Opinion ID: 2644638
Heading Depth: 2
Heading Rank: 1

Heading: sufficiency of the evidence

Text: We review the defendants’ “preserved challenges to the sufficiency of the evidence de novo.” United States v. Grant, 683 F.3d 639, 642 (5th Cir. 2012). We view both circumstantial and direct evidence “in the light most favorable to the government, with all reasonable inferences and credibility choices to be made in support of the jury’s verdict.” Id. In doing so, we ask “whether a rational trier of fact could have found the essential elements of the crime beyond a reasonable doubt.” Id. (quotation marks omitted). 1. Count 1 (Conspiracy to Commit Health Care Fraud) A conspiracy to commit health care fraud under 18 U.S.C. § 1347 requires that the fraud be the object of the conspiracy. 18 U.S.C. § 1349. The 2 The written judgment states that Njoku was sentenced to 63 months’ imprisonment on both counts. We address this issue below. 6 Case: 12-20095 Document: 00512456949 Page: 7 Date Filed: 12/02/2013 No. 12-20095 conspirators must “knowingly and willfully” execute a scheme “to defraud any healthcare benefit program” or “to obtain, [through false pretenses] any of the money or property owned by . . . any health care benefit program.” 18 U.S.C. § 1347. Conviction requires proof “that (1) two or more persons made an agreement to commit health care fraud; (2) that the defendant knew the unlawful purpose of the agreement; and (3) that the defendant joined in the agreement willfully, that is, with the intent to further the unlawful purpose.” Grant, 683 F.3d at 643. Circumstantial evidence can prove knowledge and participation. Id. In her motion for judgment of acquittal and on appeal, Njoku argues the evidence was insufficient to prove she knew of the unlawful purpose and joined the agreement willfully. We find sufficiency from the following. Adelma Sevilla testified that she worked for Family Healthcare as an RN. She admitted to falsifying forms submitted to Medicare and said that other people she worked with, including Njoku, participated. Because Sevilla could not drive a vehicle, Njoku almost always drove her to patients’ homes to perform assessments. Njoku was also present with Sevilla during those assessments and witnessed patients performing activities that belied their homebound status or need for skilled nursing. One patient who walked around without assistance directly told Njoku that he could drive himself. Sevilla confirmed that she falsified the OASIS for this patient and for others. Njoku was hardly oblivious to the requirements. She not only worked as an LVN for Family Healthcare but also had completed training on OASIS assessments and reporting. Even though Sevilla at one point expressed concern that some patients were not homebound, Njoku responded that Sevilla should process the 7 Case: 12-20095 Document: 00512456949 Page: 8 Date Filed: 12/02/2013 No. 12-20095 admissions anyway. Princewill Njoku was also an RN. After he was indicted, Caroline Njoku asked Sevilla, another RN, to sign recertification assessments in Princewill Njoku’s place. Despite not having visited any of the patients, Sevilla complied. It is reasonable to infer that Caroline Njoku knew Sevilla had not completed in-person assessments of these patients partly because Njoku usually drove Sevilla to each patient’s home. There were also times when plans of care were returned from physicians without their approval, and Njoku instructed office clerks to send the forms to a Dr. Echols, who was later shown to be involved in the scheme. The underlying scheme was to obtain money from Medicare by false pretenses. We conclude there was sufficient evidence of Njoku’s knowledge of the agreement and her willful joining of it with the intent to further its purpose. 2. Count 2 (Conspiracy to Receive or Pay Health Care Kickbacks) It is unlawful to conspire with another to commit an offense against the United States and do an act to effect the conspiracy’s object. 18 U.S.C. § 371. The substantive offenses in this case were the knowing and willful receipt of a remuneration, namely, a kickback, in return for referring a patient for home healthcare, or payment of such remuneration in order to induce someone to make such a reference. See 42 U.S.C. § 1320a-7b(b). A conviction of conspiracy under Section 371 requires the Government to prove: (1) an agreement between two or more persons to pursue an unlawful objective; (2) the defendant’s knowledge of the unlawful objective and voluntary agreement to join the conspiracy; and (3) an overt act by one or more of the members of the conspiracy in furtherance of the objective of the conspiracy. United States v. Mauskar, 557 F.3d 219, 229 (5th Cir. 2009). 8 Case: 12-20095 Document: 00512456949 Page: 9 Date Filed: 12/02/2013 No. 12-20095 “The government must prove the same degree of criminal intent as is necessary for proof of the underlying substantive offense.” United States v. Peterson, 244 F.3d 385, 389 (5th Cir. 2001). Thus, in addition to proving an intent to further the unlawful objective, there must also be proof that the defendant acted willfully, that is, “with the specific intent to do something the law forbids.” United States v. Garcia, 762 F.2d 1222, 1224 (5th Cir. 1985); see also United States v. Davis, 132 F.3d 1092, 1094 (5th Cir. 1998).
Njoku argues the evidence was insufficient to prove she knew of the unlawful purpose and joined the agreement with the intent to further that objective.3 She contends the evidence shows mere presence in a climate of unlawful activity. We disagree. Sammie Wilson testified that she received payments through checks drawn on Family Healthcare’s account in exchange for referring patients who were Medicare beneficiaries. Wilson explained that notations on the checks such as “for 4” meant the number of patients she referred. At times, she was paid $500 per patient. On at least one occasion, Princewill Njoku was in the driver’s seat of a vehicle and his then-wife Caroline was a passenger. He reached across Caroline and gave a check to Wilson as payment for patients she had referred. There also was evidence of a check dated November 10, 2008, made payable to Caroline Njoku and drawn on Family Healthcare’s account in the amount of $2,500. The memo line showed “5 from Sammie Wilson.” There was 3 In her argument on appeal, Njoku also relies on the fact jurors found her not guilty on Count 12 – a charge for a substantive offense under 42 U.S.C. § 1320a-7b(b) – and that such acquittal supports the inadequacy of the evidence on Count 2. Not so, as our “review is to be independent of the jury’s determination that evidence on another count was insufficient.” United States v. Montalvo, 820 F.2d 686, 690 (5th Cir. 1987) (quotation marks omitted). 9 Case: 12-20095 Document: 00512456949 Page: 10 Date Filed: 12/02/2013 No. 12-20095 a computerized notation on the check revealing it had been cashed. Njoku does not deny receiving the check and, in fact, attempted through cross examination to show that the check was her part of that month’s payroll. Testimony from Ana Quinteros, a certified nursing assistant who worked for Family Healthcare, showed that some recruiters were paid in cash and were also paid through other people. Wilson did testify that she never received cash payments. Regardless, Wilson’s denial of cash payments would not mean the evidence was insufficient for the jury to find Njoku guilty of conspiracy. We must draw all reasonable inferences in favor of the jury’s verdict. Grant, 683 F.3d at 642. Wilson’s testimony revealed that she and Njoku had a uniquely close relationship, more than a typical nurse-patient friendship. Wilson actively worked as a recruiter for Family Healthcare, and it is reasonable to infer that Njoku knew Wilson was being paid for those referrals as part of the underlying scheme. Further, Njoku’s activities, including her involvement with what one could infer was a payment to Wilson, are sufficient to prove Njoku willfully joined in the agreement to pay recruiters for referrals.
Porter, who was one of the alleged recruiters for Family Healthcare, argues the evidence was insufficient to prove she knew about an unlawful objective or joined the agreement with the intent to further that objective. Porter contends she referred patients to Family Healthcare because she believed they needed and would receive home health care. Porter states she had no agreement to recruit only Medicare beneficiaries. Between 2006 and 2009, Porter worked at the University of Texas Health Science Center in the Department of Physical Medicine and Rehabilitation. She 10 Case: 12-20095 Document: 00512456949 Page: 11 Date Filed: 12/02/2013 No. 12-20095 assisted physicians in administrative responsibilities. Her resume revealed that she worked with confidential patient information. Porter testified, though, that the only patient billing she handled was for compensation claims for workrelated injuries and not claims involving Medicare. She explicitly denied having access to patients’ Medicare information. Porter testified that her friend believed a nearby agency (Family Healthcare) was looking for community liaisons. She was put in touch with Clifford Ubani and eventually interviewed with him and Princewill Njoku in a vehicle outside of her place of employment. She wondered whether the two men were involved in a fraud. Porter later admitted at trial that Family Healthcare began paying her for referring patients. Agents eventually discovered a log of Porter’s referrals on the computer hard drives at Family Healthcare. Although Porter argues she was not listed as the referral source for corresponding patients on other documents, the jury heard testimony from Agent Harshaw that it was permissible to have more than one referral source per patient. Porter’s main defense was that she did not know about the Family Healthcare’s schemes or the illegality of the referral payments. She denied having an agreement with Clifford Ubani to receive payments only for Medicarebeneficiary referrals. Porter alleged he paid her for anyone she referred. There was testimony that Memorial Hermann Hospital was a teaching institution for the University of Texas in Houston. Hermann Hospital provided patient information to the University for billing purposes. Dr. Stephen Yang testified about Porter’s access to patients’ confidential information due to her employment at the University. Dr. Yang worked at the University between 2006 and 2010 as an assistant professor in the same department as Porter. He also 11 Case: 12-20095 Document: 00512456949 Page: 12 Date Filed: 12/02/2013 No. 12-20095 treated patients at the Hospital. Dr. Yang explained that he handled patients’ medical charts during his day-to-day practice. Those charts included what the Hospital called “face sheets.” The sheets contained information about patients’ insurance providers such as Medicare. Dr. Yang stated that he was required to report charges that he billed and would attach that billing data to the face sheet. He then placed the documents in a basket for processing. Dr. Yang knew Porter from their working at the University. Her desk as an administrative assistant was down the hall from where he placed documents in the basket. He also knew that Porter processed patients’ billing information because he had witnessed her speaking with a billing company. A legal privacy officer who worked for the University testified regarding Porter’s employment records. The officer reviewed documents in Porter’s employment file, which revealed one of Porter’s responsibilities was to maintain all medical billing and routine office duties. Porter had received advanced training on patients’ rights regarding the confidentiality of their health care information. We disagree with Porter that the evidence was insufficient to support a finding of guilt. Porter initially suspected Clifford Ubani and Princewill Njoku of fraudulent activity. She still agreed to work for them and admitted to referring patients to Family Healthcare and receiving payments in exchange. Porter defended her actions based on her belief that they were legitimate referrals, but the jury also heard her testify that she received payments for patients’ recertifications despite having provided no additional work in exchange. Agent Harshaw testified that the patients on a referral list associated with Porter were Medicare beneficiaries. According to his testimony, more than 12 Case: 12-20095 Document: 00512456949 Page: 13 Date Filed: 12/02/2013 No. 12-20095 three-quarters of those beneficiaries were also patients at the Memorial Hermann Hospital. This circumstantial evidence, along with the testimony that she had direct access to patients’ Medicare information and advanced training in confidentiality regulations, was sufficient to prove that Porter knew of the unlawful objective of recruiting Medicare beneficiaries and willfully joined the agreement with the intent to further that objective. 3. Counts 20 and 21 (False Statements for Use in Determining Rights) It is unlawful to “knowingly and willfully make[] . . . any false statement or representation of a material fact for use in determining rights to [any benefit or payment under a Federal health care program].” 42 U.S.C. § 1320a-7b(a)(2). The jury charge instructed that a false statement is material if it has a natural tendency to influence or is capable of influencing the recipient. The indictment alleged that Ellis described non-existent symptoms and services that were not performed for two patients. On appeal, Ellis concedes the evidence showed her nursing notes contained false statements. She argues that they were not material because they could not be used to determine either patient’s right to home health care. Ellis relies on a claims analyst’s testimony that an RN completes the OASIS questionnaire, and the RN and physician approve the resulting plans of care. Further, Medicare would not authorize payment if these forms merely were signed by an LVN such as Ellis. Ellis also acknowledges the testimony that an LVN was legally required to keep nursing notes that documented patient care. We conclude these notes were material in support of her conviction. The claims analyst explained at trial that Medicare required the preservation of nursing notes in the event of an audit. Ellis herself testified that Family Healthcare encountered two audits 13 Case: 12-20095 Document: 00512456949 Page: 14 Date Filed: 12/02/2013 No. 12-20095 while she worked with the company. In addition, Agent Harshaw testified that an RN partly relies on an LVN’s nursing notes when completing the recertification OASIS. The claims analyst testified that an RN partly would rely on nursing notes to determine future treatment. Regarding the two patients listed in the indictment for Counts 20 and 21, Ellis allegedly provided services for them as their LVN. Both patients were recertified for a second period of home health care. An RN was associated with each recertification. Family Healthcare billed Medicare for both patients. Under either circumstance, Ellis’s false statements on her nursing notes were material and capable of influence for purposes of determining rights to payment by Medicare. The evidence was sufficient to sustain Ellis’s conviction.