Opinion ID: 2647052
Heading Depth: 3
Heading Rank: 1

Heading: sufficiency of the evidence

Text: Ramos challenges her convictions under the Anti-Kickback Statute solely on the basis that the Government did not present sufficient evidence to prove that she “willfully” violated the statute.18 A procedurally preserved challenge to the sufficiency of evidence is reviewed de novo. United States v. Grant, 683 F.3d 639, 642 (5th Cir. 2012). When reviewing the sufficiency of the evidence, we view all evidence “in the light most favorable to the Government, with all reasonable inferences and credibility choices made in support of the jury’s verdict. The evidence is sufficient to support a conviction if a rational trier of fact could have found the essential elements of the crime beyond a reasonable doubt.” United States v. Ford, 558 F.3d 371, 375 (5th Cir. 2009) (per curiam) (citation omitted). Ramos argues on appeal that she could not have willfully violated the Anti-Kickback Statute because she did not know that engaging in a commissionbased pay arrangement with a Medicare provider was a violation of the law. Ramos contends that a conviction under the Anti-Kickback Statute requires proof beyond a reasonable doubt that she knew that being paid on commission was illegal. We disagree. The Anti-Kickback Statute prohibits receiving commissions in return for referring a Medicare patient to a Medicare provider. 42 U.S.C. 18 To sustain a conviction under the Anti-Kickback Statute, the Government must prove the following elements beyond a reasonable doubt: (1) the defendant solicited or received any remuneration, including any kickback or bribe, directly or indirectly, overtly or covertly, in cash or in kind, to any person; (2) that the remuneration was solicited or received to induce such person to refer an individual to a person for furnishing or arranging of an item or service; (3) that the item or service was one for which payment may be made in whole or in part under a federal healthcare program; and (4) that the defendant acted knowingly and willfully. See 42 U.S.C. § 1320a-7b(b)(1)(A). Ramos concedes that the Government satisfied its burden of proof with respect to elements 1–3. Ramos’s challenge is limited strictly to the assertion that the Government failed to prove that she acted willfully. 24 Case: 11-20805 Document: 00512476762 Page: 25 Date Filed: 12/19/2013 No. 11-20805 § 1320a-7b(b)(1)(A); see United States v. Miles, 360 F.3d 472, 479 (5th Cir. 2004) (The Anti-Kickback Statute “criminalizes the payment of any funds designed to encourage an individual to refer another party to a Medicare provider for services to be paid for by the Medicare program.”). Section 1320a-7b(h) defines willfulness as it pertains to the Anti-Kickback Statute. In doing so, Section 1320a-7b(h) clarifies that the Government is not required to prove actual knowledge of the Anti-Kickback Statute or specific intent to violate it. Instead, the Government must prove that the defendant willfully committed an act that violated the Anti-Kickback Statute. As applied to Ramos, the Government was only required to prove that she willfully solicited or received money for referring Medicare patients to TRG.19 Ramos concedes that the Government proved as much. Furthermore, the Government produced evidence that Ramos had actual knowledge of the Anti-Kickback Statute and its prohibitions even though such proof was not required. The Government showed that as part of Ramos’s employment with Four Group, she signed documents that explained that receiving commission payments in this context was illegal. By signing these documents, Ramos affirmed that she understood that such conduct was a 19 Ramos argues that we should adopt the definition of willfulness applied by the Ninth Circuit in United States v. Dearing, 504 F.3d 897 (9th Cir. 2007). Dearing holds that the willfulness component of 18 U.S.C. § 1347 (which is not the Anti-Kickback Statute, but rather, a general health care fraud statute) requires that the government prove that the defendant acted with knowledge that her conduct was unlawful. Id. at 901. Dearing, however, was decided prior to a statutory amendment that clarified Congress’ intent with respect to the willfulness element of § 1347. Section 1347 was amended in 2010 as was 42 U.S.C. § 1320a7b, the Anti-Kickback Statute. The § 1347 amendment adds language that mirrors the 2010 amendment to the Anti-Kickback Statute found in § 1320a-7b(h). Section 1320a-7b(h) made clear that the government need not prove that the defendant had “actual knowledge of the statute or a specific intent to violate the statute.” In light of the amendment, Dearing is unpersuasive on this issue. 25 Case: 11-20805 Document: 00512476762 Page: 26 Date Filed: 12/19/2013 No. 11-20805 violation of law.20 This evidence, though unnecessary to sustain a conviction, would satisfy the willfulness element even under Ramos’s erroneous construction of the Anti-Kickback Statute. For the aforementioned reasons, we hold that a rational trier of fact could have found that the Government proved the willfulness element of the AntiKickback Statute beyond a reasonable doubt.