Opinion ID: 2816733
Heading Depth: 1
Heading Rank: 2

Heading: Carlos's Insufficiency of the Evidence Claim

Text: We turn first to Carlos's appeal from the order denying his motion for acquittal based on insufficient evidence to convict. See Fed. R. Crim. P. 29. We review de novo the denial of a Rule 29 motion for acquittal, asking whether a reasonable jury could find guilt beyond a reasonable doubt. United States v. BurgosMontes, 786 F.3d 92, 112 (1st Cir. 2015). In assessing a challenge to the sufficiency of the evidence, we examine the evidence, together with all inferences that may be reasonably drawn from it, in the light most favorable to the prosecution. United States v. Andújar, 49 F.3d 16, 20 (1st Cir. 1995). Where, as here, a jury draws inferences from circumstantial evidence, a reviewing court should refrain from second-guessing the ensuing conclusions as long as (1) the inferences derive support from a plausible rendition of the record, and (2) the conclusions flow rationally from those inferences. United States v. Spinney, 65 F.3d 231, 234 (1st Cir. 1995). Our deference to jury verdicts is not without limit, however: [I]f the evidence viewed in the light most 8 This court consolidated the two appeals. - 8 - favorable to the verdict gives equal or nearly equal circumstantial support to a theory of guilt and a theory of innocence of the crime charged, this court must reverse the conviction, because in such a case a reasonable jury must necessarily entertain a reasonable doubt. United States v. Flores-Rivera, 56 F.3d 319, 323 (1st Cir. 1995) (internal quotation marks and emphasis omitted). The parties agree that the conspiracy charge9 against Carlos turns largely on whether the jury could reasonably find that Carlos knew that his brother was defrauding Medicare. The parties likewise agree that the aggravated identity theft counts required the jury to find that Carlos, either as a principal or aider and abettor, knew of the underlying health-care fraud.10 9 18 U.S.C. § 1349 provides as follows: Any person who attempts or conspires to commit [health-care fraud] shall be subject to the same penalties as those prescribed for the offense, the commission of which was the object of the attempt or conspiracy. The substantive offense of health-care fraud consists of (a) knowingly and willfully execut[ing], or attempt[ing] to execute, a scheme or artifice, either (1) to defraud any health care benefit program, or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program; and doing so (b) in connection with the delivery of or payment for health care benefits, items, or services. Id. § 1347. 10 To convict Carlos for aggravated identity theft, the government needed to prove that, during and in relation to [health-care fraud], [the defendant] knowingly transfer[red], possesse[d], or use[d], without lawful authority, a means of identification of another person. 18 U.S.C. § 1028A(a)(1); see also id. § 1028A(c)(5). To convict Carlos under an aiding and abetting theory, the government needed to establish, among other things, that Carlos consciously shared [José's] knowledge of the underlying criminal act, and intended to help [José]. United - 9 - Such knowledge for either offense could be proven by knowledge in fact, or by proof of willful blindness. To establish willful blindness, the government had to show that Carlos (1) was aware of a high probability of wrongdoing, and (2) consciously and deliberately avoided learning of the wrongdoing. United States v. Appolon, 695 F.3d 44, 57 (1st Cir. 2012). The government did manage to prove that Carlos knew that José gathered from the files of Carlos's patients information to be used by José to bill Medicare for something. In its brief and at argument, the government also claimed that the evidence showed that Carlos paid his employees to complete the CMS 1500 Forms used by José to bill Medicare. Apparently accepting the government's view of its proof in denying Carlos's motion to acquit, the district court expressly pointed to such payments by Carlos. See United States v. López-Díaz, 940 F. Supp. 2d 39, 64 (D.P.R. 2013) ([Carlos] even paid his employees for filling out billing forms when [José] was unable to pay them.). As the government clarified after oral argument, however, the record shows only that Carlos paid his employees to record his patients' vital signs for José's review, and only when José was unavailable to make this payment himself.11 Further, the government points us to no evidence States v. Lyons, 740 F.3d 702, 715 (1st Cir. 2014) (quoting Spinney, 65 F.3d at 235). 11Carlos also paid Williams and Rodríguez to help with billing and data entry for his legitimate dental services. There is no - 10 - that José needed (or even used) the vital signs data to deceive Medicare. Of course, if Carlos knew that José had no basis whatsoever to bill Medicare for any amount in connection with Carlos's patients, then his knowledge that José was billing for something could suffice to sustain the verdict. So the question is posed: Did Carlos know that José could not bill merely for the gathering and review of vital signs information? On this crucial point, the record is a complete blank. The record does not even show that such a file review is not billable, much less that Carlos knew it was not billable. The government did not submit any evidence challenging the existence of the regulation that its own witnesses cited as a reason for taking the vital signs and reviewing them. Nor did it seek an instruction on the regulation. The government also failed to counter José's testimony that [t]here are several formulas through which the physician can be paid for services to mobile dental clinics. Instead, the government simply argued in closing that José did not bill for reviewing the vital signs. This was a compelling point against José, but carried weight against Carlos only if there was evidence that Carlos knew what José was billing for. evidence that Carlos ever paid Williams and Rodríguez to help José with his billing. - 11 - In an effort to fill this gap, the government in its brief tells us that Carlos is also a medical provider, submits dental billing claims himself, and understands what is required of medical provider [sic] in order to submit claims. Cf. United States v. Singh, 390 F.3d 168, 188 (2d Cir. 2004) (jury could infer that physician/clinic owner was aware that claims he submitted were false, based on his possession of and familiarity with the applicable billing code guidebook and manual, and discussions with employees revealed his detailed knowledge about billing). The government, however, cites no evidence to support this crucial assertion, nor can we find any. To the contrary, the record shows that the dental billing codes (with which one could assume Carlos was familiar) were so different from the physician billing codes that the government's own witness on Medicare billing professed almost complete ignorance about dental billing codes.12 Our own review of the record points to no other means to close this gap. Notwithstanding the indictment's express charge that the aim of the conspiracy was to enrich both José and Carlos, there is no evidence at all that Carlos received even one penny of the fraudulent proceeds. What little else we could find on our own review of the record added nothing to the government's case; 12 While some evidence supported an inference that Carlos sometimes billed Medicare Advantage plans, there was no evidence that he used medical or surgical billing codes, rather than dental billing codes, in order to bill those plans. - 12 - rather, it helped Carlos.13 We also do not think that whether and when file reviews are billable to Medicare are matters of common knowledge that lay jurors might bring to bear to connect the toowidely spaced dots in the government's case. José's behavior as described by the government's evidence offered no hint that Carlos was aware of the nature of José's billing. The fact that José indisputably initialed the patient files suggests strongly that he was trying to deceive someone other than Medicare (e.g., Carlos?), given that the vital signs data from Carlos's patients provided no information that José used to bill or to justify billing for the surgical and other procedures he claimed to have performed. José was also careful that Williams and Rodríguez, his wife's employees whom he paid to 13 Carlos's clinic coordinator marketed the dental clinic to directors of nursing homes and residential facilities in part through PowerPoint slides. One slide indicated that the clinic had a consultant physician, whom the coordinator understood to be José. That same coordinator, who also collected patients' medical histories, testified that José told her to focus on whether the patient had had recent surgery, in order to prevent adverse reactions to the dentist's anesthesia. And the consent and release forms that the coordinator collected from Carlos's patients did not clearly prohibit use of patient information to bill for a file review by another doctor. The forms stated that the patients consented to use of their information to carry out your treatment, payment activities and operations in your health care. The attached notice of privacy practices informed the patients that Carlos may use your health information for treatment (e.g., sending copy of your clinical information to a specialist as part of your referral), to obtain payment for treatment (e.g., bill an insurance agency), or for other health care operations (e.g., evaluate the quality of treatment you receive) (emphasis added). - 13 - fill out the demographic and health plan sections of his CMS 1500 Forms, performed their task out of Carlos's presence. Neither did those two employees suggest that Carlos knew the services for which José was billing. Though not clear from its brief, the government appears to argue that the jury could infer Carlos's knowledge of José's fraud if the jury doubted the utility of the treatment protocol, and thus the plausibility of Carlos's explanation for handing his files to José. If the evidence allowed the jury to conclude that the treatment protocol was obviously useless, then the jury might have inferred that Carlos could not possibly have thought the protocol valuable. And from that the jury could, perhaps, have further inferred that Carlos must have had some other, criminal, reason for handing over his patient files to José, and thus still further inferred that Carlos must have had the requisite knowledge of José's fraud. The government, though, did not present any evidence to support such a chain of inferences. Acting almost as if it bore no burden of proof in making its case against Carlos, the government did not present any direct evidence that the protocol was, in fact, not an accepted or recognized method of ensuring that the mobile clinic's practice was adhering to medical - 14 - standards.14 Nor did the government present any direct evidence that Carlos believed the protocol was useless. And, indeed, the fact that Carlos supervised his dental assistants in taking vital signs--and paid them for doing so when José was out of town--would seem to suggest that Carlos viewed the protocol as beneficial. As a result, the record cannot support the first link in a chain of inferences that would be needed to justify the jury's verdict against Carlos on these grounds. See United States v. Burgos, 703 F.3d 1, 10 (1st Cir. 2012) ([W]e are loath to stack inference upon inference in order to uphold the jury's verdict. (quoting United States v. Valerio, 48 F.3d 58, 64 (1st Cir. 1995))). Our respect for a jury's ability to get it right does nevertheless cause us to pause cautiously before concluding that the evidence is insufficient to support the verdict. We note, though, that the prosecutor in closing told the jury that it doesn't matter for purposes of this case if [Carlos] knew what [José] was writing on those [CMS 1500 forms]. It doesn't make a difference. The prosecutor also seems to have slipped into an argument based on a lesser negligence standard, rather than knowledge or willful blindness: [Carlos], as a dentist, should 14The government also failed to challenge one of the apparent rationales for the protocol, that it was required by some Commonwealth regulation. If there is no such regulation, the government easily could have called witnesses from the relevant Puerto Rico government departments to debunk this rationale. - 15 - have known better, or should have known better to question himself- -or his brother in this case--what he was billing for if he--once he knew he wasn't even seeing his patients. While we have not been asked to vacate the verdict because of these statements, and while the statements might be read in context in a manner that would render them proper, they do explain how a jury could mistakenly convict Carlos in light of the absence of any evidence that his brother could not bill Medicare at all for his work under the protocol, or that Carlos knew of or willfully ignored such a limitation. We have in mind, too, the fact that in a three-week trial focused mostly on José, both the prosecutor and the trial judge themselves mistakenly thought that Carlos paid to have some of José's falsified claim forms completed.15 In any event, the key point now is that the record contains insufficient evidence to support a reasonable inference that, beyond a reasonable doubt, Carlos knew that José had no basis for submitting any type of claim in connection with his review of Carlos's patient records. We therefore vacate Carlos's convictions and remand for a judgment of acquittal of Carlos on all counts.16 15 See López-Díaz, 940 F. Supp. 2d at 64 ([Carlos] even paid his employees for filling out billing forms when [José] was unable to pay them.). 16 We need not address Carlos's remaining arguments. - 16 -