### I N THE UNI TED STATES COURT OF APPEALS FOR THE FI F TH CI RCUI T

No. 12-50027

UNITED STATES OF AMERICA,

Plaintiff - Appellee

v.

ANTHONY FRANCIS VALDEZ,

Defendant - Appellant

Appeal from the United States District Court for the Western District of Texas

Before HIGGINBOTHAM, OWEN, and GRAVES, Circuit Judges. JAMES E. GRAVES, JR., Circuit Judge:

T h e d e f e n d a n t A n t h o n y V a ld e z, a p sy ch i a trist, ch a lle n g e s m u ltip l e

a sp e c ts o f h is tria l a n d se n t e n ce in th i s m o n e y la u n d e rin g a n d h e a l t h ca re fra u d

ca se

. H e argues that there is insufficient evidence to support his c onviction for

money l aundering; t hat the di s t r i c t court erred in applying various

enhancements to his sentence; that the jury should h a ve been retained to decide

issues r elating to the forfeiture of his property; that the c ourt erred in admitting

evidence of medical malpractice; and that t he cumulat i v e e ffect of multiple errors requires reversal. We affirm the conviction and sentence, including the judgment of forfeiture. U n i t e d S t a te s C o u r t o f A p p e al s F i f t h C i rc u i t 

### F I L E D Aug ust 12, 2013

Ly l e W . Cay ce Clerk Case: 12-50027 Document: 00512338659 Page: 1 Date Filed: 08/12/2013No. 12-50027
I. Factual and Procedural Background

A n t h ony Valdez operated t wo pain management clinics under the name
of International Institute of Pain Management, located in El Paso and San Antonio, Texas. The indictment alleged that Valdez provided patients with prolotherapy, a “medical procedure purported to strengthen lax ligaments or to
relieve p ain by injecting an irritant.

. . such as dextrose, glycerin, calcium and phenol, around a painful joint to provoke a biological r esponse that r e sults in the growth of new c ells.” H owever, Valdez billed federal and state h ealth insurance

p r o g r a m s M e d i c a r e , M e dicaid and Tricare (collectively called “the Programs ” ) f o r
facet j oint injections, w hich temporarily e liminate pain by injecting anesthetics

and/or s teroids into facet joints in the vertebrae, and p eripheral nerve injections,

which temporarily eliminate pain by injecting a n e s t hetics near a nerve. Prolotherapy is not r eimbursable by the Programs, whereas facet joint and peripheral nerve injections are reimbursable. The indictment alleg ed that

Valdez submitted insurance claims to the Programs under the c o d e s for facet joint and p eripheral n erve injections rather t han the prolotherapy i nj e c t i o n s actually performed. The indictment further alleged t h at Valdez billed f or “Level

4” office visits, which entail extended examination and evaluation, t hat did not

occur, and that he trained and instructed his emp l o yees to perform and fraudulently bill for the s ame services. T he indictment also alleged that Valdez engaged in financial transactions involving the proceeds of health c a re fraud

with t he intent to promote unlawful activity and to conceal the p roceeds of his

health care fraud, and engaged in monetary transactio n s w i t h c r i m i n a l l y d e r i v e d funds of $10,000 or more. The indictment included a forfeiture demand.

Valdez was tried by a jury and convicted of one count o f conspiracy to

com m it health c are fraud, 1 8 U.S.C. §§ 1349 and 1347 (Count 1); s ix c ounts of

health care fraud relating t o six specif i c p a tients, i d

. § 1347 (Counts 2-7); six

counts of false statements relating to health c are matters relating to six specific

2 Case: 12-50027 Document: 00512338659 Page: 2 Date Filed: 08/12/2013No. 12-50027

insurance claims, id. §1035 (Counts 8-13); o ne count of money laundering, id

. § 1956(a)(1) (Count 14); and two counts of engaging in monetary transactions in property derived from unlawful activity, id. § 1957 (Counts 15-16).

T r i a l t e s t imony from patients and expert d o ctors supported t h e a l l e g a t i o n s
tha t V a l d e z actually performed p rolotherapy when he billed the Programs for

facet j oint or peripheral nerve injections. The e vidence included testimony that during a Texas Department of Insurance m e d i c a l review, Valdez told Dr.

Suzanne Novak that h e did prolotherapy, and during that s ame review told Dr.

Howard Smith t hat he only p erformed prolotherapy but called it “reconstructive

anesthetic blocks” i n order to bill i n s urance carriers who would not cover prolotherapy. Trial evidence, including t e stimony from employee s , p a t i e n t s , a n d
doctors, including doctors w ho reviewed video o f Valdez performing procedures,

indicated that Valdez’s medical practices were consistent w ith prolotherapy and

inconsistent with f

acet joint or p eripheral nerve in j e c t i o n s, including that he injected too much solution to be performing facet j oint injections, repeatedly injected p atients which w ould not be advisable if the injections were f acet joint

o r p e r i p h e ral n erve injections, did not have a fluoroscope (a t ype of x-ray
machine typically used for f acet injections), did not have s t e roids that are typically injected in facet joint injections but d i d h ave solutions c onsistent with prolotherapy, used a patient encoun t er form that i ncluded a section for prolotherapy but not facet j oint or peripheral nerve injections, a n d advertised prolotherapy but not facet joint or peripheral injections. T he evidence also supported the allegations that Valdez trained his employ e e s to perform proloth e rapy but n ot facet joint or p eripheral n e rve injections, including testimony from Rose Chavez, office manager at t h e El Paso clinic, who stated

that prolotherapy w a s p erformed at both clinics, but not facet joint o r peripheral

nerve injections. Chavez also testified that she spoke to Valdez about the billing

for prolotherapy a fter reading some material f rom a pain management seminar

3 Case: 12-50027 Document: 00512338659 Page: 3 Date Filed: 08/12/2013No. 12-50027

that stated that prolotherapy was not r eimbursable b y the P rograms. Chavez

testified that she mentioned the billin g i n f o r mation t o Valdez, b ut Valdez instructed Chavez to disregard it. With regard to money laundering, a t t r i a l t h e g o v e r n m e n t p r e s e n t e d

Emmanuel Gomez, an FBI agent who analyzed Valdez ’ s f i n a n c i al records. Agent

Gomez testified about Valdez’s r e c e i p t a nd spending o f reimbursements from the Programs over the course of the five-year period. The evidence showed that the proceeds of the f

r a udulent billing scheme were directly d e posited from the Programs i nto two of V aldez’s bank accounts. Based o n Agent G omez’s analysis

of the financial records, Valdez wrote chec k s f rom these accounts to pay emplo y e e s alaries and l oans, to make investments, t o p u rchase p roperty, to
make d eposits into multiple investment a ccounts, and to p urchase multiple vehicles classified as business transportation.

At sentencing, the district court adopted the pre-sentence investigation
report (“PSR”), calculated a guidelines range of life, overruled a l l of Valdez’s objections to the PSR, and imposed the following sentence:

Counts 1-7: 120 months, 18 U.S.C. §§ 1347, 1349

Count 8: 60 months, 18 U.S.C. § 1035 (to run consecutive)

Counts 9-13: 60 months, 18 U.S.C. § 1035

Count 14: 240 months, 18 U.S.C. 1956(a)(1)

Counts 15-16: 120 months, 18 U.S.C. § 1957 The district court sentenced Valdez to the statutory maximum for all offenses,

and ordered that the 60-month sen t ence for Count 8 run consecutive w ith the other sentences, for a total of 300 months of confinement.

The co u rt a lso imposed three y ears of s upervised r elease on all counts,
ordered $13,356,645.44 restitution t o federal and s t ate insurance programs and private insurers, and ordered a mandatory assessment o f $1600. The court also

o r dered forfeiture of Valdez’s property, as requested by the governmen t ,

4 Case: 12-50027 Document: 00512338659 Page: 4 Date Filed: 08/12/2013No. 12-50027

including the con t e n ts of multiple bank accounts, real property, the proceeds

from the sale of real property, four vehicles, and a money judgment of over nine

million dollars.

II. Discussion

A. Money Laundering Conviction

Valdez argues that the evidence w as insufficient to support his conviction

on one count of money laundering under 18 U.S.C. § 1956 ( a ) ( 1 )

. “We apply d e

novo review to a c h a l l e n ge to the sufficiency of t he evidence, viewing the

evidence in the light most favorable to the verdict and upholding the verdict if,

but only if, a rational j u ror could have found e ach element of the offense beyond

a reasonable doubt.” U nited States v. Pennell
, 409 F.3d 240, 243 ( 5th Cir. 2005).

Section 195 6 (a)(1) requires the government to p rove t h e following

elements: (1) Valdez conducted a financial transaction; (2) which he knew

involved proceeds arising f rom a specified unlawful activity; (3) with the intent

to promote or further those illegal a c tions ( “the p romotion prong”); or (4) with

the knowledge that t h e t r a n s action’s design w a s to conceal o r disguise the nature

or s ource of the i l l e g a l p r o ceeds (“the concealment p r ong”). See 18 U.S.C. § 1956(a)(1)(A)(i), (B)(i); Pennell
, 409 F.3d at 243. The two prongs are alternative ways to commit the offense; since Valdez was charged with both p rongs in one count, the government must establish guilt under o ne prong or the other. See,

e.g., U nited States v. Meshack
, 225 F.3d 556, 580 n.23 (5th Cir. 2000), a m en d ed

o n reh ’g in p a r t , 2 4 4 F .3 d 3 6 7 (5 th C ir. 2 0 0 1 ); United States v. Seher , 562 F.3d
1344, 1361-62 (11th Cir. 2009) (reviewing c ases from multiple circuits). Valdez

argues that there is insufficient evidence supporting either prong and that the

district court plainly e rred b y n o t g i v in g a sp e cific u n a n i m i t y j u r y c h a rg e

re g a r d in g m o n e y la u n d e rin g

. W e fin d th a t a lth o u g h th e re is i n su fficie n t

e v i d e n ce o f co n ce a lm e n t m o n e y l a u n d e rin g , th e re is su fficie n t e v id e n ce to

su sta i n V a ld e z’s co n v i ctio n fo r m o n e y l a u n d e rin g b a se d o n p ro m o tio n o f

5 Case: 12-50027 Document: 00512338659 Page: 5 Date Filed: 08/12/2013No. 12-50027

u n l a w f u l a c tiv ity
, a n d th a t it w a s n o t p la in e rro r fo r th e c o u rt n o t to g iv e a

sp e cific u n a n im ity in stru c tio n

. 1. Concealment Money Laundering

The concealment prong of § 1956(a)(1) requires the g overnm e n t t o
establish that t he d irty money transactions are “design e d

. . . to conceal or disguise the n ature, the location, the source, t he ownership, o r t h e control” of the

money involved. 18 U.S.C. § 195 6 ( a ) ( 1 ) ( B)(i) ; see United States v. Brown
, 553

F.3d 768, 786 (5th Cir. 2008). To establish the design element, the government

m u s t d e m o n s trate t hat the charged t ransactions h ad the purpose, not merely t h e effect, o f “mak[ing] it more difficult for the government to trace and demonstrate

the nature o f th[e] funds.” B rown , 553 F.3d at 787 (citing Cuellar v. United

States
, 553 U.S. 550 (2008)). We h a v e e x plained that: “In one s ense, the acquisition of any asset w ith the proceeds of illegal activity conceals those proceed s by converting t hem into a different and more l egitimate-appearing

form. But the requirement that the transaction be designed to conceal implies

that more than this trivial motivation t o conceal must be proved.” U nited States

v. Willey
, 57 F.3d 1374, 1384 (5th Cir. 1995) ( cit a t i o n s o m i tted). Here, the
government relied on Valdez’s transfers o f funds from his o perating accounts to
investment accounts, and o n V aldez’s purchases of p roperty and

investments—all d one openly, i n his name—as proof o f c o n cealment money laundering. None of the transactions pointed to by the government show a specific i ntent to conceal the nature, location, source or o wnership of the funds

used. Valdez did not use f alse names, third parties, o r a n y p articularly complicated financial m aneuvers, w hich are usual hallmarks of an intent to
conceal. See United States v. Burns
, 162 F.3d 840, 848-49 (5th Cir. 1998); Willey
, 57 F .3d at 1385 (noting t hat “ a showing of simply spending m oney in one’s own

name will ge n e r a lly not support a money laundering conviction”). There is virtually no evidence o f a d e s i gn to conceal, beyond the “trivial motivation”

6 Case: 12-50027 Document: 00512338659 Page: 6 Date Filed: 08/12/2013No. 12-50027

shown by the acquiring of assets with the proceeds of criminal activity, which Willey instructs is insufficient to establish t he necessary intent. Willey
, 57 F.3d

at 1384. We thus find that there is i nsufficient evidence of concealment money laundering, and t urn to the pr o m o tion prong of the money laundering conviction.

2. Promotion Money Laundering

To establish money laundering under the promotion prong o f § 1956(a)(1),

the government must show that the dirty money t ransaction was conducted with

the specific intent to promote the carrying on of the health c are fraud. 18 U.S.C. § 1956(a)(1)(A) ; see United States v. Brown
, 186 F.3 d 6 61, 670 (5th Cir. 1999).
Here, the government has characterized two types of t r ansactions as promotion

of u nlawful activity: (1) Va l d e z ’ s use of dirty m oney t o purchase vehicles

characterized as “business transportation,” including van s u sed to t ransport patie n t s to and from h is p ain management clinic; a nd (2) Valdez’s use of dirty

money to make ir r e g ular payments and “loans” to h is employees. Because we
find that there i s sufficient evidence to support the m oney l aundering conviction

based o n the payments to employees, i t i s unnecessa r y f or us to address the purchase of the vehicles.

T h e g o v e r n m e n t e sta b lish e d th a t V a ld e z m a d e p a y m e n t s to e m p lo y e e s

w h o p a rticip a te d in t h e fra u d u le n t sch e m e , w h o m V a ld e z h a d tra in e d o r
in s tru cte d t o p e rfo rm p ro ce d u re s a n d fra u d u l e n tly b i l l th e P ro g r a m s f o r

p ro ce d u re s n o t p e rfo rm e d o r o ffice v isits th a t d id n o t o ccu r. The government

relies on United S tates v. Warshak
, a case in which the Sixth Circuit noted that

“it is .

. . true that a number of cases support the proposition that payments to employees may constitute sufficient evidence o f an in t e n t t o p r o m o t e a n u n l a wful activity.” 63 1 F

. 3 d 266, 3 18 (6th Cir. 2010) (citing United States v. Alerre
, 430

F.3d 681, 693 (4th Cir. 2005) (“[T]he p r omotion e lement [was] satisfied when a
defendant paid his subordinate employee for b e i n g involved in an unlawful
scheme, b e c a u s e such payments compensated the employee for his illegal

7 Case: 12-50027 Document: 00512338659 Page: 7 Date Filed: 08/12/2013No. 12-50027

activities and enco u r a ged his continued participation.”)). V a ld e z a rg u e s th a t

th e se p a y m e n ts to e m p l oyees wer e s i mpl y p ayr oll p a y m e n ts a n d th u s le g itim a te

b u sin e ss e x p e n se s , w h ich ca n n o t co n stitu te p r o m o tio n m o n e y la u n d e rin g

. S ee
U n ited S ta te s v

. M

iles
, 3 6 0 F .3 d 4 7 2
, 4 7 7 (5 th C ir. 2 0 0 4 ); B ro w n , 1 8 6 F .3 d a t

6 7 1 . H o w e v e r, w e n e e d n o t g o so fa r a s to h o ld th a t n o rm a l p a y ro ll p a y m e n t s

to e m p l o y e e s o f a b u sin e ss th a t is n o t w h o l ly ille g i tim a te c o n stitu te p ro m o tio n

o f ille g a l a ctiv ity

. T h e re c o rd sh o w s th a t m a n y o f th e “p a y ro ll” p a y m e n ts V a ld e z

m a d e to e m p lo y e e s w e re i n fa ct v e ry irre g u la r, cla ssifie d n o t a s sa la ry b u t a s
“lo a n s,” u n d e rcu ttin g V a ld e z’s a rg u m e n t th a t th e y w e re n o rm a l b u sin e ss

e x p e n se s ra t h e r t h a n p a y m e n ts to se cu r e lo y a lty o r co o p e ra tio n in t h e
fra u d u le n t sch e m e

. F u rth e r, th e re is a cle a r n e x u s b e tw e e n th e p a y m e n ts a n d

th e fra u d

. The record reflects that Valdez made the payments to s ubordinates responsible for carrying out essent i a l e l ements o f the fraud: performing prolotherapy i njections a n d s ubmitting fraudulent claims predicated o n those injections. At t r ial, Rose Chavez testified t hat she was r esponsible for preparing

the fraudule nt claims to Medicare. Chavez also testified t hat Luis Cordova performed prolotherapy i njections t hat she billed to Medicare. A dditionally, two
of Valdez’s former patients testif ied that they received prolotherapy injections

from Dr. Benson Chee, Irma Sanchez, Ricardo Rios, Luis Cordova, J ames Shea,

and Alejandro Rios. A ll of these em p l o y e es, in addition to several others,

received payments from Valdez, i ncluding irregular payments c h aracterized not

as payroll but as “loans.” The evidence also establishes t hat a t least one of the employees who received the p a y m e n t s

— o f f i c e m a n a g e r R o s e C h avez—knew that

Valdez’s billing practices were fraudulent. Indeed, C h avez testified that she

continued to knowingly submit fraudulent claims because she k new that by not saying anything, she would continue to get paid. Viewing th is evidence in the light most favorable to the v erdict, we c o n c lude that a jury c ould d raw the

reasonable inference that t hese employees received paymen t s t o encourage their

8 Case: 12-50027 Document: 00512338659 Page: 8 Date Filed: 08/12/2013No. 12-50027

continued participation in the fraudulent scheme, and thus that the payments promoted the ongoing healthcare fraud. We therefore affirm V aldez’s conviction of money laundering.

3. Unanimity Instruction

V a ld e z a l s o a r g u e s th a t th e d istrict co u rt e r re d b y n o t g iv i n g t h e ju ry a

sp e cific u n a n im ity ch a rg e re g a rd in g th e m o n e y la u n d e ri n g co u n t. T h o u g h a

g e n e ra l u n a n im ity c h a r g e w a s g iv e n , V a l d e z a r g u e s th a t th e d istrict co u rt w a s

re q u ire d to in s t r u ct th e ju ry th a t it h a d to u n a n im o u s ly a g re e th a t h e w a s

g u ilty o f m o n e y la u n d e rin g b a se d o n p ro m o tio n , c o n ce a lm e n t, o r b o th
, a n d th a t

a g e n e r a l v e rd ict o n t h a t co u n t is n o t su fficie n t. V a ld e z d i d n o t o b je c t to t h e
in s tru ctio n ; th u s, w e re v ie w o n ly fo r p la in e rro r. S ee U n ited S ta t e s v

. A lfo rd
, 9 9 9 F .2 d 8 1 8
, 8 2 4 ( 5 th C ir. 1 9 9 3 ). In A l fo rd
, a p r e v i o u s ca se in w h ich t h e
d e f e n d a n t m a d e a sim i la r a rg u m e n t, th is co u rt h e ld th a t “T h e d istrict co u r t’s

fa ilu re to in clu d e a u n a n im ity in stru ctio n i n th is c a se d o e s n o t rise to th e le v e l

o f p la in e rro r.” I

d

. V a ld e z a rg u e s th a t A lfo rd co n flicts w ith R i c h a rd so n v

. U n ited S ta tes , w h i ch h e l d th a t a ju ry in a “co n tin u in g crim in a l e n te rp rise ” c a se
is re q u i r e d to a g r e e u n a n im o u sly n o t o n ly th a t th e a ccu se d co m m itte d a

co n t in u in g se rie s o f v i o la tio n s, b u t a l so w h ich sp e cific v io la tio n s m a d e u p t h e

co n t i n u in g se rie s. S ee 5 2 6 U .S

. 8 1 3
, 8 1 5 (1 9 9 9 ) (in te rp re tin g 2 1 U .S .C

. §

8 4 8 (a )). T h i s co u rt h a s a lre a d y co n s id e r e d a n d re je cte d th e a rg u m e n t th a t

R ich a rd so n a lte r s t h e h o l d in g o f A lfo r d

. S ee M e sh a ck
, 2 2 5 F .3 d a t 5 7 9 -8 0

. V a ld e z ’s a rg u m e n t i s f o r e clo se d

. T h e d i s trict co u rt d id n o t p la in ly e r r b y n o t

g iv in g a sp e c ific u n a n im ity in stru ctio n o n th e m o n e y la u n d e r i n g co u n t.

B. Sentencing Enhancements

V a ld e z a lso a rg u e s th a t t h e d istrict co u rt m isca lcu la te d th e a p p lica b l e

s e n t e n cin g ra n g e u n d e r th e 2 0 1 0 U .S

. S e n te n cin g G u id e l in e s M a n u a l b y

e rro n e o u sly a p p ly in g m u ltip le se n te n cin g e n h a n ce m e n ts. T h e s p e cific

9 Case: 12-50027 Document: 00512338659 Page: 9 Date Filed: 08/12/2013No. 12-50027

e n h a n ce m e n ts h e c h al l enges ar e: ( 1) t he 2- l e vel vul ner abl e victim e n h a n ce m e n t, § 3 A 1 .1 (b ) ( 1 ) ; ( 2 ) t h e 2

- l e v e l m u ltip le v u l n e ra b le v ictim s e n h a n ce m e n t, §

3 A 1 .1 ( b )(2 ); ( 3 ) th e 2

- le v e l a b u se o f tru st e n h a n ce m e n t, § 3 B 1 .3 ; (4 ) th e 2 -le v e l

m a ss-m a rk e tin g e n h a n ce m e n t, § 2 B 1 .1 (b )(2 )(A )(ii); (5 ) th e 2 -le v e l so p h istica te d

m e a n s e n h a n c e m e n t, § 2 B 1 .1 (b )(9 )(C ), a n d ; ( 6 ) t h e d istrict co u rt’s ca lcu la tio n o f

lo ss u n d e r § 2 B 1 .1 (b ) (1 )
, w h ich in cre a se d h is o ffe n se le v e l b y 2 2 l e v e ls, § 2 B 1 .1 (b )(1 ) (L ).

W e re v ie w se n t e n ce s f o r re a so n a b le n e ss u n d e r a n a b u se o f d iscre tio n

sta n d a rd

. S ee U

n ited S t a tes v

. C isn ero s-G u tierrez
, 5 1 7 F .3 d 7 5 1
, 7 6 4 (5 th C ir.

2 0 0 8 ). F irst, w e d e te rm in e w h e th e r t he di s t rict co u rt co m m itte d a n y p ro ce d u ra l

e r r o r , su ch a s im p ro p e rly ca lcu l a tin g th e G u id e lin e s ra n g e

. Id

. If th e re i s n o

p ro ce d u ra l e rro r o r th e e rro r is h a rm l e ss, w e m a y re v ie w th e su b sta n tiv e

re a so n a b le n e s s o f th e se n te n ce

. Id

. V a ld e z a r g u e s o n l y th a t th e d istrict co u rt

p ro ce d u ra lly e rre d b y m isca lcu la t in g th e a p p lica b le G u id e lin e s ra n g e

. B e ca u se
V a ld e z o b je cte d t o a ll th e e n h a n ce m e n ts th a t h e n o w ch a lle n g e s o n a p p e a l, w e

re v ie w th e d istrict c o u rt’s in te r p r e ta tio n a n d a p p l i ca tio n o f th e G u id e lin e s d e

n o v o , a n d r e v ie w fin d in g s o f f a ct fo r cle a r e rro r

. C isn ero s-G u tierrez, 5 1 7 F .3 d a t

7 6 4 (q u o ta tio n o m i tte d ). “T h e re is n o cle a r e rro r if th e d istrict co u rt’s fin d in g is p la u s ib l e in lig h t o f th e re co rd a s a w h o le .” Id

. 1

. V u l n era b le V

ictim a n d M

u ltip le V u ln era b le V

ictim s
T h e d istrict co u rt a d d e d tw o l e v e l s to V a ld e z ’s o f fe n se le v e l b a se d o n §

3 A 1 .1 ( b )(1 ) w h ich a p p lie s “If th e d e fe n d a n t k n e w o r sh o u ld h a v e k n o w n th a t a

v ictim o f th e o ffe n s e w a s a v u ln e r a b le v ictim ,” a n d a d d e d tw o a d d itio n a l le v e ls

b a se d o n § 3 A 1 .1 (b )(2 ), w h ich a p p lie s if “th e o ffe n se in v o lv e d a la rg e n u m b e r o f

v u ln e ra b le v ictim s.” A “v u ln e ra b l e v ictim ” is a p e rso n “w h o is a v i ctim o f t h e

o ffe n se o f co n v ictio n ” a n d a n y re le v a n t co n d u ct, a s d e fin e d b y § 1 B 1 .3
, “w h o is

u n u su a l l y v u ln e ra b le d u e to a g e , p h y s ica l o r m e n ta l co n d i t i o n , o r w h o is

10 Case: 12-50027 Document: 00512338659 Page: 10 Date Filed: 08/12/2013No. 12-50027

o t h e rw ise p a rticu la rly su sce p tib le to th e crim i n a l co n d u ct.” § 3 A 1 .1 ( b ) cm t. n

. 2

. F o r p u rp o se s o f th is e n h a n ce m e n t, “v ictim ” is d e fin e d b r o a d ly

. S p e cifica lly
, “th e 2

– le v e l a d

ju s tm e n t o f § 3 A 1 .1 (b )(1 ) a p p lie s n o t o n ly to v ictim s o f th e o ffe n se

o f co n v ictio n , b u t a lso to v ictim s o f a n y re le v a n t co n d u ct fo r w h ich t h e
G u id e l i n e s m a k e th e d e fe n d a n t a cco u n t a b l e

. ” U n ited S ta tes v

. S a la h m a n d
, 6 5 1

F

. 3 d 2 1
, 2 6 (D .C . C i r. 2 0 1 1 ); see a lso U n ited S ta tes v

. M

o o n , 5 1 3 F

. 3 d 5 2 7
, 5 4 1 (6 th C ir. 2 0 0 8 ) ; U

n ited S ta t es v

. Z

a ts , 2 9 8 F .3 d 1 8 2
, 1 8 6 -8 7 (3 d C ir. 2 0 0 2 ). T h e
d istrict c o u rt a p p lie d b o th e n h a n ce m e n ts b e ca u se a n u m b e r o f V a ld e z’s p a t i ents

w e re e ld e rly M e d ica r e re cip ie n ts a n d lo w -in co m e M e d ica i d re cip i e n ts.
O n a p p e a l, V a ld e z d o e s n o t a rg u e th a t h is p a tie n ts w e re n o t “v u ln e ra b le ,”

b u t a rg u e s th a t th e p rim a ry v ictim o f th e o ffe n se w a s th e fe d e ra l g o v e rn m e n t

a n d th a t n o p a tie n ts w e re v ictim s a t a ll b e ca u se th e g o v e rn m e n t d id n o t p ro v e
th a t a n y o f th e m w e re h a rm e d m e d ica lly o r fin a n cia lly

. 1

T h is co u rt h a s “p re v io u sly re co g n ize d th a t a p h y sicia n ’s p a tie n t s ca n b e

v ictim ize d b y a fra u d u le n t b illin g sch e m e d ire cte d a t in su re rs o r o th e r h e a lth

ca re p ro v id e rs.” U

n ited S ta tes v

. S i d h u , 1 3 0 F .3 d 6 4 4
, 6 5 5 (5 th C ir. 1 9 9 7 ). In

a p p ly in g th is e n h a n c e m e n t to sim i la r ca se s i n v o lv in g h e a l t h ca re f ra u d
, w e
h a v e d ra w n a d i stin ctio n b e tw e e n fra u d sch e m e s th a t “b e n e fitte d ” p a tie n ts, see
U n ited S ta tes v

. G i eg e r , 1 9 0 F .3 d 6 6 1
, 6 6 4 (5 th C ir. 1 9 9 9 ) (fin d in g th a t p a tie n t s

w e re n o t v ictim s w h e re sch e m e to su b m it fa lse cla i m s fo r a m b u la n c e s e r v ice s

p ro v id e d th e m w ith a fre e rid e to th e h o s p ita l), a n d ca se s “in w h ich p a tie n t s

su ffe re d h a rm o r a t le a st p o te n tia l h a rm fro m th e fra u d u le n t s ch e m e ,” id .; see
U n ited S ta tes v

. B u rg o s , 1 3 7 F .3 d 8 4 1
, 8 4 4 (5 th C ir. 1 9 9 8 ) ( fin d in g t h a t p a tie n t s

w e re v ictim s w h e re th e y “w e re o fte n a d m itte d to th e h o sp ita l n e e d le ssly o r th e ir

sta y s in th e h o s p ita l w e re e x t e n d e d b e y o n d w h a t w a s n e c e s sa ry ”); S id h u , 1 3 0

1 Vald ez is clearly correct that the U nited States governm ent is not a vulnerable victim

. U ni ted Sta tes v. G i eger , 190 F. 3d 661, 665 ( 5th Cir. 1999)

.
11 Case: 12-50027 Document: 00512338659 Page: 11 Date Filed: 08/12/2013No. 12-50027

F

. 3 d a t 6 5 5 (p a tie n t s w e re v ictim s w h e re th e y “w e re o fte n d e b ilita te d b y p a in

o r d e p re ssio n , a n d e a s i l y b e ca m e a d d icte d to th e tre a tm e n t p r o f fe re d b y [th e
d e fe n d a n t] to s u p p o r t h is fra u d ”); U n ited S ta t es v

. B a ch

y n sk y , 9 4 9 F .2 d 7 2 2
, 7 3 5 (5 th C ir. 1 9 9 1 ) (p a tie n ts w e re v ictim s w h e r e u n n e ce ssa ry tre a t m e n t w a s
fre q u e n tly in e ffe ctiv e a n d in so m e ca s e s h a rm fu l to th e p a tie n ts).

A l t h o u g h V a ld e z a rg u e s th a t h is p a tie n ts b e n e fitte d fro m h is tre a tm e n t,

th e d istrict c o u rt’s fin d in g th a t a t le a st s o m e o f h is p a tie n t s w e re v ictim s o f h is

re le v a n t co n d u ct i s “ p l a u sib le in lig h t o f th e re co r d a s a w h o le .”

C i sn ero s-G u tierrez, 5 1 7 F .3 d a t 7 6 4

. A t tria l, D r. S m i t h a n d D r. N o v a k t e stifie d

th a t V a ld e z risk e d ca u sin g n u m b n e ss, w e a k n e ss, p a in a n d p o ssib ly p e rm a n e n t

n e rv e d a m a g e to h is p a tie n ts

. B o th d o cto rs re fe re n ce d s p e cific p a tie n ts,

in c lu d in g o n e w h o re ce iv e d a p p ro x im a te l y 3 5 7 in je ctio n s, a n d o n e w h o re ce iv e d

5 0 0 i n je ct io n s i n a th re e -y e a r p e rio d

. T h e p re -se n te n ce in v e stig a tio n re p o rt

sh o w e d th a t m u l tip le p a tie n ts re p o rte d th a t e m p lo y e e s o f V a ld e z’s clin ic to ld

th e m t h e y h a d to h a v e t h e in je ctio n s in o rd e r to h a v e th e ir p re scrip tio n s f o r

p a in m e d ica tio n fille d

. V a ld e z tre a t e d h is M e d ica re - a n d M e d ica id -d e p e n d e n t

p a tie n ts, w h o w e re s e e k i n g t re a tm e n t fo r p a in
, “d u rin g t h e co m m issio n ” o f h is

fra u d u le n t b illin g , w h e n h e re q u ire d p a t ie n ts to re ce i v e t h e in je ctio n s a n d th e n
b ille d th e P ro g ra m s fo r th o se in je ctio n s. S ee S a la h m a n d
, 6 5 1 F .3 d a t 2 7 (n o tin g
th a t d e fe n d a n t tre a te d p a tie n ts “d u rin g th e co m m issio n ” o f id e n tity th e ft

o ffe n se w h e n h e w a s p o sin g a s a d o c to r ). V a ld e z h a s n o t sh o w n th a t t h e d istrict

co u r t cle a rly e rre d in fin d i n g th a t V a ld e z’s tre a tm e n t e x p o se d p a tie n t s to risk s

o f h a rm , a n d so m e tim e s to m e d ica l tre a tm e n t th e y d id n o t w a n t, a n d t h a t p a in

m a n a g e m e n t p a tie n ts w h o n e e d e d m e d ica tio n w e r e v u ln e ra b le to h is co n d u ct

o f re q u irin g th e y re ce iv e th e in je c tio n s so h e co u ld fra u d u le n tly b ill fo r th e m

. 2

2 The governm ent als o p oints to evid ence concerning V ald ez’s p res crip tion of controlled

s ubs tances , includ ing to patients who w ere ad d icted or w ho had attem p ted s uicid e. We d o not rely on any evid ence concerning p res crip tion d rugs in a f f i r m ing ap p lication of the

12 Case: 12-50027 Document: 00512338659 Page: 12 Date Filed: 08/12/2013No. 12-50027

W e fin d th a t th e d i strict co u rt co rre ctly a p p l ie d th e e n h a n ce m e n t b a se d o n t h e

v u ln e ra b i lity o f V a l d e z’s M e d ica re a n d M e d ica id p a in m a n a g e m e n t p a tie n ts,

w h o it co n stru e d a s v ictim s o f V a ld e z ’s re le v a n t u n d e rly i n g co n d u ct.

L a s t l y , th e h ig h n u m b e r o f in je ctio n p ro ce d u re s re f le cte d in V a ld e z’s

p a tie n t file s a n d b illin g re co rd s, a n d t h e e v id e n ce a d d u ce d a t tria l th a t

in d ica te d th a t V a ld e z d id n o t p e rfo rm f a ce t jo in t in je ctio n s o r p e rip h e ra l n e rv e
in j e c tio n s b u t a c tu a lly p e r fo rm e d p ro lo th e ra p y in m a n y , p o ssib ly e v e n a ll,

in s ta n ce s in w h ich h e b ille d fo r in je ctio n s, d e m o n s tra te s th a t th e d istrict co u rt’s

fin d in g th a t a l a rg e n u m b e r o f p a in m a n a g e m e n t p a tie n ts w e re v u ln e ra b l e

v ictim s o f V a l d e z’s o ffe n se s is p la u sib le in l i g h t o f th e r e co rd a s a w h o le

. T h e
d istrict co u rt d id n o t e rr in a p p ly in g th e a d d itio n a l 2 -le v e l “m u ltip le v u ln e ra b l e

v ictim s” e n h a n c e m e n t.

2

. A b u se o f T

ru st

V a ld e z n e x t ch a lle n g e s th e a p p lica tio n o f a 2

- le v e l e n h a n ce m e n t u n d e r §

3 B .1 .3 fo r a b u sin g a p o sitio n o f tru st. T h is se ctio n p r o v id e s a n e n h a n c e m e n t f o r
d e fe n d a n ts w h o h a v e “ a b u se d a p o s itio n o f p u b lic o r p riv a te t ru st

. . . in a

m a n n e r th a t sig n ifica n t ly fa cilita te d th e co m m iss i o n o r co n ce a lm e n t o f t h e

o ffe n se .” § 3 B 1 .3

. V a ld e z re lie s o n p re ce d e n t fro m th e 1 1 th C ircu i t to a rg u e th a t

a M e d ica re -fu n d e d ca re p ro v id e r, a s a m a tte r o f la w , d o e s n o t o ccu p y a p o sitio n

o f t ru st v is-a -v is M e d ica re

. S ee U n ited S t a tes v

. M

ills
, 1 3 8 F .3 d 9 2 8
, 9 4 1 (1 1 th

C i r

. 1 9 9 8 ). H o w e v e r, a s V a ld e z a c k n o w le d g e s, th is a rg u m e n t is fo re clo se d b y
circu i t p r e ce d e n t. S ee U n i ted S ta tes v

. M

iller, 6 0 7 F

. 3 d 1 4 4
, 1 4 9 (5 th C ir. 2 0 1 0 ) (h o ld in g th a t o w n e r o f a m e d ica l su p p ly sto re w h o fra u d u le n tly b ille d M e d ica re

o ccu p ie d p o s itio n o f tru st v is-a -v is M e d ica re ); U n ited S t a tes v

. I

lo a n i
, 1 4 3 F .3 d

9 2 1
, 9 2 2 -2 3 (5 th C ir. 1 9 9 8 ) (h o ld in g th a t ch iro p ra cto r o ccu p i e s a p o sitio n o f

enhancem ent in this cas e.

13 Case: 12-50027 Document: 00512338659 Page: 13 Date Filed: 08/12/2013No. 12-50027

tru st w ith re g a r d to th e in su ra n ce c o m p a n ie s th a t h e b ills). T h e d istrict co u rt

d id n o t e rr in a p p ly i n g th e § 3 B 1 .3 a b u se o f tru st e n h a n c e m e n t.

3

. M a ss-M a rk etin g
V a ld e z n e x t ch a l le n g e s th e d i strict c o u r t ’s im p o s itio n o f a 2 -le v e l m a ssm a rk e t in g e n h a n c e m e n t u n d e r § 2 B 1 .1 (b )(2 )(A )(ii). T h e G u id e lin e s d e fin e

m a ss-m a rk e tin g a s a “p la n , p ro g ra m , p r o m o tio n , o r ca m p a ig n th a t i s co n d u cte d

th ro u g h so licita t io n b y te l e p h o n e , m a il, th e In te r n e t, o r o th e r m e a n s t o in d u ce

a la rg e n u m b e r o f p e r so n s to

. . . p u rch a se g o o d s o r s e rv i ce s.

. . .” § 2 B 1 .1 cm t.

n

. 4 (A ); see U

n ited S ta tes v

. M

a g n u so n , 3 0 7 F .3 d 3 3 3
, 3 3 5 (5 th C ir. 2 0 0 2 ). T h e
d istrict co u rt a p p l ie d th e e n h a n ce m e n t b a se d o n a flie r th a t V a ld e z s e n t v i a

m a il to 1 6 ,6 2 6 E l P a so re sid e n ts i n D e ce m b e r 2 0 0 6 a n d fo u r t e le v isio n

co m m e rcia ls sh o w n o n lo ca l n e w s fro m A p ril 2 0 0 8 to D e ce m b e r 2 0 0 9
, a ll

a d v e rtisin g h i s In te rn a tio n a l In stitu te o f Pai n Management and “ r ec ons t r uc tiv e
th e ra p y , ” w h ich w a s p ro l o t h e ra p y

. V a ld e z re l i e s o n U n ited S ta tes v

. M

iller
, 5 8 8

F

. 3 d 5 6 0
, 5 6 2
, 5 6 8 (8 th C ir. 2 0 0 9 ) to a rg u e th a t th e e n h a n ce m e n t d o e s n o t a p p ly

w h e re th e m a ss-m a rk e tin g is n o t ta r g e te d a t t h e sp e cific v ictim s o f th e fra u d
,

w h ich h e a rg u e s w e re th e P r o g ra m s. T h is a r g u m e n t i s f o r e c l o se d b y circu it

p r e ce d e n t. In Isiw ele
, t h is co u rt re je cte d t h e E ig h th C ircu it’s re a so n i n g i n
M iller a n d u p h e ld th e a p p lica tio n o f th e m a ss-m a rk e tin g e n h a n ce m e n t to a
d e fe n d a n t w h o h a d re c ru ite d b e n e ficia r ie s in a sch e m e t o su b m it fra u d u le n t

b ills to M e d ica re fo r p o w e r w h e e l ch a irs. S ee U n ited S ta tes v

. Isiw ele
, 6 3 5 F .3 d

1 9 6
, 2 0 4

- 0 5 ( 5 t h C ir. 2 0 1 1 ). L ik e w i se , V a ld e z so licite d p a t i e n ts to re ce iv e
in j e c tio n s, fo r w h i ch h e th e n fra u d u l e n tly b ille d th e P ro g ra m s

. T h e d istrict

co u r t d i d n o t e rr in a p p l y in g th e 2 -le v e l § 2 B 1 .1 ( b )(2 )(A )(ii) m a ss-m a rk e tin g

e n h a n ce m e n t.

14 Case: 12-50027 Document: 00512338659 Page: 14 Date Filed: 08/12/2013No. 12-50027

4

. S o p h istica ted M

ea n s
V a ld e z n e x t ch a lle n g e s th e a p p lica tio n o f th e 2 -le v e l “so p h istica te d

m e a n s” e n h a n ce m e n t u n d e r § 2 B 1 .1 (b )(9 )(C ). S o p h istica t e d m e a n s a re d e fin e d

a s “e sp e cia lly co m p le x o r e sp e cia lly in trica te o ffe n se co n d u ct p e rta in in g to t h e

e x e c u t io n o r c o n ce a lm e n t o f a n o ffe n se

. . . C o n d u ct su ch a s h i d in g a sse ts o r

tra n sa ctio n s, o r b o th
, th ro u g h th e u se o f fictitio u s e n t itie s , co rp o ra te sh e lls, o r

o ffsh o re fin a n cia l a cco u n t s a lso o rd in a rily in d ica te s so p h istica te d m e a n s.” § 2

B 1 .1 cm t. n

. 8 ( B ). T h e d istrict co u rt a p p lie d th is e n h a n ce m e n t b e ca u se , b a se d

o n th e F B I’s a n a ly sis o f V a ld e z’s b a n k re co rd s, it co n clu d e d th a t V a ld e z w a s

a tte m p tin g to h id e h is a sse ts b y d e p o sitin g p ro ce e d s fro m th e f ra u d u le n t b illin g
sch e m e in t o h is in v e stm e n t a cco u n ts.

V a ld e z a r g u e s t h a t h is t r a n s f e r s f ro m h is o p e ra tin g a cco u n ts to h is

in v e stm e n t a c co u n ts d o n o t co n s t itu te so p h istica te d m e a n s. W e a g re e

. V a ld e z

us ed no f al s e names , f

ictitio u s e n titie s , s h e ll co m p a n ie s o r co m p l i ca te d fin a n cial

tra n sa ctio n s, o r a n y o th e r p a rticu la r ly so p h istica te d m e a n s to h id e o r co n ce a l

th e a sse ts. W e h a v e a ffirm e d th e a p p lica tio n o f t h e so p h istica te d m e a n s

e n h a n ce m e n t in ca se s in v o lv in g so m e m e th o d th a t m a d e it m o re d ifficu lt fo r t h e

o ffe n se to b e d e te cte d
, e v e n if t h a t m e th o d w a s n o t b y itse lf p a rticu la rly

so p h istica te d

. F o r e x a m p le
, i n C l em en ts , w e u p h e l d a p p l i c a t io n o f t h e

e n h a n ce m e n t w h e re th e d e fe n d a n t r e p e a te d l y c o n v e rte d re c e iv e d f u n d s in to

m u ltip le ca sh ie r’s c h e ck s m a d e o u t to h im se l f, w h i ch h e th e n d e p o site d in to h is

w ife ’s se p a ra te b a n k a cco u n t, b e ca u se h is a ctio n s “ o b scu re [ d ] th e l i n k b e tw e e n
th e m o n e y a n d

. . . h im s e lf,” a n d “u n d e n ia b ly m a d e it m o r e d ifficu lt fo r th e IR S

to d e t e ct h is e v a sio n .” U n i ted S ta tes v

. C lem en ts , 7 3 F .3 d 1 3 3 0
, 1 3 4 0 (5 th C ir.

1 9 9 6 ); see a lso U

n ited S ta tes v

. C o n n e r , 5 3 7 F

. 3 d 4 8 0
, 4 9 2 (5 th C ir. 2 0 0 8 ) (tra v e lin g to 2 3 d iffe re n t sta te s to o b ta in in f o rm a tio n a b o u t cre d it a cco u n ts a n d

u s i n g a fictitio u s n a m e a n d b u sin e ss to co n d u ct fra u d u le n t tra n sa ctio n s

15 Case: 12-50027 Document: 00512338659 Page: 15 Date Filed: 08/12/2013No. 12-50027

in v o lv e d so p h istica te d m e a n s); U n ited S ta tes v

. W

r i g h t , 4 9 6 F .3 d 3 7 1
, 3 7 9 (5 th

C i r

. 2 0 0 7 ) (d e p o sitin g a ch e ck in to a n a cco u n t a n d t h e n u sin g m o n e y to

p u rch a se a c a sh ie r’s ch e c k i n a n o t h e r n a m e in v o lv e d so p h istic a t e d m e a n s );

U n ited S ta tes v

. C h a rro u x , 3 F .3 d 8 2 7
, 8 3 7 (5 th C ir. 1 9 9 3 ) (p a rticip a tio n in la n d flip sch e m e to p u rch a s e p ro p e rty f o r in fla te d p rice invol ved so p h istica te d m e a n s

w h e re d e fe n d a n t s “stru ctu re d e la b o ra t e t ra n sa ctio n s to h id e th e ir re v e n u e s”).

H e re , h o w e v e r, th e so le re a so n g i v e n fo r a p p ly in g th is e n h a n ce m e n t is

th a t V a ld e z to o k m o n e y d ire ctly d e p o site d fro m M e d ica r e in to h i s o p e ra tin g

a cco u n t, w h ich w a s in h is n a m e , a n d m o v e d i t in to h is i n v e s tm e n t a c co u n ts,

w h ich w e re a lso in h i s n a m e

. E v e n th o u g h th is co u r t re v i e w s t h e fa ctu a l

fin d in g th a t V a ld e z u se d so p h istica te d m e a n s fo r cle a r e rro r, see C lem en ts , 7 3

F

. 3 d a t 1 3 4 0
, t h e r e is n o in d ica tio n th a t th is o p e n a n d tra n sp a re n t d ire ct

d e p o sit a n d m o v e m e n t o f fu n d s in v o lv e d s o p h istica te d m e a n s o r co u ld h a v e

m a d e it m o re d ifficu l t fo r h is o f f e n s e o f h e a l t h ca re f

ra u d to b e d e te cte d

. W e
h o ld th a t th e d istrict co u r t e rre d in a p p ly in g th e 2

- l e v e l § 2 B 1 .1 (b )(9 )(C )

so p h istica te d m e a n s e n h a n ce m e n t

. 5

. L o ss C a lcu la tio n
V a ld e z n e x t ch a lle n g e s th e d istrict co u rt’s lo ss ca lcu la tio n . T h e a m o u n t

o f l o ss re su ltin g fro m f ra u d is a sp e cific o ffe n se ch a r a cte ristic th a t in cre a se s t h e
b a se o ffe n s e le v e l u n d e r th e G u id e lin e s. S e e § 2 B 1 .1 (b )(1 )

. “L o s s” is d e fin e d a s
“th e g r e a te r o f a c tu a l lo ss o r in te n d e d lo ss.” § 2 B 1

. 1 cm t. n

. 3 (A ). “ A ctu a l lo ss”

in c l u d e s “th e re a so n a b ly fo re se e a b le p e cu n i a ry h a rm th a t re su lte d fro m t h e

o ffe n se .” Id

. cm t. n

. 3 (A )(i). “ In te n d e d lo s s” m e a n s “th e p e c u n i a r y h a rm th a t

w a s in te n d e d to re su lt fro m th e o f fe n se ,” a n d in c lu d e s “ in te n d e d p e cu n ia ry
h a rm th a t w o u ld h a v e b e e n im p o ssib le o r u n lik e ly to o ccu r (e

. g

. , a s in a

g o v e rn m e n t stin g o p e ra t io n , o r a n in su ra n ce fra u d in w h ich th e cla im e x ce e d e d

th e i n su re d v a l u e ).” Id

. cm t. n .3 (A ) (ii). W e re v i e w t h e d istrict co u rt’s m e th o d o f

16 Case: 12-50027 Document: 00512338659 Page: 16 Date Filed: 08/12/2013No. 12-50027

d e te rm in in g lo ss d e n o v o , w h ile w e re v ie w b a c k g ro u n d fa ctu a l fin d in g s fo r cle a r

e rro r. Isiw ele , 6 3 5 F .3 d a t 2 0 2

. H e re , th e d i strict co u rt ca lcu la te d t h e a m o u n t o f in te n d e d lo s s a t o v e r
fo rty -fo u r m i l l i o n d o lla rs b a se d o n t h e g ro ss a m o u n t o f th e fra u d u le n t cla im s
V a ld e z s u b m itte d t o th e P ro g ra m s. V a ld e z a r g u e s th a t b e ca u se h e n e v e r

e x p e cte d fu ll r e im b u rse m e n t, th e lo ss in te n d e d b y h is a ctio n s w a s sig n ifica n tly

le ss th a n th is a m o u n t. T h e in te n d e d l o ss ca lcu la tio n r a ise d h is o ffe n se le v e l b y
2 2 . § 2 B 1 .1 (b )(1 )(L ).

In h e a lt h c a r e f

r a u d ca se s , th is co u rt h a s e x p la in e d th a t “o u r ca se la w

re q u ire s th e g o v e rn m e n t [to ] p ro v e b y a p re p o n d e ra n ce o f th e e v id e n c e th a t t h e
d e fe n d a n t h a d th e su b je ctiv e in te n t to ca u s e th e lo ss th a t is u se d to ca l cu la te

h i s o ffe n se le v e l.” Isiw ele
, 6 3 5 F .3 d a t 2 0 3 (q u o tin g U n ited S ta t es v

. S a n d ers , 3 4 3 F .3 d 5 1 1 , 5 2 7 (5 th C ir. 2 0 0 3 )). In th e h e a lth ca r e fra u d co n te x t , th e a m o u n t fra u d u le n t ly b i lle d to M e d ica r e / M e d ica id i s p rim a fa cie

e v i d e n ce o f th e a m o u n t o f lo s s [th e d e fe n d a n t ] i n te n d e d to ca u se , b u t th e a m o u n t b ille d d o e s n o t co n stitu te co n clu s i v e e v id e n ce o f i n t e n d e d lo ss; th e p a rtie s m a y in tro d u ce a d d itio n a l e v id e n ce t o

su g g e st t h a t th e a m o u n t b ille d e ith e r e x a g g e ra te s o r u n d e rsta te s th e b illin g p a r ty ’s in te n t.

Id

. (in te rn a l q u o t a tio n m a rk s a n d cita tio n s o m itte d ) ; see a lso U n i ted S ta tes v

. S i n g h
, 3 9 0 F .3 d 1 6 8
, 1 9 3 -9 4 (2 d C i r. 2 0 0 4 ) (re m a n d in g fo r re -se n te n cin g to g iv e
th e d e fe n d a n t a n o p p o rtu n ity to sh o w th a t th e to ta l a m o u n t h e e x p e cte d to

re ce iv e w a s le ss th a n th e a m o u n t h e a ctu a lly b ille d to M e d ica re /M e d ica id ).

H e re , V a l d e z o b je cte d t o th e lo ss ca lcu la tio n a t se n te n cin g a n d a rg u e d to

th e d istrict co u r t th a t th e e v id e n ce sh o w e d th a t h e d id n o t su b je ctiv e ly in te n d

to ca u se t h e lo ss o f th e fu l l a m o u n t th a t h e b i lle d th e P r o g ra m s. H e a rg u e d th a t
fo r y e a rs h e co n siste n tly b ille d a h ig h a m o u n t , k n o w in g t h a t h e w o u ld o n ly b e

re im b u rse d fo r a fra ctio n o f w h a t w a s b ille d

. V a ld e z p o in ts to tria l te stim o n y
b y R o se C h a v e z , h is o ffice m a n a g e r, w h o t e stifie d fo r th e g o v e rn m e n t. H e r

17 Case: 12-50027 Document: 00512338659 Page: 17 Date Filed: 08/12/2013No. 12-50027

s ta t e m e n ts w e re in tro d u ce d v ia a n u n d e rco v e r re c o rd in g w ith C h a v e z, w h o

sta te d o n th e re co rd in g th a t: “T h o se a re o u r ra te s, w h ich a re u su a l l y b a se d o n
th re e tim e s o n [sic] w h a t M e d ica r e co v e rs, th a t’s p re tty m u c h sta n d a rd

p ra ctice .” V a ld e z a rg u e s th a t th is e v i d e n c e re b u tte d th e fin d in g th a t h e

su b je ctiv e l y in te n d e d to ca u se th e lo ss o f th e fu ll a m o u n t h e b ille d t h e
P r o g ra m s. T h e d istrict co u r t d id n o t re fe r e n ce th is e v id e n ce in m a k i n g th e lo ss

ca lcu la tio n

. B a se d o n th e c le a r g u id a n ce in Isiw ele
, w e f in d th a t it w a s e rro r fo r t h e
d istrict co u rt t o c a lcu la te th e in te n d e d lo ss w ith o u t co n sid e rin g th e e v id e n ce in

th e re co rd th a t r e b u tte d th e p rim a fa cie e v id e n c e o f in te n d e d lo ss. H o w e v e r, w e

n o t e th a t e v e n if w e a ssu m e th e re w a s e rro r in th e in te n d e d lo ss ca l cu la tio n ,

a n d u s e t h e a m o u n t V a ld e z a ctu a lly re c e i v e d fro m t h e p ro g ra m to ca lcu la te

l os s

— w h ich co m e s to a ro u n d th irte e n m i l l i o n dol l ar s —Val dez woul d s t i l l r ec ei ve

a 2 0 -le v e l e n h a n c e m e n t. S ee § 2 B 1

. 1 (b )(1 )(K ).

6. Harmfulness of Sentencing Errors

W e h a v e f

o u n d th a t th e d istrict co u rt e rre d in a p p ly in g th e 2 -le v e l

so p h istica te d m e a n s e n h a n ce m e n t, a n d in a p p ly in g a 2 2 -le v e l in cre a se b a se d

o n lo ss c a lcu la tio n w ith o u t co n sid e rin g t h e e v id e n ce th a t te n d e d to sh o w th a t

V a ld e z d id n o t h a v e th e su b je ctiv e in te n t to ca u s e t h e lo ss o f th e fu ll a m o u n t

th a t h e b ille d th e P r o g ra m s. W e n o w co n sid e r w h e th e r t h o s e e rro rs w e re
h a rm le ss. S ee U

n ited S ta tes v

. I

b a rra -L u n a , 6 2 8 F .3 d 7 1 2
, 7 1 3 -1 4 (5 th C ir.

2 0 1 0 ) ( h o l d in g t h a t a n e r ro r in th e ca lcu la tio n o f th e a p p lica b le G u id e lin e s

ra n g e is su b je ct to a h a rm l e ss e rro r a n a ly s is). “ [ T ]h e h a rm le s s e r r o r d o ctrin e

a p p lie s o n ly if th e p ro p o n e n t o f th e se n te n ce co n v in cin g ly d e m o n s tra te s b o th (1 )

th a t th e d istrict co u rt w o u ld h a v e im p o se d th e sa m e se n t e n c e h a d it n o t m a d e
th e e rro r , a n d (2 ) th a t it w o u ld h a v e d o n e so fo r th e sa m e re a so n s it g a v e a t t h e

p rio r s e n te n cin g .” I

d

. a t 7 1 4

. T o sa tisfy t h a t h ig h b u rd e n , th e re m u st b e

18 Case: 12-50027 Document: 00512338659 Page: 18 Date Filed: 08/12/2013No. 12-50027

“e v id e n ce in th e re co rd th a t w ill co n v in ce u s th a t th e d istrict co u r t h a d a

p a rticu la r se n te n ce in m in d a n d w o u ld h a v e im p o se d it, n o tw ith s t a n d in g t h e

e rro r.” Id

. a t 7 1 8 (q u o tin g U n ited S t a tes v

. H u sk ey , 1 3 7 F

. 3 d 2 8 3
, 2 8 9 (5 th C ir.

1 9 9 8 )).

H e re , th e c o u rt se n te n ce d V a ld e z to 3 0 0 m o n th s. T h e o rig in a l o f f e n se
le v e l w a s 4 3
, w h ich to g e th e r w ith h is crim i n a l h isto ry ca te g o ry I, s e t f o r t h a
G u id e l i n e s ra n g e o f life

. H o w e v e r , e v e n a cco u n tin g fo r th e d istrict co u rt’s

e rro n e o u s a p p l ica tio n o f th e so p h istica te d m e a n s e n h a n ce m e n t a n d th e lo ss

ca lcu la tio n , th e o ffe n s e le v e l w o u ld still b e 4 1

. 3 T h e G u id e lin e s r a n g e a p p lica b l e

to a n o f fe n se le v e l o f 4 1
, in crim i n a l h i s to ry ca te g o ry I, is 3 2 4

- 4 0 5 m o n th s.
T h u s , th e 3 0 0 m o n th se n te n ce is w ith in t h e a d ju ste d G u id e lin e s ra n g e

. T h a t th e se n te n ce w o u ld re m a in w ith in th e a d ju ste d G u id e lin e s ra n g e is

in s u fficie n t to in d i ca te h a rm le ssn e ss; “ th e c r u x o f th e h a rm le ss-e rro r in q u iry is

w h e th e r th e d istrict co u r t w o u ld h a v e im p o se d th e sa m e s e n te n ce , n o t w h e th e r
th e d istrict c o u rt co u l d h a v e i m p o s e d t h e sa m e s e n te n ce .” U n ited S ta tes v

. D elg a d o

- M

a r tin ez , 5 6 4 F .3 d 7 5 0
, 7 5 3 (5 th C ir. 2 0 0 9 ). T h e re a re t w o a d d itio n a l

fa cto rs p re se n t in th i s ca se w h ich cle a r l y in d ica te “(1 ) th a t t h e d istrict co u rt

w o u ld h a v e i m p o se d th e sa m e se n te n ce h a d it n o t m a d e th e e r ro r, a n d (2 ) th a t

it w o u ld h a v e d o n e so fo r t h e s a m e re a so n s it g a v e a t th e p rio r se n t e n cin g .”

3 For the health care fraud group of of f ens es : Bas e of

f ens e level of 6, § 2B1. 1( a) ( 2)
, p lus 20 levels f

or the calcula t i o n o f l o s s , § 2B1. 1( b) ( 1) ( K ) ; 2 levels f

or m as s m ark eting, § 1 B 1

. 1( b) ( 2) ( a) ; 2 levels f or reck les s ris k of death or s erious bod ily injury ( not challen g e d o n ap p eal)
, § 2B1. 1( b) ( 13) (A) ; 2 levels f or vulner a b le victim
, § 3A1. 1( b) ( 1) ; 2 levels f or m ultip le vulnerable victim s , § 3 A 1

. 1 ( b ) ( 2) ; 2 levels f or abus e of trus t, § 3B1. 1; and 4 levels f or an aggravated role in the of fens e ( not challenged on ap p eal)
, § 3B1. 1( a)

. Total of f ens e level: 40. For the m oney laund ering group of of f ens es : B as e of

f ens e l e v el of 30, § 2S1. 1( a) ( 2) ( ad jus ted up w ard s for s p ecif ic of f ens e characteris tics
, includ ing 20 levels f or los s calculation, 2 levels f

or m as s m ark eting, and 2 levels f or reck les s ris k of d eath or serious bod ily inj u ry) ; p lus 1 level f

or violation of § 1957 ( not challenged on ap p eal)
, § 2S1. 1( b) (2) ( A ); 2 levels f

or vulnerable victim
, § 3A1. 1( b) ( 1) ; 2 levels f or m ultip le vulnerable victim s, § 3A1. 1( b) ( 2) ; 2 levels f or abus e of trus t, § 3B1. 1; and 4 levels f or an aggravated role in the of f ens e ( not challenged

on ap p eal)
, § 3B1. 1( a)

. T otal of f ens e level: 41. T he group w ith the highes t level is us ed

.

19 Case: 12-50027 Document: 00512338659 Page: 19 Date Filed: 08/12/2013No. 12-50027

Ib a rra -L u n a , 6 2 8 F .3 d a t 7 1 4

. F irst, th e d istrict co u rt im p o se d co n se cu tiv e

se n te n ce s fo r fa ctu a lly r e la te d o ffe n s e s. T h is co u rt h a s r e c o g n ize d th a t “th e
im p o sitio n o f co n se cu tiv e se n te n ce s m a y , u n d e r s o m e c i rcu m sta n ce s,
d e m o n stra te ” t h a t a G u i d e lin e s e rro r w a s h a rm le ss. S ee U n ited S t a t e s v

. W o o d s , 4 4 0 F .3 d 2 5 5
, 2 6 0 (5 th C ir. 2 0 0 6 ); U n ited S ta tes v

. G a r za , 4 2 9 F .3 d 1 6 5
, 1 7 0 (5 th C ir. 2 0 0 5 ) (id e n tify in g i m p o s itio n o f co n se cu tiv e se n te n ce s a s o n e o f

o n ly tw o circu m sta n ce s in w h ich th is c o u rt h a s fo u n d a B o o k er s e n te n cin g e rro r

to b e h a rm le ss). W h e re o n e o f t h e c o n se cu tiv e se n te n ce s is fo r “e n tire ly

u n re la t e d co n d u ct,” th is co u rt a scrib e s n o m o t i v a tio n to th e d istrict co u rt “o th e r
th a n a d h e re n c e to t h e d e fa u lt ru le th a t to ta lly u n re la te d crim e s sh o u ld

o rd in a rily re ce iv e d i s t i n ct p u n ish m e n t.” W o o d s, 4 4 0 F .3 d a t 2 6 0

. H e re , b y

co n t ra st, t h e d istrict c o u rt im p o se d m u ltip le co n cu rre n t se n te n ce s a n d o n e

co n s e cu tiv e s e n te n ce o n o n e o f th e co u n ts o f h e a lth ca re fra u d

. T h e co n d u ct w a s

a ll p a rt o f th e sa m e fra u d u le n t sch e m e a n d a l l th e ch a rg e s w e re fa ctu a lly

re la te d o ffe n se s. T h u s , th e co u rt’s “co n scio u s d e cisio n n o t to a w a rd a co n cu rre n t

se n te n ce ,” U

n i ted S ta tes v

. P ro n es , 1 4 5 F e d

. A p p ’x 4 8 1
, 4 8 2 (5 th C ir.2 0 0 5 ), cert.

g ra n ted

, ju d

g m en t v a ca ted o n o th er g ro u n d s , 5 4 9 U

. S

. 1 0 9 3 (2 0 0 6 ), sh o w s th a t

th e co u r t p u rp o se f

u lly fa s h io n e d a se n t e n c e it t h o u g h t w a s fa ir in t h e
circu m sta n ce s, a n d w e ig h s in fa v o r o f fin d in g th a t th e se n te n cin g e r ro rs w e re
h a rm le ss, id

. ; cf. W

o o d s , 4 4 0 F .3 d a t 2 6 0

. T h e se co n d fa cto r te n d in g to

d e m o n stra te th a t th e s e n te n cin g e rro rs w e re h a r m l e ss i s th e d i strict co u rt’s

sta te m e n t th a t it w o u ld im p o se th e sa m e 3 0 0 -m o n t h se n te n ce o n re m a n d . A t

th e se n t e n cin g h e a rin g , th e d istrict co u rt sta te d :
T H E C O U R T : I’ll in fo r m y o u rig h t n o w , M r. T o rre s [d e fe n se co u n se l

a t se n te n cin g ]
, if y o u ta k e u p a n a p p e a l a n d th e a p p e a l co m e s b a ck fo r re -se n te n c i n g , I w ill fa sh io n a se n te n ce th a t w ill m e e t th e 3 0 0

- m o n th se n te n ce th a t I’v e g iv e n h im

. If I m isca lcu la t e d th e g u id e l in e ra n g e a n d it co m e s b a ck b e ca u se o f th a t, th e re ’s still a lo t to w o rk w ith

.

20 Case: 12-50027 Document: 00512338659 Page: 20 Date Filed: 08/12/2013No. 12-50027

T h is u n e q u iv o ca l s ta te m e n t ce rta in ly c o n s titu te s “ e v id e n c e in th e re co rd th a t

w ill co n v in ce u s t h a t th e d istrict co u rt h a d a p a rticu la r se n te n ce in m in d a n d

w o u ld h a v e im p o se d it, n o tw ith sta n d in g th e e rro r.” Ib a rra -L u n a , 6 2 8 F .3 d a t

7 1 8

. T h o u g h V a l d e z a rg u e s th a t th is sta te m e n t in d ica te s th a t th e ju d g e w a s
b ia se d
, i t is m e re ly a ch a ra cte riza tio n o f th e d iscre tio n th e d istrict co u rt h a d in

fa sh io n in g th is s e n te n ce

. W h e re th e se n te n ce re m a in s w i t h in t h e a d j u s te d

G u id e l i n e s ra n g e , th is sta te m e n t is cle a r e v id e n ce th a t t h e d istrict c o u r t “ w o u ld

h a v e im p o se d th e sa m e se n t e n ce ” a b se n t th e g u i d e lin e s ca lcu la tio n e rro rs, n o t

sim p ly th a t it “ co u ld h a v e . . . .” D elg a d o -M a rtin e z , 5 6 4 F .3 d a t 7 5 3

. W e th e re fo re h o l d th a t a lth o u g h th e d istrict co u rt e rre d w ith re sp e ct to

th e so p h istica te d m e a n s a n d lo ss ca lcu la tio n e n h a n ce m e n ts, th o se e rro rs w e re
h a rm le ss, a n d a ffirm th e se n te n ce

. C. Forfeiture

V a ld e z n e x t a r g u e s th a t i t w a s e rro r fo r th e d istrict co u rt n o t to in q u ire

w h e th e r e ith e r p a r ty re q u e ste d th a t th e j u r y m a k e th e fo rfe itu re d e te rm in a tio n

w ith re g a r d t o sp e cific p ro p e rty , a s p ro v id e d b y F e d e ra l R u l e o f C r i m in a l

P r o c e d u re 3 2 .2 ( b ), b e fo r e th e ju ry b e g a n d e lib e ra t io n s. T h e d istrict c o u rt issu e d

a n o rd e r o f f

o rfe itu re , w h i ch im p o se d a m o n e y j u d g m e n t a g a in s t V a l d e z in t h e

a m o u n t o f $ 9 ,7 4 1 ,6 4 9
, a n d o rd e re d h im to fo r f e it to th e U n ite d S t a t e s a ll o f h is rig h t, title , a n d in te re st in tw o re a l p ro p e rtie s, fo u r v e h icle s, a n d th e co n te n t s

o f se v e ra l b a n k a n d in v e stm e n t a cco u n ts. B e ca u se V a l d e z f a ile d t o o b je ct, w e

re v ie w th is cla im fo r p la in e rro r p u rsu a n t to R u le 5 2

. 4 F e d

. R u le C rim

. P

. 5 2 ( b ).

O n p la in e rro r re v i e w , V a ld e z “b e a rs th e b u rd e n o f p r o v in g (1 ) e rro r , (2 ) th a t is

p la in
, a n d (3 ) th a t a ffe c ts h is su b sta n tia l rig h ts.” J o h n so n , 5 2 0 U .S

. a t 4 6 6 -6 7 ;

4 Contrary to Vald ez’s argum ent that the errors im p licating the interp retation of a Rule of C rim inal Proced ure are s om ehow im m une f rom the rule requiring p res ervation, even “the

s erious nes s of the err o r c l a i m e d d o es not rem ove cons id eration of it f rom the am bit of the Fed eral Rules of Crim inal Proced ure. ” Johnson v

. U ni ted Sta tes , 520 U. S. 461, 466 ( 1997)

.
21 Case: 12-50027 Document: 00512338659 Page: 21 Date Filed: 08/12/2013No. 12-50027

P u ck ett v

. U

n ited S ta tes , 5 5 6 U .S

. 1 2 9
, 1 3 5 (2 0 0 9 ). If th e first th re e p ro n g s a re

sa tisfie d
, th e co u r t h a s “th e d iscre tio n t o r e m e d y t h e e rro r

. . . if t h e e rro r

se rio u sly a ffe ct[s] th e fa irn e ss, in t e g rity o r p u b lic re p u ta tio n o f j u d icia l

p ro ce e d in g s.” P u ck ett , 5 5 6 U .S . a t 1 3 5

. C r im in a l fo rfe itu re is a p a rt o f se n te n cin g im p o se d a fte r co n v ictio n ; it is

n o t a su b sta n tiv e e le m e n t o f th e o ffe n se

. S e e L ib retti v

. U n ited S ta tes , 5 1 6 U .S

. 2 9
, 4 1 (1 9 9 5 )

. T h e re is n o co n stitu tio n a l r ig h t to a ju ry d e te rm in a tio n o f

fo rfe itu r e

. Id

. a t 4 9

. H o w e v e r, R u le 3 2 .2 ( b ) p r o v id e s th a t “if th e in d ictm e n t o r
in f o rm a tio n sta te s th a t th e g o v e rn m e n t i s s e e k in g fo rfe itu re , th e co u rt m u s t

d e te rm in e b e fo re th e ju r y b e g in s d e l ib e ra tin g w h e th e r e ith e r p a rty re q u e sts

th a t th e ju ry b e re t a in e d to d e te rm i n e th e fo rfe i ta b ility o f sp e c i fic p ro p e rty if it

re tu rn s a g u ilty v e rd ict.” F e d

. R

. C rim

. P r o

. 3 2 .2 (b )(5 )(A ). W e a ssu m e th a t t h e
d istrict co u rt cle a r ly e rre d in n o t d e te rm in in g w h e th e r e ith e r p a rty r e q u e ste d

th a t th e ju ry d e te rm in e fo rfe i tu re , g iv e n th e cla rity o f th e in s tru ctio n s in R u l e
3 2 .2

. Id .; s ee U

n i ted S ta tes v

. M

a rq u ez , 6 8 5 F

. 3 d 5 0 1
, 5 0 9

- 1 0 (5 th C ir. 2 0 1 2 ).

W i t h re g a r d to th e e ffe c t o n h is su b sta n tia l r i g h ts, V a ld e z a rg u e s th a t sin ce t h e
d i s trict c o u r t im p o se d th e fu ll fo rfe itu r e so u g h t b y th e g o v e rn m e n t, th e r e i s a

re a so n a b le p ro b a b ility th a t a ju r y w o u ld h a v e im p o se d l es s f or f ei t u re

. H o w e v e r,
th e g o v e r n m e n t p ro d u ce d tria l e v id e n c e sh o w in g th a t V a l d e z k e p t t h e p ro ce e d s

o f h is h e a lth ca re f

r a u d in h is b a n k a n d in v e s tm e n t a c c o u n ts, a n d u se d t h e

p ro ce e d s o f t h e fra u d to p u rch a se sp e cific p ro p e rty , v e h icle s, a n d in v e stm e n ts.

R e g a r d l e ss, e v e n a ssu m in g th a t V a ld e z co u ld sh o w t h a t th e f a ilu re to su b m it

fo rfe itu r e to th e ju ry a ffe cte d h is su b sta n tia l rig h ts, w e fin d th a t th e e rro r d o e s

n o t m e e t th e fin a l re q u ire m e n t o f th e p la i n e rro r sta n d a rd

. S ee J o h n so n , 5 2 0

U .S

. a t 4 6 9 -7 0

. G iv e n th a t th e re is n o co n s titu ti o n a l rig h t to a ju ry
d e te rm in a tio n o f f

o rfe itu re , th a t th e re is su fficie n t e v id e n ce ty in g th e fo rfe ite d

p ro p e rty to th e p ro ce e d s o f V a ld e z’s h e a l t h ca re fra u d
, a n d th a t d u rin g th e tria l

22 Case: 12-50027 Document: 00512338659 Page: 22 Date Filed: 08/12/2013No. 12-50027

V a ld e z n e v e r i n d i ca t e d th a t h e w ish e d th e ju ry to d e te rm in e fo rfe itu re , w e
d e clin e to v a ca te th e fo rfe itu re o rd e r o n p la in e r ro r re v ie w

. D. Admission of Medical Malpractice Evidence

V a ld e z n e x t a rg u e s t h a t th e d istrict co u rt e rre d in a d m ittin g te stim o n y

o f p h y sicia n w itn e sse s w h o re fe rre d to V a ld e z ’s p ro l o t h e ra p y p ro ce d u re s a s

su b sta n d a rd o r n o t m e d i c a l l y n e ce ssa ry

. H e a rg u e s th e te stim o n y w a s n o t

re le v a n t p u rsu a n t to F e d e ra l R u le o f E v id e n c e 4 0 2 a n d t h a t t h e p re ju d icia l

e ffe c t o u tw e ig h e d a n y p ro b a tiv e v a lu e p u r s u a n t to F e d e r a l R u l e o f E v id e n ce

4 0 3

. H e d id n o t o b je ct to th e te stim o n y a t tria l, a n d th u s r e v ie w i s f o r p l a i n

e rro r. S ee U

n ited S ta tes v

. G o n za lez-R o d rig u ez , 6 2 1 F

. 3 d 3 5 4
, 3 6 2 (5 th C ir.

2 0 1 0 ).

T h e s p e c i fic t e stim o n y ch a lle n g e d b y V a ld e z in c l u d e s: ( 1 ) tw o d o cto rs’

te stim o n y th a t th e sta n d a r d o f m e d ica l c a re re q u ire d u sin g f lu o ro sco p y in fa ce t jo in t i n je ctio n s, a n d th a t V a ld e z d id n o t u s e a f lu o r o sco p e in h is p ra ctice ; (2 ) o n e
d o cto r ’s te stim o n y t h a t V a ld e z’s p ra ctice o f n o t o b ta in in g c o n se n t fo rm s b e fo re

p e rfo r m in g fa ce t jo in t in je ctio n s w o u ld v io la te t h e m e d i ca l sta n d a rd o f ca re ; (3 )

tw o d o cto rs’ t e stim o n y th a t it w o u ld n o t b e “m e d ica lly re a so n a b le ” o r “m e d ica lly

a cce p te d ” to g iv e a p a tie n t t h e n u m b e r o f fa ce t j o i n t in je ctio n s th a t V a ld e z

a d m in iste r e d o r to g iv e th e m a s fre q u e n t ly a s h e d id ; (4 ) o n e d o cto r ’s te stim o n y
th a t th e sta n d a r d o f ca re re q u ire d th a t m e d i c a t i o n s w i th e x p ire d d a te s b e
th ro w n a w a y , a fte r t h e g o v e rn m e n t h a d in tro d u c e d p h o t o g ra p h s ta k e n fro m
V a ld e z ’s o ffice w h ich a p p e a re d to sh o w e x p ire d m e d ica tio n s, a n d ; (5 ) a p a in

m a n a g e m e n t d o cto r’s te s tim o n y th a t, a f te r co n d u ctin g a p eer re v ie w o f V a ld e z’s

p ra ctice , th a t “I fo u n d it [th e m e d ica l ca re p ro v id e d b y V a ld e z] su b s ta n d a rd .”

T h e d istrict c o u rt g a v e th e j u r y a lim itin g i n stru ctio n r e g a rd in g a n y

te stim o n y o f m e d ica l m a lp ra ctice . T h a t in s tru ctio n p ro v id e d :
Y o u h a v e h e a rd e v id e n ce o f a cts o f th e d e fe n d a n t w h i c h m a y b e sim ila r to th o se c h a r g e d in th e su p e r se d in g in d ictm e n t, b u t w h ich

23 Case: 12-50027 Document: 00512338659 Page: 23 Date Filed: 08/12/2013No. 12-50027

w e re co m m itte d o n o th e r o cca sio n s

. Y o u a lso h e a rd o p i n io n te stim o n y a lle g in g m edi c al mal p ra ctice b y t h e d e f e n d a n t. Y o u m u st

n o t co n sid e r a n y o f th is e v id e n ce in d e c id in g i f th e d e fe n d a n t

co m m itte d th e a cts ch a rg e d in th e su p e r s e d in g in d ictm e n t.

V a ld e z d id n o t o b j e c t to th is in stru ctio n . T h is lim itin g i n stru ctio n co n ce rn in g

m e d ica l m a lp ra ctice te s tim o n y w a s a d d e d b y th e d i strict co u rt.

W e h o ld th a t t h e r e w a s n o e rro r in a d m ittin g th e te stim o n y h e r e , m u ch

le ss p la in e r r o r

. T h e o p i n io n te stim o n y co n ce rn in g m e d i ca l m a l p ra ctice w a s

e licite d in re sp o n s e to V a l d e z’s d e fe n s e , w h ich w a s t h a t h e w a s a ctu a lly

p e rfo rm in g fa ce t jo in t in je ctio n s a s d e fin e d b y th e M e d i ca re g u id e lin e s. B e ca u se
V a ld e z co n t e n d e d th a t a ll th e p ro ce d u re s w h ich th e g o v e rn m e n t a r g u e d w e re

p r o lo th e ra p y w e re a ctu a lly f a ce t jo in t in je ctio n s, it w a s n e ce ssa ry fo r e x p e r t

d o cto rs fo r t h e g o v e r n m e n t to e x p la in th e d iffe re n ce b e tw e e n fa ce t jo in t

in je ctio n s a n d p ro lot her apy, i n clu d in g th e te stim o n y th a t if V a ld e z w e re a ctu a lly

p e rfo rm in g fa c e t j o i n t in je ctio n s a s h e co n te n d e d
, th e n th e y w e re n o t c o rre ctly

p e rfo rm e d

. T h e m e d i ca l t e stim o n y a s a w h o le fo cu se d o n a co re fa ctu a l

d isp u te

— w h e t h e r V a ld e z w a s p e r f o r m in g p ro l o t h e r a p y o r fa ce t jo in t

in je ctio n s— a n d th e te stim o n y th a t V a ld e z n o w co m p la in s a b o u t w a s la rg e ly

a n c i l l a r y to th a t p u rp o se

. T h e ju d g e g a v e a lim itin g i n stru ctio n o n h is o w n
in itia tiv e

. A l im itin g i n stru ctio n m in im ize s th e d a n g e r o f u n d u e p re ju d ice

. S ee,

e.g ., U n ited S ta tes v

. C o o k s , 5 8 9 F .3 d 1 7 3
, 1 8 3 (5 t h C ir. 2 0 0 9 ). W h ile so m e o f t h e

g o v e rn m e n t’s q u e stio n in g w e n t b e y o n d th e p u r p o se o f d istin g u ish in g

p ro lo t h e ra p y fro m fa ce t jo in t in je ctio n s, s u ch a s th e q u e stio n in g a b o u t w h e th e r

e x p ire d m e d ica tio n s sh o u ld b e th ro w n o u t o r q u e stio n s a b o u t w h e th e r V a ld e z’s

p ra ctice w a s su b sta n d a rd in g e n e ra l, th o se q u e stio n s w e re lim ite d in th e co n te x t

o f th e m e d ica l te stim o n y a s a w h o le
, a n d t h e d a n g e r o f a n y p o te n tia l re su ltin g

p re ju d ice w a s re d u c e d b y th e lim itin g in stru c t io n

. F o r th e se re a so n s, V a ld e z h a s

n o t p ro v e n th a t th e in tro d u ctio n o f th is te stim o n y w a s e r ro r.

24 Case: 12-50027 Document: 00512338659 Page: 24 Date Filed: 08/12/2013No. 12-50027

E. Cumulative Error

V a ld e z n e x t a rg u e s th a t cu m u la t i v e e rro rs d u rin g h i s t ria l n e ce ssita te

re v e r s a l

. S e e U

n ited S ta tes v

. D elg a d o , 6 7 2 F .3 d 3 2 0
, 3 4 3 -4 4 (5 th C ir. 2 0 1 2 ) ( d e s c r i b in g th e cu m u la tiv e e rro r d o ctrin e ). T h e o n ly e r ro rs t h a t w e h a v e
fo u n d

— e r ro n e o u s a p p lica tio n o f tw o se n te n cin g e n h a n c e m e n ts a n d th e fa ilu re

to in q u ire w h e t h e r e ith e r p a r ty r e q u e ste d th a t t h e j u r y d e te rm in e
fo rfe itu re

— re la te to se n te n cin g a n d t h u s cle a rly d o n o t re q u i r e re v e rsa l o f t h e

co n v ictio n s.
V a ld e z a lso a rg u e s th a t fo u r tim e s, g o v e r n m e n t w itn e sse s te stifie d to a
le g a l co n c lu sio n th a t im p r o p e r b i llin g w a s fra u d
, o r th a t i n th e w i tn e ss’s o p in io n , V a ld e z h a d co m m i tte d fra u d

. F e d e r a l R u le o f E v id e n ce 7 0 4 ( a ) p ro h ib its a

w i t n e ss fro m o ffe rin g a n o p in io n o n th e le g a l co n clu s io n t h a t a d e fe n d a n t h a d

th e m e n ta l sta t e t h a t co n stitu te s a n e le m e n t o f th e o ffe n se ; h o w e v e r, t h e
d e fe n d a n t m u st m a k e a tim e ly o b je ctio n to p re se rv e th e e rro r if it o c cu rs. S ee
U n ited S t a tes v

. S etser , 5 6 8 F

. 3 d 4 8 2
, 4 9 5 (5 th C ir. 2 0 0 9 ). V a l d e z o b j e cte d o n ly

to o n e in sta n ce o f th is te s t i m o n y

. F u rth e r, th e d istrict co u rt i n stru cte d th e ju ry
th a t it sh o u l d n o t a c ce p t th e o p in io n s o f e x p e rts, b u t m u st m a k e th e ir o w n j u d g m e n ts a b o u t th e e v id e n ce

. G iv e n th e b re v i ty o f t h e ch a lle n g e d co m m e n t s

a n d t h e o v e ra ll w e ig h t o f th e in crim in a t in g e v id e n ce a g a i n st V a ld e z, a n y e rro r

w a s h a rm le ss a n d d o e s n o t ju stify re v e rsa l. S ee S etser , 5 6 8 F

. 3 d a t 4 9 5

. III. Conclusion For the foregoing reasons, we AFFIRM the conviction and sentence. 5

5 Vald ez als o reques ted reassi g n me n t o n r e mand
, arguing that the d is trict court s how ed bias agains t him

. We need not reach this is s ue becaus e w e d o not rem and the cas e. H ow ever,

w e note that we f

ind no evid ence of bias in this cas e.

25 Case: 12-50027 Document: 00512338659 Page: 25 Date Filed: 08/12/2013