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# U n ited S ta tes Co urt o f Ap p ea ls

F o rth eS e v e n th C ir cu it
N o. 12

- 3231 U NI T ED S TATE SOF A MERI CA, P la intif f-A pp ellee, v. J OHN N ATALE, D ef endant-Appellant.

A pp eal from the United S t ates Di strictC ourt fo r the N o rthernDi stricto f Illino is, Eas tern Divisi on. No . 11 CR 594

—Rebec ca R. Pal lmey er, Judge
.
A RGUED A PRI L 18, 2013

— D ECI DE D J UNE 11, 2013

B efore B AUER, F L A U M a nd S YKES, C ircu it Judges . F LA UM, Cir cu i tJudg e . W he n a no th erdo ct o rr ev i ewe d the p ost-su rgical C T scan from on e of D r. J ohn N atale’s p at ien ts , so m et h in g d id n otse em righ t. N at ale h ad p re vio us l y rep ai r ed th e pat i en t’ s ao r ti c an eu r y sm, a nd the im ages f r o m t he CT scan did not m atch the p roced ure N atal e desc ribed i n hi s o perat ive repor ts. A n i nvest i gation cu lm inated i n N atale’s i nd ictm en t for he alth care fra u d r e l a te d to h is M ed ica re billin g, m ail fra u d for h is2 N o. 12

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use o fthe m ai l s in re cei vi ng the M edi car e r ei m burse

m en t ch ec k s, an d f al se st at ement s r el at ed to he al thcare f orthe i nac c uraci es i n hi s o perat i ve re port s a nd o ther m edi ca lno te s. The j ur y a cqui tt ed N at al e o n the fr au d counts but co nvi cted hi m o fm akin g fal se sta tem ents in viol a t io n of 18 U
. S. C
. § 1035. W he n ch arging th e j ury o n the f al se s ta te m en t co unt s, the trialc o ur t us ed i nstr ucti ons that see m i ngl y per m i tte d convi c tio n f orf al se sta tem ents com ple tely unre l ate d t o M edi car e r ei m burse

m en t. Nat al e no w cha l l en g es tha t i ns truction al o ng w i th se ver alo fthe dis tri ct c ourt ’ s e vi denti ar y rulings. W e a gr ee th at t h e di str i ct c ourt ’ s instr ucti on o n the f al se st at ement s ch ar g es s weptt o o b r o adly a nd a l l o wed c o nvi cti on forco nd uct notco vere d bythe sta tutory t ext. W e now clari fy the m ean ing o f § 1 0 35 an d i d en tify th e pr o o freq uir ed f o rc o nv i ct i o n. Be ca us e th e er r o ne o us instru ction w as ha rm less i n N atale’s case, how eve r, an d be c au se w e s ee n o e rro r inth e d ist ric t c o u rt ’s e viden ti ary r ul i ng s, we affi r m Nat al e’ s co nv i ct i o n.

I . B a c kg r o und A. F a c t ua l B a c kg r o und N atal e i s a vas cul arsur geo n w ho per f or m ed su rg eri es out ofN or thw estCom m unity Hospit ali n A rlingto n H eig h ts , I llin o i s. H e s p ec ializ ed in t h e t re at m en t o f ao rt icN o. 12

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an eu ry sm s , a c o n d i t i o n in v o l v in gw e a k e n e d v a s c u l a rw a l ls i n the a o rta, th e m ain a r te r y e xi tingthe he ar t. Tr ea tment foraneur ysm s g ener al l y invol ves surg er y, duri ng wh i ch th e su r g eo n c ut s o ut the wea k en ed ar te r i alt i ss ue a nd re pla ces i t with a s ynthet i c g ra ft. Tr ea tmento fa o r ti c an e u r y sms i s es pec i al l y c o m pl ex . The aor ta i s the m ai n conduitd el i ver i ng o xygenat ed bl oo d from the h e a r t t o ot he r bod y pa rts. I t thu s con sists of a wi de tube tha t l ea ve s th e he art and e xt en ds do wn th e c en te r of a p er so n ’s t or so . See Fi gure 1. A s such, i t i s m uch l i ke an i nter sta te hi ghw ay

— l a r g e , wi de , a nd de s i g ne d t o d eli ver high volum es of bl ood ( w hich w ou ld be li ke cars on the hi ghw ay) quick l y to the desti nati on body p ar ts. A n d ju st as an i nt erstate highw ay ha s exits th at d ivert4 N o. 12

- 3231 tr affi c to s m al l erlocalr o ads , a r te r i es b r an cho fffr o m the a o r t a t o d e l i v e rb l o o d t o th e v a r i o u s o r g a n s y s t e ms th roug hou t the bod y. F o r exam p le, the h ep atic artery car ri es bl oo d to th e l i ver ; the gas tr i c ar ter y deli vers blood to the stom ach ; and the ren al arter ies ensu re p er fu sio n of th e k id n ey s. SeeF igu re 2. T h e a or ta u ltim at ely

f or ks i nto tw o bra nches, bec om i ng the l eft a nd r i ght i l i ac ar ter i es. T h e iliac ar ter i es i n turn beco m e the fem or al ar te rie s, w h ich ca rry blo od to th e le gs an d l ow er ex tr em iti es. Sur geo ns use tw o differ ent types ofsy ntheti c g ra fts to r e p a i rth e w e a k e n e d a o r t i c wal l s . A tu b e g r a ftp e r f o r msN o. 12

- 3231 5 exactly a s i ts nam e i m pli es. A tube re pla ces the weake ned ar te r i alwal l( o ri s us ed to c r ea te a b y pas s ar ou nd the w eak ened ar ter y). S e e Figures 3B and 4B
. Th e tub e graft att aches to the a or ta i tse l f, befor e the v ess elspl i ts i nto the i l i ac ar ter i es. I n contr ast, a bi furcat i on gr aft spli ts i n t o t wo b r a n c h e s a ti t s l o we re n d , wi th th e t wo b r a n c h e s a t t a c hi ng to th e i l i a c a r t e r i e s , n o tth e a o r t a . As a res ul t, the b i fur c a t i o n g r a fti t s e l fh a s the s ha pe o f an u p sid e-d ow n “Y ”. SeeF i g u r e s 3 A a n d 4 A. W hi l e a l lao rt i c aneur ysm s prese nt co m pli cati ons, aor ti c aneury sm s abov e ( suprar enal aneury sm s) or near(j uxtare nalaneur ysm s) the re nalarte ri es prove especi al l y di ffi cul t. Tre ating the se aneury sm s r equi re s the s urge on t o cl am p the r enal a rter i es, se verthem fro m the aor ta, re pla ce the j uxtare nal seg m ent of the aor ta w i th a gr aft, and r eat tach the re nal ar ter i es to th e g raft. As a r es ul t, po st
- o per at iv e r en ala r te r i es a tt ac h t o a nd bra nch offfro m the synthe ti c g ra ft, notthe natura lao rt a. M edi car e r equi re s doct or s t o subm i t bi l l s using a fi ve- dig i t “ CP T” code, wh i ch d eterm i nes the l eve lo f M edi care r ei m bur se m en t. Be ca us e an eu r y sms inv o l ving the r enalar ter i es re quir e a m or e co m ple x proce du re , M ed i car e r ei m burse s s uch surg er i es at hi gherr ate s than sim p ler rep air s. In th is cas e, th e in d ict m en t a c c u se d N at ale ofper f or m i n g th e si m ple r re pai r surg er y whil e s ubm i tt i ngthe CPT co des a nd r ec ei vingr ei m bur se m en t for tre at m en t o f th e m or e c om p lex su p ra re n al a or tic aneury sm . Fo r the s urge ri es described in the i nd i ctm ent, use o fthes e bi l l i ng co des net ted N atal e about $3, 700 mo r e , i n t o t a l , t h a n th e c o d e s f o rl e s s c o mp l e x a n e u r y s ms a l l o we d.6 N o. 12

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Rei m pl ant at i on i nvol ves repla c em en tofthe ar t er i es an d 1 re es ta b lis h m en t o f b lo o d flo w . S ee St edm an’ s M edi c al D i c t i onar y 16 72 ( 28 th ed. 20 06 ) ( en t ry f or “r epl ant at ion ,” a s ynon ym of reim p lan tatio n). T hu s, N a t a l e’s use o f this w or d sug g ests he ha d s eve re d the r en al ar t er i es fro m th e ao rt a a nd reat ta ched them afterrepair ing the aneurysm , a procedure thatw ou ld ha ve j us t i fi ed the hi ghe r bi l l i ng c odes f or anan eury sm inv olv ing the re na l arteries. M ore sp ecifi cally, N atale faced tw o cou nt s of he alth care fra u d , see 18 U .S.C . § 13 47, on e c ou n t o f m a i l frau d , s e ei d. § 13 41 , and two co unt s o fmakingf al se s ta te m en ts r el at i ng to h ea lth ca re m at te rs , see id. § 1 035. A t the r oo t o fal lfi ve co un t s s a ta l l e g e d f a l s i t i e s c o nt a i ne d in the o pe r a t i ve r epo r ts for se ve r alo fNat al e’ s pat i en ts
. Acco r di ngt o the gov er n m en t, these st ate m ents gave the i m press i on that N atale ha d perform ed t h e m ore com p lex p roced ure i nvol vi ng the r enalar ter i es. A m ong othe r sta tem ents, f or e xa mpl e , N a t a l e d i c t a t e d th a th e “ r e i mp l a n t e d ” o r“ i mpla n ted” r enalar ter i es ofse ver alpati ents. H i s o perat i ve 1 not es also stated that a “b ut ton of th e ri gh t renal artery tissue w as th en cut out an d sew n to a p o r tion of th e graft w i th 5- 0 Pr ol ene. ” Thus, he des c ribed sewing the r enal ar ter i es dir ectly into the synthet i c graft (the 5-0 Pro l ene) as i fhe ha d repai re d an aneury sm i nvol vi ng the r enal ar ter i es. In additi on t o these st ate m ents (and other s) su ggesti ng i nv olvem en t of th e renal arteries, N atale’s oper ati ve re port s and othernot es sugge ste d use o fbi furcati on g ra fts rath er t h an tube gr afts. Fo r exam ple , o ne not e expla i ns thathe “ extended th e lim bs o fthe bi furcat i on gr aft d own to the externali l i ac a rt er y b ulg e. ” In re al i ty,N o. 12

- 3231 7 the g o v e r nme ntc ha rg ed, Na t a l e h a d p e r f o r med a s i mpl e r e pa i r b e l o w the r e na l a r t e r i e s us i ng o nly a tube gr aft. These al l ege dlyf al se sta tem ents i n the oper ati ve rep orts p rovide d both the m isrepre s en tations nec essary for th e s c h e m e to de fraud and the falsi ties nec essary f orthe f al se sta tem ent c ounts.

B . P roc ed u ral H is tory At t r i al, the g o ve r nm en t o ffer ed th e exp er t te st i m o ny ofDr. Geor ge A nton, a surg eon w i th H i l lcr est H ospi tal inC lev ela n d . A n to n te st ified th atN at a l e s u p p or te d h is use o fthe hi gher -p ay i ng bi l l i ng co des thr ough the st ate
m en ts i n the o per at i ve r epo r ts
. Ope r at i ve r epo r ts g en erall y p r ovide a sum m ary of th e surge ry

— des cr ibing w hat pr oce du re was done, wh at the doct ornot i ced, wh at c o mp l i c a t i o n s , i fa n y, o c c u r r e d , e t c . N o r th we s tC o mm unity pol i cy re quir ed com p leti on o fand subm i ssi on o f oper ati ve re port s fol l owing al lsur ger i es. A nton a l so id en ti fi ed w hat he bel i eve d w er e f al se st at ement s i n Nat al e’ s oper at i ve r epo r ts
. W hi l e th e re po r t s i nd i c a t e d tha tNa t a l e h a d ins e r t e d b i fur c a ti on gr afts i nvol vi ng the r enalar teries, A nton be l i eve d that N at al e ha d i ns te ad us ed si m pl e tube g r afts bel ow the re nalar ter i es

— a pr o ce dur e th atwoul d no t j us ti fy the b illing co d es N at ale h ad su b m itt ed . A n to n rea c h ed th is concl usi on byco m pari ng post
- su rg icalCT scans o f N at ale ’s p at ien ts w ith th e p ro c ed u r e s d es c rib ed in N at ale ’s o p er at ive rep or ts a n d oth er n ot es . A n to n co u ld m ake thi s com p ar iso n beca use s ynthet i c m ate ri al ap p ea rs di ffer entl y fro m natur alti ssue on the CT scans.8 N o. 12

- 3231 Thu s, w h en vie w i ng the se scans, A nton co uld s ee pr ec i se l y whatty pe o fg r aft N at al e ha d us ed an d w here thes e g ra fts att ached to the aor ta. A cco rd in g t o A nton, the CT sca ns sho w ed onl y a tube g r aft, th e to p o f whi ch at ta ch ed to th e ao r ta below the r en ala r te r i es a nd th e b ott o m o fwhi cha tt ac he d t o the ao rt a a b ov e t h e iliac art er ies
. See F i g ur es 3B an d 4 B. N atale’s op erative rep orts an d oth er not es , h o w ever, su ggeste d that N atale ha d i ns e r t e d a bifurc ation graft th at atta ch ed to the ao r ta abov e the renal arteri es

— ther eby re quir i ng tha t the r enalar ter i es att ach to an d bran ch o fff rom the syn th etic graft

— an d b el o w the en d of th e a or ta , att ac h in g t o e ac h iliac art er y. SeeFi gure s 3A and 4A

. A l though th e op er ati ve re port s descr ibed bi furcat i on g ra fts, N atal e di d not use bi l l i ng c odes f or bi fur ca ti o n g r afts
. Anto n a l so us ed demons tr at i ve e xh ibi ts to hel p the j ury vi sual i ze hi s o pini ons and t es tim on y.N o. 12

- 3231 9

A nothergo vernm ent w i tness , K el l y H ar tung, descr ibed M edi ca r e pr ac ti ce s, polic i es , a nd pr o ce dur es . Har tu ng w or ked f orthe cor pora te contr acto r charg ed w i th adm i ni ster i ng the M edi car e pr ogr am i n I l l i noi s a nd se ver alo ther M i dw estst ate s. S he tol d the j ury that N atal e had subm i tte d bi l l i ng codes f oraneur ysm r epai r i nvol vi ng the r enal arteri es , c o ns i st en t wi thNat al e’ s no te s buti nc o ns i st en t w i th A nton’ s r eadi ng o fthe CT s cans. H ar tung al so tes ti fi ed that, w hen d oct or s enro l lin the M edi car e pr ogr am as an aut horized bil ler, they receive no t ic e of M ed icare poli ci es , pr o ce dur es , a nd r ul es, a nd a ckno wl edg e ha ving re ad and und er sto od t h ose r ule s. A t v ar i ous o therpoi nts inth e c laim su b m iss ion p ro c es s, d oc to rs rea ffirm th eir k no wl edg e o fM edi ca r e bi l l i ngr ul es a nd po l i ci es , v er i fy i ng10 N o. 12

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th atth e b ills th ey h av e s u b m itt e d w e r e for w or k a c tu ally per f o r m ed an d m edi ca l l y ne ce ss ary. F i na l l y, Har tu ng to l d the j ury abo utM edi ca r e’ s au di tingpr o ce ss , e xpla i ni ng tha t duri ng an audit, M edi car e “w oul d request docum entat i on . That r equest
. . . can be forthe oper ati ve re port [ , ]
. . . X- ra ys, l ab no tes , [ and/or ] personal offic e n ot es th ata p h ys icia n m ay h av e m ad e.” Lik e the M edi car e r epres entat i ve, A nton a l so disc ussed oper ati ve re port s. H e m ade n o m enti on o fthei r re l evance i n M e di c a r e b i l l i ng, b uth e di d e xp l a i n tha to pe r a t i ve r epo r ts he lp do ct o r s m ak e tr ea tmentde ci si o ns f o l l o wi ng su r g ery . The y a r e es pec i al l y he l pful

— an d i m po r ta nt

— f or phy si ci an s who di d no t per f o r m the s ur g ery on th e pati ent b ut ar e t ask ed w i th future tr eat m ent.N o. 12

- 3231 11 M edi ca r e ne ve rr eque st ed, rec ei ve d, o rr ev i ewe d the op er at ive rep or ts d es c rib in g th e s u rg er ies atiss u e in th is ca se . Nordi d thi s ca se a r i se fr o m a M edi ca r e au di t. Ins t e a d , o n e o fN a t a l e ’ s p a t i e n t s so u g h tt r e a t me n tfr o m a com peti ng va scul arsur geo n at N or thw estCom m u n ity. ( I t’ s unc l ea r, b utul ti m at ely i rrelev an t, whethe rthe pat i en t so ughtt reatm entf o rthe s ame o ra di ffer en t co ndi ti o n. ) Tha t su r g eo n o r der ed th e CT s ca ns a nd noticed the di scr epanci es to w hi ch A nton l ate r tes ti fi ed at tr i al

. H e re port ed N atal e to the re view co m m i tte e atN or th w es t C om m u n ity , ult im at ely res u ltin g in th is i nv es ti g at i o n a nd pr o se cut i o n. N atal e t est i fi ed i n hi s o w n defe nse. H e a cknowle dged that the g ra fts at i ssue did notexte nd abo ve the ren al ar te r i es , but des cr ibe d th e an eu r y sm as j uxt ar en al, pl ac i ng i tj us tb e l o w the r e na larte ri e s . As a r e s ul t, h e e xp l a i ne d, “ther e was i nsuffi ci ent he al thy aor ti c ti ssue bel ow the r enal ar te rie s w ith w h ich to se w th e t op en d of th e g ra ft.” T h is si tuati on o rdi nari l y w ou ld re quir e the sy ntheti c g ra ft t o ex te n d bey ond the a or ti c j uncti on with the re nalar ter i es, ther eby requir i ng the sur geo n to i ncor pora te the r enal arteries i nt o the graft. R ath er than d o in g so , how ever, N atal e t ol d the j ury he used a techni que that he had l ea r ne d a s a r es i d en t a t Rus h P r esby te r i an( dubb ed th e “Rush Technique” at tr i al )
. A ccor ding to Dr. Cyrus Se rry, w ho serv ed a s a tten d ing p hy sician at R us h d uring N atale’s r es i den cy, the Rus h t echn iqu e i nv o l ve s f o l di ngo ve rthe wea k en ed ao r ti c wal lt o do ubl e i ts thi ckne ss . Thi s do ubled

- o ve rt i ss ue s tr en g th en s th e ao r ti c wal l, pe r m i tt i ng att achm ent o fth e to p end ofthe gr aft where, pre vi ousl y, th e ti ss ue ha d be en to o wea k to su ppo r t su ch at ta ch

m en t. B e c a u s e th e graft can att ach to the d ou bled -over,12 N o. 12

- 3231 str engthe ned aor ti c wall, the re nal a rt er i es need not be seve red and sew n into th e graft. Th is techn iqu e, Serry testifi ed , i s m o r e c o m p lex th an the sta nd ard repa ir for a su p r aren al aneu rysm becau se th e surge on m us t ens ure that the doubl ed-o verfl aps do no t obstruct the o penings to th e r en ala r teri es. M o r eo ve r, b ec au se the t ec hni que i nvol ves a doubl in g-overo fao rt i c ti ssue and no syntheti cs, us e o fthi s te chni que woul d no t a ppea ron a l at erCT s ca n. M edi car e has not desi gnate d a bi l l i ng code f or the Rush Technique. ( N othing i n the m edi cal l i ter atur e ha s e ver des cr ibe d the Ru sh Tec hni que . ) As a r es ul t, Nat al e ex p lai ne d , he d id as h e w a s i n stru cted at M ed icare tr ain i ng se ssi ons and chose the b i l l i ng co de that m ost approxi m ate d the pro cedure he had perfor m ed. Because the Rush Techni que w as, i n N atal e’ s v i ew , the “functi onal equi val ent” of a pro cedure i ncor pora ti ng the r enal ar te r i es i nt o the s y nthe ti c g r aft, Nat al e su bmi tt ed the bi l l i ng c o des f o rtha t pr o ce dur e, r athe rtha n the b i l l i ng co des f o rr e p a i ro fa n a o r t i c a n u e r y s m n o ti n v o l v i n gthe re nalar ter i es. N ata l e al so a dm i tt ed th athi s o per at i ve r epo r ts a nd othe r note s co ntai ned i naccura c ies. H e a tte m pted to explain away the se er ro rs bychar acte ri zi ng the m as in n oc en t m ist ak es . Th ey aro se , h e t o ld th e jur y, from h is sta tus a s the “busi estcar dio vasc ula r thor aci c sur geo n i n the Nor th wes t S ubu rbs ” a nd hi s s l o ppi ne ss i n di ct at i ng the r epor ts

— a s man y a s e i g hty t o o ne hu nd r e d r eco rd s at a ti m e, so m et i m es se ve r al wee k s after p er f o r m i ng the s urge ry . Final l y, N ata le to ld the j ury he di d not ha ve b i l l i ngi n mi nd w he n di ct at i ngthe r epo r ts , no tingN o. 12

- 3231 13 th atthe r epo r ts i den ti fi ed seve r alpr o ce dur es a nd i tem s that he shoul d have bi l l ed to M edi car e but did not

. T he govern m en t’s rebut tal w itness cha ll en ged N atale’s in vo ca ti o n o fthe Rus h Te chni que . W hi l e Dr
. J o hn Pe ters

— N at al e’ s su r g i ca la ss i st an t atthe t i m e o fthe su r g er ies a t i ss ue

— admi tt ed th atthe Rus h Te chni que
“ s o u n d e d f a mi l i a r, ” h e t e s t i fi e d th a th e d i d n o tr e me mbe rNat al e per f o r m ing the Rus h Te chni que dur i ng the s urge ri es i n thi s ca se. A fter cl osin g a rgum en ts, th e pa rties agreed on j ury i ns truct i o ns

— wi th o uto bj ec ti o n fr o m N at al e o n the i nst r uct i o ns a t i ss ue

— and the di str i ct c ourt so instr ucted the j ur y . The di st r i ctc o ur t al so , o ve rNat al e’ s obj ec ti o n, perm i tte d the j ury to t ake A nton’ s dem onst ra ti ves i nto th e j ury r o o m dur i ngde l ibe r at i o ns . I m po r ta nt l y, the g o ve r nm en t “ st r i pped do wn” the de m o ns tr at i ve s th atthe j u r y u s e d d u r i n gd e l ib e r a t i o n s . U n l i k e th e t wo di a g r a ms prese nted i n Fi gure s 3 and 4, the dem on st ra ti ves used du r i ngde l ib e r a t i o ns di d n o tc o nt a i n the h e a di ng s “ Op

er ati ve Report ” a nd “Actual Op er ati on. ” Instea d, i t j ust conta i ned the pi cture s that An ton used w hen te sti fyi ng. The ju ry ul ti m ate l y a cquit ted N atal e o n al lthr ee fra ud counts but f ound hi m gui l ty on the f als e stat em en t co unts. N at al e m o ve d f o ra ne w tr i alb as ed o n the j ury’ s use o fthe dem onst ra ti ves d u ring del iber ati ons, w hi ch the dist ri ct c ourtdeni ed. H e m ade no othe r po st
- tr i almo ti o ns a nd r ec ei ve d a t en - m o nth pr i so n s en tence o n to p ofa $40, 000 fi ne. N atal e no w appeal s.14 N o. 12

- 3231 I I . Discussi on A . Th e Pl ai n Err ori n the Dist r i ctCourt ’ s Fal se St at em ent I nstructi ons W as Harmle ss N atal e’ s pri m ar y chal l enge to hi s convi ction f ocuse s o n the j ur y i ns truct i o ns tha t th e tr i alj udg e i ss ue d o n the f al se sta tem ent c ounts. The go vernm ent res p ond s that N at al e ha s wai ve d a ny c ha l l en g e to the se i ns tructi o ns bec au se he affirm at ively ap p roved of th em at the j ury i nstr ucti on co nfe re nce. M oving thr ou gh the pro posed i nstr ucti ons one by one, the dist ri ct cour t ask ed, “[Pr oposed Ins tr u c ti on] N o. 29 i s m aking f al se sta tem ents i ns truct i o n o uto f1 8 Uni te d S ta te s Code , S ec ti o n 1 00 1, a nd 18 U ni ted S tat es Code, S ecti on 1035. A ny probl em with th at ?” De fen se c o uns el ’ s r es po nse: “No. ” Cou ns ele ng ag ed i n a s i mi l a rqu e s t i o n - an d- an swe rc o l l o quyr eg ar di ng the r em ai nd ero fthe i nstr ucti ons on the f alse st ate
m en ts c o unt s, wi ththe t r i alc o ur t as k i ngc o uns el ifhe

“ ha d a ny pr o b l e m wi th” e a c h pr o po s e d i ns t r uc t i o n. Each ti m e, co u nselaffi rm ati vel y e xpresse d havi ng no probl em with the pro posed i nstr uct ion . Th e g ove rnm ent no w su g g es ts tha t th e defen se a tt o r ne y ’ s co m m en ts dur i ng thi s e xchange a ffi rm ati velyapprov ed the j ury i nstr uction, resu lti ng i n w aiver. Ordinar i l y, wh en a defe nd ant doe s no t obj ect to a j ur y i ns tru cti o n b efo r e th e j ur y r et i r es t o de l ibe r at e, the d efe n d an t m ay lat er at ta c k th atins tr u c tio n on ly for p lain er ro r. Fe d . R
. C r im . P. 30 (d ); Jo hn son v. U nited Sta tes , 520 U
. S. 461, 465-66 (1997 ). H o wev er , a d efe nda nt who w ai ves

— ra therthan f or fei ts

— h is ob j ec tio nca n n otav ail hi m sel fo fev en the dem anding pla i n er ro r sta nd ard o fN o. 12

- 3231 15

re vie w . Se eU ni t e d S t at e s v. O l ano , 507 U.S
. 72 5, 73 2- 33 ( 19 93 ) ( “Devi at i o n fr o m a l eg alr ul e i s ‘ er r o r ’ unl es s th e ru le h as be en w a i v e d .”); U nite d States v. D iSantis , 56 5 F
. 3d 35 4, 3 61 ( 7th Ci r . 2 00 9) ( “Wa iver ‘ ex ting ui sh es a ny er ro r’ and ‘ precl ud es appell ate r evi ew . ’ ” ( ci ti ng U n i ted Sta tes v. P ree, 4 08 F.3d 85 5, 8 72 ( 7th Ci r . 2 00 5) )
. He h as no re c ou rs e a n d ge n er ally m u stlive w ith h is e ar lier d ec isio n n ot to press the er ro r. S uch w ai vero ccurs o n ly w he n a de fe nd a ntma k e s a “ k no wi nga nd i nt e nt i onal deci si on” to f or go a chal l enge bef or e the di str i ct c ourt
. U nited S t a tes v. Jaim es-Jaim es , 406 F.3d 845 , 848 (7th C ir. 20 05 ). In co n tr as t, w h en t h e “ d efe n d an t n eg lige n tly by pas se s a va l i d a r g um en t, ” he ha s m er ely f o r fei te d the cl ai m and can r ai se i t o n appeal, subj ect to pla i n er ro r re vie w . U nited Sta tes v. Va squez , 673 F.3d 680, 684 (7th C ir. 2012 ) ( c iting U ni t e d S t at e s v. Ande rs on , 60 4 F
. 3d 997, 10 01 (7t h C ir. 20 1 0 ) ) . W e g en er ally co n st ru e w aiv er “lib er ally i n f avo r ofthe defe nd ant. ” Ja im es-Jaim es , 40 6 F
. 3d at 848. A l though pass i ve si l ence w i th r ega rd to a j ury i nstru ctio n p er m its p lain e r r or rev iew , seeFed

. R. Crim
. P. 30(d ); see, e . g. , U ni t e d S t at e s v. M i t an , 96 6 F
. 2d 1165 , 11 77 ( 7th Cir
. 19 92) , a d efe nd ant’ s a ffi rm ati ve approvalo fa prop os ed ins tr u c tio n res u lts in w aiv er , e . g. , U nited Sta tes v. Cour t r ight, 63 2 F
. 3d 363, 37 1 ( 7th C ir. 2011)
. Our ca ses ha ve s tr i ct l y a ppl i ed th i s r ul e to affi r m at i ve e xpr es si o ns ofapprov alwitho ut exam i ni ng wh etherthe sta tem ents w er e a “know i ng and i ntenti onaldeci si on” orr esul ted16 N o. 12

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O ther circui ts have not app li ed this ri gid rule and ins tead 2 ha v e an aly zed w he the r a d elib era te, s tr a t e g ic reaso n co u ld have jus ti fie d the at torney’ s a ffirm ati ve app roval ofa j ury in str u ct io n . U n i te d S tat es v. R u cker, 41 7 F . A p p ’ x 71 9, 7 21 -22 (10th C ir . 20 1 1 ) (no n -p re ce d en tia l d ec isi o n ); Vi rgi n Isl an ds v. R osa , 399 F .3d 28 3 , 29 1 ( 3 d C i r . 2 0 0 5 ); U n i te d S tat es v. P erez , 116 F. 3d 840, 8 4 5 -4 6 (9t h C ir . 19 9 7 ) (en b a n c); U ni t ed S tates v. D ro ugas , 748 F .2d 8, 30 ( 1stCir. 1984) ( “D efense counselex plic it ly approv ed th e r ea so n a b le d o u b t in s t ru ct io n an d is th u s p re cl u d ed

. . . fr o m n o w o b jec tin g ab se n t p la in er ro r.” ); U ni t ed Sta t es v. Wigg i ns , 53 0 F .2d 101 8, 102 0 (D .C. C i r . 19 76 ) (ap p lyin g p lain er ro r st anda rd whe n de fen s e c ouns ele xpr es s ed s at i s f ac t i on w ith ju ry in str u ct io n ). fro m “n eg lige n tly by p as s[ i n g ] a va lid arg u m en t.” See 2 Cour t r ight, 63 2 F.3d a t 3 71 ; U ni t e d S t at e s v. O ’ Connor, 65 6 F.3 d 63 0, 64 4 (7 th C ir . 2 01 1); D iSantis , 56 5 F
. 3d at 361; U nite d States v. G ri

ff in , 493 F. 3d 856, 863 ( 7th C ir. 20 07) [hereina fter Gri

f f i n I ] ; U ni t e d S t at e s v. Ani f owos he, 30 7 F
. 3d 64 3, 65 0 (7th C i r . 2 0 0 2); U ni t e d S t at e s v. Sa l e r no , 10 8 F
. 3d 73 0, 74 2 (7t h C ir. 19 97 ); U nite d States v. Lak ich , 23 F. 3d 1203 , 12 07 -08 (7t h C ir. 19 94 ); U ni t e d S t at e s v. Cani no , 949 F. 2d 928, 9 4 0 ( 7 th Ci r . 1 9 9 1 )
. As a r e s ul t, a ffi r mat i v e s t a t em ents as si m ple as “no o bj ecti on” or“n o p ro bl em ” when aske d about the a cceptabi l i ty ofa proposed in structi on have re su lte d in w aiv er . Se eO ’ Connor, 656 F.3d at64 4; Gri f f i n I , 49 3 F .3d at86 3; Ani

f owos he, 30 7 F.3d at 65 0; U nited Sta tes v. G ri ff in , 84 F. 3d 912, 92 3- 24 ( 7th C ir. 1 99 6) [ here i nafter G ri ff in II ]. B ut se e U nited Sta tes v. R o gli eri, 700 F. 2d 883, 88 8 ( 2d Cir

. 1983) (apply i ng p l ai n er ro r re vi ew w here defense cou ns el ex p li citly ex p ressed no obj ection to th e j uryN o. 12

- 3231 17 i nstr u c tio n). W e hav e a pp l i ed thi s rule st ri ctl y b ecause o f th e di ffi cul tyi n t ea singo utthe s ubj ec ti ve mot i va tions be hi nd the “ no o bj ec ti o n” s ta te m en t

— fr o m tha t st at ement al one, a cour t ca nnot e asi l y disc ern w hetherthe att or ney b yp as se d a ch alle n ge for st ra te gic re as on s (w h ich w o u ld re sul t in w ai ve r) or wh etherthe att or ney s i m plyf ai l ed t o r e c o g ni z e e r r o rtha th e o the r w i s e wo ul d h a v e r a i s e d. A s A nifo w o she expla i ned, f ai l ure to fi nd waiv erfro m affi r mat i v e s t a t e men t s o f“ no o bj e c t i o n” a nd the l i ke w oul d “cre ate an a l m osti nsurm ountabl e s tan d ard to proving waiv er . ” 3 07 F. 3d at 650. This approach can so m eti m es produce esp ec i al l y har sh re su lts . Jus t a s t h e d ist ric t c ou rtd id in N at ale ’s c as e, a t h o r o u g h d i s t r i c t c o u r t j u d g e wi l l a l mo s t a l wa y s h o l d a j ury i nstr ucti on co nfe re nce a nd put up the pro p osed i nstr ucti ons, o ne byo ne, f ordi scussi on bythe att or neys. S e e U n i ted S ta tes v. Ho lling er, 553 F.2d 535 , 542 (7th C ir. 19 77) ( “A n on -th e-r ec or d ins tr u c tio n s c on fer en c e . . . clea rly en ab l es the t r i alj udg e, i n a dva nc e o fi ns truct i ngthe j ury, to have er ro neous aspects [ ofth e ins tr ucti ons] poi nted out to hi m . ”)
. T he r esul t: A tr i alco urt w i l lal m ost al w ays r equi re o fco unselso m e affi rm ati ve re sponse

— s u c h a s “ n o o bj e c t i o n ” o r“ n o p r o b l e m”

— that w i l lo perat e as w ai vero n appeal

. Onlyr ar el y wil la j ury i nstr uct i o n co n fer en c e p ro vid e th e o p p or tu n ity for a gn os tic si l en ce tha t pr es er ve s pl ain e r r o rr ev i ew . In sh o r t, a s o ur case s hav e a pp l i ed thi s rule , a d efense att or ney who has not obj ecte d t o a propos ed i nstr ucti on w i l l ne ar ly a l w ays w aiv e a n y p ot en tia l obj ec tio n, reg ar d les s o f w h et h er h is “n o ob j ec tio n ” re su lte d f ro m a re as on ed , str at eg ic d ec i-18 N o. 12

- 3231

Suc h h ar s hne s s i s on l y m agnifi ed by the i m por t anc e ofthe 3 j ury ins tr ucti on in a t ri al. Ev en thoug h er ro n eous j ury ins tr uction s are no t the ty p e of struc tu ral err or tha t nece ssarily cr ea te s h a rm in a c ri m in a l tr ia l, se e U ni t ed Sta t es v. G riggs , 569 F. 3d 341, 344 ( 7th Cir

. 2009) , the Ru le s ofCivil Procedure re c ogni ze the wei ghty r ol e j ur y i ns t ru ctions fi l l : I n a l l butthe c on t e x to fjur y i ns t r uc t i on s , a pa r t y who f a i l s t o pr e s e r ve an erro r in a c i v i l t rial h as no reco u rse on ap p eal. In co ntr ast, a p arty can stillcha lleng e a jur y instru ction in a c i v i l case for p lain erro r no tw ithstan d ing his earlier f ai l u r e to ob ject. F ed . R . C iv . P . 51 (d ). sion or from a negligent failure to recognize th e error. 3 An appr oach tha t m i g htmit i g at e th i s ha r shne ss a nd l eave o pen a widerwindow f orf or fei ture than our case s h av e p re vio u sly d on e c ou ld be co n sid er ed w h e n, as in th i s ca se , de fen se c o uns el ’ s affi r m at i ve a p pr o va lo fthe j ury i nstr ucti on is n othing m or e than a s i m ple “no ” o r “n o o bj ec ti o n” dur i nga r o te cal l

- an d- r es po ns e co l l o quy w ith th e d istri ct j ud ge. I n such an instan ce, w e cou ld m ore cl ose l y e xam i ne wh etherthe d efend ant has trulywaive d h i s chal l enge to the j ury i nstr ucti on o r m er el y for fei ted it. C f. U nite d States v. A lcala , 678 F.3d 5 74, 579 ( 7th Cir. 2012 ) (“[N ]arrative respon ses in a p lea c o lloqu y are superi orto i nquir i es fro m the cour t that e l i ci t ‘ yes ’ or ‘ no’ an sw er s[.]” ); U nite d States v . G roll, 992 F.2d 75 5, 76 0 n .7 (7th C ir. 1993) (“[ S]i m p le affi rm ative or negat ive answ ers to th e c ou rt ’s ro te int er ro ga to rie s g i v e u s p au se in find ing tha t [the d efend an t] en tered he r p lea know ingly. ”); U nite d States v. Fountain , 77 7 F
. 2d 351, 35 6 ( 7th C ir. 19 85) ( “Si m ple affi rm at ive ornega ti ve answ er s o r re sponsesN o. 12

- 3231 19

w hi ch m er el y m i m i c the in d ictm ent o r the pl ea agr eem e nt c a nn o t ful l y e l uc i da t e the de fe nd a nt ’ s s t a te of m ind as requ ired by R ule 11.”). A dd i ti onal l y, w e note that w ai ver i s not an abs ol ute b a r o n o u r c o n s i d e r a t i o n o f i s s u e s n o t p r e s e r ve d b el o w, eve n i fi ntenti onal l y for ego ne f orst ra teg i c r eas ons. W hen th e “int er es ts o fj us ti ce ” so requ ir e, we m ayr ea chthe m er its of a w a i v e d iss u e. Se eFl e i s hm an v. Cont ’ l Cas
. Co. , 69 8 F
. 3d 59 8, 6 08 ( 7th Ci r . 2 01 2) ( ci tingJudg ev. Q ui nn , 62 4 F.3d 3 52 , 3 60 ( 7th Ci r . 2 01 0) )
. Pe r ha ps er r o ne o us j ury i ns truct i o ns

— esp eci al l y j ury i nstr ucti ons that i naccurat el y s tat e the l aw by m i ni m i zi ng o r om i tting el em ents re quir ed f orco nvi cti on

— woul d m or e r ea di l y pr es en t the c i rcum sta nces that al l ow consi derat i on o fwaive d iss u es : a “m isc ar ria ge of j u s tic e,” “e q u itie s h ea vily preponderat [ i ng] in fa voro fco rr ecting” the er ro r, o r “pl ain e r r o rtha t se r i o us l y a ffec te d the f ai r ne ss , i nte gr ity , or p u b lic re p u ta tio n of th e jud icia l p ro c ee d in gs .” Id. at60 8-0 9 (c itin g 3 6 C .J.S. Fe d er al C ou rt s § 45 8)); see a l s o Ol ano , 50 7 U.S
. at73 6 ( noting tha t “ convi cti on o r sente nci ng o fan a ctual l y i n n ocent defendant” qual i fi es as a “m iscarriage ofj us tice”). I n any eve nt, w e n eed notr each a ny o fthes e i ssues i n thi s ca se fore ve n in a ppl y i ngpl ain e r r o rr ev i ew t o the i ns tru c t i o n s i n Na t a l e ’ s c a s e , we fi n d n o e r r o rr e q u i r i ng a new trial. Thu s, we l eave o pen the quest i on o fwh ether Gri f f i n I , Ani f owos he, and ouro th er w ai vercas es have dr aw n to o confi ni ng a l i ne byvi ew i ng affi rm ati ve ap p ro va l so e x p an siv ely as to inc lu d e “ n o ob j ec tio n ” in r e s p o n s e t o a t r i a lc o u r t ’ s in q u i r y . An d ne i th e rd o we20 N o. 12

- 3231 ad d ress tod ay w he th er Ru le 30( d ) requ ires the m ore se ar c h i ng analysi s use d by o therci rcui ts that dive s into th e sub j ective m otivations of coun sel, hop ing to disce rn w he th er strategy o r ina d verten ce m otivated the affi rm ati ve ap p ro val

. Final l y, we express no opi ni on o n whethe rthe e rroneous i ns truct i o ns i n thi s ca se pr es en t the inter est s o fj usti ce that r eq u ire o ur co nsi derat i on no twi th st an di ng any wai ve r . I n sh o r t, when revi ewing the j ury i nstr ucti ons und er pla i n er ro r as N atal e a sk s of us , we se e no r ea so n t o v ac at e hi s co nv i ct i o n. Pl ai n er ro r re quir es “obv i ous” er ro r that i s “cl earunder curr ent l aw .” U nited Sta tes v. M cG ee, 60 F. 3d 1266 , 12 71- 72 (7t h C ir. 19 95 ). E ve n th en , rev er sa l is ap p ro p ria te on ly w hen the er ro r affects the defe nd ant’ s s ub st an ti alr i ghts. U nite d States v. G arci a , 580 F.3d 528 , 5 36 (7th C ir. 2009). N at ale rais es fou r c h alle n ge s to t h e j u ry ins tr u c tio n s in h is case . Fi rs t, he a rgues that the di str i ct c ourti m prop er ly f ai l ed to i nstr uct the j ury that convi cti on u nd er§ 1035 re quir es that the f al se sta tem ent b e m ad e in co nnecti on wi th a ma t t e r i n v o l v i n g a h e a l th c a r e b e n e fi tp r o g r a m. Se c on d , N at al e st at es th atth e jur y in st ru c tio n sh ou ld ha ve req uired f alse statem en ts m aterial to the health care benefit p rogr am . Thi rd, N atal e s ugges ts that § 1 035 re qui r es s pec i fi c i nt en t to mis l ea d o rde ce i ve an d tha t th e d ist ric t c ou rtd id n otso info rm th e jur y. Fin ally , N at ale ar gue s th at th e j ur y i ns truct i o n a s g i ve n v i o l at es due pr o ce ss b y pe r m i tt i nga rbi tr ary o rdi scri m i na to r y e nf o r ce m en t. Al th o ugh po r ti o ns o fthe di st r i ct cou rt ’ s i nstr ucti on co ntai ned er ro rs , thes e e rr or s di d not a ffect N atal e’ s s ubstanti alr i ghts.N o. 12

- 3231 21

At t ri al, the di s t ri c t j udge pro vi ded the f ol l owin g i ns t ru c t i ons 4 on the false statem en ts cha rg es: C ou nts IV an d V c ha rg e the d efend an t w ith m ak ing f alse st atem ents and represe ntat ions rel ati ng to heal thcar e m atter s. T o su stain th e ch arg e of m ak ing f alse statem en ts r e l a t i ngt o he a l thc a r e m a t t e r s , the go ve r nme nt m us tpr ov e the f ollo w ing p ro p osition s: First, the defen dantm ade a f al s e, fi c t i t i ous , orfra udul en t s t at em en torr epr es en t at i on. Seco nd , the statem en t or rep resen tatio n w as m ater ial. T hird , the sta tem en t or rep resen tatio n w as m ad e k no w ing ly and wi l l ful l y. And f our th, the defen dantdi d s o i n c onn ectio n w i th the del i ver y oforpay m en tfor he al thc ar e ben efi t s , i t em s , or serv ices. Ifyou fi nd from your consi derati on of allthe evidence that e a c h ofthe s e pr op os i t i on s h a s be e n prove d b e yo nd a rea son ab le d ou b t as to a p articu lar co u nt, then yo u sho u ld find the d efend an t gu ilty as to tha t cou nt. I f, o n th e o th e r h a n d, y o u fi n d fr o m yo u r c o n s i de r a t i on ofal l the e vi denc e tha tan y on e ofthe s e pro pos i t i ons has no tbe enpr ove d beyo nd a r ea s onabl e doubtt o a (co n tin u ed ...) 1 . Th e Di s t r i c tC o urt ’ s Pl a i n E r r o ri n Omi t t i ngt he H eal t h Care Benef i tPro gr am Req uir em ent f r om t he J uryI nstructi on W as Harmle ss N atal e’ s fi rs t chal l enge to t he j ury i nstr ucti on a ccuses th e tr i alj udg e o fo m i tt i nga n e ss en ti ale l em en t o fthe offe n se from th e in st ru c tio n . Sec tio n 10 35 p ro h ibit s , “ in 422 N o. 12

- 3231

(
. . . c on t i nu e d) 4 par t i c ul ar c ount, the n yo u s houl d fi nd the defen dantno t gui l t y. A s t at em en t i s f al s e or fi c t i t i ous i f unt ru e when m ade an d the n kn own t o be unt ru e by the pe rs on m aki ng i t or c aus i ng itto be m ade. A s t a t e m e nto r r e pr e s e nt a t i oni s f ra udu l e nti fk no wn t o be u ntr u e an d m ad e o r c au sed to b e m ad e w ith inte nt to deceive. A f al s e or fra udul en ts t at em en t, pr et en s e, or r epr es en t at i on is m a te ri a l if ith a d th e e f f e c to fi n flu en ci n g th e a ct io n o f a pe r s ono r e nt i t y orwa s c a pa bl e o f or ha d the po t e nt i a l t o do s o. I ti s no tne c es s ar y thatthe s t at em en t, pr et en s e, or re pre s en t at i on ac t ual l y ha ve thati nfl uen c e or b e re l i ed o n by the pe rs on or e ntity so l ong as i tha d the pot en t i al or c apa c i t y t o do s o. A n a ct is do ne w illfu lly if d on e v olu nta rily a nd inten tion ally an d w ith inte nt to d o so m eth ing the law f or b id s. A heal th c are benefitprogram i s “ a n y p ub li c or private plan 5 or cont ract, affect ing com m erce , und er which any m edical ben efi t, item , ors er vi c e i s pr ovi ded t o a ny i ndi vi dual an d incl ud es any individu al or e n ti ty wh o is prov iding a m edical be n e fi t, i t e m, o r s e r v i c e f o r wh i c h p a y me n t ma y be m a de un de r the pl a n orc on t r a c t
. ” 1 8 U. S
. C. § 2 4 ( b)

. Co ur t s h a ve inter p reted “affecting com m erce ” t o m ean affectin g intersta te co m m er ce . S ee U n ite d S t a te s v . K lein , 54 3 F .3d 206 , 21 1 (5th C ir . 20 0 8 ). a n y ma t t e ri n v o l v i n ga he a l th c a r e b e n e fi tp r o g r a m, 5 knowingly and wil l fully . . . m ak[ i ng] any m ate ri al l y f al se, fict itio u s, or frau d u len t s ta te m en t[] o r re p re se n ta tio n []
. . .N o. 12

- 3231 23 i n connect i on with the del i ver y o fo r p ay m ent for he a l th c a r e b e ne fi t s , i t e ms, o rs e r v i c e s [
. ] ” 18 U. S
. C. § 1 035( a) ( 2)
. N atal e a rgues t h at the j ury i nstr ucti on e rr ed i n om i tting the heal th ca re bene fi t pr ogr am r eq uir em ent. W e a gr ee but fi nd thater ro r harm l ess .

a. Convict i on U nd er§ 1035 R equ i r es as an Esse nti al E l e me nto fPr o o ft ha tt he D ef e nda ntMad e t he F alse S tatem en t in a M atterI n volving a H ealth Car e Be nefi tPro gr am W e ca nno t fi nd a ny c as e i n o urcircuit cl ea r l y l ay i ng ou t th e e sse nti alel em ents f or§ 1035
. N orhas our ci rcuit yetadopted a pattern j ury i nstr ucti on forthi s o ffen se. I n cra fti ng the j ury inst ruc tion, th ou gh, the d is trict court appea re d t o re l y o n the pattern j ury i nstr ucti on for18 U
. S. C. § 1 001 and i dentified fourel em ents re quir ed f or convi cti on u n d er § 1035 : ( 1) m aking a f al se, fi cti ti ous, or frau d u len t s ta te m en t o r re p re se n t a tio n (2) th atis m at er i al, ( 3) kno wi ng l y a nd wi l l ful l y made, a nd ( 4) do ne i n connect i on with the del i ver y o fo r p ay m en t fo r heal thcar e be nefi ts, i tem s, o r ser vi ces. A qui ck com pari son of§ 1035 with thi s j ury i nstr uct ion r ev eal s that the tr i al co ur tn e v e ri n s t r u c t e d th e j u r y th a tth e f a l s e s t a t e me nt m u staris e i n a “m at te r in vo lvin g a h ea lth ca re be n efit p ro gr am .” Om i ss ion fr om the j ury i nstr ucti on o fan e sse nti al ele m en to f th e o ffen se is er ro n eo u s. See Neder v . U nited Sta tes , 527U .S. 1, 9-1 0 (1 99 9); U ni t e d S t at e s v. Gr iggs , 56 9 F. 3d 341, 34 4 ( 7th Ci r. 2009 )
. W e concl ud e that “any m att er24 N o. 12

- 3231 i nvol vi ng a heal th car e benefi t prog ra m ” f or m s a n ess enti al el emento fthe o ffen se . Othe rc i r cui ts ha ve a g r ee d, e xpl aining tha t the govern m en t m us t prov e a l ink to a health care be ne fi t pr o g r am to s ec ur e co nv i ct i o n und er § 1 03 5 an d o th erhea l thcar e o ffen se s. I n re vi ewi nga cha l l en g e t o the su f f i c ien c y of t h e e vid en c e, for ex am p le, th e Six th C irc u it no te d tha t “[ t] o e stab li sh gui l t unde r[ § 10 35 ]
. . . the G ov er n m en t m u stp ro ve th atth e d e f en d an t k n ow in gly an d wi l l ful l y made f al se s ta te m en ts o rr epr es en ta ti o ns i n connect i on with th e d elive ryo fo r paym ent for heal th car e be nefi ts, i tem s, o r ser vice s and i n a m att er i nvol vi ng a heal th ca re b enefi t pr ogr am . ” U nited Sta tes v. H unt, 52 1 F
. 3d 636, 64 7- 48 ( 6th Ci r. 20 07) ( i nter nal p un ctu ation om itted ); s eeals o U nite d States v. K le in , 54 3 F.3 d 20 6, 2 1 1 (5 th C ir. 20 08 ) (h old in g h ea lth ca re be n efit pr ogr a m r e qu i r e men ti s e s s e nt i a le l e men to f1 8 U. S
. C. § 1347 ); U nited Sta tes v. W hit ed, 311 F. 3d 259 , 261

- 62 ( 3d Cir

. 20 02) ( anal yz in g heal th car e be nefi t pr ogr am r equir em ent o f18 U
. S. C . § 66 9 ( em bezz l em ent in connection w ith he alth care) as essen tial elem en t of crim e). T h e la n gu ag e o f 18 U .S.C . § 10 01 (a) a lso su p p or ts th is concl usi on. The heal th ca re bene fit progr am r equi re m en t is th e jur isd i c t i o n a l elem en t o f § 10 35 . I t la rg ely tr ac k s, b o thi n wo r ds us ed an d pl ac ementw ithin the st at u te , t h e jur isd ict ion al e lem en t o f § 10 01 (a). C o m pa re § 1 035( a) ( “[ w ] hoeve r, i n any m att eri nvol vi ng a heal th c ar e b en efitp ro gr am . . . ”), with § 1 00 1(a ) (“ w h o ev er , in any matt erwi th i n the j ur i sdi ct i o n o f

. . . [a] b r an cho fthe Gover nm ent o fthe U ni te d State s . . . ”)
. The j uri sdic ti onal ele m en t o f § 10 01 is a n es se n tia l elem en t o f th atoffe n se , seeN o. 12

- 3231 25 U nited Sta tes v. M o o re, 446 F.3d 671 , 677 (7th C ir. 200 6), su p p or tin g ou r c on c lu sio n th atth e h ea lth ca re b e n e f it prog ra m r equi rem ent l i kewis e qual i fi es as an es senti al el em ent of§ 1035
. Cf. U ni t e d St at e s v. Ranum , 96 F. 3d 1020 , 10 27 ( 7th Ci r . 19 96 ) ( fi ndi ng an al o g y to § 10 01 a “use ful avenue of ex p lorati on, i n l i ght o fthe dearth ofcas e l aw i nt e r pr e t i ng ” the f a l s e s t a t e men ts t a tut e a ti s s ue )
. Ind e e d, the l egi sl ati ve hi sto rym ake s cl earthat, i n cr eat i ng hea l th car e fra ud and re l ated cri m es, Congr ess worr i ed m ost about fra ud per pe tr ate d on i nsurance com panie s that drove up the co st of heal th i nsurance and, m or e g ener al l y, h ea l t h ca re . See H eal th Care Fr aud: A l lPubl i c & Pri vate Payer s Need FederalCri m i nalA nti

- Fr aud Prot ecti ons, H
. R. R e p. No
. 1 0 4

- 74 7, a t2 , 1 2 ( 1 9 9 6 )
. Lab e l i nga “ matter i nvol vi ng a heal th car e be nefi t pr ogr am ” a nythi ng o ther th ana n e ss en ti al el emento fthe c r i m e woul d s ee m i nc o ng r u e n twi th th e c o n c e r n s th a tmo t i v a t e d th e l a w. T he govern m en t d oes not disp ut e the d istri ct cou rt’s fai lure to i ns tru ct th e j ur y o n t h e statu te’s hea lth care be ne fi t pr o g r am l an g ua g e. Ins te ad, i t argu es tha t th e c o ur t ’ s i ns t r uc t i o n o n the f o ur th e l e men t“ c a me fr e i g ht e d” w i th the heal th car e be nefi t pr ogr am r equi re m ent b eca us e t hat i ns truct i o n r equi r ed a co nne ct i o n t o “ th e del i ver y o fo r paym ent forheal th car e be nefits , i tem s o r se r vi ce s. ” Ad di ti o na l l y, the g o ve r nm en t co nt in ue s, the j ud ge had instr ucted the j ury on the m eani ng o f“hea l th car e be nefi t pr ogr am ” s eve ra lm i nutes ear lierwh en des cr ibingth e he al thc ar e fr au d c o unt s. Br i dgingthe an aly ti ca lg ap be twe enthe se t wo i ns tr uct i o ns a nd the sta tute’ s j uri sdic ti onal ele m ent, however, i s a di sta nce too wide f orthe j ury to cro ss on i ts ow n : N eit her ofthes e26 N o. 12

- 3231 i nstr ucti ons expli ci tl y requi re s fo r convi cti on un der § 10 35 fin d in g a m att eri nvol vi ng a heal th car e be nefi t co rpor ati o n. And the tr i al j udg e g av e no i ndi ca ti o n tha t any o fthe fra ud i nstr ucti ons al so appli ed t o th e f al se sta tem ents co unt s. W ha t i s m o r e, th e i ns truct i o n o n the f o ur the l ement of the fal se state m en ts ch arge p r e s e nt ed “hea lth care be ne fi ts ” al o ng si de “i te m s” a nd “ se r vi ce s, ” phr as ed i n the disj uncti ve. Thus, the f ourth i nstr ucti on, st anding al one, sugge sts to the j ury that the absence o fheal th ca re bene fi ts i s i r r el ev an t i fthe fac ts de m o ns tr at e a f al se s ta te m en t m ad e in conn ection w ith he alth care it em s or health ca re ser vi ces. But und er the sta tutory t ext, ev en co nvi cti on f orf al se sta tem ents m ade i n connec tio n w i th i tem s o r ser vi ces sti l lm ust r el ate to a “m att eri nvol vi ng a heal th car e be nefi t pr ogr am . ” Th e d i str i ct c ourt ’ s j ury i nstr ucti ons did notco nvey that re quir em ent.
b . Al t h o u g h t h i s E r r o rWa s P l a i n ,O m i t t i n gt he H eal t h Care Benef i tPro gr am Req uir em en tf r om the Jury Ins tru ction D id N ot A ff ec t N atale’s S u b stan ti al R ights The g o ve r nm en t as se r ts tha t even i fe r r o ro cc ur r ed, the erro rwas no t “pl ain” o r“ cl ea r ” be ca us e no pa tt ern j ury in st ru c tio n ex is t e d f o r § 1 03 5 a n d n o c as e a ffirm at ive ly d elin ea te d th e e lem en ts of th e o ffen se . Se eO l ano , 50 7 U. S
. a t 73 4. The g o ve r nm en t i g no r es th e t ex t o fthe sta tute, howe ve r, wh i ch quit e cl ear l y i m poses the heal th car e benefi t prog ra m re quir em ent. M or eov er, o ther ci rcui ts have f ound thi s r equi re m ent a n ess enti alel em en t o f § 10 35 an d oth er rela te d offe n se s. SeeKl ei n ,N o. 12

- 3231 27

The gove rn m en tc or re c t l y c har ac t er i ze s Nata l e’ s ar gum en t 6 a s r e l yi ngs ol e l y up onthe “ pu r po s e , c on t e x t, an d l e gi s l a t i ve his t or y” o fthe s t a t ut e . W hi l e t r ue tha tNat a l e c ou l d h a ve p ro v id ed m or e exp an sive textu al an al y sis, N ata le’ s f ailu re to m i ne the s t atut or y t ex tf or f avor abl e ar gum en t s doe s no t req u ire u s to close o u r ey es to the lang u ag e of C on g ress. 54 3 F .3d at21 1; H unt, 521 F .3 d at64 7-4 8; Whit ed, 31 1 F. 3d at 261- 62. Thus, the er ror w as “cl earunder curr ent l aw . ” U nited Sta t e s v . E berha rt, 46 7 F
. 3d 659, 66 8 (7th C ir. 2006). 6 N everth eless, w e see n o harm i n th e d istri ct cou rt’s failu re to in s tr u c t th e jur y on th e h ea lth ca re be n efit p ro gr am req u ire m en t. Se e, e . g. , Neder, 52 7 U.S
. at9- 10 ( ha r m l es s er r o ra na l y si s appli es to j ur y i ns truct i o ns om itt i n g ele m en t); Griggs , 5 6 9 F
. 3 d a t3 4 4

- 4 5 ( s a me )
. No one disp ut es th at M ed ica re qu ali fi es as a he alth care b en efitp ro gr am . See U nited Sta tes v. R edc o rn , 52 8 F
. 3d 727, 734 ( 10th C ir. 2008 ) (noting M ed icare an d M ed ic a id a re “u nques ti o nabl y ” he al thc ar e be ne fi t pr o g r ams)
. And al lag re e that the sur ger i es at i ssue i nvol ved M edi car e: N at al e admi ts b i ll in gM edi ca r e f o rthe s ur g er i es a nd adm i ts to f al si ti es i n hi s o perat i ve re port s, wh i ch

— a s we expla i n bel ow

— ar e m ate ri alto M edi car e’ s paym ent for th e su r g er i es . Be ca us e “[ t] he r e was ne ve rdo ubt ” th atthe su r g er i es “ i nv o l ve d” a he al thc ar e be ne fi t pr o g r am, no harm r esul ted fro m the dist ri ct c ourt ’ s failu re to i nstr uct on th is iss u e. S e eG r iggs , 5 69 F. 3d at 345 ( “There was neverdoubt that the co nspir acy had i n vol ved the use ofi nter sta te com m unica ti ons by wir e, wh i ch m ay be28 N o. 12

- 3231

N at al e al s o a rg ues thatc ri m i nal i zi ng f alse s t at em en t s un- 7 hi nge d fro m the he al th c ar e ben efit progr am r equi re m en t w ou ld p u nish a b ro ad sw ath of inno cen t con d u ct tha t C on g ress ne veri nt end ed t o r ea c h. Fore xa m pl e, a pat i en twho l i es on the new p atien t qu estion na ire reg ard i n g h i s lifesty le ha b its (e. g ., a l c o ho l or to b acco use), p ast d iseases, etc. m ay v iola te the law b eca u se s u c h false statem en ts w ou ld b e m ad e in con ne ction w ith th e d eliv ery of hea lth ca re serv ices
. N ata le is corre ct, but thes e c oncerns ar e ass uaged by ou r holding that § 10 35 requ ires a m atter inv olv ing a he alth c a re b en efit prog ram and f als e st atem ents m ater ial to that health care benefitprogram . As w e ex plain, the se erroneous j ury ins tr uction s w ere har m less in N ata le’ s case, a result he can n o t a v o id b y p ostu lating ho w th e g ov ern m en t m igh t ab u sive ly a p p ly § 10 35 on a d ifferen t set of f acts. w hy the l aw yer s a nd the dis tr i ct j ud ge didn’tnot i ce th e om issi on from the instru ctions
. ”). 7

2 . Th e Di s t r i c tC o urt ’ s Pl a i n E r r o ri n F a i l i ngt o I nst ruct t he J u ry that t he Fals e St at em ents M ust Be M ate r i al t o the H eal t h Care Benef i tPro gr am W as Harmle ss N atale’s nex t ch all en ge attac ks th e d istrict cou rt’s m a teriali ty instru ction. A s given, the instru ction p erm i tt ed th e j ur y to co nv i ct as l o ng as th e fal se st at ement “h ad th e effec t o fi nfluenci ngthe a ct i o n of a pe rs on or ent ityo rwa s c a pabl e ofo rh a d the p o t e nt i a lt o do so . ” ( Em pha si s adde d. ) He po si ts tha t, b y r eq uir i ng m ate ri al i ty onl y a s to a “perso n orenti ty, ” the j ury i nstr ucti on i m perm i ssibl y b road ened the sco pe ofthe sta tuteN o. 12

- 3231 29 to i ncl ud e pr ose cuti on forf al se sta tem ents that re l at e t o the de l i v e r y o fh e a l th c a r e b e ne fi t s , i t e ms, o rs e r vi ces b u tth a th a v e n o eff e c t o n a h e a l th c a r e b e n e fi tp r o g r a m. N atal e ur ges thatco nvi cti on un d er § 1035 r equi re s f al se sta tem ents m ate ri al to a hea l th car e be nefi t pr ogr am ra th er th an to a n y p er so n or en tit y. O n c e a ga in, N at ale provi des the properi nter preta ti on o fthe sta tute but, be ca u s e n o h a r m fl o we d fr o m th i s e r r o n e o u s i n s t r u c t i o n, we s ee no ne ed to o ve r tu r n Nat al e’ s co nv i ct i o n.

a. Fals e St at em ents U nd er§ 1035 M ust Be M at er i al t o the H eal t h Care Benef i tPro gr am Se cti on 1 035 onl y c ri m i nal i zes “ m ater iallyf al se, fi cti ti ous, or fra u d u len t sta te m en ts or re p re se n ta tio n s .” (E m p h as is add ed. ) I t doe s no t, however, pre cise l y desc ribe t o what or t o whom the sta tem en ts m us t be m aterial. Th e tex t offers tw o p os sib le a n sw er s. O n on e h an d , “m at er ially ” c ou ld r efer b a c k wa r d t o th e p r e f a t o r y c l a u s e o fth e s t a tu t e a nd re quir e s tat em ents m ate ri alto a heal th car e be nefi t pr ogr am . On th e o th er , “m at er ially ” c ou ld lo o k f o rw ar d in th e statu te, requ iring statem en ts m aterial to the de li very ofo r paym ent forheal th ca re bene fi ts, it em s, o r ser vi ces. Either re adingse em s pl ausibl e fro m the text. W i th the te xt am bi guous, we turn t o si m i l ar l y worded sta tutes and the l egi sl ati ve hi sto ryf orgui dance . Analo gy to § 1 001 aga i n prov es hel pfulbut, atfi rs t g l anc e, not dispos i ti ve. M ate ri al i ty und er§ 1001 r equi re s “ a natural te nde nc y t o i nfl ue nc e, o rb e c ap ab l e o fi nfl ue nc i ng, the deci si on o fthe de c isionm aking bo dy to wh i ch i t was add re sse d.” U ni t e d S t at e s v. Lu pton , 62 0 F
. 3d 790, 80 630 N o. 12

- 3231 (7t h C ir. 20 10 ); a cco rd U nited Sta tes v. Turn er, 55 1 F
. 3d 657, 663 (7t h C ir. 20 08) ( quoti ng K un gy s v. U nited Sta tes , 48 5 U
. S. 75 9, 77 0 ( 1988 ) )
. Th u s, c ou rt s hav e a pp l i ed the m ate
ri al i ty re quir em ent o f§ 1001 to th e j uri sdic ti onalel em en t, r equi ring st ate m ents m ate ri alto an a gencywithin the U. S. go ve rnm ent. In § 1 035, the cor re sponding j uri sdict i onalel em ent i s t he heal th car e be nefi t pr ogr am re quir em ent. Thus, apply i ng the l ogi c o f§ 1001 c as es to § 1 035 re quir es f al se sta tem ents m ate ri alto the heal th c a r e b e n e fi tp r o g r a m. B u t§ 1 0 0 1 h a s n o e l ement an alo go u s t o th e “ inco n n ec tio n w ith

. . . ” e lem en t in § 10 35
. The t ex t o f§ 1 00 1 thus c o nt ains o nl y o ne po i nt o fr efer en ce f o r“ m at er i al l y . ” I n c o nt r as t, § 1 03 5 o ffer s tw o possibl e r efer ences, m aking § 1035 m or e co m ple x an d m inim izi ng the va lue of § 1001 as a com p arator. A cl o se l o o ka t ho w th e m at er i al i tyr equi r ement b e c a me a p a r to fth e s t a tu t e , h o we v e r, r e s o l v e s th e a mbi gui ty and s ol i difi es the c om parat i ve re l evance o f§ 1001
. I n the b eg i nni ng , the v er si o n o f§ 1 03 5 pas se d i n the Ho us e c o nt a i ne d n o ma t e r i a l i ty r e qu i r e men t
. I tr e a d: W hoe ver, in any m atter involving a h ealth ca re b en efitp r o g r am , kn ow in gly m ak es an y fa lse , fi c titio u s, or f r a u d u len t s ta te m en ts or re p re se n ta tio n s . . . i n c o nne ct i o n wi ththe de l i ve r y of orpa y m en t for h ea lth ca re be n efit s, ite m s, or se rv ice s, sh all b e fin ed

. . . or im p ris on ed [.] H eal th Insurance Por tabi l i ty and A ccountabi l i ty A ct o f 1996 , H
. R. 31 03, 10 4th Cong. , ti t. I I, § 244( a) ( 1996 ) ( as passed bythe H ou se on M ar . 28 , 19 96)
. The H ouse b ill l ar ge ly tr ac ks th e la n gu ag e o f w h atu ltim at elyN o. 12

- 3231 31

The bi l l s have one oth erdi ffer en c e as wel l

. The Hous e ver s i on 8 refe r s t o a “h ealth care b en efit p ro g ram ” w hile th e Sen ate v ersion u ses the term “h ealth car e p ro g ram .” E ach p hr a se fills the sam e rol e, how ev er, and w e use both phrases i nter changeabl y i n thi s di s c us s i on. b ec am e la w , w ith tw o m ain d i f f e re n c es : I t o m its “w illful l y, ” o ptingi ns te ad f o ro nl y “ k no wi ng l y ” as the mens re a. A n d th e H ou s e bill als o lac ks th e w or d “m at er ially ,” w hi ch i n the fi nalenact m ent pr ecedes “f al se, fi cti ti ous, or frau d u len t s ta te m en ts or re p re se n ta tio n s.” T he se tw o w ord s are foun d i n th e Sena te bil l, how ever. I n the Se nate ver si on, so m eone com m i ts a cr i m e when he: i n a n y ma t t e r i n v o l v i n g a h e a l th c a r e p r o g r a m, kn o win gly and wil l fully . . . m ake s a ny m ate ri al l y f al se, fict itio u s, or fra u d u len t sta te m en t or re p re se n ta tio n [.] H
. R. 30 31, ti t. V, § 544( a) ( as am ended and enact ed by th e S en at e o n Apr
. 2 3, 199 6)
. Thu s, the S en at e bi l lc o n- 8 tains the “m ate ri al l y” l angu age abs ent fro m the H ouse bi l l

. I t a l so m uch m or e c l ose l y t ra cks the l anguage o f § 10 01 , si m pl y swa ppi ng o ut th e fede ral gov ernm en t j urisd ictional el em en t in § 10 0 1 f or the h ealth ca re prog ra m j uri sdic ti onalel em ent r el evantto the goal s o f § 1 03 5. C o m pa reH. R. 3 03 1, t i t. V, § 5 44 ( a) ( as am en ded an d enacte d by the S enate o n A pr. 23 , 19 96 ), wit h § 1 001( a) ( 2) ( “[ W ] hoeve r, i n any m att erwithi n t h e j uri sdic ti on o f the ex ec u tive , l egi sl ati ve, o r j ud i ci albr anch ofthe Governm en t
. . . , kno wi ng l y a nd w il l ful l y . . . make s any m ate ri al l y f al se, fi cti ti ous, o r fra ud ule nt st ate m ent o r rep resen tation .
. . shall be fined

. . . or im p r is one d [. ]”).32 N o. 12

- 3231 M or e i m port antl y, i n the Se nate ver si on, “m ate ri al l y” can only r efer to a he al th ca r e pr o g r am f o r pr ec i se ly the sam e r eas on “ m ate ri al l y” in § 10 01 re fer s o nl y t o an enti ty i n the j uri sdic ti on of the federa l g ove rnm ent: th e Se n at e v er sio n lac ke d th e “ inco n n ec tio n w ith

. . . ” l an g ua g e f o und in the Hous e bi l ls o the r e was no th i ng els e in th e Se n at e v er sio n to w h ich “m at er ial ly” co u ld re fer . Thus, t h e Se nate ver si on qui te cl ear l y r equi re d f al se sta tem ents m ate ri al to the heal th car e benefit p ro gr am , notf al se sta tem ents m ate ri alto the del i ver y o f heal th ca re bene fi ts, i tem s, o r ser vi ces. The am bi guous l anguage o fthe fi nale nactm ent r esul ted fro m the com bi nati on of the Se nate an d H ouse ver si ons i n Confe re nce. The Confer ence Com m itt ee adopted the House l anguage

— i ncl ud i ng i ts “i n connect i on wi th

. . . ” t ex t

—b u t in se rt ed th e “ w illfu lly” an d “m at er ia l l y ” r e qu i r e men t s f o un d i n the S e na t e bi l l

. H
. R. Co nf

. R e p. N o. 104- 736, at 259 ( 1996 )
. Thu s, w hen the C onfer ence C om m itt ee ad op te d th e Se n at e’s “ m at er ially ” la n gu ag e, it al so m ust hav e a dopted the m ea n ing a scr ibed to that lan gu ag e b y th e Se n at e. SeeInt’lAss’ n of Bridge, Str uctural, & O r n ame n t al Ir on worke rs v . NLRB , 94 6 F
. 2d 1264, 12 68- 69 (7th C ir. 1991 ) (l ooking to Sena te R ep ort forstatu tory m eani ng w hen Confe re nce Com m i tte e adopted Se n ate ve r si o n o fb i l l ); F roc k v. U
. S. R. R. Re t
. Bd. , 68 5 F
. 2d 1041 , 1046 n. 6 ( 7th Ci r. 19 82) ( l oo kin g to expla nati on o fS enate ver si on o fbi l li n Confe re nce Repor t when Senat e v er si on ultim ately ad op ted i nt o l aw ); s e eal s o Val e r o Ene rgy Corp
. v. U nited Sta tes , 5 69 F. 3d 626, 63 4 ( 7th Ci r. 20 09) ( “A confer ence re port, unl i ke th e w or ds ofa si ngl e [ l egi sl ato r ] , i s o fte n a g o o d r ec o r d o fCo ng r es s’ s in te nt [
. ] ”)
. AndN o. 12

- 3231 33 because the Se nate used “m ateri al l y” to m ean “ m ate ri al to a he al thc ar e progra m ” so t o o musttha t be the m eani ng o f“m ate ri al l y” i n the fi nalenact m ent. Fi nal l y, i fst ate m ents m at er i alto the del i ver y o fheal th car e be nefi ts, i te m s, orse rv i ces w er e s uffi ci ent t o convi ct, the sta tu te w oul d cri m i nal i ze a wide s w ath o f see m i ngl y innocent “w hi te l i es” to tal l y unconnect ed to th e c on d u c t th atm ot iva te d p as sa ge of th e s ta tu te , see foo tn ot e 7, sup ra

— heal th car e fra ud that detri m ents h ea lth ca re p ay er s. See H
. R. Rep. N o. 104- 747, at2, 12 (“ C o ng ress sh ou ld en act legisl ation to m ake h ealth ca re fra ud ag ai nst publ i c and pri vate payer s a Feder alcr i m i nal offen se.”). U nless com p ell ed to d o so by th e tex t, w e are gener al l y s kepti calo fi nterpret ati ons ofcr i m i nalst atute s that bro adlycr i m i nal i ze see m ingl y innocent acti vi ty. C f. Sta ples v. U nite d S t a tes , 51 1 U.S
. 60 0, 61 0 ( 1994 ) ( noting “par ti cul arcar e [Su p rem e Cour t has ] ta ken t o av o i d c o ns trui nga s ta tu te t o di spe ns e w ith m ens rea w here doi ng s o w oul d ‘c ri m i nal i ze a br oad r ange of apparentl y i nnocent conduct’ ” ( quoti ng Lip a rota v. U nited Sta tes , 471 U .S. 41 9, 4 2 6 (1 98 5)); U ni t e d S t at e s v. Ye r m i an , 468 U
. S. 6 8, 71 ( 1984 ) ( noting “i fCongr ess had i ntended to pr o hibi t al li nt en ti o na lde ce i t o fth e F eder alGo ve r nm ent, i t would have used .

. . br oad l anguage . . . w hi ch by i ts speci fi c te rm s, e x tend s br oadl y t o eve ryco nspir acy to defr aud the Un i ted S tat es . . . . ” ( i nter nalpu n c tu ati on om i tte d)). In the end, nothi ng support s a r eadi ng o f the s t a tut e tha two ul d r e qu i r e f a l s e s t a t e men t s ma t e r i al to the del i ver y o fheal th c ar e be nefi ts, i tem s, o r ser vi ces w hen the H ou se b i l lco ntai ned no such m ate ri al i ty re quir em ent and the Se nate bi l l ti ed the m ate ri al i ty re quir e-34 N o. 12

- 3231

K ungys i nvol ved the m ea ni ng of m at er i al i t y unde r a di ffer en t 9 st atute , but ital so e xplai ned that, i n t h e contextofcr im inal f als e s tat em ents , “m ater ial ” is a “ter m [ ] that ha[s ] acc um ulate d se tt le d m eaning und er e ith er e q uity or the com m on law.” 485 U .S. at 77 0. Th u s, in u sing the w or d , “ C o n g ress m ean s to incor porate [ it s] es tabli shed m eaning[
. ] ” Id. As with th e s t atut e ati s s ue i n K ungys , whendet er m i ni ng the m ea ni ng o f “m ate ri ali ty” i n § 1035, “w e s ee no r eas on not t o f oll ow w hat has been done w ith the m ater ial ity requir em ent und er other st atute s dealing with m is repres entat ions [
. ] ” Id. at 772. T he am b igu ity in the statu te com b ined w ith th e d ear th o f case 10 l aw s pec i fi c al l y i nte rpre t i ng the m at er i al i t y r equi re m en tof (co n tin u ed ...) me n tt o th e h e a l th c a r e b e n e fi tp r o g r a m. Thi s unde r st an di ng o f “mat er i al l y ” i s no tabl y abs en t fro m the dist ri ct c ourt ’ s j ury i nstr u c tions, wh i ch br o ade ne d m at er i al l y t o i nc l ud e st at ement s i nfl ue nc i ng orcapabl e o fi nfluenci ng anyper son oren tit y. A pro per in st ru c tio n on th e m at er ialit y e lem en t in § 10 35 w ou ld re quir e that f al se statem ents “ha[ ve] a natura lte nd ency to i nfluence, or [ar e] ca pabl e o fi nfluenci ng, the deci si on of” th e h ea lth ca re be n efitp ro gr am . Kungys , 48 5 U
. S. at 770
. 9

b. Th e Di s t r i c tC o urt ’ s E r r o ne ous Mat e r i a l i tyI nst ructi on W as Harmle ss Altho ugh the di st r i ctc o urt g av e ane r r o ne o us m ate ri al i ty i nstr ucti on, gi ven the proofand ar gum ents att r i al, tha t error w as ha r m l es s. Dur i ngc l o singa r g u- 10N o. 12

- 3231 35

(
. . . c on t i nu e d) 10 § 10 3 5 al so su g g es ts t h a t su ch er ro r w a s n o t p la in
. S ee Ola no , 507 U.S. at 734 ( pl a in e rr o r re quires “err or [ that ] i s cl ear u n d er cu rr en t la w ” ). m ents, the gov er nm ent t ol d the j ury that th e fa l se sta tem ents m ust “have the effect of i nfluenci ng the a c tio n ofM edi car e or [ w er e] capabl e o fo r had the pot enti alto do so

. ” Thus, the gov er nm ent ne verpre sented at t ri al the a rgum ent o verwh i ch N atal e no w fre ts

— th athe vi o l at ed th e st atut e be ca us e hi s f al se s ta te m en ts i n the o per at i ve r epo r ts wer e m at er i alt o fu tu r e tr ea tment d e c i s i o n s ma d e b y o th e r d o c t o r s . I n s t e a d , i t a r g u e d a nd pr es en te d pr o o fo fm at er i al i tyunde rthe mean i ng N at al e no w adv an ce s, tha t th e f al se s ta te m en ts c o ntained i n th e op erative rep orts an d other n otes w ere m ate ri alto M edi car e. To thatend, the gov er nm ent o ffer ed evi dence that, w hen M ed i car e a ud i ts cl ai m s, i t s om eti m es re quests o per at i ve r epo r ts a s wel la s o th erphy si ci ann otes and docum entat i on. A dm i tte dly, M edi car e nev erper f or m ed a n a u d i ti n th i s c a s e a n d n e v e ra c tu a l l y v i e we d th e o per ati ve re port s co ntai ni ng the f alse st ate m ents. But m ate
r i al i tyr equi r es o nl y a po te nt i al i ty of infl ue nc i ngthe d ec i s i on m ak er ; i t d oe s n otreq u ire ac tu al re lian c e. U nited St at e s v. Gulley, 9 92 F. 2d 108, 11 2- 13 ( 7th Ci r. 19 93)
. N otw i thsta nd i ng N atal e’ s a sse rt i ons on a pp eal, he ne ver ar gued to the j ury that the f al se sta tem ents in th e o perati ve re port s were not m ate rial t o M edi car e a nd neve r chal l enged th e evi dence thatM edi car e would r el y o n36 N o. 12

- 3231 op er at ive rep or ts d u rin g a n au d it. Ins te ad , N at ale ar gued intent. H e a dm i tte d m i sta kes i n the oper at i ve re port s but tol d the jurytho se er ro rs r esul ted fro m car el es sn es s an d a n av er si o n t o pa per wor k, no t k no wi ng and w i l l fu l lie s. A nd nei therdi d the g ove rnm ent e ver ar gue that othe r doctor s’ , r atherthan M edi car e’ s, r el i ance on the o perative r epor ts sat i sfi ed the m ate ri al i ty re quir em ent. True, the gov er nm ent di d at t i m es ch aracte ri ze th ese rep orts a s i m p ortan t d ocu m en ts for a p atient ’s futu re treatm en t. B ut i t d id so onl y t o a ttac k N atale’s d e f e n se of car ele ss n es s: ac c or d in g to th e gov er n m en t, a su rgeon w ho hi ghl y v al ued and d eepl y c ar ed f orh is pati ents

— as N at a l e t old th e jur y h e d id

— w oul d not ha pha zar dl y pr epa r e do cument s so i m po r ta ntf o ra nd cr i ti ca lt o a pa ti en t’ s futur e ca r e. Thu s, the g o ve r nm en t t o l d the j ury, h e mus th a v e kno wi ng l y a nd wi l l ful l y l i e d. I n shor t, N atal e’s d efense i n thi s co urt differ s fro m the defense he pre sente d to the j ury. T h e m at er i al i ty of th e s ta te m en ts in t h e op er at ive rep or ts sim p ly w as n otin issue at tr i al

. The go vernm ent c onceded thatco nvi cti on re quir ed m ate ri al i ty as to M edi car e a nd pre sente d proo f th atM ed ica re w ou ld look t o t h e op er at ive rep or ts in th e e ve n t o fa n a u d it. N at ale leftth atev id en c e u n c h all e ng e d. N at al e su g g es ts tha t hi s ac qui tt alof h eal thc ar e fr au d shows othe rwis e. “[ T]he j ury, ” he ar gues, “d i d not bel i eve a r el at i o ns hi p b etwe en the a l l eg ed ‘ f al se s ta te m en ts ’ a nd M ed ica re w as p ro ve d b e y on d a re as on ab le d ou b t” or it woul d ha ve c o nv ic te d hi m o ffr au d. Thi s co nc l us i o n, how eve r, as sum es congruence be tw een a l lele m ents ofN o. 12

- 3231 37 he al thc ar e fr au d a nd f als e st at ement s. In t r uth ( an d perhaps un surpri si ngl y) , the sta tutes di ffer . A s e xplained m or e fully b elo w , the heal th car e fra ud st atute r equi re s proo fo fspeci fi c intent to defr au d w h ile the f al se sta tem ent s tatute r equi re s o nl y know i ng and w i l l ful f al se sta tem ents. Giv en N atale’ s defense f ocusing hea vi l y o n hi s innocent sta te ofm i nd , the j ury coul d have co ncl ud ed that N atal e l acke d the s pecific intent to decei ve re quir ed f or a fraud convi cti on but never thel ess wil l fully fi l l ed his op erative rep orts w ith state m en ts he k n e w w ere f al se . As s uch, the j ur y ’ s ve r di cti s co ns i st en t wi tho ur own i nter preta ti on o fthe sta tute. Fi n ally, bo th N atal e a nd am i cus l am ent the poss ibi l i ty tha tmi s s t a t e men t s i n o pe r a t i v e r e po r t s a nd o ther m edi ca l r ec o r ds m ay l ea d to fede r al i ndi ct m ent. Am i cus especi ally w orri es about the c hi l l i ng effect case s s uch as N at a l e ’ s may ha v e o n med i c a l r e c o r d- k e e ping a nd i ts c o n s e q u e n c e s o n p a t i e n tc a r e . T h i s c o n c e r n i s n o tc o mpl et ely misgui ded, b uti t do es i g no r e th e k no wi nga nd wi l l ful r equi r ement i n § 10 35
. The tr uly i nno ce nt m i st ake s o verwh i ch am i cus worr i es ar e no t the del iber at e fa lse h oo d s t h atfed er al l a w cr im in aliz es . N at ale w as not c onvi cted be cause he m ade i nnocent m i sta kes ar i s i ngfr o m ca r e l e s s ne s s i n the p r e pa r a t i o n o fh i s o perati ve re port s. H e was co nvi cted be cause th e j ury did not be l i ev e N at al e when he t o l d the m he made i nno ce nt m i sta kes

. In any eve nt, to the exten t § 1 035 produces “u n d u ly h ar s h res u lt[s ] on th os e w h o in te n tio n ally m ake false statem en ts to [health ca re ben efi t prov iders], i t i s f o rCo ng r es s a nd n ot thi s [ c] o ur t to a m en d the cri m i nalst atute
. ” Yer m i an , 46 8 U.S
. at75
.38 N o. 12

- 3231 Forthes e r eas ons, no h arm acc rued fro m the dist ri ct cour t’ s inadequ ate j ury i nstr ucti on o n m ate ri al i ty. That el ementhe l d a seco nda r y r o l e to the r ea lf o cus o fthe tr i al

— N at al e’ s st at e o fmin d. Nat al e cann o t no w ar g ue h arm fro m thi s e rr orbyputti ng f or th a new defense on appe als i m pl y b ec au se the j ur y disb el i ev ed th e o ne he p ro ffer ed attria l.

3 . Th e Di s t r i c tC o urtDi d No tE r ri n Omi t t i ng a Spe c i f i c I nt e ntI ns t ruc t i o n N atal e a rgues that co nvi cti on under § 10 35 re quir es proo fo fa speci fi c intent to decei ve. N eit h er t he te xt nor c on te x t o f t h e s ta tu te su gg es ts § 10 35 req u ire s a sp ec ific i ntent to decei ve. T o b eg in, no th in g in th e t ex t o f § 1 0 3 5 e x p licit ly re quir es that the de fendant m ake a f al se sta tem ent with i ntent to decei ve. A s the S up re m e Cour t e xplained w hen r ev i ewi ngs i m i l arl an g ua g e i n § 1 00 1, no thing i n the t ex t “s ugges t[ s] any add i ti onalel em ent o fi ntent, such a s a r equi re m ent th at fals e s tat em ents be [ m ade]

. . . ‘ w i th i ntent to decei ve the F edera lGovernm ent. ’ ” Ye r m i an , 468 U
. S. at69
. I nd eed, w hen Congre ss has i ncl ud ed i ntent to d ecei ve as an el emento fa f al se s ta te m en ts c r i m e, i t ha s do ne so ex p licit ly. See 18 U. S
. C. § 5 13 ( a) ( cr i m i na li zing “m ak[ i ng] , utte r[ i ng] , o r posse ss[ i ng] a counter fei ted secu rity o fa St ate
. . . with intent to decei ve anothe r p er so n . . . ”); i d. § 1033 ( a) ( 1) ( cri m i nal i zi ng cer ta in f al se st at ement s m ade w ith “int en t to de ce i ve ” bype r so nsN o. 12

- 3231 39

E xp licit “ inten t to d eceiv e” la ng u ag e w as no t ev en the o nly 11 w ay C o n g res s could hav e ac hieved thi s goal. For ex am ple, Co ngress could have cri m inal ize d fal se s tat em ents m ade f or t hepurpo s eof

i nf l ue nc i ng a he al th c ar e ben efi tpr ogr am , l ang uage it h a s u se d i n o th er sta tu te s, to o . S ee 15 U.S. C. § 714m ( a) (crim ina lizing som e false statem en ts m ad e “for th e p u r p ose ofi nfluenci ng in any w ay the ac ti on of the Co rpor a tio n ” ); 18 U. S. C. § 10 14 ( c ri m i nal i zi ng f al s e s t at em en t s m ade “for the purpo s e of i nfl uen c i ng i n any way the ac t i on” ofv ario us fed er a l a g en ci es ); i d. § 10 26 ( crim ina l i z i ng f alse statem en ts m ade “for the pur pos e ofi nfl uen c i ng i n a ny way the ac t i on of the Secretar y ofAg ri culture”)
. Bu t Congress did not even requir e this s om ew hat l es se r purp ose requir em ent in § 1035. “enga ged in the busi ness of i nsurance w hose act i vi ti es affe c t in te rs ta te co m m er c e” ); i d. § 1 8 6 1 ( c r i mi n a l i zi ng f a l s e s t a t e men ts l ab e l i ngp r o pe r ty a p ub l i c l a nd i fma de w i th “intent to decei ve the per son to w h om such r eprese n ta tio n is m ad e” ); i d. § 2073 ( cri m i nal i zi ng f al se en tries ofoffici al r ecord s m ad e w ith “inten t to de ceive”). Each ofthes e s tatutes predate d t h e enactm ent o f§ 1035
. T h u s , h ad C on gr es s w an te d to req u ire sp ec ific in te n t in p rosecu t ion s for fal se state m en ts related to health care ser vi ces, i t coul d e asi l y have used the “i ntent to d ecei ve” l a ngua g e f o un d in the s e s t a tutes
. Se eYe r m i an , 468 U
. S. 11 at 73. But Congre ss did n ot
. Instea d, i t r equi re d fa l se sta tem ents m ade i n connect i on with the d eliv ery o fo r paym ent forheal th car e in a m att er in vol vi ng a heal th car e be nefi t pr ogr am and nothi ng m or e. G ive n th e a b se n c e o f su c h st at u to ry la n g u a g e, N at ale l oo ks to the “ w i l l fully” req u ire m ent a s the te xtualanchor40 N o. 12

- 3231 f o ra n i n t e n tt o d e c e i v e r e q u i r e me n t
. “ [ W] i l l ful l y, ” h o weve r, i s “ a no tor i ousl y pl ast i c word. ” Un i t e d S t a t e s v. Pulu ngan , 5 6 9 F
. 3 d 3 2 6 , 3 2 9 ( 7 th Ci r . 2 0 0 9 )
. An d we have p r e v i o us l y r e fus e d t o fi nd a n i nt e ntt o de c e i ve re q u i re m ent in “wil l fulne ss” l anguage fro m o ther, si m ilar ly w or d ed fals e s t a te m en t s ta tu te s. U ni t e d S t at e s v. Ranum , f orexam ple , f ound no i ntent to de c eiv e r equi re m ent in the “w i l l fu l” m ens r ea re quir ed f orco nvi cti on und erthe st at u te cri m i nal i zi ng f al se sta tem ents used to “obt ai n” federa l l y- guar antee d s tudent l oans. 96 F.3 d at1 02 7 ( an aly zing2 0 U. S
. C. § 1 09 7( a) )
. In r ea ch i ng th atco n c lu sio n, R a n u m str ongl y s ugges ted co nvi c ti on und er § 1001 al so re quir ed no s peci fi c intent to decei ve. I t s peci fi cal l y a pp ro ved ofthe § 1 001 pattern j ury i nstr ucti on on w i l l fulne ss

— u se d in N at ale ’s c as e a s w ell

— that m ad e no m en tio n of in te n t t o d ec eiv e. Id. a t1 0 2 7

- 2 9
. We do no t st an d a l o ne i n ou r sug g es ti o n tha t § 10 01 ha s no speci fi c intent re quir em ent: the Su p re m e Cour t has sugg es te d the s ame. Di ct a i n Yerm i an f o un d l a ngua g e s up port i ng a speci fi c intent to decei ve “[ n]o ti ceably l acki ng” fro m § 1001
. 46 8 U.S
. a t 73 . G iven the abs ence of expli ci t “ i ntent to decei ve” l anguage i n § 1 035, we now f o l l o w the l ea d of Ran u m and “re fuse[ ] to supply, by j u d icia l int er p re ta t i o n , an ad d itio n al e lem en t o f sp ec ific i ntent to decei ve. ” Ranum , 96 F. 3d at 1027
. N ot w ith st an d in g th e Su p re m e C ou rt ’s g u id an c e in Ye rm ia n, so m e ci r cui ts ha ve i m po se d a s pec i fi c i nt en tN o. 12

- 3231 41

C o m p a re U n ite d S ta te s v . R ic c io , 529 F. 3d 40, 46- 47 ( 1st Cir. 2008) 12 ( “wi l l ful ne s s ” i n § 1 00 1 m eans “n othi ng m or e . . . thanthatthe de fe nd a ntk ne w thath is s t a t e m e ntwa s f a l s e whe n he m a de i tor

— whic h a m ount s i n the l aw t o the s am e thi ng

— con sciou sly di s re gar ded orave rt ed h i s e ye s fro m i t s l i ke l y f al s i t y” ( quo t i ng U n i te d S tat es v. G on sal ves , 43 5 F .3d 64 , 72 (1 s t C ir . 20 0 6 ))); U n i te d S tat es v. R u sso , N o. 98-32 45 , 2 0 0 0 W L 142 98 , at *5 (10th Ci r. J an. 10 , 20 00 ) ( “wi l lful” in § 1 00 1 “ does no tr equi re pr oof ofe vi l i nt e ntbu tr a the r o nly t ha t‘ the a c t[ was ] do ne de l iber at el y a nd with knowle dge’ ” ( quo t i ng Wal ker v. U n i te d S tates , 1 9 2 F .2d 4 7, 4 9 (1 0 th C ir . 19 5 1 ))); U ni t ed Sta t es v. Hi l debrandt, 961 F .2d 116 , 11 8-19 ( 8th C ir. 19 92 ); ( “w illfu l” in § 100 1 “sim p ly m ean s that th e d efend an t d id the forb id d en a c t ‘ d elib era tely and w ith know le dg e. ’ Iti s not neces sar y that the defe nd ant ac t w ith th e in te n t to d ec ei v e th e U n ite d St a te s” (cit a tio n s o m itt ed )); and Un i t ed Sta t es v. Ver duzco- C ont re ra s , N o . 8 8

- 5 1 2 0 , 1 9 9 0 WL 34 14 7, at * 3 ( 9th Ci r. M ar . 27, 19 90 ) ( “[ T] he gove rn m en tne ed n ot pro ve i nt en tt o d eceiv e under18 U. S. C. § 10 01
. ” ( c i t i ng U n i te d Stat es v. Vaughn , 79 7F .2d 14 8 5 , 14 9 0 (9t h C ir . 19 8 6 ))), w ith U ni t ed Sta t es v. G uzm an , 781 F. 2d 428, 431 (5th Cir. 1986) ( § 1001 requir es a “ f als e re prese ntat ion .
. . that

. . . i s m ade w ith an in te n t to d ec ei v e o r m isl ea d ” ); U n i te d S tat es v. G eisen , 6 12 F. 3d 47 1, 48 7 ( 6th Ci r. 20 10 ) ( § 10 01 re qui re s that the “statem en t w as m ade w ith know le dg e of it s f als ity and an ‘ int ent to dece iv e’ ” (cit a tio n s o m itt ed )); a nd Uni t e d S t a t e s v. Dothard , 666 F. 2d 498, 503 ( 11th Cir

. 1982) ( “Proof th at the def endan t has the s pec i fi c i nt en t t o dec ei ve by m aki ng a f al s e or f rau dul en t sta te m en t is a p re re q u isi te to co n v ic tio n u n d er 18 U .S.C
. § 10 0 1 .” ( c i t i ng U ni t ed Sta t es v. Lange, 52 8 F .2d 12 8 0 , 12 8 6 (5t h C ir . 19 7 6 ))). re quir em ent forco nvi cti on under § 10 01. N atal e r el i es 12 he avily on th ese cas es an d also invokes J ud ge E schba c h’s R a n u m diss ent. N eit her provi des N atal e a n esc ape hatc h42 N o. 12

- 3231 fr o m the g l ar i ngabs en ce o fthi s r equi r ementi n the t ex t o f the s t a tut e , tho ugh. Th e c i r c ui t s pl i t o n § 1 0 0 1 does nothi ng to und er m in e Ranum ’s st ro n g s u gg es tio n th at, in thi s ci rcui t, § 1001 r equi re s no i ntent to deceive

. In f act, Ranum co nsi de red and r ej ecte d those cas es. 96 F. 3d at 10 29
. Nordo es the s pl i t ca l li nt o que st i o n Ranum ’ s ho l di ng that § 1097 l i kewis e re quir es no speci fi c i ntent. B oth st a t u t e s c on ta inlan gu ag e s im ilar to § 10 35 , an d N at ale provi des no re alexpl an at ion fo r w hy R a n u m er r ed an d the m i nor i ty ci rcui ts’ i nter preta ti on i s co rr ect. J ud ge Eschbach’s Ranum d i s se n t s im ilar ly offe rs N at ale no s up port
. J ud ge Eschbach to ok i ssue w i th the R a num m aj or i ty’ s co m p ar iso n to § 1001 , r oo ti ng hi s di sag re em ent in textual d i ffer ences between § 1097 ( a) and § 1 001. H e e xplained that, i n § 1 097( a) , the w or d “w i l l fully” m odi fi ed the phrase “obtains by” the m aking o fa f al se st at em en t. Ranum , 96 F. 3d a t 10 32( E schbac h, J

. , dissen ting). W i l l ful l y ob t a i ningthr o ugh a f a l s e s t a t e men t, h e a r g ue d, n ec es sa rily re q u ire s in te n t t o d ec eiv e. Id. T he di sse nt ev en adm i tte d “agr ee[ m ent] with the m aj or i ty [ that § 1 097 woul d ha ve no i nt ent t o d ec ei ve r equi r ement ] i fthe st at u te sa id ‘an y p er so n w h o kn ow in gly an d w i l lfu lly . .

. m ake s a f al se st at em en t .
. . . ” Id. Tha t pr ec i se l an gu ag e is fou n d in § 10 35 (a): “W h oe ve r . . . kn ow in gly and wil l fully . . . m ake s any m ate ri al l y f als e, fi cti ti ous, or frau d u len t s ta te m en ts or re p re se n ta ti o n s . . . .” Thu s, J ud ge E sc hbach’ s r eas oning ac ti vel y underm i nes N atal e’ s a rgum ent. Placin g § 1 035 w ithin th e con tex t of th e ent ire statu tory sc he m e th atCo ng r es s en ac te d o nl y c o nfi r m s o urr eadingN o. 12

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o fthe pl ain t ex t. Co ng r es s en ac te d § 1 03 5 as p art o fthe H eal th Insurance Por tabi l i ty and A ccountabi l i ty A ct o f 1996 ( H I PA A )
. A l ong w i th the pro vi si ons of§ 1035 , H I PA A cr i m i nal i zed heal th car e fra ud ( am ong othe r h ea l th ca re sp ec ific c rim in al off en se s). Se e, e . g. , 1 8 U. S
. C. § 1 34 7(a )(1) (m ak in g i t illeg al t o “ kn ow in gly an d w illfu lly execute[ ] , o r att em pt[] to e x ec ute, a schem e o r ar ti fi ce to de fr aud a ny he al thc ar e be ne fi t pr o g r am”)
. And i ntent to defr aud it sel fr equi re s a sp ecifi c intent to d ec eiv e o r m isle ad

. U ni t e d S t at e s v. Awad, 55 1 F
. 3d 930, 940 ( 9th Ci r. 20 09) ( notin g j u ry w as i nstr ucted i n § 1 347 pros ecuti on that “ ‘ i ntent to defra ud ’ [ i s] defi ned as ‘ an in te n t t o d ec eiv e o r c h ea t ’ ” ) ; U nited Sta tes v. C ho iniere, 517 F
. 3 d 9 6 7, 9 7 2 ( 7 th Ci r . 2 0 0 8 ) ( no t i ngj ury i ns t r uct i on i n § 1 347 c as e d efi ned “ ‘ i ntent to defr aud’ t o m ean ‘ that th e ac ts c ha r g ed wer e do ne kno wi ng l y wi th th e i nt en t to d ec eiv e o r c h ea t th e v ict im s’ ”); U nite d States v . White, 492 F. 3d 380, 39 3- 94 ( 6th Ci r. 20 07) ( to convi ct und er§ 1347 “t h e g ov er n m e n t m u stp ro ve th e d efe n d an t’s ‘sp ec ific in te n t t o d ec eiv e o r d efr au d ’ ”); see also U ni t ed S t at e s v. Vall one, 6 98 F. 3d 41 6, 4 83 ( 7th Ci r . 2 01 2) ( ci tingU nited Sta tes v. Ho w a rd, 619 F.3d 723 , 727 (7th C ir . 2010)); U nited Sta tes ex re l. B a lta z a rv . Wa rden , 63 5 F
. 3d 866, 86 8 ( 7th Ci r. 20 11) ( ci ti ng M e r ck& Co. v. Reyn o l ds , 13 0 S
. Ct. 1784 , 1796 (2 0 1 0 )) . I f he alth care frau d and health care f al se sta tem ents both re quir ed speci fi c intent to decei ve, th e t wo s t a tu t e s w o u l d c r i mi n a l i z e e s s e n t i a l l y th e s a me con d uc t. E sp ecia ll y beca us e con viction for he alth care fra ud car ri es tw i ce the m axi m um penal ty as the f al se st at em e n ts st at u te , co m pa re § 1 03 5(a ) (five -ye ar m ax im u m p ris on te rm ), wi t h § 13 47 ( a) ( te n- y ea rmaxi m um44 N o. 12

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An d j us ta s “ wi l l ful l y” c r e a t e s n o s pe c i fi c inte ntt o de c e i ve 13 req u irem en t, ne ither d oe s th e statu te’ s m ater iality requ irem en t. A m at er i al s t at em en tha s “ ‘ a n atur al t en denc y t o i nfl uen c e, or [ i s ] c apa bl e ofi nfl uen c i ng, the dec i s i on of’ the dec i s i onm aki ng (co n tin u ed ...) pr i so n t er m ( twe nty i fthe c ri m e r es ul ts i n b o di l y i nju r y )) , an interp retation of the tw o statu tes th at cove rs substa nti al l y the sa m e co nd uct m ake s no se nse. S om eth i ng m us t war r an t th e ha r sh er pen al ty f o r th e fr au d charg es. That s om ethi ng i s the e n h anced cul pabi l i ty att en d an t in a per son’ s s peci fi c intent to decei ve orm i sl ead. Fr aud requi res th at proo f; f al se sta tem ents do not. A dm i tte dly, “[ t] he m er e f act that tw o federa lcr i m i nal st atut es c r i m i na l i ze s i m i l arc o nduc t sa y s l i tt l e ab o utthe sco pe ofei ther

. ” P a squa ntin o v. U nite d Sta tes , 54 4 U.S
. 34 9, 359 n. 4 ( 2005 ) . B u t an i nter preta ti on o f§ 1035 that re quir ed i ntent to d ec eive would not m er el y c ri m i nal i ze c on d u c t s i m i l a r to th atp ro h ibit ed by § 13 47, i t w ou ld r es ul t i n n ea r l y c o m pl et e o ve rla p: a ny f al se s ta te m en t m ad e w ith inten t to de ceive w o u ld n eces saril y qu ali fy a s a s c he me t o de fr a ud under § 1 3 4 7
. We fi nd i to dd th a t C o n g r e s s w o u l d i n t e n d s u c h a r e s u l t fr o m t wo st atut es e na ct ed i n the s ame pi ec e o fl eg i sl at i o n. In s h or t, the t ext o f§ 1035 , co urts ’ i nter preta ti ons of si m i l art ex t i n o th er f al se s ta te m en ts s ta tu te s, a nd the con tex t in w hich Con gress en acte d § 1035 allrequ ire the c oncl usi on that § 10 35 d oe s n ot re quir e pr oo fo f sp ec ific in te n t t o d ec eiv e. T h e d ist ric t c ou rtth u s p ro p er ly i nstr ucted the j ury on the st atute ’ s wil lful ness re quir em ent. 13N o. 12

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(
. . . c on t i nu e d) 13 bo dy t o whi c h i twa s a ddr e s s e d.” K ungys , 4 8 5 U. S
. a t7 7 0
. As such, m ater ial ity ob j ect ivel y f ocuse s o n a h yp o th et ic a l liste n er ’s res pon se to th e sp eech un d er th e circu m stan ces. In con trast, int ent to decei ve f ocuses on the speaker’s m oti vati on s f or the sp eec h. Thu s, m ater ial ity and int ent to deceive differ : A s pe a k e r c a n ma k e ma t e r i a l l y f a l s e s t a t e me n t s wi th o u ti ntending decepti on. A sp eaker c an als o m ake im m ater ials tat em en ts ho p in g to d eceiv e. An d , of cou rse, a spea k er co u ld m ake m at er i al l y f al s e s t at em en t s whi l e i nt en di ng de c ept i on. 4. A p p li c a ti on of§ 1035 to N atale D id N ot V iolat e D ue Proc ess N atal e’ s fin alchal l enge to the j ury i nstr ucti ons ass er ts a due pro cess vi ol ati on. A p pli cati on o f§ 1035 to si tuati ons whe r e the f a l s e s t a t e men t s ha v e no c o nn e c t i o n to M edi car e, he a rgue s, p re sents an unconst i tuti onall ack o fc l a r i ty th a to p e n s th e s t a tu t e t o a rb i t r a r y a n d d i s c r i mi natory enfo rce m ent. N atal e co ncedes, however, that § 1 035 sat i sfi es const i tuti onalr i gorwh en app lied to f al se s ta te m ent s m at er i alt o a he al thc ar e be ne fi t pl an . A s w e hav e exp lai ne d , the p roof at trialplaces N atale’s c as e s q u ar ely w ith inth is c at eg or y. * * * To s um m ar i ze , c onv ict i o n fo rf al se s ta te m en ts r el at i ng to heal th car e m att er s, 18 U
. S. C . § 10 35( a) ( 2) , r equi re s p ro of th atth e d efe n d an t (1 ) kn ow in gly an d w illfu lly ( 2) m ade f al se, fi cti ti ous, o r fra ud ule nt st ate m ents or re prese ntati ons ( 3) i n connect i on with the del i very ofo r p a y m e n t fo r h ea lth ca re be n efit s, ite m s, or se rv ice s (4 ) in46 N o. 12

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any matt eri nv o l vinga he al th c are be ne fi t pr o g r am, a nd (5 ) t h e statem en ts w ere m aterial to the health care benefi t pr ogr am . W h il e m ate ri al i ty re quir es a natural te nde nc y t o i nfl ue nc e, o rb e capa ble o fi nfl ue nc i ngthe heal th car e be nefi t p rogr am , nei therthe m ate ri al i ty el em ent no r the wil l fulne ss el em en t r equi re s the go ver nm ent t o prove t h e defendant m ade the f al se sta tem ents w i th i ntent to decei ve. The dis tr i c t co urt’ s j ury i nstr ucti ons in N atal e’ s ca se did notr efl ect al lo fthes e r equi re m ents. N eve rthel ess , w hen vi ew ed aga i nst the bac kdro p ofthe e vid ence presente d at t rialand N atal e’ s defense to the j ury, thes e er ro rs did not a ffect N atal e’ s s ubstanti alr i ghts or rend er his tri al unfair.

B. Nata l e’ s Convi ct i on W as Not a M anif estI njust i ce N at al e a t t a c k s th e s u ffi c i e n c y o fp r o o fo n wh i c h the j u r y c o n v i c t e d h i m o fma k i n gf a l s e s t a t e me n t s . He a d m i t s , ho w ev er , th attria l co u n se l ne ve r re n ew ed h is m oti on forj ud gm ent o facqui tta latthe cl ose o fev i dence. T h u s, to su c c es s fu lly at ta c k th e s u fficie n c y of t h e e viden ce , he musts ho w hi s con vi ct i o n r es ul te d i n a m an if es t m isc ar ria ge of j u st ice
. Turn er, 55 1 F
. 3d at 662. T h i s “ mo s td e ma n d i n gs t a n d a r d o fa p p e l l a t e r e v i e w” perm i ts re ver salo nl y i f“the r eco rd i s devo id ofev i dence poi nti ng to gui l t, o r i fthe evi dence on a k ey el em ent o f the o ffense w as so tenuous th at a co nvi cti on would be shock i ng. ” Id. ( quoti ng U ni t e d S t at e s v. Tayl or, 22 6 F
. 3d 593, 59 7 -9 8 ( 7th Cir. 2000)). In att em p ting to satisfy thi s hi gh ba r, N at ale ar gues the g ove rnm ent pr oducedN o. 12

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no e vi den ce o fe i th ermate r i ali ty ori nt en t. Nots o . To sh o w m at er i al i ty, the g o ve r nm en t pr es en te d t es ti m o ny th at, ha d M ed ica re au d ite d t h e billin g c od es N at ale subm i tte d, i t would have r equeste d opera ti ve re port s and m edi c al n otes. Because M edi car e would have l oo ked to and re li ed on these re port s a nd not es i n the eve nt o f an audi t, the re port s and no tes w er e “ capabl e o fi nfluenci n g ” th e d e c i s i o n o fth e he a l t h c a r e b e n e fi tp r o g r a m. Thu s, the re cor d i s not “devoi d” ofev i dence on m ate ri al i ty. A nd nei the r i s the r eco rd “devo i d” ofev i dence on i nt en t. Nat al e r ea di l y a dm i ts he “ k ept i na cc ur at e an d i m preci se re cor ds. ” The crux ofargum ent a t t ri al cente re d on wh etherthati naccurac y a nd i m preci si on r es ul ted f r o m i nno ce ntc ar el es sn es s o rkno wi nga nd w i l l ful m i sr epres entat i ons. The M edi car e r epres entative testifi ed that w he n p hy sician s e n r ollas prov iders und erM edi car e, theyr ecei ve m ult i ple not ice s reg ar di ngthe ne ed to a cc ur at ely c o m pl ete f o r m s an d t r uthfully r epres ent s er vi ces re nd er ed. M or eov er, atl eas t s o m e o f th e fa lse st at em en ts oc c u rre d d u rin g or sh or tly afte rthe s ur g ery, c as tingdo ubto n Nat al e’ s as se r ti o ns th at he i na d verten tly desc ribed the inc orrect p roced ure bec a us e o f hi s de l a y i n pr e pa r i ng the no t e s . On t o p of that, m any o fN atale’ s no tes pro ved qui te detai l ed

— not the v ague general i ti es that usual l y a ccom pany i naccuraci es re sul ti ng fro m car el ess ness, i nadvert ence, o r th e p as sa ge of t im e. Fr om a ll th is e vid en c e, th e jur y c ou ld i nfer th atthe f al se s ta te m en ts r es ul te d fr o m kno wi ng d elib er at ion ra t h e r th an ca re les s in ad ve rt en c e. N at ale i gnor es thi s e vi de n c e an d now r e- l i ti gat es hi s ca re l ess ness defe nse o n appeal

. The j ury dis b eli eve d that s tory,48 N o. 12

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an d th e e vid en c e p er m itt ed th e jur y t o in fer kn ow ledge and wil l fulne ss. A s a re sul t, N atal e cannot es tabl i s h tha ta ma ni fe s tmi s c a r r i a g e o fj us t i c e o c c ur r e d.

C . T h e D is tric t C ou rt D id N ot E rr in P erm ittin g th e Ju ry t o Take An t on’s D em onst r at i ves i nto t he J uryRoom N atal e a l so ap p eals the dist ri ct c ourt ’ s deci si on t o per m i t th e j ur y t o b r i ng A nt o n’ s demons tr at i ve s i nt o the j ury ro om duri ng deliberat i ons. W e r evi ew the dist ri ct cou rt ’ s deci si on t o send dem onst ra ti ves to the j ury ro om for ab u se of d isc re tio n . Sal e r no , 10 8 F
. 3d at 742. So lo nga s th e co ur t i s “e ve nha nde d” i n r ul i ngo n the ev i den ce , i t ha s “wi d e d is cr et i o n” i n de te r m i ni ng w he th er to a llow the j ury to take an ex hibit to the j ury ro om . Id. at74 5. T h e d i str i ct c ourther e s how ed such f ai r ne ss , o ffer ing N at al e as wel lthe o ppo r tu ni tyt o s en d d em on st ra tiv e e x h ibit s t o th e jur y ro om (w h i c h h e u ltim at ely a cc ept ed)

. Nev er th el es s, Nat al e ar g ue s that th e A nton d i agr am s m i sl ed the j ury by “st ro ngl y s ugges t[ i ng] to t he j ury th at th e bifurc ation graft versu s tub e graft iss u e w as sign ifica n t b ec au se of th e g ro ss d iffer en c e in sh ape , s i ze a nd g en er ala pp earan ce o fthe g r afts i n the il l us tr at i o ns . ” I n r ea l i ty, he c o nt i nue s, Anto n’ s as se r ti o ns th at th e op era t iv e reports de scribed a bifurc ation graft w er e i m m ate ri albec ause the g ove rnm ent ne verar gued that he bi l l ed M edi car e forsuch g ra fts. N atal e i s co rr ect that the b il l i ng co des he subm i tte d i denti fi ed proce du re s r el ate d to the renalar ter i es, notuse o fb i fur ca ti o n g r afts
. Buthe do es no t di spu te th attheN o. 12

- 3231 49

N ata le d oe s po int to on e ina ccu rac y in the d em on strativ es. 14 Ant on adm i t t ed a tt ri al that the dem ons t ra t i ve c ont ai ne d one er ro r, d es c ribi ng the at t ac hm en tofon e t ube gr aftas “e nd- t oen d” wheni ts houl d have r ea d “e nd- t o- s i de. ” Th i s m i nore rr or has no beari ng on the thrustofN atal e’ s operati ve rep o rt s. In an y ev e n t, A n t on corr ected him self in fron t of the jur y so the j ury w as aw are ofthi s sm allm is take. oper ati ve re port s co ntai ned in accura ci es and that those i na cc ur ac i es s ug g es te d us e o fa b i fur ca ti o n g raft

. The i m port ant quest i on i s n ot wh etherthe dem onst ra ti ves ac curatel y r efl ec te d whathe b i l l ed to M edi ca r e but w hetherthe dem onst ra ti ves accura tely r efl ecte d w hat th ey pur po r te d to sh o w: N at al e’ s des cr i pti o ns of th e pr o ce dur es i n the o per at i ve r epo r ts a s co m p ared to the pr o ce dur es de pi ct ed i n the CT s ca ns . Nat al e g i ve s no s u g g e s t i o n th a t th e y mi s l e a d th e j u r y i n th a t r e s p e c t
. He admi ts the o per at i ve r epo r ts c o nt ai ned i na cc ur ac i es b ut o ffer s no e vi den ce s ho wi ngthe de m o ns tr ati ves ina cc ura te ly d e p i c t t h e s ta te m en ts in h is op er at ive rep or ts
. In 14 that sense , the dem onst ra ti ves si m plypor tr ay w hat, as the g o v e r nme ntp o i nt s o ut, Na t a l e h a s c o nc e de d. N or d id th e d em on st ra tiv es h av e th e im p er m iss ible effect of“tra nsport i ng” Anton i nto the j ury ro om dur i ng del ibe r at i o ns . The de m o ns tr at i ve s us ed dur i ng A nt o n’ s te st i m o ny c o nt aine d v ar i o us l ab el s i den ti fy i ng w hic h dia gr am depic ted A nton’ s co ncl usi ons and w hi ch d iagram de p icted the p roced u re de scribed i n N atale’s o p e ra tiv e n ot es . Th e g ov er n m en t re m ov ed th es e la b els fro m the exhibi ts sent to the j ury ro om , however, r equir i ng j uro rs to i denti fy the co ntent ofthe dem onst ra -50 N o. 12

- 3231 ti ves fro m thei r re col l ecti on o fA nton’ s t es tim ony. Thus, th e demons tr at i ve s di d no t ha ve th e effec t o fsend i ng A nt on h im self into th e j ury room w ith th e j urors. Con trary to N at ale ’s s u gg es tio n, U nited Sta tes v. Wa re does not r equi r e a co nc l us i o n o th er wi se . Tha t ca se f o cus ed on the adm iss ibility o fthe evi dence, not i ng o nl y that thi s e rr or in a d m ission w as “com p ou nd ed ” by th e d istri ct cou rt’s deci si on t o al l ow j uroruse ofthe ex h ibit s d uri ng del iber at ion s. U nited Sta tes v. Wa re, 24 7 F
. 2d 698, 700- 01 ( 7th Ci r . 1 95 7)
. Nat al e do es n ot conte stthe a dm i ss i o n o fthe dem onst ra tives her e s o Wa re offer s no support f or hi s a rgum ent. I n shor t, N atal e fully a dm i tte d discrepancies betw een th e pr ocedur es de sc r ibe d i n h i s o per at i ve r epo r ts a nd the proce du re s he perf or m ed. H e cannot now su ggest p rej udi ce i n pe r m i tt i ngthe j ur y dur i ngde l ibe r at i o ns t o e xa mi ne de mon s t r a t i v e e v i de nc e c o ns i s t e ntwi th hi s o w n adm i ssi ons.

D . T h e D istrict C ou rtD id N ot A b u se Its D is creti on i n E xc lu d in g th e G ov ern m en t R ep ort N atal e’ s fi nalat tem pt at ove rturni ng hi s co nvi cti on f ocuse s o n the dist ri ct c ou rt ’ s e xcl usi on o fa re portpubl i shed by the Dep ar tm ent o fH eal th and H um an S er vi ces ( H H S )
. The r epo r t sh o wed e r r o rra te s i n Medi ca r e co di ng and paym ents as hi gh as 46 % f orcl ai m s s ubm i tte d by va sc ul ars urge o ns i n thi s r eg i o n. The di st r i ctc o ur t ex c l u d e d th e e v i d e n c e as i r r e l e v a n ta n d a s h e a r s a y . We re vie w ev id en tia ry ru lin gs for a b u se of d isc r e t ion
. U nited St at e s v. Cunn i ngh am , 462 F.3d 708 , 712 (7th C ir. 2006).N o. 12

- 3231 51 U l ti m ate l y, we need not c on sid erN atal e’ s a rgum ents on this front bec au se an y error in th e d istri ct c ou rt’s ex c lu sio n of th e re p or t w as h ar m les s. Se eU ni t e d S t at e s v. Jac ks on , 5 40 F
. 3d 57 8, 5 93 ( 7th Ci r. 2 008) ( “Ev eni fthe d i str i ct cour t er re d in excl ud i ng such evi dence, w e w ill not reverse ifthe error w as ha rm less. ”). Rel evantev i dence has the t endency to m ak e any f act ofco nsequence m or e o r l ess probabl e. Fed . R . E vi d. 401. Acco r di ng to N at al e, a g o ve r nm en ta l r epo r t d emon str ating a 46% er ro r ra te bear s directl y o n hi s intent, supp or ti ng hi s a rgum ent that he m ade a goo d fa i th effo rtto fin d t h e M ed ica re co d e th atm os t a c c u ra te ly d escribed the p roced ure he p erfo r m ed w he n M ed icare provi ded no bi l l i ng co de dir ectly o n poi nt. Re g ar dl es s o fthe pr o pr i ety o fthe di st r ict c our t’ s co ncl usi ons on re l evance and he ar say, N atal e’ s own bri ef ex pl ains why, as th e ca se st an ds no w, th e r epo r t ha s no re l evance and an y er ror fro m i ts excl usi on i s har m l ess . “ Th a tthe er r o rr a t e ap pr o a c he d 5 0 p e r c e nt, ” h e e xp l a i ne d,

“ s t r o n g l y s u g g e s t s s i g n i fi c a n tc a u t i o n b e f o r e i n fe r r i ng i ntent to defr aud or m isle ad fro m an inaccurac y. ” Thus, the o nl y r el evance N atal e o ffer s t o j usti fy a dm iss ion of the r eport li es i n the j ury’ s dete rm i nati on o fi ntent to defr au d o rmis l ea d. N atale was a cqui tt ed o n the fr au d c h ar ge s, tho ugh, and as w e hav e e xplained, § 1035 r equi r es no s pec i fi c i nt en t to de ce i ve . The o nl y i nt en t r el ev an t to Na t a l e ’ s c o n v i ct i o n was whethe r he kn ow in gly an d w illfu lly inc lu d ed fals e s ta te m en ts in the o pe r a t i v e r epo r t s , a que s t i o n ha v i ngn o thingt o do w i th M edi car e bi l l i ng inaccurac i es.52 N o. 12

- 3231 M or eov er, f al se sta tem ents i n N atal e’ s o pera tive re port s a nd o therphysi ci an not es

— not hi s s ubm i ssi on of the M edi car e bi l l in g c odes

— provi ded the basi s for h is c on vic tio n u n d er § 10 35 . O t h e r p h ys icia n s’ e rro rs in su bmi tt i ngM edi ca r e bi l l i ngc o des t el lus no th i ngabo ut th e m i st ake s N at al e m ade i n his o wn r eco rds a nd r eport s . Be ca us e th e j ur y a cqui tt ed N at al e o fthe fr au d c h ar ge s re lat ed to h is M ed ica r e b i llin g, an y e rro r in the di str i c tc o ur t ’ s e xc l us i o n o fthe r e po r t s n o w s t a nd s harm l ess .
I I I . Concl usio n T h e ins tr ucti ons und erwh i ch the j ury convi cted N atal e w er e e rr oneo us. They perm i tte d convi cti on forf al se st at em en ts h av in g n o re lat ion to a h ea lth c ar e b en efit prog ra m i n dir ect contr adic tio n to the te xtualr equi re m en ts o fthe s tatut e. Not wi th st an di ngthe se e r r o ne o us i ns truct i o ns , the pr o o fa t tr i alwas mor e th ans uffi ci en t to s ho w tha t th e surge r i es de sc r ibe d i n the i ndi ct m en t i nvol ved a heal th car e be nefi t pr ogr am , M ed i car e, and t hat Natal e’ s f al se sta tem ents w er e m ate ri alto M edi car e. Thus, the e rr oneo us i nstr ucti ons w er e har m l ess . Lik ew i se, the gov er nm ent pr ese nted suffi ci ent evid ence ofm ate ri al i ty and i nten t so no m ani festm i scar ri age ofj usti ce r esul ted fro m N atal e’ s convi cti on. Final l y, nei the ro fthe c ha l l e ng e d e v i de nt i a r y de c i s i o ns r e qu i re s r ev er sa l

. The di st r i ctc o ur t’ s per m i ss i o n t o s en d the demons tr at i ve s to the jur y r o o m dur i ngde l ibe r at i o ns was no t er ro ne o us , a nd Nat al e’ s ac qui tt alo n the fr au d cou n t s r e nd ered harm less any error i n th e d istri ct cou rt’sN o. 12

- 3231 53 excl usi on o fthe H H S report
. W e A F F I RM N at al e’ s co nvi ct i o n.

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