Opinion ID: 2644638
Heading Depth: 3
Heading Rank: 1

Heading: Mary Ellis

Text: Ellis contends the district court erred in calculating her offense level at sentencing. In considering her argument, “we review the district court’s factual findings for clear error and its interpretation of the Guidelines de novo.” Mauskar, 557 F.3d at 232. At sentencing, the district court applied an enhancement under U.S.S.G. § 2B1.1(b)(1)(H) (2011) based on an attributable loss of more than $400,000. 30 Case: 12-20095 Document: 00512456949 Page: 31 Date Filed: 12/02/2013 No. 12-20095 Ellis objected. She argues on appeal that the evidence did not support a finding that she subjectively intended to cause such a loss and that the loss was not based on her conduct. Commentary to Section 2B1.1 states that the “loss is the greater of actual loss or intended loss.” § 2B1.1 cmt. n.3(A). Given the arguments at sentencing and the court’s stated determinations, we examine the “actual loss,” which is “the reasonably foreseeable pecuniary harm that resulted from the offense.” U.S.S.G. § 2B1.1 cmt. n.3(A)(i). Actual loss requires a causal connection in fact, that is, a finding that Ellis truly caused the loss. See United States v. Olis, 429 F.3d 540, 545-46 (5th Cir. 2005). The district court “need only make a reasonable estimate of the loss.” § 2B1.1 cmt. n.3(C). The court “is entitled to find by a preponderance of the evidence all the facts relevant to the determination of a Guideline sentencing range.” Mauskar, 557 F.3d at 234. The district court estimated that the loss attributable to Ellis was $401,000. At sentencing, the Government initially contended the loss was $1,025,899.87 and presented an exhibit which listed beneficiaries for whom Ellis had prepared at least one nursing note and the amount billed to Medicare for each patient. Ellis objected, arguing that she did not know at least 12 of the patients on the exhibit. She also contended the total was $131,000 based on the patients she admitted to referring, which would have resulted in a reduced enhancement. See § 2B1.1(b)(1). The court was persuaded that the Government could prove at least $400,000 in loss because the evidence showed that Ellis provided skilled nursing services in addition to the referrals of patients who did not need those services and were recruited instead of referred by physicians. Additionally, the Government directed the court to Trial Exhibit 47, which was 31 Case: 12-20095 Document: 00512456949 Page: 32 Date Filed: 12/02/2013 No. 12-20095 a summary exhibit of Ellis’s patients and their respective recertifications, Medicare claim amounts, and certifying physicians. The total of these claims was $760,551.66. Agent Harshaw testified that a person under his direction created Trial Exhibit 47 based on claims data, referrals sheets located on the computer, and the filed face sheets. Agent Harshaw also stated that he created a related exhibit which was admitted and revealed the same amount based on the claims data he personally reviewed during his investigation. Ellis presented exhibits to show contradictions in the initial summary exhibit the Government presented. She also presented a list of 26 patients who Adelma Sevilla believed were not homebound. Finally, Ellis narrowed the Government’s list of patients and claims down to those associated with Dr. Echols, who arguably was more clearly involved in the fraud. The district court considered the evidence and ultimately assessed the loss at $401,000. The court found the Government’s records more reliable than Ellis’s recollection and based its decision on the presented exhibits, including Ellis’s referral list, patient list, and logs of patient care admitted at trial. On appeal, Ellis argues the district court did not consider evidence that contradicted the Government’s evidence that Ellis was a referral source for all of the patients in the first sentencing exhibit. At trial, though, Agent Harshaw testified that there could be more than one referral source based on his review of the evidence. Ellis next argues that she did not recall at least twelve of the patients on the Government’s exhibit, but she has not shown clear error in the district court’s explicit credibility finding. Third, Ellis contends that some patients had prescriptions for home health care, but Agent Harshaw testified that out of the hundreds of patient files he reviewed, only three or four had 32 Case: 12-20095 Document: 00512456949 Page: 33 Date Filed: 12/02/2013 No. 12-20095 prescriptions. Thus, this contention does not sufficiently alter the loss calculation for us to determine there was clear error in the factual findings. Further, Ellis contends that some patients were not homebound and that the court did not distinguish between legitimate nursing visits and illegitimate ones. She also argues her skilled nursing services were provided after beneficiaries had received plans of care, which means Medicare would have already paid a percentage of the claims under the bifurcated payment system. As the district court reasoned, though, a central idea of this scheme was to generate sources of income: Medicare beneficiaries. The claims analyst, who had also worked as a nurse, testified at trial that a physician’s prescription was required before home health care could be initiated. Although evaluations could be conducted before that prescription was written, that was not the general practice according to her experience. In fact, almost all referrals came from treating physicians. Here, Agent Harshaw’s testimony provided evidence that only three or four patients had prescriptions. Ellis’s skilled nursing services were also important to the scheme. Evidence shows that Ubani was the RN for many patients for whom Ellis was listed as the LVN. Ana Quinteros testified at trial that Ellis did not provide all of the skilled nursing services she reported and that OASIS questionnaires were signed by Ubani without her having seen the patients. In fact, the OASIS questionnaire would be blank, signed by the patient, and subsequently completed to obtain a physician’s signature and permit the Medicare claim. Thus, the inquiry does not turn on whether each patient ultimately was not homebound or in need of skilled nursing services because evidence proved that Ellis engaged in conspiracies to commit health care fraud and receive 33 Case: 12-20095 Document: 00512456949 Page: 34 Date Filed: 12/02/2013 No. 12-20095 kickbacks in exchange for referrals, which ultimately resulted in payments by Medicare. This conduct is prohibited. Her recruitment and nursing activities provided direct causal links to the claims and pecuniary harm as she referred patients who did not have prescriptions and falsified her nursing notes, which were used in the process of generating plans of care and subsequent recertifications. Ellis’s position at Family Healthcare and relationships with coworkers and patients ensure that the losses she caused were reasonably foreseeable. The Government presented reliable evidence to prove it was more likely than not that Ellis was accountable for over $700,000 in Medicare claims related to the conspiracies. The district court took into consideration her contrary evidence but remained unpersuaded that she was accountable for less than $400,000. Ellis has not shown on appeal that the findings were clearly erroneous or that the court misapplied the law. Accordingly, her argument that her sentence should be vacated is rejected.