Opinion ID: 2644638
Heading Depth: 4
Heading Rank: 4

Heading: Nature and Scope of the Activity

Text: There is some overlap in the description of the offenses charged in each indictment. Both indictments alleged that claims were submitted to Medicare for either equipment or services that were unnecessary or not provided to patients. The patients were recruited through referral sources, and these sources received remunerations in exchange for supplying the beneficiaries. We are convinced, though, that the Government sought to punish different activities in the skilled nursing case and in the DME case. The skilled nursing indictment alleged additional manners and means through which the conspiracy was accomplished. For example, as an LVN, Ellis allegedly falsified patient files to make it appear Medicare beneficiaries qualified for services; Princewill Njoku and Ezinne Ubani, who were RNs, allegedly falsified OASIS questionnaires to ensure the beneficiaries qualified; the indictment also alleged they approved recertifications and plans of care that were not medically necessary. There was evidence in both trials of similar activities, including evidence of Ellis’s knowledge that the paid referrals were illegal, her employment history, and kickback checks. Evidence also shows that some patients may have been recruited for and received both DME and home health care services. The possible overlap, though, involves only a portion of the activity involved in both the DME and the skilled nursing cases. We must “review the entire record and take a commonsense approach in determining the substance of each alleged conspiracy.” Levy, 803 F.2d at 1395. 22 Case: 12-20095 Document: 00512456949 Page: 23 Date Filed: 12/02/2013 No. 12-20095 The DME indictment focused on Ellis’s activity as a recruiter. The kickback checks she received for the DME beneficiary referrals made up the central evidence presented against her at trial; these checks were not admitted into evidence in the skilled nursing trial. The skilled nursing trial involved evidence regarding Ellis’s false nursing notes for home health care services, which were not part of the DME trial.5 Cf. id. False medical certifications were inescapably part of the conjunctively listed purposes in the skilled nursing indictment. For the jury to find Ellis guilty of the charge in Count 1, it was required to find that Ellis knew of this unlawful purpose and joined this agreement with the intent to further that purpose. We find this activity was of a different nature and scope than the referrals. Accordingly, this factor weighs in favor of finding two conspiracies existed.