FILED U.S. COURT OF AP P E A LS E LE V EN T HC IRC U IT DE CEM B ER 12, 2005 THOMAS K. KAH

N CLERK [ P UB L I S H] I N TH E U N I TED STA TES C O U R T O F A PPEA LS F O R T H E E L E V E N T H C IR C U IT

________________________ N o. 03- 12185

________________________ D. C . Do c k e tNo . 0 0 - 0 0 6 8 3 - C R - J AL U N I T E D S T A T E S O F A M E R I C A , P la in tif f - A p p e lle e , v ersu s G R I S E L A R I A S , M A R C O B U R G O S , S U Z A N N E B U R G O S , P E D R O S A R D U Y , I D A N I A C . A R I A S , D A L I A L A N D R O V E , M I C H A E L I H E A G W A R A , D e f e n d a n ts - A p p e lla n ts .

________________________ N o. 03- 14589

________________________ D. C . Do c k e tNo . 0 0 - 0 0 6 8 3 - C R - J ALHonora

ble Richard Mills, United States District Judg e for the Central District of

I llinois , sitti ng * by designation. 2 U N I T E D S T A T E S O F A M E R I C A , P la in tif f - A p p e lle e , v ersu s G R I S E L A R I A S , D e f e n d a n t- A p p e lla n t.

________________________ N o. 04- 14839

________________________ D. C . Do c k e tNo . 0 0 - 0 0 6 8 3 - C R - J AL U N I T E D S T A T E S O F A M E R I C A , P la in tif f - A p p e lle e , v ersu s S U Z A N N E B U R G O S , D e f e n d a n t- A p p e lla n t.

________________________ A p p eal s f

rom th e U n i te d S tate s D i st ri ct C ou rt f o r t he So ut he r n D i s t r i c t o f Fl o r i da

_________________________ ( D e c e m b e r 12, 2005) B ef ore T JO F L A T an d B A R K E T T , C i rc u i t Ju d ges, an d M IL L S , D i st ri ct * Ju d ge.In appeal No. 04-14839, Suzanne Burg os appeals the denial of her motion for a new trial, base d 1 on an alleg ed B rady

violation. Finding no error , we a ffirm the r uling of the district court without further discussion. DME companie s supply

medical e quipment such as whe el chairs, hospital beds and, more 2 specific ally

in this case, the nebuliz er machines utiliz ed by some patients to vaporize aerosol me dic atio n s o th at th epatient c an e a sily inh a leit. 3 B A R K E T T , C i rc u i t Ju d ge: In co n so l i d at ed ap p eal s N o . 0 3 -1 2 1 8 5 an d N o . 0 3 -1 4 5 8 9 , G ri sel A ri as, M ar co B urgo s, S uzanne B urgo s, P edro S ar du y, Idani a C . A ri as , D al i a L androv e, and M i chae l Ihea gw ar a app ea l thei r c on vi ct i on s f or conspi ra cy and o ther c ri m es r e la tin g to a s c h e m e to d e f r a u d th e M e d ic a r e p r o g r a m . W ith th e e x c e p tio n o f D a lia L a n d r o v e , e a c h a ls o ap p e a ls th e s e n te n c e im p o s e d b y th e d is tr ic t c o u r t. 1 I . Ba c k g r o und T he s c he m e t o de f

r a ud M e di c a r e i nvol ve d the c ol l us i on of doc t or s a nd ph ys i ci ans’ as si st ant s, ph arm ac i st s, re crui t ed “ pat i ent s, ” a nd du rabl e m edi ca l equi pm ent(“ D M E ”) com pani es . T he al l eged head of the sc hem e, Jose A ri as 2 ( w ho w a s c ha r ge d i n the i ni t i a l i ndi c tm e nt , a nd s ubs e que nt l y pl e d gui l ty t o the c ons pi r a c y c ounta nd c oope r a t e d w i th the gove r nm e nt ) i nc orpor a t e d s e ve r a l of the D M E co m p an i es an d o w n ed tw o cl i n i cs, F i rstO p t i o n D i ag n o st i c C en t er an d F i rst O p tio n M e d ic a l C e n te r . T h e s c h e m e o p e r a te d a s f o llo w s . T he D M E com pani es p ai d recru i t ers t o l o cat e M ed i care-eli g i b l e p erso n s t o serv e as p at i en t s. T h ese re cr u it ed “p atien ts” w er e p aid to v isitA rias ’ cli n ics, w h er e d o cto rs o r p h ys ician ’sAcc ordingto the g overnment, the compoundingwas moreprofitable, but would also benefit the 3 fra udulent schemeby

makingit more difficult for an investig ator to asc ertain that the pharmacies 4 as si st ant s f

al se l y c er t i fi ed di agno se s. T he pri nci pal di agno si s i n t he sc hem e w as Ch r o n i c O b s tru c t i v e Pu l mo n a r y D i s e a s e ( “ CO PD ” ) , a d i s e a s e w h o s e s y mp t o ms i nc l ude s hor tne s s of

br e a th, c oughs , a nd de c r e a s e d e xe r c i s e c apa bi l i ty . O nc e the fa l se di agno si s w as m ade, a c er t i fi ca t e of m edi ca l nece ss i ty ( “ C M N ”) w as si gn ed by a doct or st at i ng thatthe M edi ca re benefi ci ary r equi re d cer t ai n m edi ca l e qui pm e nta nd r e s pi r a t or y m e di c a t i on. T he C M N a c t e d a s a pr e s c r i pt i on f orthe r e q u i r e d m e d i c i n e a n d e q u i p m e n t . T h e C MN s w e r e th e n s e n tt o th e D ME com pani es , w hi ch bi l l ed M edi ca re for the un nece ss ary C M N -pre sc ri bed m edi ca l e qui pm e nta nd r e s pi r a t or y m e di c a t i ons , pa r t i c ul a r l y c e r t a i n a e r os ol m e di c a t i ons supp l i ed by the ph arm ac i es . A s par tof the sc hem e, the ph arm ac i es supp l i ed “c o m p o u n d e d ” r e s p ir a to r y a e r o s o l m e d ic a tio n s to th e D M E c o m p a n ie s . C om poundi ng i s a pha r m a c y pr oc e dur e i n w hi c h a pha r m a c i s tm a ke s m e di c a t i on by m i xi ng se vera l ra w m at er i al s a tthe ph arm ac y. C om po un ded m edi ca t i on s a re r a r e l y pr e s c r i be d by doc t or s a nd, a c c or di ng t o e xpe r tt e s t i m ony , s houl d onl y be prov i ded t o a pat i entw hen speci fi ca l l y pre sc ri bed. H ow ever , the ph arm ac i es i n v o l v ed i n th e sch em e al m o stal w ays p ro v i d ed co m p o u n d ed aero so l m ed i cat i o n s, e ve n though c om m e r c i a l l y - m a nuf a c tur e d, F D A - appr ove d a e r os ol m e di c a t i ons w er e a vai l abl e. 3were purpor ting to supply

a greater amount of medicine to the DME c ompanies than would be possible, based on the a

mount of medicine or materials purc hased f rom manufacturers. The evidencealso indicated that the pharmacies did not follow proper proc edure s in making a nd storing theaerosol medication. The g overnment argued that the sloppy compoundingfurther evidenc ed the f

raudulent scheme: the pha rmac ies were lax in their procedures bec ause they knew that no patient ac tually

neede d or used the me dication they were compounding . We do note that although compoundingplayed an integral pa rt in the overall scheme, the evidenc e re lating to c ompounding provided only circumstantial evidenceof the fraud. As the jury was properly

instructed, the c ompounding alone was not illeg al. Altho ugh th eDM E c omp anie s p ic ke d u p th epre scripti on s in

bulk, theph arm a c y

wo uld 4 fra udulently date the la

bels to vary

the dispensal date s, cre atingthe appe ara nce that the pre sc ripti on s w e reiss ue d in theno rm a l c ours eof

bu sin e ss. 5 T he D M E c om pa ni e s pa r t i c i pa t i ng i n the s c he m e os t e ns i bl y pr oc ur e d the m e di c a t i on f

r om the pha r m a c i e s on be ha l f of the pa t i e nt s , of

t e n obt a i ni ng the pa t i e ntm e di c a t i ons i n m a s s qua nt i ty , br i ngi ng s t a c ks of pr e s c r i pt i ons t o the pha r m a c i e s onc e a m onth. S om e t i m e s the D M E c om pa ni e s de l i ve r e d the 4 re spi ra t ory m edi ca t i on s t o p at i ent s; i n o ther i nst ance s, the D M E com pany never del i vere d t he m edi ca t i on t o t he pat i ent . A dd i t i on al l y, the ph arm ac i es att i m es d e l i v e r e d o n l y h a l f

th e p a t i e n t s ’ me d i c a t i o n t o th e D M E c o mp a n i e s . I n s o me i n s t a n c e s , th e p h a r m a c i e s p r o v i d e d o n l y l a b e l s a n d i n v o i c e s t o th e D ME c o m p a n ie s , r a th e rth a n a n y a c tu a l m e d ic a tio n . D e f e n d a n t s G r i s e l A r i a s , I d a n i a A r i a s , a n d D a l i a L a n d r o v e o p e r a t e d D ME c o m p a n i e s i n v o l v e d i n th e s c h e m e . I d a n i a Ar i a s a l s o o wn e d a n d o p e r a t e d J &A B i l l i ng C om pany, throu gh w hi ch al l M edi ca re cl ai m s f rom the D M E com pani es w er e proces se d. P edro S ar du y w as a doct or atF i rs tO pt i on M edi ca l C ent er , w hereF ivea dditi on a l c o- de fend ants weretrie d jo intly wi th t heAppe lla

nts . Thejur

y a c quitt e d f

our: 5 Re inaldoL and

ro ve , a n o ff ic e r o f a DM E c omp any ; Jan e ideRe gue iro, wh o w or ke d at So uth Be ach Phar

macy ; and Azubueze Ikejiani and Magnus Ogbenna, theco-owners of Maz Pharmacy (with Michae l Iheagwara). Thefifth, Vincente B ouza, a doctor, w as convic ted but did not appeal. Marc o Burg os did not indi vidually submit a brief, a

nd instead adopte d the arguments of the 6 other Appe llants. Other Appe llants have va riously adopted the a

rguments of their c oAppellants, as we ll. Bec ause theonly two arguments in which we f ind merit aff

ect only the indivi du a ls who ma dethem, t hereis n o n e e d f

or us to de tail thepa

rtie s’ a dopti on

of arguments , and wedo not do so. 6 he a l l e ge dl y f

a l s e l y di a gnos e d the “ pa t i e nt s ” w i th C O P D . M a r c o a nd S uz a nne B urgo s, w ho w er e m arri ed du ri ng the t i m e of the conspi ra cy , op er at ed S ou th B ea ch P ha r m a c y a nd L a M ode r na P ha r m a c y , tw o of the pha r m a c i e s s uppl y i ng the a e r os ol m e di c a t i ons t o the f

r a udul e ntD M E c om pa ni e s . M i c ha e l I he a gw a r a w a s a c oow ne rof L a M ode r na be f

or e l e a vi ng t o c r e a t e M a z P ha r m a c y . I he a gw a r a a nd S u zan n e B u rg o s w ere b o th p h arm aci st s. I I . D i s c u s s i on A s not e d e a r l i e r , J os e A r i a s , the a l l e ge d he a d of the s c he m e , pl e d gui l ty a nd c oope r a t e d w i th the gove r nm e nt , a l though he di d nott e s t i f y a ttr i a l . A f

t e ra j oi nt tr i a l be f or e a j ury , the A ppe l l a nt s w e r e c onvi c t e d. W e c ons i de ra l l of the 5 a r gum e nt s of

e a c h A ppe l l a nti n tur n, bute nga ge i n a n e xt e nde d di s c us s i on reg ard i n g o n l y M i ch ael Ih eag w ara an d P ed ro S ard u y. 6 A . G ri sel A ri a s G r i s e l A r i a s a r gue s tha the rc onvi c t i on s houl d be r e ve r s e d be c a us e : ( 1) the7

ev i d en ce w as n o tsu ffi ci en tt o su p p o rth er co n v i ct i o n ; (2 ) h er C o n fro n t at i o n C l au se r i ght s w e r e vi ol a t e d w he n the c our tr e f us e d t o pe r m i the rt o r e - c a l l a gove r nm e nt w itn e s s w h o p le d g u ilty to a n u n r e la te d d ru g c h a r g e s u b s e q u e n t to te s tif y in g in th is c a s e ; ( 3) the gove r nm e ntw i thhe l d e xc ul pa t or y e vi de nc e i n vi ol a t i on of B r a dy v. M aryl and, 37 3 U . S . 83 (196 3); (4) the di stri ctcourterre d i n d enyi ng her r equest ed c ont i nua nc e w he n a s upe r s e di ng i ndi c tm e ntw a s i s s ue d one m onth be f or e tr i a l ; a nd ( 5 ) th e c o u r t e r r o n e o u s ly r e f u s e d to g iv e a r e q u e s te d ju r y in s tru c tio n p e r ta in in g to the e vi de nc e tha ts he ha d a c t e d i n “ good f a i th” a nd notw i th f

r a udul e nti nt e nt . S he a l s o a r gue s tha the rs e nt e nc e s houl d be va c a t e d be c a us e i n c a l c ul a t i ng he rgui de l i ne se nt ence , the di stri ctcourti ncorrec t l y c al cul at ed the l oss a t tri bu t abl e t o h er . W e h av e carefu l l y co n si d ered th e reco rd an d fi n d n o m eri tt o an y o f th ese c o n te n tio n s . F ir s t, th e e v id e n c e w a s c le a r ly s u f f ic ie n t to s u p p o r t h e rc o n v ic tio n . W i thoutc a t a l ogui ng e a c h pi e c e of e vi de nc e a ga i ns tG r i s e l A r i a s , w e not e tha tthe go vernm entsubm i t t ed do cum ent s e st abl i shi ng thatG ri se l A ri as w as the ori gi nal pres i dentand i ncorpo ra t or of tw o D M E com pani es i nv ol ved i n the fr aud schem e, B i rd R oad M edi ca l S ervi ce s a nd , subsequent l y, N ew A dv ance d M edi ca l E qu i pm entC orpo ra t i on ; on the evi dence pres ent ed, the j ury c ou l d h ave c on cl ud ed thatthese com pani es w er e notcond uct i ng any l egi t i m at e tra nsac t i on s. G ri se l a u th o r iz e d M e d ic a r e p r o v id e rap p lic a tio n f o r m s f o rb o th th e s e D M E c o m p a n ie s .This evidencesupporting Grisel Aria s’ conviction on the c onspiracy charg e wa s also sufficient 7 to support her c onviction on the “kickback” c ounts. Under the Pinker ton theory

of vica rious liability , Grisel could beconvicted f or the kickback off

enses even without proof of her dire ct involvement, beca

use the kickbacks were reasona bly fore seea ble and in fur

thera nce of the conspiracy . See United States v. Mother sill, 87 F.3d 1214, 1218 (11th Cir. 1996). Ordinarily , druguse is not a valid subject for impeachment. See United States v. Clemons, 32 8 F .3 d 1 50 4, 15 11 (1 1th

Cir . 1 99 4) (“ Th is c irc uit

ha s lo nga dh e re d totheprop os iti on that a wi tne ss' s u seof

dr ug s ma y no t beus e d toattac k h is g e neral c re dib ili ty, b ut o nly his a bil ity to perc eive the underlying events and to testify lucidly at trial.”) . Thus, had the g overnment not opened thedoor to the subject of Amador’ s druguse duringdirec t examination, questi ons relating to Amador ’s druguse would cle arly have be en impermissible. 8 A lth o u g h s h e a lle g e d th a t s o m e s ig n a tu r e s w e r e f o r g e d , th e ju r y w a s e n title d to d e t e r mi n e th a tth e d o c u me n t s we r e a u th e n t i c . Ad d i t i o n a l l y , Ca r l o s Ama d o r , a La M od erna ph arm ac y t ec hn i ci an w ho pl ed gu i l ty t o t he conspi ra cy , t es t i fi ed that G r i s e l w oul d c om e t o the L a M ode r na f a c i l i ty “ [ a ] tl e a s tonc e a m onth” dur i ng the y e a rhe w or ke d the r e , a nd tha ts he pi c ke d up ha l f - f i l l e d pr e s c r i pt i ons of

a e r os ol m ed i cat i o n s fro m h i m atth e p h arm acy. 7 S e c ond, the di s tr i c tc our tdi d nota bus e i t s di s c r e t i on i n r e f us i ng t o a l l ow the r e c a l l of A m a dororthe i ntr oduc t i on of doc um e nt s r e l a t i ng t o the drug c ha r ge agai nsthi m . T he sol e purpo se i n see ki ng further t es t i m on y f rom A m ador w as i m pe a c hm e nt , the que s t i oni ng w oul d ha ve be e n c um ul a t i ve of tha ta l r e a dy p e r m itte d d u r in g c r o s s e x a m in a tio n , a n d A m a d o rh a d r e p r e s e n te d th a t h e w o u ld s im p ly in v o k e h is F if

th A m e n d m e n t p r iv ile g e if r e c a lle d . T h ir d , G r is e l A r ia s d id

8 no thave a val i d B ra dy cl ai m , beca use w hen v i ew ed i n con t ext , the pu rport ed co n trad icti o n s b etw ee n Jo se A rias ’ sen ten cin g testim o n y a n d th e p ro se cu ti o n ’sAmador’ s testimony that he delivered “le g itimate” drug s to Grisel does not provide a 9 f o un d at i o nf

o r u s t o f i n d g o o d f ai th , a s h i s o wnt e s t i m o ny c o n f i r m s th atth ed e l i v e r

y w a s o f o n l y a half portion of “leg itimate” medication. It is the miss ing half-portion that establishes the f raud, here , not the “leg itimate” half-portion that was delivered. 9 pretri al l ett erdesc ri bi ng hi s s t at em ent s a re no tm at er i al . F ou rth, i n t hi s c om pl ex m ul t i - de f

e nda ntc a s e , the di s tr i c tc our tdi d nota bus e i t s di s c r e t i on by de ny i ng G ri se l a c on t i nu ance af

t erthe se cond supers edi ng i nd i ctm enti ncl ud ed addi t i on al de t a i l s c onc e r ni ng the D M E N e w A dva nc e d M e di c a l E qui pm e ntC orpor a t i on; the g o v ern m en th ad p rev i o u sl y d i scl o sed N ew A d v an ced m at eri al s d u ri n g d i sco v ery, a nd the s upe r s e di ng i ndi c tm e ntdi d nota dd ne w c ha r ge s ora l t e rthe the or y of pr os e c ut i on. F i f

th, the di s tr i c tc our tdi d nota bus e i t s di s c r e t i on by r e f us i ng G r i s e l ’ s r e que s tf

ora “ good f

a i th” i ns truc t i on, a s the r e i s no f ounda t i on i n the e v id e n c e f

o rs u c h a n in s tru c tio n . F in a lly , th e d is tr ic t c o u r t d id n o t e r rin 9 ca l cul at i ng the am ou ntof l oss a t tri bu t abl e t o G ri se l – i n a j oi nt l y und er t aken c r im in a l a c tiv ity , e a c h d e f e n d a n t is r e s p o n s ib le f

o r“a ll r e a s o n a b ly f

o r e s e e a b le a c ts and o m i ss i on s of others i n furthera nce of the j oi nt l y und er t aken cri m i nal ac t i vi ty. ” U . S . S . G . § 1 B 1. 3(a) (1)( B ). B . I d an i a A r i as Idani a A ri as ar gu es thatthe di stri ctcourterre d b y r ef usi ng t o adm i tevi dence t o su p p o rth er d efen se th atsh e w as co m p l et el y su b serv i en tt o h er h u sb an d , Jo se A r i a s , a nd the r e f

or e una bl e t o f

or m ul a t e the m e ns r e a f orthe c r i m e a nd by r e f

us i ngThe district cour t did allow I dania to pre sent evidenc e of Jose Arias’ physical and mental 10 a bu seof I da nia , a s w e ll a s re le va

nt evide nc ea

bo ut Jos e ’s mis tre ss’ inv olv e ment in b us ine ss matters re lating to the c onspiracy . The e x cluded evidenceoffered by I dania related to, inter

alia, a home invasion at the Arias residenc e, the kidnappingof I dania a nd her youngsons, and I dania’ s menstruation stopping at ag e thirty-two. Ne ither the home inva sion nor the kidnapping was purpor

ted to have be en committed by anyone involved in the conspiracy . 10 t o d i sm i ss the m on ey l aund er i ng char ge agai nsther, w here there exi st ed a f at al v a r ia n c e b e tw e e n th e c r im e c h a r g e d in th e in d ic tm e n t a n d th e p r o o f a t tr ia l. R e ga r di ng he rs e nt e nc e , s he a r gue s tha tthe di s tr i c tc our ts houl d ha ve or de r e d a p s y c h ia tr ic e v a lu a tio n a f te rh e rc o u n s e l r e p r e s e n te d th a t s h e w a s u n a b le to m e a ni ngf

ul l y a s s i s ti n pr e pa r i ng f ors e nt e nc i ng. T he di stri ctcourtdi d n otabuse i t s di sc re t i on i n excl ud i ng Idani a’ s e xp er t w itn e s s . I n o r d e rto b e a d m is s ib le , th e e x p e r t e v id e n c e m u s t e s ta b lis h th a t I d a n ia w as n o tab l e t o fo rm th e m en s rea fo r th e cri m e; h o w ev er, Id an i a’ s ex p ertw i tn ess prov i ded evi dence of j ust i fi ca t i on , no tl ac k o f m ens r ea . N or di d t he di stri ctcourt abuse i t s di sc re t i on by excl ud i ng Idani a’ s other e vi dence re gardi ng subservi ence , ba s e d on i t s de t e r m i na t i on tha tthe e vi de nc e w a s notr e l e va nt . T he c our tdi d not 10 e r rin r e f u s in g to d is m is s th e m o n e y la u n d e r in g c h a r g e a g a in s t I d a n ia . T h e f a c ts pr ove d a ttr i a l di d notde vi a t e m a t e r i a l l y f r om the l a ngua ge of

the i ndi c tm e nt , a nd b a n k r e c o r d s p r o v id e d b y th e g o v e r n m e n t in d is c o v e r y s u f f ic ie n tly n o tif

ie d I d a n ia tha tf a c t s r e l a t i ng t o M e di c os M a r ke t i ng tr a ns a c t i ons w oul d be i nc l ude d i n the m one y l a unde r i ng c a s e . F i na l l y , a f t e rhe a r i ng t e s t i m ony f

r om I da ni a ’ s tr e a t i ng11

p s y c h ia tr is t a t F D C M ia m i, th e d is tr ic t c o u r t h a d a d e q u a te in f o r m a tio n to e v a lu a te Idani a’ s m ent al cond i t i on , and d i d n otabuse i t s di sc re t i on i n d enyi ng further ps y c hi a tr i c e va l ua t i on be f or e s e nt e nc i ng. C . D al i a L an d r ove D al i a L androv e a rgues thatthe di stri ctcourterre d b y f ai l i ng t o rem ov e a j ur orf orc a us e ort o i nqui r e m or e thor oughl y i nt o tha tj ur or ’ s a bi l i ty t o be f a i ra nd i m part i al , and b y a l l ow i ng the prosecut i on t o charac t er i ze her t ax re turns as frau d u l en tw i th n o ev i d en t i ary b asi s. W e f in d th a t th e d is tr ic t c o u r t’s in q u ir y in to thi s j ur or ’ s m i s c onduc tw a s w e l l w i thi n the c our t ’ s di s c r e t i on, a nd tha tthe prosec ut i on ’ s use of L androv e’ s t ax re turns ca nn otbe deem ed a harmful error. D . S u z an n e B u r gos S uzanne B urgo s a rgues thatthe evi dence w as no tsuff i ci entt o sup po rther c onvi c t i on; tha tthe di s tr i c tc our te r r e d by a dm i t t i ng c e r t a i n e xtr i ns i c e vi de nc e a nd by tre at i ng an i nspect or’ s aud i tas i nt ri nsi c r ather than ext ri nsi c e vi dence; and t hat th e d is tr ic t c o u r t s h o u ld n o t h a v e in s tru c te d th e ju r y o n d e lib e r a te ig n o r a n c e . B ur gos a l s o a r gue s tha ti n de t e r m i ni ng he rgui de l i ne r a nge f ors e nt e nc i ng, the di stri ctcourti ncorrec t l y c al cul at ed the l oss a t tri bu t abl e t o h er . A f te rc a r e f u l r e v ie w o f

th e r e c o r d , w e f

in d th a t th e e v id e n c e w a s s u f f ic ie n t to s uppor tthe j ur y ’ s c onc l us i on tha tS uz a nne B ur gos know i ngl y pa r t i c i pa t e d i n the12

c o n s p ir a c y . D o c u m e n ta r y e v id e n c e e s ta b lis h e d th a t S u z a n n e w a s a c o rp o r a te offi ce r of bot h L a M od erna P harm ac y a nd S ou th B ea ch P harm ac y, and sever al w i tn esses t est i fi ed th atS u zan n e w as i n v o l v ed i n h i ri n g p erso n n el fo r th o se pha r m a c i e s , i nc l udi ng pe r s onne l w hos e w or k i nvol ve d f i l l i ng the f

r a udul e nt a e r o s o l p r e s c r i p t i o n s . M a r y Gh a b r i a l , wh o wo r k e d a s a ma n a g i n g p h a r ma c i s ta tLa M ode r na a nd w a s notc ha r ge d w i th a ny w r ongdoi ng, t e s t i f i e d tha tS uz a nne B ur gos w a s m a n a g e ro f

th e p h a r m a c is ts a t th e s e p h a r m a c ie s a n d “a lw a y s m a d e it a p o in t to k n o w w h a t w a s g o in g o n in e a c h p h a r m a c y . . . . S h e c a lle d a t th e e n d o f th e d a y to getthe sa l es and h ow m any [ pres cr i pt i on s] . . . . ” I n h erdai l y r eport s t o S uzanne, G h a b r ia l w a s r e q u ir e d to r e p o r t a e r o s o l s a le s s e p a r a te ly . G ha br i a l f

ur the rt e s t i f

i e d tha ta l though s he w a s hi r e d t o s upe r vi s e onl y the pr e s c r i pt i on a r e a a tL a M ode r na , w hi c h di d noti nc l ude the a e r os ol c om poundi ng se ct i on , she bec am e a w ar e thatsi gn i fi ca ntqu ant i t i es of ae rosol m edi ca t i on w er e n o n e th e le s s b e in g d is p e n s e d w ith L a M o d e r n a la b e ls , o f te n w ith G h a b r ia l’s in itia ls a s di s pe ns i ng pha r m a c i s t , w i thouthe rs upe r vi s i on. G ha br i a l t e s t i f i e d tha ts he in fo rm ed S u za n n e B u rg o s a b o u t th is. A d d it io n ally, acc o rd in g to G h ab rial’s t e s t i m ony , A r e t a R ui z , a pha r m a c y t e c hni c i a n, w a s di s pe ns i ng a e r os ol m e di c a t i on f r o m P e r i p h e r a l DM E, a DM E c o mp a n y l o c a t e d n e x td o o rt o a n d a f f i l i a t e d wi th La M o d ern a, w i th n o ap p aren tp h arm aci stsu p erv i si o n , as i s req u i red b y l aw . O n cro ssPharmac y technicia n Odalys Reg il, who pled guilty and cooperate d with the prosecution, 11 testified that L a Moder

na Pharmacy

would borrow aerosol medication from South Beach Pha rm a c y to f illthepre scripti on s and

that sh ekn e w theme dic atio ns sh ewa s h e lpingdispens e were not for actual use by patients bec ause “the DME owners would bragabout [the fraud].” Ghabrial' s testimony

undersc ored thecooperation between the B urg os’ two phar macies in filling the aerosol presc riptions for the DME c ompanies, testifying that after L a Moder

na moved to a new loca tion, the aerosol medications were no long er c ompounded or filled at L a Moder na. Rather, the D ME companies f axed prescriptions di rec tly to South Beac h, where medication was c omp ound e d, fi lle d in

bo xes, and

de liv e re d toL a

Mo dern a fo r disp e ns a l. Additionally , Carlos Gomez, a L a Moder na phar macy technicia n, testified that B urg os was 12 a c tiv ein s up e rv ising

thec omp ounding , even dire c tin ghim to m odif y thefo rm ula . Re g il testified to the sloppy

compoundingand dispensal methods at L a Moder na, as discusse d below, Section II .E. Although Reg il testified that Michael Iheagwara wa s her primary manag ing pharmacist at L a Moder

na, Suzanne B urg os would occa sionally substitut e as ma

nag ing pharmacist and, like Iheagwara, failed to supervise Reg il's wor k supplying prescriptions for the DME companie s. Finally, Suz anne B urg os’ initials appear in L a Moder

na log s on numerous oc c a sio ns a s th edispens ingph arm a c ist fo r ae ro so l me dic atio ns . 13 e xa m i na t i on, G ha br i a l t e s t i f i e d tha tR ui z r e por t e d t o e i the rM a r c o orS uz a nne B urgo s. A dd i t i on al l y, G habri al t es t i fi ed thatJa nei de R egui er o, a pharm ac y t ec hn i ci an atS ou th B ea ch P harm ac y, t ol d G habri al thatS uzanne B urgo s knew that R e gui e r o w a s f

i l l i ng a e r os ol pr e s c r i pt i on vi a l s w i th i nc or r e c tvol um e s of m e di c a t i on. I n l i ghtof

the e vi de nc e e s t abl i s hi ng the s ubs t a nt i a l f r a udul e nta e r os ol bu si ness on go i ng atbo th L a M od erna and S ou th B ea ch P harm ac i es , the j ury w as 11 ent i t l ed t o i nferthatS uzanne B urgo s, a l i ce nsed ph arm ac i stw ho m evi dence e s t a bl i s he d w a s a c t i ve i n m a na gi ng both the pe r s onne l a nd da y - t o- da y a c t i vi t i e s of b o th p h arm aci es, w as a k n o w i n g p art i ci p an ti n th e frau d u l en tco n sp i racy. 12 S im ila r ly , th e d is tr ic t c o u r t d id n o t e rrb y in s tru c tin g th e ju r y o n d e lib e r a te i g n o ran ce, as th ere w as ev i d en ce t o su p p o rtan i n feren ce th atS u zan n e B u rg o s,14

th r o u g h h e rr o le a t S o u th B e a c h a n d L a M o d e r n a P h a r m a c ie s , w a s a w a r e o f f a c ts th a t s h o u ld h a v e p u t h e ro n n o tic e o f th e f r a u d u le n t a c tiv ity , b u t d e lib e r a te ly in s u la te d h e r s e lf

f r o m p o s itiv e k n o w le d g e . T h e d is tr ic t c o u r t d id n o t a b u s e its d is c r e tio n b y a d m ittin g e x tr in s ic e v id e n c e o rb y a llo w in g A g e n t C e s a rA r ia s to te s tif y a b o u t h is a u d it o f

L a M o d e r n a a n d S o u th B e a c h P h a r m a c ie s , a s th e a u d it re pres ent ed i nt ri nsi c e vi dence thatthe ph arm ac i es had p urpo rt ed t o sel l m ore prod uctdu ri ng the t i m e per i od of the conspi ra cy than t he vo l um e of s up pl i es they p u r c h a s e d w o u ld h a v e a llo w e d . A s t o S uz a nne B ur gos ’ s e nt e nc e , the di s tr i c tc our tdi d note r ri n c a l c ul a t i ng the am ou ntof l oss a t tri bu t abl e t o S uzanne B urgo s – i n a j oi nt l y und er t aken c r im in a l a c tiv ity , e a c h d e f e n d a n t is r e s p o n s ib le f

o r“a ll r e a s o n a b ly f

o r e s e e a b le a c ts a n d o m is s io n s o f

o th e r s in f

u r th e r a n c e o f

th e jo in tly u n d e r ta k e n c r im in a l a c tiv ity .” U .S .S .G . § 1 B 1 .3 ( a ) ( 1 ) ( B ) . E . M i ch eal Ih eagw ara M i chae l Ihea gw ar a, a l i ce nsed ph arm ac i st , i ncorpo ra t ed tw o p harm ac i es thatw er e a l l egedl y i nv ol ved i n t he fr aud schem e, L a M od erna and, l at er , M az P h arm acy. H e arg u es th ath i s co n v i ct i o n fo r co n sp i racy m u stb e v acat ed b ecau se the di stri ctcourterre d i n fi nd i ng thatR ul e 408 of the F eder al R ul es of E vi denceIheagwara also a rgues that the district cour t erre d at sentenc ing by

depar ting upwa rd under the 13 sentenc ingguide lin e s and by orderingre sti tution

so e xce ssivea s to vio latetheEi ghth Am e ndment. We f

ind no meri t in

e ith e r o f t

he searguments . 15 di d n otappl y t o cri m i nal proceedi ng s, and t hu s e rr on eousl y a dm i t t ed evi dence 13 a r i s i ng f r om a s t a t e a dm i ni s tr a t i ve c om pl a i nta ga i ns thi m . T he a dm i ni s tr a t i ve com pl ai ntati ss ue w as brou gh tby the F l ori da D epar tm entof H ea l th agai nstM az P h arm acy. In h i s rep resen t at i v e cap aci ty as an o w n er o f M az P h arm aceu t i cal s, Inc. , Ihea gw ar a s i gn ed a s t at em enti n res po nse t o t he com pl ai ntw here i n h e a gree d t o: ( i ) a dm i ta s true the drug- a l t e r a t i on a l l e ga t i ons m a de i n the a dm i ni s tr a t i ve com pl ai nt ; and (i i ) perm i tthe D epar tm entof H ea l th t o ent era f i ne and fi nal order i n o rdert o avo i d m ore f orm al adm i ni stra t i ve proceedi ng s a nd the po t ent i al p e n a ltie s a r is in g th e r e f

r o m . T h e d is tr ic t c o u r t o v e r ru le d I h e a g w a r a ’s o b je c tio n to the a dm i s s i on of

the s t a t e m e nt , hol di ng tha tR ul e 408 di d notba ri t s a dm i s s i on b e c a u s e R u le 4 0 8 d o e s n o t ap p ly to c r im in a l p r o c e e d in g s . R u le 4 0 8 p r o v id e s th a t “[ e ]v id e n c e o f . . . f u r n is h in g . . . a v a lu a b le consi dera t i on i n com prom i si ng or att em pt i ng t o com prom i se a c l ai m w hi ch w as di s put e d a s t o e i the rva l i di ty ora m ount , i s nota dm i s s i bl e t o pr ove l i a bi l i ty f oror i nv al i di ty of the cl ai m or i t s a m ou nt . ” F ed. R . E vi d. 40 8. O ur si st erci rc ui t s a re di vi de d on the que s t i on of w he the rR ul e 408 appl i e s t o c r i m i na l c a s e s : the S e c ond, S i x th , an d S ev en th C i rcu i t s h av e h el d th atth e R u l e ap p l i es o n l y i n ci v i l cases,In B onna rd v. City of Pric ha rd , 6 61 F .2 d 1 20 6, 12 09 (1 1th Cir . 1 98 1) (en b anc ), theEl e venth 14 Circ uit a dopte d a s b indingpre c e dent all F if th C irc uit pre c e dent h and e d down p ri or to t hec los e of business on September 30, 1981. 16 w hi l e the F i f

th a nd T e nth C i r c ui t s ha ve he l d i tappl i c a bl e i n both c i vi l a nd cr i m i nal ca se s. C om pare , M anko v. U ni t ed S t at es , 87 F . 3d 50 , 54 -55 (2d C i r. 1996) ( hol di ng R ul e 408 i nappl i c a bl e i n c r i m i na l c a s e s ) , U ni t e d S t a t e s v. L oga n, 250 F . 3d 350, 367 ( 6th C i r . 2001) ( s a m e ) , a nd U ni t e d S t a t e s v. P r e w i t t , 34 F . 3d 436, 439 ( 7th C i r . 1994) ( s a m e ) , w i th U ni t e d S t a t e s v. H a y s , 872 F . 2d 582, 588- 59 ( 5th C i r . 1989) ( hol di ng tha tR ul e 408 pr e ve nt s the i ntr oduc t i on of s e t t l e m e nt a gr e e m e nt s i n a c r i m i na l pr oc e e di ng) a nd U ni t e d S t a t e s v. B a i l e y , 327 F . 3d 1141, 11 46 (10t h C i r. 20 03 ) ( sa m e) . W hi l e w e not e the di vi si on of em i nentautho ri t i es o n th is is s u e , w e a r e p e r s u a d e d th a t R u le 4 0 8 ap p lie s to b o th c r im in a l a n d c iv il p ro ceed i n g s. F i rs t , the pl ai n l angu age of R ul e 110 1(b) re nd er s e ac h o f the F eder al R ul es of E vi de nc e – i nc l udi ng R ul e 408 – ge ne r a l l y appl i c a bl e t o c r i m i na l c a s e s a nd pr oc e e di ngs . F e d. R . E vi d. 1101( b) ( “ T he s e rul e s appl y ge ne r a l l y t o c i vi l a c t i ons and p roce edi ng s, i ncl ud i ng adm i ra l ty a nd m ar i t i m e c as es , [a nd ] t o cri m i nal ca se s a nd pr oc e e di ngs . . . . ” ) ; s e e a l s o, U ni t e d S t a t e s v. M e a dow s , 598 F . 2d 984, 989 ( 5th C i r . 1979) ( “ [ W ] e a s s um e the appl i c a bi l i ty of R ul e 408 t o gove r n the adm i ss i on of re l at ed ci vi l se t t l em entnego t i at i on s i n a cr i m i nal tri al . ”) . 1417

F ur the r m or e , w he r e the dr a f t e r s of the R ul e s i nt e nde d t o pr e ve ntthe appl i c a t i on of a pa r t i c ul a rR ul e t o c r i m i na l c a s e s , the y pr ovi de d s o e xpr e s s l y . S e e B a i l e y , 327 F . 3d a t1146 n. 6 ( c i t i ng F e d. R . E vi d. 803( 8) ( b) a s i ndi c a t i ng tha t“ the dr a f t e r s of th e R u l es k n ew h o w t o ex p ressl y ex cl u d e cri m i n al p ro ceed i n g s fro m th e R u l es’ appl i c a t i on w he n the y w a nt e d t o . . . . ” ) . W he r e the dr a f t e r s of R ul e 408 di d not e x p r e s s ly p r e c lu d e ap p lic a tio n o f R u le 4 0 8 to c r im in a l c a s e s , w e a r e r e lu c ta n t to co n stru e th atd eci si o n as i n ad v ert en t . W h i l e so m e co u rt s h av e read th e R u l e’ s u se o f th e te r m s “c la im ” a n d “v a lid ity ” to im p ly th a t R u le 4 0 8 w a s m e a n t to ap p ly onl y t o c i vi l c a s e s , s e e , e . g. , P r e w i t t , 34 F . 3d a t439, w e f i nd the s truc tur e of

the R ul e s a nd the e xpr e s s c om m a nd of R ul e 1101( b) m or e c om pe l l i ng. S ec on d, the l as tse nt ence of R ul e 408 spec i fi ca l l y s t at es thatthe R ul e “ do es n o t r e q u ir e e x c lu s io n w h e n th e e v id e n c e is o f f e r e d f o ra n o th e rp u rp o s e , s u c h a s . .

. p r o v i n g a n e f

f o r tt o o b s tru c ta c r i mi n a l i n v e s t i g a t i o n o rp r o s e c u t i o n . ” Fe d . R. E vi d. 40 8. Indeed, the advi sory com m i t t ee ’ s not es expl ai n t hatevi dence of “ an ef fortt o ‘ bu y off’ the prosecut i on or a prose cut i ng w i tness i n a cr i m i nal ca se ” p r o v id e s o n e e x a m p le o f e v id e n c e th a t is g e n e r a lly s u b je c t to R u le 4 0 8 , b u t th a t is re nd er ed adm i ss i bl e by the R ul e’ s l as tse nt ence . F ed. R . E vi d. 40 8, advi sory c o m m itte e ’s n o te ( 1 9 7 2 p r o p o s e d ru le s ) ( e m p h a s is a d d e d ) . I f th e d r a f te r s o f R u le 4 0 8 in te n d e d th e R u le to ap p ly s o le ly in c iv il c a s e s , th e r e w o u ld b e n o o c c a s io n to18

c a r v e o u t a n e x c e p tio n f o rc e r ta in c ir c u m s ta n c e s in c r im in a l c a s e s , m u c h le s s to add an adv i sory no t e di re ct l y c on ce rni ng the R ul e’ s e ff ec ti n cri m i nal ca se s. S ee U ni t e d S t a t e s v. S ke ddl e , 176 F . R . D . 254, 257 ( N . D . O hi o 1997) ; s e e a l s o S t a t e v. G a no, 988 P . 2d 1153, 1159 ( H a w . 1999) ( hol di ng tha tpa r a l l e l s t a t e rul e of e v id e n c e ap p lie d to c r im in a l c a s e s , b e c a u s e “c o n s tru [ in g ] th e ru le a s ap p ly in g o n ly i n ci vi l proceedi ng s w ou l d render the fi nal se nt ence of the rul e unn ec es sa ry ”) . T hi rd, appl yi ng R ul e 408 t o cri m i nal ca se s f urthers the po l i cyi nt er es t s that u n d e r g i r d th e R u l e . T h e a d v i s o r y c o m m i t t e e ’ s n o t e s c l a r i f y th a tth e r e a r e two ju s tif ic a tio n s f o rth e e x c lu s io n s th a t R u le 4 0 8 r e q u ir e s : ( i) th e e v id e n c e is i r r e l e va nt , a s the c om pr om i s e a ti s s ue m a y ha ve be e n m ot i va t e d by a de s i r e f or p e a c e r a th e rth a n a n y c o n c e s s io n a s to th e m e r its o f th e p a r ty ’s p o s itio n ; a n d ( ii) the excl usi on prom ot es se t t l em entof di sput es . F ed. R . E vi d. 40 8, advi sory c om m i t t e e ’ s not e ( 1972 pr opos e d rul e s ) . I ti s s e l f - e vi de nttha ta de f

e nda nti n a ci vi l sui ti s f

arl es s l i kel y t o o ff

ert o sett l e acl ai m i f e vi dence of thatoffe r c an la te rb e in tr o d u c e d to p r o v e c r im in a l lia b ility f o rth e s a m e c o n d u c t. L im itin g R u le 408 t o c i vi l pr oc e e di ngs thus unde r m i ne s the publ i c pol i c y i n f a vorof com prom i se thatthe R ul e a i m s t o further. M oreover, w hi l e the S ec on d C i rc ui thas f ound tha tthe i nt e r e s ti n a c c ur a t e de t e r m i na t i ons i n c r i m i na l tr i a l s outw e i ghs the i n t eresti n p ro m o t i n g ci v i l set t l em en t s, th i s rat i o n al e o v erl o o k s a b asi c p rem i se19

unde r l y i ng R ul e 408: e vi de nc e of c om pr om i s e i s notne c e s s a r i l y pr oba t i ve of l i abi l i ty. Indeed, the advi sory com m i t t ee ’ s not es i nd i ca t e thatevi dence of a set t l em en to ffer i s o ft en i rrel ev an tt o l i ab i l i ty fo r th e ch arg ed co n d u ct , b ecau se

“ the [ s e t t l e m e nt ] of

f e rm a y be m ot i va t e d by a de s i r e f orpe a c e r a the rtha n f

r om any c on ce ss i on of w ea kn es s of posi t i on . ” F ed. R . E vi d. 40 8, advi sory c om m i t t e e ’ s not e ( 1972 pr opos e d rul e s ) . I n thi s l i ght , pe r m i t t i ng the a dm i s s i on of ci vi l se t t l em entoffe rs i n sub se qu entcr i m i nal prosec ut i on s a ctual l y c om prom i se s the ac cura cy of the j ury’ s det erm i nat i on . A s the F i fth C i rc ui texpl ai ned, “ [i ] tdo es nott a x the i m a gi na t i on t o e nvi s i on the j ur orw ho r e t i r e s t o de l i be r a t e w i th the n o tio n th a t[ ,] if

th e d e f e n d a n ts h a d d o n e n o th in g w r o n g , th e y w o u ld n o t h a v e p a id the m on ey back. ” U ni t ed S t at es v. H ay s, 87 2 F . 2d 58 2, 58 9 (5t h C i r. 19 89 ); se e a l s o, B a i l e y , 327 F . 3d a t1145 ( di s c us s i ng “ the dr a m a t i c e f f e c t[ tha t ] e vi de nc e of a n a dm i s s i on of

l i a bi l i ty c oul d ha ve upon a c r i m i na l de f e nda nt ” ) ; G a no, 988 P . 2d a t1159 ( “ [ T ] he pot e nt i a l i m pa c tof e vi de nc e r e ga r di ng a c i vi l s e t t l e m e nt a g r e e m e n t is e v e n m o r e p r o f o u n d in c r im in a l p r o c e e d in g s th a n it is in c iv il proceedi ng s. ”) . F o rth e s e r e a s o n s , w e jo in th e F if th a n d T e n th C ir c u its in h o ld in g th a t R u le 40 8 app l i es t o b ot h ci vi l and cri m i nal proceedi ng s. Itfol l ow s thatthe evi dence and t es t i m on y a ti ss ue w as i nadm i ss i bl e und erR ul e 408 , and t hatthe di stri ctcourtWhil e Iheagwara argues for the first time on appe al that the evidence at issue also violates 15 Rule 403, we ne ed not re ach this issue, as our holding on Rule 408 grounds is disposit ive. 20 a bus e d i t s di s c r e t i on i n a dm i t t i ng the e vi de nc e . S e e K oon v. U ni t e d S t a t e s , 518 15 U .S . 8 1 , 1 0 0 ( 1 9 9 6 ) ( “A d is tr ic t c o u r t b y d e f in itio n a b u s e s its d is c r e tio n w h e n it m a k e s a n e r r o ro f

la w .” ) . H ow e ve r , a non- c ons t i tut i ona l e r r ori s ha r m l e s s i f , vi e w i ng the pr oc e e di ngs i n t hei r e nt i re ty, a c ou rtdet erm i nes thatthe error “ di d n otaf fe ctthe verdi ct , or had b u t v e r y s lig h t e f

f e c t.” S e e U n ite d S ta te s v . M a g lu ta , 4 1 8 F .3 d 1 1 6 6 , 1 1 8 0 ( 1 1 th Ci r . 2 0 0 5 ) ( i n t e r n a l ma r k s o mi t t e d ) ; s e e a l s o K o t t e a k a s v . U n i t e d St a t e s , 3 2 8 U . S. 75 0, 76 2, 76 4 (19 46 ). H er e, as w e det ai l bel ow , the go vernm entpres ent ed ove r w he l m i ng e vi de nc e of I he a gw a r a ’ s know l e dge of a nd pa r t i c i pa t i on i n the conspi ra cy . T here fore , w e f i nd thatthe adm i ss i on of Ihea gw ar a’ s s t at em entw as m e r e ly c u m u la tiv e a n d d id n o t a f f e c t th e v e r d ic t. Th e g o v e r n me n tp r e s e n t e d e v i d e n c e th a tI h e a g wa r a i n c o rp o r a t e d b o th La M o d e r n a P h a r m a c y ( a d /b /a f o rM & M P h a r m a c y ) , w h ic h h e c o - o w n e d w ith M ar co B urgo s, and M az P harm ac y. P harm ac y t ec hn i ci an O dal ys R egi l , w ho pl ed g u ilty a n d c o o p e r a te d w ith th e p r o s e c u tio n , te s tif ie d th a t I h e a g w a r a h ir e d h e rto w o rk atL a M o d ern a an d trai n ed h er t o co m p o u n d th e aero so l m ed i cat i o n , an d al so de s c r i be d L a M ode r na ’ s s t a nda r d pr oc e dur e s f orc om poundi ng the a e r os ol m edi ca t i on un der I heagw ar a’ s di re ct i on . A cc ordi ng t o R egi l , she a nd Ihea gw ar a21

d id n o t a c c u r a te ly w e ig h th e c h e m ic a ls m ix e d in th e c o m p o u n d s ; h ap h a z a r d ly di s pe ns e d the m e di c a t i on i nt o i ndi vi dua l dos a ge vi a l s , of t e n i gnor i ng the a m ount sp eci fi ed o n th e p rescri p t i o n ; d i d n o tcl ean th e m ach i n e u sed t o d i sp en se m e di c a t i on i nt o i ndi vi dua l vi a l s , s o tha ti tde ve l ope d agr e e n f ungus i n the d i sp en si n g h o ses; al l o w ed a n i g h tcrew t o l ab el th e m ed i cat i o n , u n su p erv i sed b y a pha r m a c i s t ; a nd w oul d pr i ntda t e s on m e di c a t i on l a be l s tha tdi d notm a t c h the ac tual dat e di spense d (as they s ho ul d). T he j ury c ou l d rea sonabl y c on cl ud e that these egre gi ou s vi ol at i on s i nd i ca t e I heagw ar a’ s kno w l edge thathe w as m a nuf a c tur i ng a nd di s pe ns i ng m e di c a t i on onl y t o c r e a t e a f a c a de of l e gi t i m a c y f

or th e f r a u d s c h e m e , a n d n o t to a c tu a lly s e r v e s ic k p a tie n ts . A ddi t i ona l l y , R e gi l t e s t i f i e d tha tw hi l e s he w or ke d a tL a M ode r na , s he a nd I h e a g w a r a s o ld h a lf

p o r tio n s o f

m e d ic in e to J o s e A r ia s , a n d th a t th e tw o a ls o s o ld un af fi xed l abel s t o Jose A ri as on the si de, re ce i vi ng a c as h p ay m entw hi ch they s ha r e d. L a t e r , R e gi l a nd I he a gw a r a l e f tL a M ode r na , a tw hi c h poi ntthe y ope ne d a D M E com pany t o con t i nu e the sc hem e, and Iheagw ar a e st abl i shed M az P h arm acy. M er ce des J er ez , w ho w orked atS un shi ne M edi ca l D M E and al so pl ed g u ilty in th e c a s e , te s tif

ie d th a t M a z P h a r m a c y w o u ld s e ll S u n s h in e la b e ls u n a f f ix e d to m e d ic a tio n , a s w e ll a s la b e ls b a c k d a te d b y s e v e r a l m o n th s . S peci al A gentT on y I l l as t es t i fi ed thatthe com po un di ng ar eaatM azJ &ABillingsubmitt ed the DME c ompanies’ c laims to Medicare . 16 Iheagwara argues that bec ause thedistrict court instructed thejury that the settlement 17 statement wa s admissible only ag ainst Iheagwara, and not Maz P harmacy co-owners Magnus Ogbenna a

nd Azubueze Ikejiani, the jury ’s ac quittal of Ogbenna a nd Ikejiani alone demonstrates 22 P harm ac y w as “ sl op py, ” “ st i cky, ” a nd “ fi l thy. ” I l l as al so t ol d t he j ury thatM az P ha r m a c y l a be l s w e r e s e i z e d pur s ua ntt o a s e a r c h of J & A B i l l i ng, a nd tha tthe

16 pr i nt e d s he e t s c ont a i ne d pr e s c r i pt i on l a be l s f orpa t i e nt s f

r om di f f e r e ntm onths on the sa m e s heet . T hese anom al ou s s heet s provi ded evi dence thatthe l abel s w er e notpr i nt e d i n c onj unc t i on w i th a c tua l di s pe ns a t i ons of m e di c a t i on t o pa t i e nt s , but r a th e rw e r e g e n e r a te d s im p ly to c r e a te a n ap p e a r a n c e o f le g itim a c y in th e r e c o r d s . M az P harm ac y l abel s s ei ze d d uri ng a s ea rc h o f F i rs tO pt i on M edi ca l C ent er s im ila r ly in c lu d e d d if

f e r e n t m o n th s o n th e s a m e p r in te d s h e e t. A dd i t i on al l y, Invest i gat or L ou i s C ol l ado t es t i fi ed thatw hen t hey vi si t ed M a z P ha r m a c y , he f

ound pr e - a nd pos t - da t e d a e r os ol m e di c a t i on pr e pa r e d f or di s pe ns a l ; the pha rm a c e ut i c a l or de r s c ont a i ne d onl y ha l f the c ont e nt s i ndi c a t e d on th e la b e ls . T h e te s tim o n y o f A g e n t C e s a rA r ia s c o r r o b o r a te s C o lla d o ’s te s tim o n y . F i na l l y , w hi l e w e ha ve s pe c i f i c a l l y de s c r i be d onl y the e vi de nc e i m pl i c a t i ng I he a gw a r a i ndi vi dua l l y , w e not e tha tthe gove r nm e ntpr e s e nt e d ove r w he l m i ng evi dence thata f

raud conspi ra cy exi st ed, general l y. B ec ause the subst ant i al e vi de nc e i nc r i m i na t i ng I he a gw a r a a s s ur e s us tha tthe e r r one ous a dm i s s i on of the st at em entw as harm l es s, w e a ff i rm Ihea gw ar a’ s c on vi ct i on and sent ence . 17that the statement wa s harmful to Iheagwara’s substantial rights. Our review of therec ord,

however, indicate s that Ogbenna a nd Ikejiani were not similarly situated, in terms of the e vide nc epre sente d tothejur y . A lth ough th e y

werec o- owners of

Maz Pha rm a c y , th e ir

sim ila ri ty to I he a gwa ra e nd s th e re . Ind e e d, the ir c o- owners hipof

Maz Pha rm a c y wa s v ir tually theon ly e v i d e n c ei mp l i c at i n gO gb e nn a an d Ik e j i an i . R e g i lt e s t i f

i e d th ati nh e r

v i s i t s t o M azP h ar

m a c y, “the only one I would actually

see f illing aerosol medications would be Michael [Iheagwara].” The g overnment presente d no evidenc e of personal knowledg e or involvement by Ogbenna or Ikejiani. The evidenceag ainst Ikejiani and Og benna thus a

ppear s compara

ble to that presented a g ains t Re inaldoL and

ro ve , who wa s also a c quitt e d. Th is evide nc edid no moretha

n e sta bli sh that Ike jia ni a nd Og benn a werec or po rateof fi c e rs fo r a

nd wereoc c a sio nally

pre sent at a

bu sin e ss implicated in the fra

ud scheme , perf

ormingtasks such as c ompounding or deliveringmedicine that they could plausibly

have e x ecute d with no personal knowle dg e of theunderly ing f raud. More c ompara

ble to Iheagwara were Ma rco a nd Suz anne B urg os, co-owners of L a Moder na. As with Iheagwara, the evidencedemonstrated tha t the Burg os wereactive in da y-to-day manag ement of businesse s involved in the fra ud over thecourseof several year s. Therewas testimony establishing that both Marco a nd Suz anne had specificknowledg e of f raudulent activity , and were active par ticipants. The jury ’s guilty verdic ts for Marco and Suzanne, the evidenc e ag ainst whom was compa rableto that ag ainst Iheagwara, bolsters our c onclusion that the er roneous admission di d not affe ct the jury ’s verdict on Iheagwara. 23 F. Pe dr o Sa r duy P ed ro S ard u y, a m ed i cal d o ct o r w h o w o rk ed atth e A ri as-o w n ed F i rst O p ti o n M ed ical C en ter, w as co n v icted o f c o n sp irac y b as ed o n th e g o v er n m en t’ s al l egat i on s thathe part i ci pat ed i n t he fr aud schem e by c er t i fy i ng fa l se di agno se s of C O P D . S a r duy a r gue s tha tthe di s tr i c tc our te r r e d by r e f us i ng t o i ns truc tthe j ury on h i s def

ense of w i thd ra w al fr om the conspi ra cy , beca use there w as s uf f i c i e nte vi de nc e t o s uppor tthe c onc l us i on tha the w i thdr e w f r om the conspi ra cy m ore than fi ve ye ar s bef ore the go vernm entchar ged h i m . If the j ury a c c e pt e d hi s w i thdr a w a l de f e ns e , the s t a tut e of

l i m i t a t i ons w oul d pr e c l ude c o n v ic tio n . T h u s , h e c la im s th e d is tr ic t c o u r t e r r e d b y r e f u s in g to c o r r e c tly24

i ns truc tthe j ur y on thi s de f e ns e , a nd tha thi s c onvi c t i on m us tbe r e ve r s e d. A c r i m i na l de f

e nda ntha s the r i ghtt o a j ury i ns truc t i on on hi s the or y of defe nse, se para t e a nd apar tfr om i nstruct i on s gi ven o n t he el em ent s of the charged of f e ns e . S e e M a the w s v. U ni t e d S t a t e s , 485 U . S . 58, 63 ( 1988) ; U ni t e d S t a t e s v. R u i z, 5 9 F . 3 d 1 1 5 1 , 1 1 5 4 (1 1 th C i r. 1 9 9 5 ). If th e p ro p o sed i n stru ct i o n p resen t s a va l i d de f e ns e a nd the r e ha s be e n “ s om e e vi de nc e ” a dduc e d a ttr i a l t o s uppor tthe de f e ns e , a tr i a l c our tm a y notr e f us e t o c ha r ge the j ur y on tha tde f e ns e . R ui z , 59 F . 3d at11 54 . T he bu rden of prese nt i ng evi dence s uffi ci entt o sup po rta j ury in s tru c tio n o n a th e o r y o f d e f e n s e is “e x tr e m e ly lo w .” I d . “[ T ]h e d e f e n d a n t is ent i t l ed t o h ave pres ent ed i nstruct i on s r el at i ng t o a theory of defe nse f or w hi ch the r e i s a ny f

ounda t i on i n the e vi de nc e , e ve n though the e vi de nc e m a y be w e a k, i ns uf f i c i e nt , i nc ons i s t e nt , orof doubt f ul c r e di bi l i ty . ” U ni t e d S t a t e s v. L i ve l y , 803 F . 2d 1124, 1126 ( 11th C i r . 1986) ( i nt e r na l m a r ks om i t t e d) . I n r e vi e w i ng the e v id e n c e a d d u c e d , th e c o u r t m u s t v ie w th e e v id e n c e in th e lig h t m o s t f a v o r a b le to th e a c c u s e d . R u iz , 5 9 F .3 d a t 1 1 5 4 . A n a c c u s e d c o n s p ir a to r ’s p a r tic ip a tio n is p r e s u m e d to h a v e c o n tin u e d u n til al l obj ec t s of the conspi ra cy have been acc om pl i shed or un t i l the l as tov er tac thas be e n c om m i t t e d by a ny of the c ons pi r a t or s . U ni t e d S t a t e s v. R e e d, 980 F . 2d 1568, 1583 ( 11th C i r . 1993) . H ow e ve r , i f a c ons pi r a t ore s t a bl i s he s the a f f i r m a t i veThe g overnment asserts that a c onspirator c annot withdrawafter an overt ac t has been 18 committed. First, we noteunder theoffense cha rg ed here, the c onspiracy

does not existuntil the commission of an overt act. See 18 U.S.C. § 371. Second, while w e havestated that “withdra wal [from a c onspiracy] i s impossi ble oncean over t act is committed,” seeUnited States v. Marolla, 766 F .2d 457, 461 (11th Cir. 1985), we c learly noted that “withdra

wal is not altog ether irrelevant” a fter theovert act, as “withdrawal prec ludes liability for acts occurring after the withdra

wal.” Id. Thus, an ef

fec tive withdrawal insulates the defendant from Pinkerton liability for the substantive crimes of c o-conspirators committed in furthera nce of the conspiracy after his withdrawal. Finally , even though withdrawal will not absolve the defendant from liability for the inc hoate c rime of c onspiracy, which is completed upon c ommissi on of an overt act, the statute of limitations for that charg e will beg in to run at the time of withdra wal. Here, Sarduy ’s withdraw al from the c onspiracy did not absolve him of criminal liability for the conspiracy

charg e. However, thesubsequent runningof the statute of limit ations for that prior pa rtic ipatio n w ould p re c ludetheg ov e rnment f ro m pros e c utinghim

fo r t ho sea c ts. Se e18 U. S.C. § 3282(a) ; United States v. Read, 658 F .2d 1225, 1232-33 (7th Cir. 1980) (“ Withdraw al bec omes a completedefense only

when c oupled with the def ense of the statute of limitations.”). 25 de f e ns e of w i thdr a w a l , the s t a tut e of l i m i t a t i ons w i l l be gi n t o run a tthe t i m e of w i th d r a w a l . I d . a t1 5 8 4 ; s e e a l s o U n i t e d St a t e s v . U . S. G y p s u m Co . , 4 3 8 U . S.

18 42 2, 46 5 n . 38 (197 8). O therw i se , the st atut e w i l l no tbegi n t o run un t i l the fi nal a c tof the c ons pi r a c y ha s oc c ur r e d. R e e d, 980 F . 2d a t1584. B ec ause w i thd ra w al const i tut es a val i d d ef ense t o t he conspi ra cy char ge, S a r duy w a s e nt i t l e d t o hi s r e que s t e d i ns truc t i on i f the r e w a s “ a ny f

ounda t i on i n the e vi de nc e ” t o de m ons tr a t e tha the w i thdr e w f r om the c ons pi r a c y m or e tha n f i ve years b efo re h e w as i n d i ct ed . S ee R u i z, 5 9 F . 3 d at1 1 5 4 . T h u s, S ard u y m u st de m ons tr a t e tha tthe e vi de nc e pr ovi de d a f ounda t i on t o s a t i s f

y thi s c i r c ui t ’ s tw opron g t es tfor w i thd ra w al : “ fi rs t , the defendantm ustprov e thathe has t aken affi rm at i v e st ep s t o d efeatth e o b j ect i v es o f th e co n sp i racy; an d seco n d , h e m u st s how e i the rtha the m a de a r e a s ona bl e e f f or tt o c om m uni c a t e the s e a c t s t o hi s c o-S ar d

uy al s o n o t es th e t es t i m o ny

o f go v ernm entwi tn es s Ad o l fo Baro n , a f o rm er p hys i ci an 's 19 assistant at First Option, who testified that Sarduy depar ted Fir st Option during the f irst half of 1995. 26 conspi ra t ors or di sc l osed the sc hem e t o l aw enforce m entautho ri t i es . U ni t ed S t a t e s v. Y oung, 39 F . 3d 1561, 1571 ( 11th C i r . 1994) . M e r e c e s s a t i on of p art i ci p at i o n i s n o tsu ffi ci en tt o est ab l i sh w i th d raw al ; th e accu sed m u stal so e s ta b lis h th a t h e c o m m u n ic a te d h is w ith d r a w a l e ith e rto h is c o - c o n s p ir a to r s o rto l aw enforce m ent . S ee U ni t ed S t at es v. F i nest on e, 81 6 F . 2d 58 3, 58 9 (11 th C i r. 19 87 ). T he ac cuse d p ar t i ci panti s notre qu i re d t o n ot i fy “ ea ch ot her m em ber” that he w i l l no l on ger part i ci pat e, bu tthe ac t s of w i thd ra w al m ustbe “ com m un i ca t ed i n a m a nne rr e a s ona bl y c a l c ul a t e d t o r e a c h c o- c ons pi r a t or s . ” S e e U ni t e d S t a t e s v. U .S . G y p s u m C o ., 4 3 8 U .S . 4 2 2 , 4 6 4 - 6 5 ( 1 9 7 8 ) . S ar du y a rgues thatthe evi dence provi des asuff i ci entfoun dat i on for aj ury t o i nferthathe had w i thd ra w n from the conspi ra cy , and t hatw i thd ra w al had b ee n co m m u n i cat ed t o Jo se A ri as, th e h ead o f th e sch em e. F i rst , h e p resen t s an A u g u st 2 8 , 1 9 9 5 l e t t e rt o Bl u e Cr o s s / Bl u e Sh i e l d , a s a d mi n i s tr a t o rf o rM e d i c a r e Pa r tB, w he r e i n he a dvi s e d the m tha the w a s no l onge rs e e i ng pa t i e nt s a tF i r s tO pt i on, a nd re qu es t ed hi s c ance l l at i on as prov i der a tF i rs tO pt i on . S ar du y’ s e xp er tt es t i fi ed 19 thata physi ci an coul d rea sonabl y a ss um e thatby no t i fy i ng M edi ca re thathe w as no l on ger w orki ng for apart i cul arcl i ni c, M edi ca re w ou l d n ot i fy any otherThese f

orms were signed by

convicted c o-conspirator I dania Arias. 20 27 part i ci pat i ng prov i ders . C i t i ng thi s e xp er tt es t i m on y, S ar du y a rgues thatthe l ett er to B lu e C r o s s /B lu e S h ie ld th e r e f o r e c o n s titu te d a c o m m u n ic a tio n “r e a s o n a b ly c a lc u la te d ” to r e a c h J o s e A r ia s , th e s c h e m e ’s p r in c ip a l. A dd i t i on al evi dence i nd i ca t es thathi s c om m un i ca t i on of w i thd ra w al w as i nde e d s uc c e s s f

ul , bol s t e r i ng hi s c l a i m . D a y s a f t e rhe m a i l e d the A ugus t28, 1995 l e t t e rt o B l ue C r os s / B l ue S hi e l d, hi s na m e w a s c r os s e d outf r om the l i s tof i nd i vi du al prov i der num bers on F i rs tO pt i on M edi ca l C ent er ’ s M edi ca re e l e c tr oni c bi l l i ng e nr ol l m e ntf or m . F ur the r , c he c ks s ubm i t t e d by the 20 gove r nm e nt , a s w e l l a s a c ha r tof thos e c he c ks s ubm i t t e d i nt o e vi de nc e by the g o v e r n m e n t, illu s tr a te th a t th e c h e c k s p u rp o r te d ly p a y in g S a r d u y f o rh is i nv ol vem enti n t he sc hem e c ea se i n S ept em ber 199 5. F i nal l y, S ar du y a rgues that t e s t i m ony by hi s f

or m e rof f i c e m a na ge rs t a t i ng tha tJ os e A r i a s a c qui r e d a subsequentO ct ob er16 th “ T o w ho m i tm ay concern” l ett erfr om S ar du y, i n w hi ch S ar du y w rot e that“ I w i l l be prov i di ng m edi ca l se rvi ce s a tF i rs tO pt i on M edi ca l C ent er , ” i nd i ca t ed thatA ri as had actual l y r ec ei ved S ar du y’ s c om m un i ca t ed w ith d ra w al (in th e A u g u st 2 8 th lett er ), an d w as attem p ti n g to en g ag e S ar d u y’s c ont i nue d pa r t i c i pa t i on. A f t e rthi s O c t obe re xc ha nge , a f i na l D e c e m be r4, 1995 l ett ert o B l ue C ross / B l ue S hi el d agai n request s S ar du y’ s c ance l l at i on as a provi der28

f orF i r s tO pt i on, a nd a dvi s e s B l ue C r os s / B l ue S hi e l d tha the ha d nots e e n a ny p a tie n ts s in c e s e n d in g th e p r e v io u s c a n c e lla tio n le tte rin A u g u s t. V i ew i n g th i s ev i d en ce i n th e l i g h tm o stfav o rab l e t o S ard u y, s e e R ui z , 59 F . 3d a t1154, a n d in lig h t o f th e “e x tr e m e ly lo w ” b u r d e n th a t S a r d u y m u s t m e e t, i d. , w e f i nd tha the ha s pr ovi de d a s uf f i c i e ntf ounda t i on i n the e vi de nc e f r om w hi c h a j ur y c oul d c onc l ude tha the t ook a f f i r m a t i ve s t e ps t o w i thdr a w f r om the co n sp i racy an d t o co m m u n i cat e th atw i th d raw al t o h i s co -co n sp i rat o rs. B ecau se S ar du y a dd uced evi dence s up po rt i ng hi s val i d t heory of defe nse, he w as ent i t l ed to th e ju r y in s tru c tio n h e r e q u e s te d . T h e d is tr ic t c o u r t’s e r r o n e o u s r e f u s a l to c h a r g e th e ju r y a s r e q u e s te d m a n d a te s th a t w e v a c a te S a r d u y ’s c o n v ic tio n . CONCL US I ON H a vi ng c ons i de r e d the r e c or d a nd a r gum e ntof c ouns e l , w e f

i nd no r e v e r s i b l e e r r o ra s t o G r i s e l A r i a s , M a r c o Bu r g o s , Su z a n n e Bu r g o s , I d a n i a C. A r i a s , D a l i a L a ndr ove , orM i c ha e l I he a gw a r a , a nd a f f i r m the i rc onvi c t i ons a nd s e nt e nc e s . H ow e ve r , f

orthe r e a s ons s e touta bove , w e va c a t e the c onvi c t i on a nd s e n te n c e o f

P e d r o S a r d u y a n d r e m a n d f o ra n e w tr ia l. A F F IR M E D i n p art V A C A T E D i n p art.