Opinion ID: 695152
Heading Depth: 2
Heading Rank: 1

Heading: evidentiary sufficiency claims

Text: 11 The physician-appellants argue that the evidence was insufficient to establish their knowledge of the fraudulent nature of the clinics' operations, and Ross further argues that there was insufficient proof of the existence of a pattern as required under RICO. 12 In determining whether the evidence was sufficient to convict the defendants, we must view the evidence in the light most favorable to the government and construe all possible inferences in its favor. United States v. Badalamenti, 794 F.2d 821, 828 (2d Cir.1986); see also Jackson v. Virginia, 443 U.S. 307, 319, 99 S.Ct. 2781, 2789, 61 L.Ed.2d 560 (1979). The standard is whether any rational trier of fact could have found the essential elements of the crime beyond a reasonable doubt. Jackson, 443 U.S. at 319, 99 S.Ct. at 2789 (emphasis in original). In making this determination, we do not engage in piecemeal review, but rather, we review the evidence as a whole. United States v. Carson, 702 F.2d 351, 362 (2d Cir.), cert. denied, 462 U.S. 1108, 103 S.Ct. 2456, 77 L.Ed.2d 1335 (1983). Moreover, the government may prove membership in a conspiracy by circumstantial evidence alone, United States v. Miranda-Ortiz, 926 F.2d 172, 176 (2d Cir.), cert. denied, 502 U.S. 928, 112 S.Ct. 347, 116 L.Ed.2d 287 (1991), and a defendant may be convicted of conspiracy even though he is unaware of all the conspiracy's unlawful aims, as long as he has knowledge of some of those aims, see United States v. Lanza, 790 F.2d 1015, 1022-23 (2d Cir.), cert. denied, 479 U.S. 861, 107 S.Ct. 211, 93 L.Ed.2d 141 (1986). Finally, the government can prove knowledge by showing that the defendant was aware of a high probability of the fact in dispute and consciously avoided confirming that fact. United States v. Rodriguez, 983 F.2d 455, 458 (2d Cir.1993).

13 Williams argues that the evidence presented at trial was insufficient to prove that she had knowledge of the scheme to defraud Medicaid. We disagree. The leader of the enterprise, Mohammed Sohail Khan, testified that Williams was aware of his relationship with Clin Path and that she agreed to pay him forty percent of her Medicaid receipts. To this end, Williams entered into a bogus lease agreement under which she agreed to pay Khan $1500 per week for rent. Khan also testified that, in May of 1991, he was notified that he and all the physicians were to be excluded from Medicaid. He said that when he told Williams that he was going to close the clinics because he did not want to be a front anymore, she volunteered to take over as the front, with Khan paying her expenses from the money that he received from Clin Path. The clinics remained in operation until July of 1991, when Clin Path lost its certification from Medicaid. 14 Other co-conspirator evidence inculpating Williams included the testimony of Dr. Sadaphal, who testified that she became concerned when she realized that all the patient charts had remarkably similar diagnoses. When Sadaphal asked Williams about these similarities, Williams misled her by claiming that the similarities were representative of the community in which the clinics were located. Also, a patient named Larita Mitchell testified that she gave the receptionist a list of fake ailments and then met with Williams in an examination room. Mitchell said that Williams did not ask her any questions and did not perform a medical exam and, after a short while, Williams simply told Mitchell to go next door and take blood. After giving blood, Mitchell obtained her prescription and left; she had the prescription filled and sold the drugs on the street. 15 Williams argues that Mitchell was not credible because she was a crack addict and falsely testified that she recalled meeting Dr. Williams because it was the same day she took her son to the Boy Scouts when there was no Boy Scouts meeting. The government conducted a painstaking investigation into allegations that Ms. Mitchell's testimony was perjured. The results were inconclusive, but in any event there is no evidence that the government had knowledge of any perjury when it proffered Ms. Mitchell as a witness. Moreover, Ms. Mitchell's credibility was vigorously disputed before the jury. The jury, after hearing this testimony, was permitted to assess the credibility of these witnesses and to draw reasonable inferences. See Lanza, 790 F.2d at 1019. 16 The government also presented expert testimony indicating that the number of similar diagnoses was statistically not possible. Finally, evidence of the lack of medical supplies at the clinics and of the presence of signs discouraging repeat visits was put before the jury. All this evidence supplied the jury with enough evidence to allow a reasonable juror to conclude beyond a reasonable doubt that Williams knew of the fraud, see id., or that Williams consciously avoided confirming its existence, see Rodriguez, 983 F.2d at 458.
17 Khalil contends that, because she rarely was at the clinics and took no active role in the medical care given there, the evidence was not sufficient for a jury to find that she had the requisite knowledge of the criminal nature of the scheme. This contention is without merit. 18 First, Khalil urges this court to discredit Khan's testimony. However, the credibility of witnesses is the province of the jury and we simply cannot replace the jury's credibility determinations with our own. See United States v. Losada, 674 F.2d 167, 173 (2d. Cir.), cert. denied, 457 U.S. 1125, 102 S.Ct. 2945, 73 L.Ed.2d 1341 (1982). 19 Second, the fact that Khalil rarely was present at the clinics simply highlights the reasonableness of the jury's inference that a physician who received substantial remuneration for doing almost no medical work or supervision is aware of the fraudulent nature of her conduct. Khalil received $138,816 from Medicaid during her seven-month association with the clinic. Furthermore, there was evidence that Khalil made several conflicting statements regarding the amount of time she spent at the clinics doing work and whether she actually treated patients or merely supervised the PAs. The government also presented expert testimony indicating that the medical and blood tests ordered for Khalil's patient's were medically unnecessary. This evidence was sufficient for reasonable jurors to infer knowledge beyond a reasonable doubt.
20 Lo also argues that there was insufficient proof that he knew of the fraudulent nature of the scheme. Again, we disagree. The evidence showed that Lo was associated with the Khan enterprise from July to December 1990, at which time he was barred from the Medicaid program. During this period, he received over $100,000 for doing essentially no work. In addition, when Medicaid requested an exit conference in which Lo could explain his billings, he failed to appear. As with the other defendants, the government presented expert testimony establishing the facially fraudulent nature of Lo's patient documentation. Finally, there was testimony that, when a PA was diagnosing men with a condition commonly occurring in women, Lo, without seeing any patients, brought this discrepancy to the PA's attention and provided an alternative diagnosis that would allegedly justify the ordered medication.4. Ross 21 Ross contends that the evidence was insufficient to establish his knowledge of the clinics' fraudulent nature. His contention also is without merit. Aside from the expert testimony indicating the fraudulent nature of Ross' patients' charts, there was specific evidence of Ross' knowledge. Ross was present at the clinic for approximately three days each week, and therefore had ample opportunity to observe the utterly inadequate facilities. In addition, he met with staff members in the area where signs were posted indicating that only new patients were welcome. Finally, in March of 1991, after a DSS representative had taken custody of twenty of Ross' files, Ross sent a letter to his PA directing that a certain drug be prescribed only when the condition for which it should be prescribed is present. The timing of this letter in connection with the DSS audit is evidence that Ross wrote the letter to cover his tracks. Ross left the clinic shortly after this incident. 22 Ross also chose to testify at trial. By taking the stand and offering his own version of events, [the defendant] waives any claim as to the sufficiency of the Government's case considered alone. United States v. Friedman, 998 F.2d 53, 57 (2d Cir.1993) (internal quotations omitted). Ross testified at trial that he had no knowledge of the fraud at the Khan clinic, and the jury obviously rejected this testimony. Under Friedman, the jury was entitled to consider Ross' credibility in determining his knowledge. 23 Moreover, the evidence also was consistent with conscious avoidance. When Ross was informed that all of the patients came in with the same complaints, he did nothing. When the PA suggested to Ross that he speak to Khan about a nonsensical prohibition on urinalysis, Ross did nothing. This, and the evidence mentioned above, is consistent with awareness of a high probability of the criminal nature of the scheme and the decision to avoid confirming its criminality. See Rodriguez, 983 F.2d at 458.
24 Ross argues that, because he was at the Khan clinics for no more than nine weeks, his conduct cannot amount to a pattern of racketeering activity. We disagree. To demonstrate a pattern of racketeering activity under 18 U.S.C. Sec. 1962(c), the government must prove relatedness and continuity or a threat of continuity. United States v. Indelicato, 865 F.2d 1370, 1381 (2d Cir.) (in banc), cert. denied, 493 U.S. 811, 110 S.Ct. 56, 107 L.Ed.2d 24 (1989). 25 Relatedness can be established by showing that the predicate acts had the same or similar purposes, results, participants, victims, or methods of commission. Id. at 1382 (internal quotations omitted). In this case, all the predicate acts of mail fraud were performed in the same way with the same purpose--to defraud Medicaid. Accordingly, relatedness was clearly established in this case. 26 In regard to continuity, the Supreme Court has noted that the threat of continuity may be established by showing that the predicate acts or offenses are part of an ongoing entity's regular way of doing business. H.J., Inc. v. Northwestern Bell Tel. Co., 492 U.S. 229, 242, 109 S.Ct. 2893, 2902, 106 L.Ed.2d 195 (1989). The entity, moreover, may be a legitimate business that regularly engages in illicit activity. See id. at 243, 109 S.Ct. at 2902-03. In light of these principles, it seems clear that there was a threat of continuity present here, because the clinics regularly engaged in defrauding Medicaid.