### In the 

# United States Court of Appeals
For the Seventh Circuit

____________________ No. 16

- 2053

U NITED S TATES OF A MERICA , Plaintiff

- Appell ee ,

v.

W ANDA S HORTER , Defendant

- Appell ant

.

____________________
Appeal from the United States District Court for the
Northern District of Indiana

, South Bend Division.
No. 3:14

- cr

- 32

— Jon E. DeGuilio

, Judge

.

____________________

A RGUED F EBRUARY 8, 2017

— D ECIDED N OVEMBER 1

, 2017

____________________

Before W OOD , Chief Judge, F LAUM , Circuit Judge

, and

C ONLEY , District Judge

. ∗

C ONLEY , District Judge. In 2014, f ollow ing investigation s by the Indiana Attorney General and FBI, a g rand j ury issued a
four

- count indict ment for Medicaid fraud against defendants
Wanda Shorter and her company, Empowerment Non

- Emergency Medical Transport, Inc. (“Empowerment”). Specifically,

∗ Of the Western District of Wisconsin, sitting by designati on.2 No. 16

- 2053

Short er and Empower ment were charg ed with one count of health care fraud in violation of 18 U.S.C. § 1347

, and three counts of misusing a means of identificati on in violation of 18 U.S.C. § 1028A. After a petit jury found h e r guilty on all four

count s, Shorter filed this direct appeal, challenging the indictment
, the admission of certain evidence at trial and the sufficiency of the evidence as a whole

. For the reasons that follow

, we affirm.

I. Procedural History

A. B ackground

I n early 2011, Shorter

, already a licensed nurse, formed Empowerment to provide transportation services to Medicaid
cli ents. She was its sole shareholder

. Following a single training session on Indiana Medicaid ’s billing protocols in April

2011 , Sh orter began submitting invoices for Emp owerment’s

services

.Indiana Medicaid provides reimbursements for health related transportation services to eligible patients. The provider of those services agrees to follow Medicaid’s billing policies and to seek reimbursement for only medically necessa ry and truly rendered services. To ensure compliance , transportation

pro viders must maintain trip ticket s that include the recipient’s name and identification number, date of transport, type of services rendered, whether it was one

- way or round trip,
and t he mileage driven.No. 16

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Each type of service is assigned a Medicaid code used for
reimbursement. 1 The service provider submits the applicable codes to Medicaid, which reimburses according to set rates specific to the type of service provided

. For instance, Medicaid reimburses twice as much if the patient is wheelchair

bound, and it provides additional reimbursement when an attendant rides along or when rides are more than 20 but fewer
than 100 miles round

- trip

. Along with a few other individual s working under Shorter’s direction, she continued to bill and
receive Medicaid reimbursements usin g these codes until early 2014.

B. Indictment

On March 12, 2014, the grand jury named Shorter and Empowerment as defendants in a four

- count indictment . Count

1 allege s that between 2011 and 2014, Shorter and Empowerment knowingly engaged in a scheme to defraud Indian a Medicaid in violation of § 1347 by requesting payment for services and transportation never actually pro vided, or if provided, for higher paymen ts than justified b y actual services

1 The codes relevant to the convictions here are:

• A0130: “nonambulatory” patient who must be transported in a wheelchair;

• T 2003: “ambulatory” patient who does not need to ride in a wheelchair;

• A0130 TK: attendant or parent who travels with a nonambulatory patient;

• A0130 TT: nonambulatory patient the provider picks up when a Medicaid client is already in vehicle;

• A0425 U5: transport of a nonambulatory patient for more than 20, but less than 100, miles round

- trip.4 No. 16

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and transportation provided. Counts 2 through 4 of the indictment charged the defendants with violatin g § 1028A by
know ingly using “without lawful authority a means of identification of another person during and in relation to health
care fraud ... and wire fraud

. ” In Count 2

, defendants were charged with fraudulently using the identification of “C.C. (di fferent person from Count s 3

- 4) ” in August 2012, while Counts 3 and 4 charged them with fraudulently using the
identifica tion of “C.C.” in June and August 2013 , respectively

. At no time before trial, did Shorter challenge the sufficiency
of the indict ment.

C. Evidence at Jury Tri al
To prove the alleg ations in Count 1 , the gov ernment submitted evidence of : (1) Shorter’s personal involvement in Empowerment’s billing practices; (2) the results of a September 2013 Indiana Attorney General Investigation into Empowerment ’s billing pract ices ; (3) an October 2013 FBI search of Empowerment’s records; and (4 ) the experiences of Empowerment employees and of clients who us ed its services. As f o r Shorter’s personal involvement, a n FBI agent testified that Shorter confirmed during an interview her owne rship of Empowerment , as well as her train ing and comfort with Medicaid bill ing. Shorter also told the agent that her aunt

, Annette Gates, did some of Empowerment’s Medicaid reimbursement request s between April 2012 and October 2013

. Moreover,

t her e was substantial evidence that Shorter personally trained
Aunt Annette and a cousin, Lakesha Gates, on how to prepare Medicaid bill s

.No. 16

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Specifically, both Annette and Lakesha testified that : (1) they submitted bills for Medicaid reimbursement in accordance with Shorter’s instructions ; (2) they ha d no knowledge
about the Indiana Medicaid billing process before beginning work for Empowerment ; and (3) they receive d no formal training beyond Shorter’s instru c tions. They both further testified that Shorter t augh t them to use the same four codes for every trip : transport of a non

- ambulatory patient, when another client is already in the vehicle, with an attendant and
more than 20 miles round

- trip

. Multiple agents involved in the Indi ana Attorney General ’s September 2013 investigation also testified to arrang ing
for transportation services with Empowerment using fake
names but real Medicaid identification numbers. Each agent arranged for and took one

- way trips without use of a wheelchair or presence of an at tendant

. Nevertheless, Empowerment billed each of these transports as round

- trip for a wheelchair

- bound client with an attendant . Similarly, there was testimony that trip s of 3.4 miles an d 4.2 miles were billed b y Empowerment for 77 mi les and 40 miles , res pectively . A n agent further testified that despite cancelling a trip

, Empowerment
later billed for the 40

- mile transport of a wheelchair

- bound
client with an attendant. Finally, t he agents testified that Empowermen t submitted bills for their transport in J une, July, and August 2013, well before they began requesting transportation

. A s further proof of Count 1

, twelve former client s and
three former drivers testified about their actual experiences with Empowerment. This testimony was also inconsistent
with Empowerment’s actual billings for those same transports as reflected in government summary exhibits

. Among other6 No. 16

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things, t he se exhibits showed that Empowerment coded transports to claim a wheelchair

- bound patient, round

- trips, and attendant trips, while on ly one client, Chitika Cox, testified that she used a wheelchair, and then only for one week at
the end of 2013. C lient s further testified that their trips with Empowerment were often one

- way, not round

- trips as coded

, and only two of the twelve clients te stified t o us ing an attendant

. 2 This client testimony was confirmed by former Empowerment drivers. For example, one former driver testified
that in two months dr i v ing for Empowerment

, she had three
to five wheelchair patients and one patient who needed an attendant. A second driver testified that between five and ten percent of her riders needed an attendant, while a third driver
testified that attendants were not frequent ly present during trips

. Yet for each trip, defendants submitted reimbursement request s seeking compensation for these additional services.

To prove Counts 2

- 4, the government submitted additional testimony and documentary evidence with respect to
the “ C.C. ” references in the indictment

, includ ing that “C.C.”
stood for Cassamdra Coo k in Co unt 2

, and for Chitika Cox in
Count s 3 and 4

. W ithout objection, the government also submitted Exhibits 18 and 20, which included Empo werment’s trip tickets from Cook and Cox trips, respectively, as well as

2 In addition, clients testifie d about the poor quality of th eir transports by Empowerment, including that their rides were often late or never showed up, and that Empowerment’s vans were shoddy and sometimesbroke down. Drivers similarly testified that the vans were in poor condition. This was consistent with driver testimony that they rarely had contact with Shorter; and their payroll check bounced at times. Shorter admitted that she never reconciled the billings and that she used the Medicaid reimbursement money to buy a new house and car.No. 16

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Exhibits 35 and 40

, which were summary charts

, respectively
entitled “ Empowerments Billings for Chitika Cox ” and “Empower ment’s Billings for Casam dra [sic] Cook .”

At trial, Chitika Cox acknowledged us ing Empowerment to transport her to dialysis a ppointments three times a week,
but testified that excep t f or one week at the end of 2013, shenever used a wheelchair, and she never traveled with an attendant. For five of her scheduled trips during the period that Empowerment billed Indiana Medicaid for this transport

, Cox cancelled altogether, and Empowerme nt did not drive
her to dialysis

. Specifically, Empowerment’s May 6, 17, 22, and June 10 and 19 , 2013, trip tickets showed that Cox cancelled,
and her medical records confirm that she did not appear for her medical appointment on those dates. However, the government submitted evidence that Empowerment billed each
of those dates as round

- trip, wheelchair trips with an attendant. Similarly, the trip tickets from May 1, 10, 29 and June

5 , 2013, show that Cox either did not appear or did not list any
mile age, b ut Empowerment billed those trips as round

- trip

, wheelchair transports as well

. In addition, Cook testified that she used Empowerment on a regular basis for transport t o a standing appointment on Tuesdays at 5 p.m., but that s he did not use a wheelchair. Because her mother would always pick her up, Cook also testified that these Tuesday trips were always one

- way. Nevertheless , Empowerment billed two of the se appointments as wheelchair trips on the wrong dates, with Cook as both a primary and secondary pass enger. For her part, defendant Shorter did not attempt to defend Empowerment ’s billing practices . I nstead , she opt ed to take
the stand in an attempt to divo r ce herself from he r company’s8 No. 16

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billing failures by emphasizing that she created Empowerment to offe r services to the very type of people that she originally became a nurse to serve

, while admitting that she did not keep good rec ords, which lead to the billing errors here. In particular, Shorter denied ever “willfully and intentionally and fraudulently, knowingly and purposely” bill ing for things to which she was not entitled.

D. Charge to Jury
At the close of the government’s case, Shorter moved for acquittal under Federal Rule of Criminal Procedure 29. In doing so, Shorter’s counsel did not challenge the language of the
indictment. In fact, he conce ded that the government “identified Chitika Cox and Cassamdra Cook as the ‘CC’ individuals
involved in the indict ment,” and that there was evidence Empowerment submitted bills without t heir authorization, bu t argued that no evidence tied Shorter to those billings, nor was
there evidence of her intent to defraud Indiana Medicaid

. The
court denied Shorter’s Rule 29 motion as to all of the counts,concluding that there was “ample evidence of fraudulent billing” and sufficient evidence with respect to the identity theft

counts. At the close of the evidence, Shorter renewed her Rule 29 motion, which was denied for the same reasons

. The court then instructed the jury on the law

, including the following instruction as Shorter had proposed : “A person who acts on behalf of a corporation also is personally responsible
for what she does or causes someone else to do. However, a person is not responsible for the conduct of other s performed on behalf of a corporation merely because that person is an officer, employee, or other agent of a corporation. ” Obviously agreeing with the government’s view of the evidence, t he juryNo. 16

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returned a guilty verdict on all counts, and the district court sentenced Shorter to 75 months of impris onment.

II. Discussion

A s to all counts of conviction, the defendant challenges the
district court’ s admission of certain evidence as irrelevant or unduly prejudicial under Federal Rule s of Evidence 401 or 403

. Specifically, defendant challenges the admission of evidence that : (1) Empowerment’s checks sometimes bounced ; (2) Empowerme nt’s vehicles and equipment were in disrepair; (3) Empowerment was late or absent for pickup s ; (4) defendant paid for a cruise for herself and her family ; and (5) def endan t bought a car and new house. Defendant argues this evidence was clearly irrelevant, highly prejudicial and only introduced to taint the jury’s view of Shorter. As defendant failed to object to any of this evidence, we review for plain
error and see none. See United States v. Haldar , 751 F.3d 450, 456 (7th Cir. 2014) (citing United States v. Alexander , 741 F.3d 866, 870 & n.1 (7th Cir. 2014) (the defendant having failed to object at trial, we review for “ plain error ,” meaning an error “so obvious and prejud icial that the district judge should have intervened without being prompted.”).
Certainly this evidence present s the possibility of prejudice, but each was relevant to the government’s rebuttal o f Shorter’s defense that she created Empowerment for altruist ic reasons and billed incorrectly due to mere negligence. Accordingly, we see no error in the district judge ’s failure to sua sponte exclude these questions

. See United States v. Whiting , 471 F.3d 792, 801 (7th Cir. 2006) (no abuse of discretion in admitting evidence of defendant’s “management fees, expense reimbursements, and personal expenditures” to prove specific intent to defraud).10 No. 16

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Defendant’s challenge s to Counts 2, 3, and 4 of the indictment face a similar uphill battle , having failed to raise any object ion before the district court as to a defect in the indictment as required

. See F ED

. R

. C RIM

. P

. 12(b) (3) (if “reasonably available” and resolvable without a trial on the merits

, a defendant

must challenge a defect in an indictment by moti on ); F ED

. R.
C RIM

. P. 12(c)(3) (i f a defendant fails to file such a pretrial motion, he or she must show “good cause” for raising this argume nt for the first time on appeal). Since defendant makes no claim that her challenges on appeal were unavailable in the district court, nor that she had good cause for not raising them
until on appeal , h er challenge to the indictment fails on that ground alone. See United States v. Acox , 595 F.3d 729, 730

- 32 (7th Cir. 2010) (failure to meet good cause standard is a sufficient ground to reject new argument on appeal ) ; United States v. Johnson , 415 F.3d 728, 730

- 31 (7th Cir. 2005) (same)

. Even if the good cause standard were satisfied

, however,
the defendant has not demonstrated that Counts 2 through 4

as charged in th e indictment were so “ obviously defective as not to charge the offense by any reasonable construction .”
United States v. Cox , 536 F.3d 723, 726 (7th Cir. 2008) ( quoting
United States v. Sandoval , 347 F.3d 627, 633 (7th Cir. 2003)). Specifically, defendant argue s for the first time on appeal that : (1)
Counts 2

- 4 failed to include “essential facts c onstituting the offense charged ” as required by Federal Rule of Criminal Procedure 7(c) ; and (2) the indictment provide d her with inadequate notice and subjected her to duplicitous counts of conviction. As explained more fully below, the record contradicts
both assertions . Moreover

, t he defendant has not shown that the phrasing of the i ndictment actually prejudiced the outcome of the trial

. Se e United States v. Vaughn , 722 F.3d 918, 925No. 16

- 2053 11

( 7th Cir. 2013) (indictment is subject to dismissal if the requirements of Rule 7(c) are not satisfied and the defendant suffered prejudice).

As for notice, the defendant would now take issue with the government ’s repeated us e of “C.C.” to identify two , different individuals in Counts 2, 3, and 4 , both of whose identities Shorter is charged with taking to commit Medicaid fraud

. Defendant further argues that the government exacerbated this error by failing to sepa rately identify the two individual s identified as C.C. by name in its o pening statement . Finally

, defendant notes that summary Trial Exhibits 35 and 40 , which
did contain the individuals’ actual names, were never mentioned during trial, meaning the indictment fails because defendant will be unable to plead double j eopardy in future prosecutions regarding her company’s use of either C.C. during this same period of time

. As an initial matter, the indictment’s failure to include
Cook’s and Cox’s n ames does not by itself warrant reversal

, even if the objection had been timely made

. To the contrary,

t he record shows that the defendant here knew the identities
of both C .C.s by the time of trial . R egardless , defendant made
no effort to show that she wo uld have received a more favorable outcome as to any of the three c ounts at issue had the charges been more explicit in this regard

. United States v.
Smith , 230 F.3d 300, 306 ( 7th Cir. 2000) ( failure to identify a person in the indictment is insufficient to warrant reversal “especially when no prejudice is alleged” ).
With regard to t he indictment not specifically identifying Cook and Cox by name , defendant and her counsel knew the
actual identity of each C.C. by trial , at the latest

. T o the extent
there wa s any remaining confusion as to which C.C. was12 No. 16

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which, the trial evidence certainly cleared that up. In particular

, t he testimony and exhibits relat ing to Empowerment’s billings show that Cook correspond s with the C.C. in Count 2 (involving only August 201 2 billings) , as Empowerment submit ted no bill s for Cook in June or August of 2013. Likewise, Empowerment’s billings for Cox correspond to the C.C. in Counts 3 and 4 (involving June and August 201 3 billings)

, since Empowerment did not even begin billing using Cox’s
information until June of 2013. Indeed, at the close of the government’s evidence, defendant’s counsel acknowledged Cook and Cox were the people described in the indictment and that
there was evidence of unauthorized use of their identities. 3

E ven assuming defendant and her counsel were somehow
unaware of the identit ies of each C .C., she cannot show prejudice because h er defense at trial was not specific to separate
or distinct billings; instead, defendant claimed that she was not responsible f or any of th e billings errors because she had
no intent to defraud. Given this, it is unclear at best, howthings would have been different had the indictment explicitly charged a specific, single misuse of the C.C. identity in each count charged. Regardle ss, we s ee no potential for prejudice.

3 For this reason, a ppellant’s citation to United States v. Stringer , 730 F.3d 120 (2d Cir. 2013), only hurts her argument here . In Stringer , the courtrejected the defendant’s complaint that the indictment should be dismissed because it did not ide ntify the name of the persons whose identities had been misused, in part because the defendant had actually known
the victim’s names before trial. Id. at 124. The same is true here: the trial
record shows that Shorter knew that Cook and Cox were the C.C.’s referred to in Counts 2

- 4 both before and certainly during the trial itself

.No. 16

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As for defendant’s challenge to Counts 2

- 4 being duplicitous, our review is under a plain error standard

. An indictment is deemed “ duplicitous ” when it “charges two or more distinct offenses within a single count.” United States v. Hassebrock , 663 F.3d 906, 916 ( 7th Cir. 2011); United States v. Davis

, 471 F.3d 783, 790 ( 7th Cir. 20 06). In Count s 2

- 4, the defendant
here is charged with “knowingly transfer [ing] , possess [ing], or us[ing] , without lawful authority, a mea ns of identification of another person” in furtherance of health care fraud in violation of 18 U.S.C. § 1028A. Given the evidence at trial showed that Empowerment submitted multiple billings using Cox’s
and Cook’s identities during the relevant time period for each
Count

, defendant argues those counts are duplicitous. The
defendant points in particular to Trial Exhibits 35 and 40

, which contain multiple examples of fraudulent billings for
each of the time frames described in Counts 2

- 4.
The defendant raises an interesting question of law

, although it is not yet one addressed by this court

. See, e.g., United
States v. Resnick , 823 F.3d 888, 897 (7th Cir. 2016) (citing United
States v. Olano , 507 U.S. 725, 732 (1993)

, for the proposition th at
an error is not plain “unless [it] is clear under current law” ).
In particular

, this court has not squarely decided whet her each charge brought under § 1028A may be satisfied by more than one misuse of another’s identity. Th e defendant cites
United Stat es v. Soto , 799 F.3d 68, 87

- 88 (1st Cir. 2015), in which
the court held that “each use constitutes its own violation of §
1028A

, ” but that decision does not plainly answer the question before this court

. I n deed

, in Soto

, the First Circuit cited to a decision from this court, United States v. Cejas , 761 F.3d 717, 731 (7th Cir. 2014)

, in support of its holding, but Cejas actually rejected a d ou ble jeopardy challenge to two violations of 18 U.S.C. § 924(c) , after finding the two violations involved “two14 No. 16

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drug offenses based on separate and distinct con duct .” 761
F.3d at 731. While t he Cejas and Soto decisions may provide support for defendant’s position, they certainly do not expressly address the proper unit of prosecu tion fo r § 1028A in
this circuit . Given that this issue is before us on plain error

review , therefore, any arguable error is certainly not plain

. Even assuming plain error , defendant has not show n actual prejudice. Duplicitous charges may prejudice a defendant in four ways: “the defendant may not understand the charges against [ her ] , might be convicted by less than a unanimous jury, may be prejudiced by evidentiary rulings at trial, or may be subjected to double jeopardy.” Davis , 471 F.3d at

790. Defendant argue s that she has been prejudiced in three
of those four ways , but none of those ways has any traction
on this record

. First, defendant argues that the i ndictment did not properly inform her of the nature of the charges

, because it grouped together the Cook a nd Cox billings from August 2012, June 2013 and August 2013. However, the prejudice inquiry concern s whether the defendant was able to prepare a
defense at trial. See United States v. Kimberlin , 781 F.2d 1247, 1250 (7th Cir. 1985). As explained above, t he trial rec ord does not suggest that appellant was confused a bout the charges

. As mentioned already

, defendan t’s theory a t trial was not to disput e the inaccuracy of any individual billings. I nstead

, defendant general ly challenge d her culpability for any and all

errors based on her lack of intent

. Perhaps most s ignificantly,
defendant makes no showing that her defense would have changed if the indictment were more precise or limiting in its description of the specific false billing s at issue with respect
to C ount s 2

- 4

.No. 16

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Second, the defendant argues even less persuasively that
the indictment’s broad language might prevent her from asserting a double jeopardy argument with respect to these

c ounts in the future. As t he government points out, b roadly

worded indict ments charging the defendant with fraudulent billings during a specified time period would bar later prosecution for any billings during those time periods. See United
States v. Folks , 236 F.3d 384, 392 (7th Cir. 2001) ( precluding the possibility of a second prosecution for conduct encompassed by a broadly

- worded indictment)

. Defendant argues alternatively that she may not assert double jeopardy in the future because there is no pleading that actually identif ies which

C.C. is involv ed for each count
, and another court will not be equipped to determine who each of the victims actually were

. To give t hat po sition any credence, however, the court would
have to ignore the trial record identifying each C.C. by name

, since defendant would be able to cite to that record in the highly unlikely event that another jurisdiction would attempt to pros ecute her for the Cook August 2012 billings or the Cox June and August 2013 billings.

Third, appellant contends that duplicitous counts created the possibility of non

- unanimous verdicts as to Counts 2

- 4

, because the jury was not instructed that they had to all agree

on a “particular billing

. ” While an instruction on unanimity may have been preferable in th is context

, defendant was the one in the best position to both see and raise that issue. Obviously, the defendant did not perceive any problem with this,
nor do we

. Even if defendant could articulate some specific animus or material problem of different i at ion, she again failed to object

, and w e can see no plain error here. See United Sates
v. Mannava , 56 5 F.3d 412, 415 (7th Cir. 2009) ( “An error is plain16 No. 16

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if it is clearly an error and could with some nontrivial probability have changed the outcome of the cas e.”) ; see also United
States v. Pavloski , 574 F.2d 933, 936 (7th Cir. 1978) ( “no possibility of prejudice through lack of unanimity” because the defendant did not dispute that he did the acts).

F inally, the defendant challenges the sufficiency of the evid ence as to Counts 2

- 4. To clear this “nearly insurmountable
hurdle” in revers ing a conviction, defendant has to show that there was “no evidence, no matter how it is weighed, from which a rational jury could find guilt beyond a reasonable
doubt.” United States v. Bek

, 493 F.3d 790, 798 (7th Cir. 20 0 7). As the government submitted a substantial amount of evidence to support the convictions for Counts 2

- 4, defendant’s challenge also fails to clear that formidable hurdle

. This then leaves defendant ’s c hallenge to the admissibility
of Trial Exhibits 35 and 40 . As an initial matter, the admission
of these exhibits was never an issue at trial. While d efendant
would now argue that Federal Rule of Evidence 1006 requires

a witness to testify that the content of summaries are accurate to admit them at trial, citing to United States v. Green , 428 F.3d 1131, 1134 (8th Cir. 2005) , defendant expressly stated that she
had no objection to any of the trial exhibits, so she has waived her right to do so on appeal

. Uni ted States v. Murry , 395 F.3d 712, 717

- 19 (7th Cir. 2005). In fact, the government elicited testimony that Exhibit 35 was a summary of Empowerment’s billing for Cox, and the government referred to Exhibit 40 during closing without objection

. Regardless

, the Green opinion is mistaken in reciting the requirements f or admission of a 1006 summary. In particular,
there is no explicit requirement that a witness testify about its

accuracy at trial

. To the extent t he Eighth Circuit s uggest e dNo. 16

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otherwise in Green

, i t misappli ed its earlier decision in United

S tates v. King

, 616 F.2d 1034 (8th Cir. 1980), which was a case involving the admissibility of pedagogical charts prepared bya government witness to summarize her knowledge of the organization of housing project s. Id . at 1041. I n that case , the presence of a witness was crucial. However , a proponent of a summary exhibit need only make a showing “that the underlying records are accurate and would be admissible as evidence.” United States v. Oros

, 578 F.3d 703, 708 ( 7th Cir. 20 09 ).
If defendant had objected to the admissibility of Exhibits 35 and 40, a witness may have been the government’s avenue to lay such a foundation, but since the defendant never objected, we are left to guess whether the 1006 summaries were a ccurate compilations of admissible evidence

. Since they appear

to be

, we certainly have no basis to second

- guess the district court’s exercise of sound discretion in admitting them. At

minimum

, the defendant has once again failed to establish
clear error in the summaries’ admission.

Moreover, Trial E xhibits 35 and 40 support defendant’s

convictions for Counts 2

- 4 , along with other substantial, independent evidence admitted at trial . For instance, Cook and Cox both testified that they did not ride in a whee lchair during the relevant time periods, while Exhibits 35 and 40 show that Empowerment bill ed for Cook and Cox ’s supposed need
for wheelchair assistance during the relevant time period

. Further, Empowerment’s 2012 billing s for Co ok showed that
she was bot h the first and second passenger, support ing the jury’s finding as to Count 2

. Finally, even though Cox testified
that she did not have an attendant dur ing her 2013 rides, the
evidence shows Empowerment bill ed for an attendant during the relevant time peri ods for Counts 3 and 4

.18 No. 16

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Significantly, defendant fails to address Exhibit 18, Empowerment’s actual trip tickets for Cook and Cox during the relevant time periods, which independently support the conclusion that she used t heir identities to carry out Medicaid
fraud

. Nor does defendant attempt to explain away the testimony of Cook or Cox. Instead, defendant would have us focus on the fact that there was no direct evidence that she personally submitted the billings for reimbursement

. In particular, defen dant points to testimony of witnesses that she only sometimes did the billings, and Annette submitted the billings during the relevant time periods as to Counts 2

- 4

. However, t his argument ignores the other, powerful circumstantial evidence that permitt ed the jury to convict her, especially because the jury could reasonably infer from the evidence that she “caused” the fraudulent billings. United States

v. Thomas , 763 F.3d 689, 693 (7th Cir. 2014) (“ [D] irect evidenceis not required to find an element of a crime beyond a reasonable doubt”)

. In fact, the testimony of the trial witnesses amply support s the conclusion that Shorter either personally submitted fraudulent billing using Cook’s and Cox’s identities h erself or that Annette or Lakesha submitted those billing s at the defendant’s direction. First, there is Shorter ’s statements to an FBI agent that she was both comfortable with and actively i nvolved in the billing process. Second, the evidence showed that Shorter was actively involved in both training Annette and Laskesha and managing how they prepared the bills. Third

, Annette and Lakesha both testified generally that they did the billing for Empowerment consistent with the training that the defendant prov ided , and they each
testified specifically to cod ing Empowerment’s Medicaid billings using only the four codes that Shorter instructed themNo. 16

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to use without knowing if they applied

. T o the extent the evidence showed that Shorter did not personally prepare the relevant fraudulent billings

, therefore, the jury had ample grounds to reasonably conclude that t h os e fraudulent bills
were submitted at her direc tion

. Accordingly , w e A FFIRM

.