiracy to commit health care fraud in violation of 18 U.S.C. § 1349 and destroying 

records in a federal investigation in violation of 18 U.S.C. §§ 1519 and 2. 

After a twelve-week trial, a jury found the Defendants guilty on all counts. The district 

court sentenced Ms. Williams to five years’ confinement on both counts against her to run 

concurrently, two additional years of supervised release, and approximately $2 million in 

restitution payments. Ms. Al-Jumail received a sentence of four years’ imprisonment on both 

counts against her to run concurrently, three years of supervised release, and approximately 

$500,000 in restitution payments. The district court sentenced Mr. Al-Jumail to ten years’ 

imprisonment on the conspiracy to commit health care fraud count and three years’ 

imprisonment on the conspiracy to pay and receive health care kickbacks count to run 

concurrently, one year of supervised release, and over $8 million in restitution payments.

These appeals followed.

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III. Discussion

A. Felicar Williams

Ms. Williams raises four questions for this Court’s review on appeal. For the reasons 

articulated below, we affirm the district court’s judgment against Ms. Williams in its entirety.

1. Sufficiency of the Evidence Claim

First, Ms. Williams claims that the evidence presented at trial was insufficient to support 

the jury’s guilty verdict. The defendant bears a “heavy burden” when challenging the 

sufficiency of the evidence supporting a jury verdict on appeal. United States v. Maliszewski, 

161 F.3d 992, 1005 (6th Cir. 1998). This Court reviews properly preserved sufficiency 

challenges de novo, asking whether, “after viewing the evidence in the light most favorable to 

the prosecution, any rational trier of fact could have found the essential elements of the crime 

beyond a reasonable doubt.” United States v. Bankston, 820 F.3d 215, 235 (6th Cir. 2016) 

(quoting Jackson v. Virginia, 443 U.S. 307, 319 (1979)). To that end, this Court draws “all 

available inferences and resolve[s] all issues of credibility in favor of the jury’s verdict.” United 

States v. Smith, 749 F.3d 465, 477 (6th Cir. 2014).

Ms. Williams was convicted of conspiracy to commit health care fraud and conspiracy to 

pay or receive health care kickbacks and claims that both convictions were based on insufficient 

evidence. See 18 U.S.C. §§ 1347, 1349 (2012) (conspiracy to commit health care fraud); id.

§ 371 (conspiracy to pay or receive health care kickbacks). Conviction for conspiracy to commit 

health care fraud requires that the jury find that the defendant voluntarily made an agreement, 

“tacit or explicit,” to knowingly defraud a health care benefit program. United States v. 

Medlock, 792 F.3d 700, 711 (6th Cir. 2015); see 18 U.S.C. § 1347 (defining health care fraud). 

Evidence of actual fraud against Medicare and a defendant’s knowledge thereof and benefit 

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therefrom is sufficient proof to uphold a conviction under § 1349. Medlock, 792 F.3d at 711. 

Conviction for conspiracy to pay or receive health care kickbacks requires an agreement to offer, 

pay, solicit, or receive remuneration in exchange for a patient referral for services payable by a 

federal health care benefit program. See 18 U.S.C. § 371; 42 U.S.C. § 1320a-7b(b)(1)(A) 

& (2)(A).

Ms. Williams fails to carry her “heavy burden” with respect to both convictions. 

See Maliszewski, 161 F.3d at 1005. The evidence at trial readily supports a finding that 

Ms. Williams committed conspiracy to commit health care fraud. Sharma testified that he and 

Ms. Williams founded Haven together and that they both were aware that many of the services 

being provided to their clients were worthless. Several of the employees under Ms. Williams’s 

supervision at Haven testified that she routinely directed them to fabricate records for services 

that were never actually provided. And if there was any question as to Ms. Williams’s 

motivation for doing so, it is answered by the testimony indicating that Williams ensured that the 

records were left undated so that they could be strategically dated in order to avoid raising 

suspicion when Haven submitted its claims to Medicare for reimbursement. The United States 

also presented evidence at trial that Haven actually submitted claims for reimbursement for the 

fabricated services. In light of the Government’s proof of a voluntary agreement between 

Sharma and Williams to defraud Medicare, of actual fraudulent claims submitted to Medicare,

and of Ms. Williams’s knowledge of and benefit therefrom, a reasonable trier of fact could have 

found Ms. Williams guilty of conspiracy to commit health care fraud beyond a reasonable doubt.

See Medlock, 792 F.3d at 711 (upholding a guilty verdict under highly similar facts).

The evidence at trial also supported a finding that Ms. Williams conspired to receive 

health care kickbacks. Several witnesses testified that they played various roles in an 

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arrangement between Ms. Williams and Mr. Al-Jumail whereby Mr. Al-Jumail paid Ms. 

Williams for Haven’s patients’ billing information so that he could use those patients in his own 

scheme to defraud Medicare. Documentary evidence of checks issued by one of Mr. Al-Jumail’s 

businesses to Williams and certain Haven staff members corroborated that testimony. 

The contemporaneous nature of the payments in question and the exchange of patient billing 

information would permit a rational trier of fact to conclude beyond a reasonable doubt that Ms. 

Williams had entered into an agreement to provide patient referrals to Mr. Al-Jumail’s home 

health agency in exchange for cash payments.

Ms. Williams takes issue with the Government’s failure to produce the individual who 

actually submitted claims to Medicare, but that testimony was not necessary to her conviction for 

conspiracy to commit health care fraud. Evidence at trial showed that Williams directed the 

production of billing sheets for services that were never provided, that Williams gave those 

sheets to Haven’s biller, and that the biller returned the sheets after she submitted them to 

Medicare. While this evidence is not perfect proof that the fraudulent claims were actually 

submitted to Medicare, it is certainly sufficient to permit a reasonable jury to conclude that they 

were. Additionally, the fact that the offense in question is conspiracy to commit health care 

fraud—as opposed to the substantive offense of health care fraud—suggests that proof of the 

actual submission of false claims might not have been necessary to prove the underlying offense 

so long as there was sufficient proof of an agreement to defraud the government and of some 

overt act in furtherance that agreement. See United States v. Edmond, 815 F.3d 1032, 1040 (6th 

Cir. 2016) (outlining the basic elements of the federal conspiracy offense). Accordingly, the 

Government was not required to produce the biller at trial in order to convict Ms. Williams of 

conspiracy to commit health care fraud.

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 Ms. Williams also argues that her convictions were based on insufficient evidence 

because many of the Government’s best witnesses testified as conditions of their plea 

agreements. To the extent that this attack is based on the witnesses’ possible motivations to 

testify favorably to the Government, it is a dispute about their credibility. Aware of our own 

institutional limitations, this Court has long adhered to the rule foreclosing “arguments regarding 

a government witness’s lack of credibility” on appeal. United States v. Howard, 621 F.3d 433, 

460 (6th Cir. 2010) (quoting United States v. Talley, 164 F.3d 989, 996 (6th Cir. 1999)) (internal 

quotation marks omitted). While it is true that the Government’s case relied heavily upon the 

testimony of individuals whose plea agreements required them to testify, the fact of those 

agreements was presented to the jury and the jury chose to believe the witnesses. Accordingly, 

we refuse to overturn the jury’s verdict under the theory that it was unduly influenced by 

witnesses whose plea agreements required them to testify.

For the reasons stated above, the jury’s verdict was supported by sufficient evidence and 

we affirm the district court’s denial of Ms. Williams’s Rule 29 and Rule 33 motions for 

judgment of acquittal.

2. Impermissible Character Evidence Claim

In addition to her generalized attack on the sufficiency of the evidence, Ms. Williams also 

contends that the trial court erroneously admitted testimony that she directed the creation of false 

patient notes at TGW—another adult day care business that Ms. Williams co-owned until it was 

shut down after some of her partners were indicted for fraud. Williams moved to exclude the 

evidence on the grounds that there was not a sufficient factual basis for its admission and that it 

was offered for the purpose of proving action in accordance with character. The district court 

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denied her motion and admitted the evidence, reasoning that it was relevant to show “absence of 

mistake, intent, or . . . knowledge,” and that it was “more probative than prejudicial.”

Rule 404(b) requires exclusion of evidence of past bad acts when those acts are offered 

“to prove a person’s character in order to show that on a particular occasion the person acted in 

accordance with the character.” Fed. R. Evid. 404(b)(1). However, Rule 404(b)(2) permits 

admission of the evidence so long as it is offered for “another purpose,” including to establish 

“knowledge,” “intent,” or “absence of accident.” Fed. R. Evid. 404(b)(2). The standard of 

review that we apply to a district court’s Rule 404(b) ruling is the subject of some debate in this 

Circuit. Some panels have held that, when reviewing the trial court’s decision to admit evidence 

of past bad acts, this court applies a “tripartite” standard of review.5 See United States v. Barnes, 

822 F.3d 914, 920–21 (6th Cir. 2016). Other panels have held that the Supreme Court’s decision 

in General Electric Co. v. Joiner, 522 U.S. 136, 141 (1997), requires that all evidentiary rulings

by the district court be reviewed only for abuse of discretion. United States v. Allen, 619 F.3d 

518, 524 n.2 (6th Cir. 2010); see also United States v. Clay, 667 F.3d 689, 703 (6th Cir. 2012) 

(Kethledge, J., dissenting). Regardless of the applicable standard, this much is clear: the district 

court’s threshold finding that the past bad act actually occurred is subject to reversal if it is 

clearly erroneous. See Allen, 619 F.3d at 523 (applying the abuse of discretion standard and 

noting that “[a] district court abuses its discretion when it relies on clearly erroneous findings of 

fact”). A finding of fact is “clearly erroneous” if it leaves the reviewing court with “the definite 

and firm conviction that a mistake has been committed.” Max Trucking, LLC v. Liberty Mut. Ins.

 

5

“We review for clear error the district court’s factual determination that the other act occurred; we examine de 

novo the court’s legal determination that evidence of the other act is admissible for a proper purpose; and we review 

for abuse of discretion the court’s determination that the probative value of the evidence is not substantially 

outweighed by a risk of unfair prejudice.” United States v. Barnes, 822 F.3d 914, 920–21 (6th Cir. 2016).

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Corp., 802 F.3d 793, 808 (6th Cir. 2015) (citing Anderson v. City of Bessemer City, 470 U.S. 

564, 573 (1985)).

On appeal, Ms. Williams’s primary argument is that the district court’s finding that she 

was involved in the fraud at TGW was not based on sufficient evidence because she was not 

indicted in the criminal proceedings that followed the dissolution of TGW. However, plenty of 

evidence indicated that Williams both knew about and participated in the earlier fraud at TGW. 

Specifically, one of Williams’s employees at TGW testified that Williams directed her to 

fabricate patient records for services that were never provided in order to ensure that Medicare 

did not take back any funds from TGW. This evidence supports the district court’s finding that 

Ms. Williams was involved with the fraud at TGW. We affirm the trial court’s preliminary 

finding that Ms. Williams was involved in the fraud at TGW because it was not clearly

erroneous.

Ms. Williams also suggests that the evidence of her actions at TGW was admitted for the 

improper purpose of showing action in accordance with bad character. However, our precedents 

interpreting the text of Rule 404(b) make clear that evidence of past bad acts is admissible so 

long as it is probative of “material issue[s] other than character,” including intent, knowledge, 

and absence of accident. Barnes, 822 F.3d at 921; see also Fed. R. Evid. 404(b)(2). Because 

one of Ms. Williams’s primary defenses to liability in this action is that she was simply 

following orders and that she did not intend to defraud Medicare through her actions, she placed 

the question of her intent in issue. “To determine if evidence of other acts is probative of intent, 

we look to whether the evidence relates to conduct that is substantially similar and reasonably 

near in time to the specific intent offense at issue.” United States v. Bell, 516 F.3d 432, 443 (6th 

Cir. 2008) (internal quotation omitted). Since Ms. Williams’s conduct at TGW was practically 

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identical and extremely close in time to her conduct at Haven, the district court properly admitted 

the evidence of that conduct for the permissible purpose of proving that Ms. Williams intended 

to defraud Medicare. Since the result of our analysis is the same under both abuse of discretion 

and de novo review, we need not resolve the intra-circuit split on the appropriate standard of 

review for the district court’s Rule 404(b) ruling.

3. Confrontation Clause Claim

Ms. Williams next argues that the district court’s decision to admit a chart summarizing 

Medicare claims relevant to Haven’s operations violated her rights under the Confrontation 

Clause of the Sixth Amendment. Specifically, she claims that the Government’s failure to 

produce the biller who submitted the claims in question for cross-examination renders the chart

inadmissible. In response to Ms. Williams’s objection, the district court found that the 

Confrontation Clause did not apply to the claims underlying the charts because they were not 

“testimonial” statements within the Supreme Court’s understanding of that term.

The Confrontation Clause of the Sixth Amendment protects the criminal defendant’s 

right “to be confronted with the witnesses against him.” U.S. Const. amend. VI. It has been 

interpreted by the Supreme Court to prohibit the “admission of testimonial statements of a 

witness who did not appear at trial unless he was unavailable to testify, and the defendant had 

had a prior opportunity for cross-examination.” Crawford v. Washington, 541 U.S. 36, 53–54 

(2004). This Court assesses whether a statement was “testimonial” within the meaning of the 

Confrontation Clause by asking if the declarant “intended to bear testimony against the accused.” 

United States v. Collins, 799 F.3d 554, 576 (6th Cir. 2015) (quoting United States v. Cromer, 

389 F.3d 662, 675 (6th Cir. 2004)). The inquiry is objective and asks if “a reasonable person in 

the declarant’s position would anticipate his statement being used against the accused in 

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investigating and prosecuting [a] crime.” Id. (quoting United States v. Johnson, 581 F.3d 320, 

325 (6th Cir. 2009)). Statements that are not “testimonial” are not subject to the strictures of the 

Confrontation Clause; they are admissible so long as admission is appropriate under the Federal 

Rules of Evidence. United States v. Arnold, 486 F.3d 177, 192–93 (6th Cir. 2007) (citing Davis 

v. Washington, 547 U.S. 813, 823 (2006)).

Ms. Williams suggests that the admission of charts summarizing several of Haven’s 

disputed Medicare claims violated her right to confront the witnesses against her because the 

Government did not present the individual who actually submitted the claims for crossexamination. While the precise contours of Ms. Williams’s Confrontation Clause argument are 

not clear from her brief, any viable Confrontation Clause violation centers on the Medicare 

claims underlying the chart—as opposed to the chart itself6—because the agent who prepared the 

chart was actually available for cross-examination at trial. 

The viability of Ms. Williams’s Confrontation Clause challenge thus depends upon 

whether the underlying Medicare claims constitute “testimonial” statements. The Medicare 

claims at issue on appeal were admitted into evidence under the “business records” exception to 

the hearsay rule. See Fed. R. Evid. 803(6). The Supreme Court has made clear that records kept 

in the ordinary course of business or government are generally not “testimonial” for purposes of 

the Confrontation Clause because they are “by their nature, made for a purpose other than use in 

a prosecution.” Michigan v. Bryant, 562 U.S. 344, 362 n.9 (2011); see also Melendez-Diaz v. 

Massachusetts, 557 U.S. 305, 324 (2009) (“Business and public records are generally admissible 

absent confrontation . . . because—having been created for the administration of an entity’s 

 

6 While illustrative charts and diagrams are often not actually admitted into evidence, the chart disputed here was 

admitted as substantive proof under Federal Rule of Evidence 1006. As such, it could theoretically be the subject of 

a Confrontation Clause challenge in a case where the individual who prepared the chart was not available for crossexamination.

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affairs and not for the purpose of establishing or proving some fact at trial—they are not 

testimonial.”). Elaborating on that observation, this Court has also suggested that the mere fact 

that a business record might foreseeably be relevant to a subsequent prosecution does not 

automatically transform the record into a “testimonial” statement. See Collins, 799 F.3d at 586 

(“Although law enforcement officers may use [identification verification] records to track 

pseudoephedrine purchases, the [identification] system is designed to prevent customers from 

purchasing illegal quantities of pseudoephedrine by indicating to the pharmacy employee 

whether the customer has exceeded federal or state purchasing restrictions.”)

Here, the Medicare claims in question were clearly submitted and prepared not for the 

purpose of litigation, but rather for the routine and ordinary business purpose of obtaining 

payment from Medicare. As the district court rightly noted, there is no indication that the claims 

documents in question were made “in anticipation of being presented in a Court relative to a 

case.” While the possibility of an audit or prosecution for fraud is present whenever a claim for 

payment is submitted to the government, a reasonable person in the biller’s situation does not 

intend to bear testimony against the billing entity each time they submit a claim. Much like the 

pharmacist who entered information into the identification verification system in Collins, the 

biller here cannot be reasonably said to have anticipated that the specific claims at issue would 

be relevant to a subsequent prosecution. At most, the reasonable biller anticipates that the claims

she submits will be reviewed by the Government and subsequently approved or denied. 

Therefore, the Medicare claims at issue here are not “testimonial” for purposes of the 

Confrontation Clause, and we affirm the district court’s admission of the summary chart.

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4. Sentencing Claims

Ms. Williams’s final claim on appeal is that the district court abused its discretion when it 

denied her requests for an “aberrant behavior” downward variance in her already belowGuidelines sentence. She also claims that the district court did not adequately account for her

advanced age, her low risk of recidivism, and her lack of criminal history when imposing her 

sentence pursuant to the factors enumerated at 18 U.S.C. § 3553.

Our review of the district court’s sentencing order is limited to reasonableness review 

under a deferential abuse-of-discretion standard. United States v. Bazazpour, 690 F.3d 796, 803 

(6th Cir. 2012). We assess the reasonableness of sentences both procedurally and substantively. 

See United States v. Erpenbeck, 532 F.3d 423, 430 (6th Cir. 2008). A sentence is procedurally 

unreasonable if the district court “fail[s] to calculate (or improperly calculate[es]) the Guidelines 

range, treat[s] the Guidelines as mandatory, fail[s] to consider the [18 U.S.C.] § 3553(a) factors, 

select[s] a sentence based on clearly erroneous facts, or fail[s] to adequately explain the chosen 

sentence—including an explanation for any deviation from the Guidelines range.” Gall v. 

United States, 552 U.S. 38, 51 (2007). Substantive reasonableness requires the sentence imposed 

by the district court to be reasonable based upon the totality of the circumstances. Id.

With respect to Ms. Williams’s argument that she should have received a downward 

variance under the “aberrant behavior” provision of the Sentencing Guidelines,7we normally do 

not review that question “unless the record shows that the district court was unaware of, or did 

not understand, its discretion to make such a departure.” Bazazpour, 690 F.3d at 804. A review 

of the transcript of Ms. Williams’s sentencing reveals that the trial court was well-aware of its 

 

7

This provision of the Sentencing Guidelines provides: “The court may depart downward under this policy 

statement only if the defendant committed a single criminal occurrence or single criminal transaction that (1) was 

committed without significant planning; (2) was of limited duration; and (3) represents a marked deviation by the 

defendant from an otherwise law-abiding life.” U.S.S.G. § 5K2.20(b).

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discretion to make a downward departure. We therefore reject Ms. Williams’s appeal on that 

ground.

Finally, we reach Ms. Williams’s claim that the trial court did not adequately consider the 

sentencing factors enumerated at 18 U.S.C. § 3553(a) when fashioning her sentence. 

Ms. Williams received a sentence that was substantially below the lowest end of the range 

recommended by the Sentencing Guidelines. While the trial court calculated the Guidelines 

range to be between 121 and 151 months, it sentenced Ms. Williams to only 60 months in jail. In 

explaining its sentence, the district court emphasized that its decision to issue a below-Guidelines 

sentence—despite the severity of Ms. Williams’s offense—was motivated primarily by

Ms. Williams’s lack of criminal history and her low risk of recidivism. Instead of unthinkingly 

imposing a sentence tethered only to the Guidelines’ recommendations, the district court 

engaged in a thoughtful and independent assessment of each of the § 3553(a) factors.

That assessment ultimately convinced the court that a below-Guidelines sentence was warranted. 

This is precisely the type of reflective judgment that judges should exercise when sentencing 

criminal defendants under the Guidelines. Under these circumstances, we find that Ms. 

Williams’ sentence is both procedurally and substantively reasonable and we affirm the trial 

court’s sentencing order.

B. Jamella Al-Jumail

Ms. Al-Jumail raises four questions for this Court’s review on appeal. For the reasons 

articulated below, we affirm the district court’s judgment against Ms. Al-Jumail in its entirety.

1. Sufficiency of the Evidence Claim

Like Ms. Williams, Ms. Al-Jumail claims that the evidence presented at trial was 

insufficient to support the jury’s guilty verdict against her with respect to the conspiracy to 

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commit health care fraud count. We analyze this claim according to the same standard applied to 

Ms. Williams’s sufficiency claim.

Ms. Al-Jumail’s only contention with respect to the sufficiency of the evidence is that the 

Government failed to produce sufficient evidence to permit a reasonable trier of fact to find that 

she ever entered into a voluntary agreement with another conspirator with intent to defraud 

Medicare. See Medlock, 792 F.3d at 711 (requiring proof of voluntary agreement to defraud a 

health care benefit program). While Ms. Al-Jumail does not dispute that she was in charge of 

Accessible’s day-to-day operations or that Accessible did in fact defraud Medicare, she does 

allege that she was merely following her father’s orders and that she lacked the requisite intent to 

defraud Medicare through her actions. The testimony of Mr. Sharma and several Accessible 

employees told a different story at trial. Mr. Sharma testified that he and Ms. Al-Jumail worked 

together to falsify documents to obtain permission to bill Medicare for home health services. 

Additionally, two Accessible employees testified that Jamella orchestrated and oversaw an 

elaborate system of document fabrication in order to ensure that Medicare would not catch wind 

of the ongoing fraud at Accessible. The Government’s evidence at trial also indicated that Ms. 

Al-Jumail forbade Accessible’s billing staff from discussing their concerns about Accessible’s

billing practices with anyone but herself or her father. Taken together, this evidence was 

sufficient to permit a reasonable juror to infer that Ms. Al-Jumail knew of the fraudulent nature 

of Accessible’s business model and that she had at least tacitly agreed to participate in Mr. AlJumail’s scheme to defraud Medicare.

Like Ms. Williams, Ms. Al-Jumail also argues that the Government’s failure to produce 

the biller who actually submitted the fraudulent claims to Medicare means that the jury’s verdict 

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was based on insufficient evidence. For the same reasons discussed above with regard to Ms. 

Williams, this argument is unavailing. 

Thus, the jury’s verdict against Ms. Al-Jumail was supported by sufficient evidence and

we affirm the district court’s denial of Ms. Al-Jumail’s Rule 29 and Rule 33 motions for 

judgment of acquittal.

2. Prosecutorial Misconduct Claim

Ms. Al-Jumail also asserts that certain statements made by the Government’s lawyers 

during closing arguments amounted to unconstitutional burden-shifting entitling her to a new 

trial. In an attempt to convince the jury to find their clients not guilty, Mr. Al-Jumail’s, Ms. 

Williams’s, and Dr. Vigor’s attorneys all made reference to the fact that the Government failed 

to produce the biller who actually submitted the disputed claims to Medicare as part of their 

closing arguments. After obtaining leave of the district court, the Government’s lawyer said the 

following to the jury in rebuttal:

Now, Mr. Johnson, Mr. Louissell, they complain that the 

Government didn’t call Cassandra Cochran[, the biller]. Do we 

have the burden of proof in this case? Yes. Absolutely. 

Absolutely. Do they have to call one single witness? Nope. I have 

the entire burden of proof. But they could have called her. They 

could have.

On appeal, Ms. Al-Jumail argues that these statements impermissibly shifted the Government’s

burden of proof by suggesting that the Defendants were obliged to produce witnesses to establish 

their innocence.

This Court has long held that a criminal defendant’s Fifth Amendment privilege against 

compelled self-incrimination entitles him to a new trial when a prosecutor’s improper comments 

at trial flagrantly shift the burden of proof from the government to the defendant. See United 

States v. Wimbley, 553 F.3d 455, 461 (2009) (citing United States v. Robinson, 651 F.2d 1188, 

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1197 (6th Cir. 1981)). We apply a two-step analysis when we assess claims of prosecutorial 

misconduct: “First, we must determine whether the statements were improper. If we conclude 

the statements were improper, then we must determine whether the remarks were flagrant and 

thus warrant reversal [and a new trial].” United States v. Carson, 560 F.3d 566, 574 (6th Cir. 

2009) (internal citations omitted). Claims of prosecutorial misconduct are mixed questions of 

law and fact and we review them de novo. Id.

Our precedents hold that a prosecutor’s suggestion that the defendant could have called a 

given witness is not improper when made in rebuttal to an implication by the defendant during 

closing argument that “the government failed to call a witness because the evidence would be 

favorable to the defendant.” United States v. Newton, 389 F.3d 631, 638 (6th Cir. 2004) 

(describing United States v. Clark, 982 F.2d 965, 968 (6th Cir. 1993)), vacated on other grounds, 

546 U.S. 803 (2005). Clark involved a set of facts highly similar to the facts here: Clark was 

questioned by two federal agents after being charged with several federal drug offenses. Clark,

982 F.2d at 966–67. The government opted to offer the testimony of only one of the federal 

agents, Agent Milhills, at Clark’s subsequent trial. Id. at 967. At closing, Clark’s attorney 

suggested that the government might have kept the second agent from the jury because he would 

not have corroborated Milhills’s testimony. Id. In rebuttal, the government noted that Clark had 

the “opportunity,” but “not the responsibility” to call the second agent if he believed that the first 

agent was lying. Id. This Court held that the prosecutor’s remarks did not amount to misconduct 

because they “were made in response to defense counsel’s argument that implied that the 

government had not called the other agent to testify because Milhills lied on the stand,” and 

because they “did not imply in any way that the burden of proof was on the defendant to prove 

his innocence.” Id. at 969.

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A similar analysis guides our decision here. As in Clark, the Government’s statement 

that the defendants “could have” called the biller was made directly in response to the suggestion 

of several defendants’ closing arguments that the Government kept the witness from the jury 

because the evidence would not corroborate the testimony of the federal agent who testified 

about the claims that ABC, Accessible, and Haven submitted to Medicare. The Government in 

this case was even more unequivocal about who bore the burden of proof in this case than the 

prosecutor in Clark: the Assistant United States Attorney giving the rebuttal stated squarely that 

he had “the entire burden of proof” in the case and that the defendants did not “have to call one 

single witness.” Because these statements were made in response to the defendants’ claims that 

the Government was keeping unfavorable evidence from the jury and because the prosecutor

clearly stated that the Government retained the burden of proof, the statements do not rise to the 

level of unconstitutional prosecutorial misconduct.

3. Erroneous Sentencing Calculation Claim

Ms. Al-Jumail claims that the trial court erroneously calculated her sentence because it 

did not make a sufficiently “individualized finding” as to the amount of loss attributable to her 

after she joined the conspiracy because the court never made a specific finding as to the date she 

joined the conspiracy. Because she did not raise this specific issue when the district court asked 

if Ms. Al-Jumail had any additional objections after receiving her sentence, we review this claim 

for plain error. See United States v. Bostic, 371 F.3d 865, 872–73 (6th Cir. 2004). To rise to the 

level of plain error, the defendant must show that the alleged error was “obvious or clear” and 

that it affected both the “defendant’s substantial rights,” and “the fairness, integrity, or public 

reputation of the judicial proceedings.” United States v. Vonner, 516 F.3d 382, 386 (6th Cir. 

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2008) (quoting United States v. Gardiner, 463 F.3d 445, 459 (6th Cir. 2006)) (internal quotation 

marks omitted). A finding of such error is “exceptional.” Id.

The district court calculated Ms. Al-Jumail’s offense level in part by applying a 14-level 

increase on the basis of the judge’s determination of the intended losses at Accessible. Notably, 

the district court did not attribute the intended losses of any of the other relevant entities to 

Ms. Al-Jumail, as it could have. Since the evidence at trial suggested that, at a bare minimum,

Ms. Al-Jumail was involved with the fraud at Accessible from its very inception, the district 

court’s determination that Ms. Al-Jumail’s conduct was responsible for all of the intended losses 

at Accessible was reasonable and well within the trial judge’s broad discretion when calculating 

the offense level. See United States v. Johnson, 732 F.3d 577, 584 (6th Cir. 2013). Any error by 

the district court in calculating Ms. Al-Jumail’s offense level cannot be said to be “obvious or 

clear.” Vonner, 516 F.3d at 386. We therefore affirm the trial court’s calculation of Ms. AlJumail’s offense level. 

4. Apprendi Claim

Ms. Al-Jumail’s final claim on appeal is that the district court’s order directing her to pay 

$589,516.69 in restitution under the Mandatory Victims Restitution Act, 18 U.S.C. § 3663A, was 

unconstitutional under Apprendi v. New Jersey, 530 U.S. 466 (2000), because the jury never 

determined the loss attributable to her participation in the conspiracy. Ms. Al-Jumail did not 

raise this claim at the sentencing hearing, so we review it only for plain error. Bostic, 371 F.3d 

at 872–73.

In Apprendi, the Supreme Court held that “any fact that increases the penalty for a crime 

beyond the prescribed statutory maximum must be submitted to a jury, and proved beyond a 

reasonable doubt.” 530 U.S. at 490. This Court subsequently held that restitution awards are not 

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subject to the Apprendi rule because “restitution statutes do not specify a statutory maximum.” 

United States v. Sosebee, 419 F.3d 451, 461 (6th Cir. 2005). Despite the Supreme Court’s 

expansion of the Apprendi rule to cover the facts used to assess criminal fines, see S. Union Co. 

v. United States, 132 S. Ct. 2344, 2357 (2012), this Court very recently held that Southern Union

did not disturb Sosebee’s holding that restitution awards are not subject to Apprendi. United 

States v. Churn, 800 F.3d 768, 782 (6th Cir. 2015) (“Apprendi does not apply to the MVRA.”); 

United States v. Sawyer, 825 F.3d 287, 297 (6th Cir. 2016) (“Southern Union did nothing to call 

into question the key reasoning at the heart of Sosebee, namely that the restitution statutes do not 

specify maximum awards.”).

In light of the clear import of our precedents on this question, Ms. Al-Jumail’s reliance 

upon Southern Union as support for her claim is misplaced. Because Apprendi review does not 

apply to restitution awards, the trial court did not plainly err by failing to submit the issue to the 

jury.

C. Abdul Al-Jumail

Mr. Al-Jumail’s only claim on appeal centers on the district court’s denial of his motion 

to sever his trial from the trial of his daughter and co-conspirator, Ms. Al-Jumail. For the 

reasons articulated below, we affirm the district court’s denial of Mr. Al-Jumail’s motion.

Mr. Al-Jumail contends that the trial court should have granted his Rule 14 motion to 

sever his trial because a joint trial with his daughter would involve a substantial likelihood that 

the jury would infer that he was guilty if it found Ms. Al-Jumail guilty by virtue of their familial

relationship. See Fed. R. Crim. P. 14. Because Mr. Al-Jumail did not renew his motion to sever 

at the close of all evidence, we review the district court’s ruling only for plain error. United 

States v. Walls, 293 F.3d 959, 966 (6th Cir. 2002).

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Because joint trial of defendants who were indicted together “promote[s] efficiency” and 

“serve[s] the interests of justice,” Federal Rule of Criminal Procedure 14 has been interpreted to 

require severance “only if there is a serious risk that a joint trial would compromise a specific 

trial right of one of the defendants, or [would] prevent the jury from making a reliable judgment 

about guilt or innocence.” Zafiro v. United States, 506 U.S. 534, 537–39 (1993). “[D]efendants 

are not entitled to severance merely because they may have a better chance of acquittal in 

separate trials.” Id. at 540. Instead, defendants should point to discrete sources of “specific and 

compelling prejudice” to their trial rights or the jury’s ability to reliably decide the case before 

severance will be granted. Walls, 293 F.3d at 966. Generalized allegations of prejudice

associated with the “spillover of evidence” are almost never sufficient to require severance 

without more. United States v. Fields, 763 F.3d 443, 457 (6th Cir. 2014). Many of our sister 

Circuits hold that the mere fact that two defendants are closely related is not sufficient to require 

severance of a joint criminal trial. See, e.g., United States v. Nguyen, 493 F.3d 613, 625–26 (5th 

Cir. 2007) (severance not required in joint trial of twin brothers).

Mr. Al-Jumail does not argue that any specific trial right of his has been prejudiced 

because of his joint trial with his daughter. Rather, he claims that the jury would infer that he 

was guilty if it found his daughter guilty. While it is probably true that a jury that convicted Ms. 

Al-Jumail would also be likely to convict Mr. Al-Jumail, that is because they were both coowners and operators at Accessible, not because Mr. Al-Jumail was Ms. Al-Jumail’s father or 

because the jury could not separately consider the evidence against each of them. In light of the 

generalized nature of Mr. Al-Jumail’s allegations of prejudice and the weight of persuasive 

authority in favor of the proposition that familial relationships alone are not sufficient to require 

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severance under Rule 14, the district court did not plainly err in denying Mr. Al-Jumail’s motion 

for severance.

The judgments of the district court are AFFIRMED.

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