Court Opinion

ID: 4845655
Source: CourtListenerOpinion
Date Created: 2021-08-23 18:00:34.463221+00
Date Added: 2024-06-11T08:11:40.230238
License: Public Domain

Case: 19-20797    Document: 00515989992         Page: 1   Date Filed: 08/23/2021

           United States Court of Appeals
                for the Fifth Circuit                             United States Court of Appeals
                                                                           Fifth Circuit

                                                                         FILED
                                                                   August 23, 2021
                                 No. 19-20797
                                                                    Lyle W. Cayce
                                                                         Clerk

   United States of America,

                                                          Plaintiff—Appellee,

                                    versus

   Dayakar Moparty; Harcharan Singh Narang,

                                                     Defendants—Appellants.

                 Appeal from the United States District Court
                     for the Southern District of Texas
                            USDC 4:17-CR-290-3

   Before Jones, Southwick, and Costa, Circuit Judges.
   Edith H. Jones, Circuit Judge:
         Dr. Harcharan Singh Narang and Dayakar Moparty were convicted of
   health care fraud, conspiracy to commit health care fraud, and money
   laundering. They both assert alleged errors in the trial and sentencing.
   Moparty further challenges the sufficiency of the evidence supporting his
   convictions. Some inexcusable trial errors were committed or permitted by
   the government, which counsel on appeal explained as the reason for an
   incredibly long (132-page) appellate brief: the government wanted to make
   abundantly clear that the errors were “harmless.”       Nonetheless, we
   AFFIRM.
Case: 19-20797       Document: 00515989992            Page: 2     Date Filed: 08/23/2021

                                       No. 19-20797

                                 I. BACKGROUND
          This direct criminal appeal stems from various federal health care
   fraud convictions.      On May 17, 2017, a grand jury indicted Narang,
   Dr. Gurnaib Singh Sidhu, and Moparty on one count of Conspiracy to
   Commit Health Care Fraud in violation of 18 U.S.C. § 1349 and seventeen
   counts of Health Care Fraud in violation of 18 U.S.C. § 1347. It further
   indicted Narang and Moparty on three counts of Engaging in Monetary
   Transactions in Property Derived from Specified Unlawful Activity in
   violation of 18 U.S.C. § 1957.
          Narang is an internist who practiced at his self-owned clinic, North
   Cypress Clinical Associates, P.A. (“North Cypress”) in Cypress, Texas.
   Sidhu also practiced as an internist and was employed by Narang, primarily
   at the second North Cypress office. 1 Moparty co-owned Red Oak Hospital
   (“ROH”) and served as an administrator for Spring Klein Surgical Hospital
   DBA Trinity Health Network (“Trinity” or “Spring Klein”). Trinity
   provided staffing and administrative services to a number of health care
   entities including Cleveland Regional Medical Center (“CRMC”), 2920 ER,
   2920 Open MRI Digital Imaging, ROH, and Cleveland Imaging and Surgical
   Hospital DBA Doctor’s Diagnostic Hospital (“DDH”).
          The indictment alleged that Narang, Sidhu, and Moparty conspired
   to and executed a scheme where Narang and Sidhu ordered unnecessary
   medical tests for patients and then authorized Moparty to bill for these tests
   through ROH at the higher hospital rate even though these patients were
   seen and treated at Narang’s North Cypress office. Further, when insurers
   denied claims originating from ROH, Moparty would resubmit them from

          1
           Sidhu is not a party to this appeal. He entered into a plea agreement with the
   government prior to trial and later succumbed to cancer.

                                             2
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                                    No. 19-20797

   another entity associated with Trinity. The indictment alleged that this
   scheme resulted in fraudulent billing of over $20 million to Blue Cross Blue
   Shield, Aetna, and Cigna. Those companies paid Moparty at least $3.2
   million in reimbursement for those claims which he allegedly split with
   Narang through a series of financial transactions.
          An eight-day jury trial began on February 11, 2019.
   A. The Government’s Case-in-Chief
          At trial, the government introduced extensive testimony to
   demonstrate how the scheme operated. As the government describes, the
   scheme had three key parts: (1) a patient intake and testing component; (2) a
   billing component; and (3) a financial distribution component.
          1. Patient Testing
          In 2013, Forever Fit Wellness Center, PLLC (“Forever Fit”), a
   “medi-spa”—owned by Narang’s wife Ranjit Kaur—that shared office
   space with North Cypress, began offering coupons for “Lipotropix weight-
   loss shots” on Groupon. The coupon offered weekly injections but required
   the purchaser to perform a 30-minute consultation with a medical
   professional prior to beginning the regimen. At trial, four women who
   purchased these coupons and Rikesha Burton, Narang’s former medical
   assistant, testified about the process. Upon arrival at Forever Fit, the
   patients were asked to fill out medical and personal history forms. After
   completing these forms and undergoing a vitals check, the patients were seen
   by Narang.    During the consultation, Narang would ask wide-ranging
   questions related to dizziness, headaches, backaches, or other generic
   ailments. Even though these women indicated they were in relatively good
   health and that the weight loss shot was the primary reason for the visit,
   Narang’s open-ended questioning elicited affirmative answers from the
   patients.

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          Narang then persuaded the patients to undergo brief testing at North
   Cypress and explained that their insurance would cover any costs and they
   would not pay anything. 2 Narang would then typically order cardiac and/or
   abdominal ultrasounds, ENGs, nerve conduction tests, electromyography
   tests, allergy tests, and artery and/or vein doppler tests. Approximately 80–
   90% of Groupon patients with insurance received this battery of additional
   tests—all patients getting the injections were required to have an EKG
   performed. Burton testified that she and other medical assistants sometimes
   warned Groupon patients that they were not obligated to undergo additional
   testing. Burton also testified she was later reprimanded for doing this. After
   Narang ordered the tests, the testing orders were typically approved under
   Sidhu’s name although he did not see the patients. The tests were then
   performed at the North Cypress location.
          This same pattern also occurred with patients who visited Narang for
   medical treatment unrelated to the Groupon injections. One patient in acute
   pain sought medication for an ulcer. She saw Narang and received an
   echocardiogram and nerve conduction velocity test despite a lack of
   underlying symptoms that would warrant those tests.
          The government presented four expert witnesses who testified
   regarding the medical necessity of the testing ordered by Narang. First,
   Dr. Richard Gans, a vestibular and balance disorder specialist, reviewed a
   sample of 29 patient files. He found that key data were often missing, such
   as calibrations results and the actual test recordings, rendering the test results
   useless.
          Second, Dr. Rubina Wahid, an allergy and immunology specialist,
   examined 33 patient charts and found no conclusive indicators that would

          2
              Patients without insurance were not encouraged to do any additional testing.

                                                4
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                                        No. 19-20797

   warrant allergy testing. Further, Dr. Wahid noted that tests had been
   improperly performed and recorded, and the files were missing detailed
   patient histories, assessments, plans, discussions of results, and follow-ups.
   Finally, Dr. Wahid testified that the patients presenting for weight loss
   injections were documented to have a variety of maladies and received a
   “battery of tests.”
           Next, Dr. Peter Grant, an internist with an expertise in
   electrodiagnostic medicine, reviewed tests for 68 patients and determined
   that 83–94% of the tests were not medically necessary. Further, Dr. Grant
   found the tests were “fraught with errors and inaccuracies” and
   approximately 80% of the tests were “worthless.”
           Finally, Dr. Michael Bungo, a cardiologist, reviewed 40 patient files.
   The majority of the files he reviewed were 30–68-year-old females with low
   statistical probability of cardiovascular disease. He disparaged the idea that
   many patients would exhibit the very same array of symptoms 3 as “so
   medically improbable that it bordered on impossible” and that he didn’t
   “have 40 people in thousands of patients that all present with the
   constellation of symptoms that are identical.” Further, Dr. Bungo observed
   that analysis of the patients by Narang was lacking, appropriate tests were not
   ordered, doctor’s notes were missing or contradictory when present, and
   testing was unrelated to patient symptoms.
           Additionally, the government called Dr. Aditya Samal, a board-
   certified cardiologist, as a fact witness. Narang had hired Dr. Samal to read
   echocardiograms and vascular studies. Narang sent Samal approximately
   800 studies in one year, a number that Samal noted was unusually high.

           3
           Symptoms included chest pain, swelling of the ankles, dizziness, runny nose, calf
   cramping, and palpitations.

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                                       No. 19-20797

   Further, Dr. Samal explained that the quality of the tests fell below
   appropriate medical standards—some had been done months earlier and
   most were medically unnecessary based on the patient’s symptoms, age, and
   sex. This reflected a pattern of “low quality, inappropriate studies” and
   caused Samal to end the arrangement.
          2. Billing Practices
          The crux of the government’s argument was that Narang and
   Moparty executed a “pass-through billing scheme” where services are
   rendered at one location, but the bills are submitted from a different place at
   a higher rate. Central to this theory was the testimony of Keon Warren,
   Moparty’s billing director. 4 Warren testified that in 2012 he met with
   Moparty, Narang, and Kaur—Moparty explained that they were going to be
   billing for Narang’s office which would function as “an extension of the
   hospital, part of the HOPD [hospital outpatient department].” Pursuant to
   this arrangement, Warren “would get directions . . . as to what we were going
   to bill” and “receive the emails, what’s going to be on them, what we’re
   going to be billed, and so forth.” These emails included the patients’
   demographics, their forms and signatures, insurance information, tests, and
   billing codes—all the information needed to generate the bills. Warren would
   then prepare the claims to bill the patients’ insurance companies.
          Moparty was copied on these emails and provided Warren instruction.
   Initially, the tests were billed through DDH, beginning during the summer of
   2012. Then in late 2012, billing shifted over to 2920 ER (or Trinity
   Healthcare as it was also known) after it received a freestanding emergency
   center license. Finally, in March 2013 billing shifted again to ROH. Moparty

          4
            Warren’s signature line indicates that he worked for Trinity Healthcare, ROH,
   and 2920 ER LLC.

                                             6
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                                     No. 19-20797

   informed Warren that Narang’s office was going to be an extension of ROH
   and showed him an email representing this. Thereafter, all billing flowed
   through ROH.          Warren would generate billing amounts based off the
   Medicare rates and “what [he] knew about markup.” These were all billed
   at a hospital rate.
          Occasionally, insurance companies would deny ROH claims. When
   this occurred, Warren would consult Moparty and then rebill the claim
   through CRMC. On one occasion, after the rebilled claim was rejected again,
   Moparty instructed Warren to submit it a third time through 2920 MRI. This
   practice of “rebilling” started happening in 2013 when initial billing was
   shifted to ROH.
          After receiving a claim from ROH or similar entity, the insurance
   companies typically prepare an explanation of benefits (“EOB”) for the
   patient which details the services received, the entity that performed them,
   and the amount billed to the insurance company. Upon receiving EOBs after
   visits to North Cypress, patients saw exorbitant prices billed from entities
   they had no recollection visiting. One patient’s EOB reflected thousands of
   dollars of billing from CRMC and ROH, but the patient had no knowledge of
   those entities’ involvement. That patient was certain that no paperwork had
   indicated ROH and there was nothing at the North Cypress office to
   demonstrate affiliation with ROH or CRMC. Other patients also expressed
   surprise at seeing Sidhu’s name listed on their EOB after only seeing Narang.
   The patients uniformly discovered that their insurance companies had been
   billed for tests they never received, and their medical files noted symptoms
   they denied having.
          Three fact witnesses representing the major insurance companies
   testified for the government. These individuals provided context on general
   insurance billing practices. Generally, when a physician submits a claim, the

                                          7
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                                          No. 19-20797

   location of the place of service must be disclosed. However, when a facility,
   such as ROH, submits a claim, a different form is used which does not
   indicate the location—that information would only be available if the
   insurance company requested the patient files. These witnesses testified that
   their respective insurance companies would not pay claims that erroneously
   indicated that they were performed at a hospital or were medically
   unnecessary. The amount the insurance company will pay for a given service
   is typically dependent on who provided it, where it was provided, and
   whether the provider is inside or outside of the company’s provider network.
   Though Narang and North Cypress were in-network for these insurers, ROH
   was not. This resulted in drastically higher billing rates.
          For example, on one set of claims, ROH was eligible to receive
   $34,359.50 compared to $3164.32 that Narang could have submitted under
   his network agreement. Similarly, another patient’s claims were billed at
   nearly $37,000 compared to the Narang’s rate of $1400. By billing these
   claims through ROH, rates were inflated up to 25x higher than if Narang had
   billed directly for the tests. One patient’s hour-long visit to Narang resulted
   in a bill of $800,000 from ROH to Blue Cross Blue Shield. 5 In total, ROH
   and other Moparty entities 6 billed over $20 million to Aetna, Cigna, and Blue
   Cross Blue Shield and received approximately $3.2 million.
          3. Financial Distribution
          The final aspect of the scheme was described by Agent Lammons, who
   had 14 years of experience investigating health care fraud. Lammons testified
   that the insurance and billing records corroborated the pass-through billing

          5
              ROH later claimed that a “billing error” was the cause.
          6
           These entities included: CRMC, ROH, 2920 MRI, DDH, 2920 ER, and Spring
   Klein/Trinity.

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                                        No. 19-20797

   testimony of the other witnesses. Similarly, the data reflected instances of
   “rebilling” as described by Warren. Lammons explained that the common
   thread through this scheme was Moparty’s ownership in these various
   entities. 7 Money that flowed in from Moparty’s various entities ended up
   with Trinity. Lammons described it as “an account that collects money from
   all sorts of places”—a shell company. From there, money was transferred to
   a series of entities related to Narang and his wife. Roughly 85% of the money
   received by ROH for Narang’s patients was represented in payments from
   Trinity to those entities.
          Kathleen Anderson, an FBI forensic accountant, testified and
   explained how specific sums of money moved through the accounts from
   Moparty’s entities to those controlled by Narang and Kaur. Anderson
   specifically traced the transactions related to the three money laundering
   counts: funds moved from 2920 ER and Cleveland Imaging through Spring
   Klein to an LLC owned by Narang (Count 19); funds moved from 2920 ER
   through Spring Klein to a corporation owned by Narang (Count 20); and
   funds moved from 2920 ER through Spring Klein to another LLC owned by
   Narang (Count 21).
          At the close of the government’s case, both defendants moved for
   judgments of acquittal. Further, they both moved for mistrials based on two
   references to Sidhu’s guilty plea. The district court denied the motion for
   acquittal but took the motion for mistrial under advisement.

          7
              Moparty did not own DDH but “he exerted a lot of control in the operation of
   that facility” and DDH had paid Moparty over $17 million between 2011 and 2012.
   Lammons testified, supported by documentary evidence, that Moparty did have ownership
   interests in CRMC, ROH, 2920 MRI, 2920 ER, and Spring Klein/Trinity.

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                                    No. 19-20797

   B. Defense Case
          For his defense, Narang called four witnesses. First, Sean Coffey, a
   medical equipment distributor, rebutted testimony by Dr. Gans that Narang
   lacked sufficient equipment to perform certain tests. Second, Kershaw
   Kumbatta, a certified public account, testified that it was good business
   practice to have separate accounts associated with different business entities
   and he had advised Narang and Kaur to set up different accounts for their
   various entities. Next, Narang called his long-time medical technician
   Edward Castillo. Castillo testified that North Cypress had a sign about “Red
   Oak or Trinity” and that “we’re working together.” He thought the
   arrangement lasted six months and the sign was present most of that time.
   He further testified that he “perform[ed] tests as a technician for Red Oak.”
   Finally, Neena Satia, Narang’s receptionist since 2003, testified that North
   Cypress was clearly associated with ROH and denied that anybody had
   manipulated patient forms.
          For his part, Moparty called one witness and then testified himself.
   First, Dilip Amin, Moparty’s real estate attorney, testified as to the validity
   of three one-page contracts documenting real estate transactions between
   Moparty’s entities and Narang’s totaling over $9 million. According to
   Amin, it was “not unusual” for the “Old British India” community “to not
   rely on lawyers for the initial buying and selling of property.” He further
   dismissed the misspelling of Moparty’s name (spelled Moparti) as a “not
   uncommon” translation error.
          Next Moparty testified and explained that Spring Klein functioned as
   a staffing company, which provided CRMC, 2920 ER, and ROH with
   employees and management. Further, he testified that ROH included the
   clinic supposedly associated with Narang at North Cypress. Pursuant to this
   structure, Moparty stated that Spring Klein would collect and distribute

                                         10
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                                         No. 19-20797

   money as appropriate. Moparty denied any ownership interest in ROH,
   CRMC, and 2920 ER. Moparty explained the real estate transactions as
   efforts by ROH and 2920 ER to expand into the Spring, Texas area to
   coincide with Exxon’s move to that location. He said he had researched how
   he could open an outpatient facility in Narang’s office (which he claims was
   Narang’s or Kaur’s idea); the research entailed reading the Texas
   Department of Health and Human Services website and emailing the Texas
   Department of State Health Services. 8
           Moparty testified that ROH had leased office space from North
   Cypress to perform ambulatory testing and he emailed North Cypress to put
   up signage and have the staff wear badges identifying ROH. Moparty claimed
   he hired Kaur to help with business development and she purportedly signed
   a program management agreement which placed her in charge of the ROH
   outpatient clinic. 9 He alleges that Kaur hired and employed all technicians,
   but no ROH employees worked at North Cypress. Moparty flatly denied that
   he intended to violate the law, conspire with Narang, or launder money. 10 At
   the close of the defense case, Moparty renewed his motion for a judgment of
   acquittal and the court again denied it.
           The jury convicted Narang and Moparty on all counts.

           8
            Moparty insists that he received “authorization from the Department of Health”
   through a series of emails. But instead those emails “very strongly recommend[ed]” that
   Moparty obtain legal counsel and refused to provide a legal opinion on the validity of the
   proposed agreement. Moparty further denied that he needed a separate license to operate
   the HOPD.
           9
            Lammons noted that the “flow of money” to Kaur was not consistent with the
   agreed upon amount in her contract.
           10
             The government contends that Moparty was frequently evasive or
   nonresponsive to its questions.

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                                          No. 19-20797

   C. Post-verdict Proceedings
           The defendants’ joint motion for mistrial principally argued that the
   government’s two references to Sidhu’s guilty plea prejudicially affected
   their right to a fair trial. The first reference was deliberately voiced during
   the opening statement when the government counsel said that Sidhu “is a
   co-conspirator in this case” but he “is not in this trial because he already pled
   guilty.” The second came during the questioning of Lammons. 11 There, the
   government’s counsel inquired, “we haven’t talked a lot about Dr. Sidhu yet.
   . . . Why is that?” Lammons answered: “He’s already pled guilty.” Further,
   they argued that Dr. Grant impermissibly referenced a conviction of one of
   the specialists used by Narang to evaluate diagnostic tests and that the
   government misled them about Grant’s prior experience as an expert
   witness. 12
           The district court noted that the defendants did not object to the first
   reference but did object to the second, and the court sustained the objection
   and immediately issued a limiting instruction. 13 Further, the court noted that
   it had rejected the confrontation clause challenge because the defendants had
   the ability to subpoena Sidhu if the government didn’t call him. The court

           11
              The government had previously represented to the court that Sidhu was not
   going to be called as a witness.
           12
              When asked about the doctors supervising Narang’s technicians, Grant
   responded: “Dr. Ahmed, as I googled his name, I found that he’s a convicted felon for
   health care fraud in January of 2017.”
           13
               “Dr. Sidhu is not here. He plead [sic] guilty. The fact that he’s guilty it not
   evidence that any other person is guilty of wrongdoing. His case was considered separately,
   and you’re not to draw any adverse inference from the fact that Dr. Sidhu may believe he
   is guilty. It’s not relevant to this case. These defendants are presumed to be innocent. The
   fact that somebody else may be guilty does not in any way affect the presumption of
   innocence that cloaks them and remains with them until such time, if ever, that the
   government can prove these defendants guilty of anything.”

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   then considered the introduction of Sidhu’s plea under the factors articulated
   in United States v. King, 505 F.2d 602, 608 (5th Cir. 1974) (explaining that
   four factors are relevant: (1) the presence or absence of a limiting instruction;
   (2) whether there was a proper evidentiary purpose for the introduction of
   the plea; (3) whether the plea was improperly emphasized or used as
   substantive evidence of guilt; and (4) whether introduction of the plea was
   invited by defense counsel).
          The court acknowledged that neither party contested that the plea had
   not been invited, and then proceeded to weigh the remaining factors. The
   court noted that while there was not a proper evidentiary purpose for the
   second reference, 14 the first two factors weighed strongly in favor of the
   government and any error was “harmless beyond a reasonable doubt.” The
   court found that “[t]he admissible evidence presented to the jury
   ‘overwhelmingly eclipses the two [brief] mentions of Sidhu’s plea.’”
          Finally, the court found no error relating to Dr. Grant’s testimony.
   The court noted that the defendants were in possession of Dr. Grant’s expert
   report which stated that he had previously testified for the government as an
   expert. 15 Second, the court determined that while Grant’s statement was not
   proper impeachment evidence and lacked any proper evidentiary purpose, it

          14
             “The court concludes that there is no indication that either of the challenged
   statements were made in bad faith. While the government arguably had a legitimate
   purpose for referencing Dr. Sidhu’s plea in its opening statement, the government can
   point to no proper purpose for Agent Lammons’ testimony. The dubious purpose of at
   least one of the challenged statements weighs slightly in favor of granting Defendants’
   Motion.”
          15
            The court also agreed with the government that there was no prejudice because
   neither Dr. Grant nor the government were in possession of any transcripts of that prior
   testimony.

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                                    No. 19-20797

   was harmless, nonetheless. Accordingly, the district court denied the motion
   on all grounds.
   D. Sentencing
          The Presentence Report (PSR) for Moparty calculated a total offense
   level of 38 and a guideline range of 235–293 months. Moparty prevailed on
   his objections to the total loss amount and Government health care program
   enhancement. The court denied Moparty’s objection to the abuse of trust
   enhancement, U.S.S.G. § 3B1.3. These rulings resulted in a new total offense
   level of 31 and a guideline range of 108–135 months. The court sentenced
   Moparty to 108 months imprisonment, three years of supervised release, and
   joint and several liability with Narang for $2,621,999.04 in restitution.
          Narang’s PSR calculated his total offense level at 39 with a guideline
   range 262–327 months. Like Moparty, Narang prevailed on his loss amount
   and Government health care program objections.             However, the court
   overruled Narang’s objection to the “10 or more victims” enhancement,
   U.S.S.G. § 2B1.1(b)(2)(A)(i), and the “use of any means of identification to
   produce or obtain another means of identification” enhancement, U.S.S.G.
   § 2B1.1(b)(11)(C)(i). Based on these rulings, the new offense level was 32
   and the guideline range was 121–151 months. After discussing the 18 U.S.C.
   § 3553(a) sentencing factors, the court sentenced Narang to 121 months in
   custody and $2,621,999.04 in restitution. Both defendants timely appealed.
                                II. DISCUSSION
          The defendants raise a litany of issues on appeal.         Specifically:
   (1) Moparty and Narang challenge the district court’s denial of their mistrial
   motion; (2) Moparty claims Anderson impermissibly testified on the
   ultimate issue of criminal intent; (3) Moparty claims the district court erred
   in allowing the insurance company representatives to testify as experts;
   (4) Moparty challenges the sufficiency of the evidence supporting his

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                                           No. 19-20797

   convictions; (5) Moparty claims that cumulative government errors violated
   his right to a fair trial; (6) Moparty challenges one sentencing enhancement;
   and (7) Narang challenges two sentencing enhancements.
   A. Mistrial
           Both Narang and Moparty argue that the district court erred in
   denying their motion for a mistrial.               Specifically, they claim that the
   government’s two references to Sidhu’s guilty plea and Dr. Grant’s
   testimony relating to Dr. Ahmed’s prior conviction substantially prejudiced
   their right to a fair trial, warranting a mistrial. Both defendants objected to
   Agent Lammons’s testimony on Sidhu’s guilty plea. They both also objected
   to Grant’s testimony. However, neither objected to the government’s
   opening statement reference to Sidhu’s plea.
           This court reviews a denial of a motion for mistrial for abuse of
   discretion. 16 United States v. Velasquez, 881 F.3d 314, 343 (5th Cir. 2018). “If
   a defendant moves for a mistrial on the grounds that the jury heard prejudicial
   testimony, ‘a new trial is required only if there is a significant possibility that
   the prejudicial evidence has a substantial impact upon the jury verdict,
   viewed in light of the entire record.’” United States v. Zamora, 661 F.3d 200,
   211 (5th Cir. 2011) (quoting United States v. Paul, 142 F.3d 836, 844 (5th Cir.
   1998)). This court gives “great weight to the trial court’s assessment of the

           16
              The government argues that since neither party objected to the opening
   statement, that statement should be reviewed for plain error only. See United States v.
   Sanders, 952 F.3d 263, 281 (5th Cir. 2020) (“[W]here counsel does not object
   contemporaneously to the actions that form the basis for the mistrial motion, plain error
   review follows.”). It is not clear that Sanders squarely applies to the present situation where
   the government made the same error twice and one occasion was properly objected to.
   Further, had the government called Sidhu to testify, referencing his plea in the opening
   statement would have been a permissible action. Ultimately, the standard of review is not
   determinative because this claim falters under either standard.

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                                        No. 19-20797

   prejudicial effect of the evidence” and “prejudice may be rendered harmless
   by a curative instruction.” United States v. Valles, 484 F.3d 745, 756 (5th Cir.
   2007).
            1. Dr. Sidhu’s Guilty Plea
            “Defendants are entitled to have questions of guilt based on the
   evidence against them, not on whether a government witness or a
   codefendant has plead guilty to the same charge.” United States v. Delgado,
   401 F.3d 290, 299 (5th Cir. 2005) (citations and quotations omitted). But, in
   “some circumstances the government might have a legitimate evidentiary
   reason for bringing out testimony relating to its witnesses’ prior convictions,
   even when those convictions are for charges similar or identical to those upon
   which the defendant is being charged.” United States v. Fleetwood, 528 F.2d
   528, 532 (5th Cir. 1976). When considering the effect of a co-conspirator’s
   guilty plea, the court looks to four factors: “1) the presence or absence of a
   limiting instruction; 2) whether there was a proper evidentiary purpose for
   introduction of the guilty plea; 3) whether the plea was improperly
   emphasized or used as substantive evidence of guilt; and 4) whether the
   introduction of the plea was invited by defense counsel.” United States v.
   Murray, 988 F.2d 518, 523 (5th Cir. 1993). As noted, the introduction of the
   plea was not invited by defense counsel, so the focus is on the remaining three
   factors.
            The court provided its first limiting instruction relating to Sidhu’s
   guilty plea immediately after the defendants objected to Lammons’s
   testimony. The second instruction was agreed on by the parties and given at
   the close of evidence. 17 “The ‘almost invariable assumption’ is that jurors

            17
             “You have heard that Dr. Sidhu pled guilty to a crime. Do not consider his plea
   as any evidence of guilt. It is not. Dr. Sidhu’s decision to plead guilty was a personal
   decision. Disregard Dr. Sidhu’s guilty plea completely when considering DR. NARANG

                                              16
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                                         No. 19-20797

   follow such instructions.” United States v. Ramos-Cardenas, 524 F.3d 600,
   611 (5th Cir. 2008) (quoting Richardson v. Marsh, 481 U.S. 200, 206,
   107 S. Ct. 1702, 1707 (1987)). To overcome this presumption, there must be
   an “‘overwhelming probability’ that the jury will be unable to follow the
   court’s instruction . . . and a strong likelihood that the effect of the evidence
   would be ‘devastating’ to the defendant.” Greer v. Miller, 483 U.S. 756, 766
   n.8, 107 S. Ct. 3102, 3109 n.8 (1987) (citations omitted).
           Narang and Moparty argue that this case presents “aggravating
   circumstances” such that the court’s limiting instructions were unable to
   cure the prejudice. See United States v. Baete, 414 F.2d 782, 783–84 (5th Cir.
   1969) (“There may be aggravated circumstances in which the strongest
   corrective instruction would be insufficient, as, for example, when the guilty
   plea of one codefendant necessarily implicates another or others.”). They
   premise this argument entirely on the fact that the government mentioned
   Sidhu not once, but twice. Standing alone, this is insufficient to upset the
   “general rule.” See Ramos-Cardenas, 524 F.3d at 611–12 (“If we are to
   assume that the jury . . . was able to follow the district court’s instructions
   and disregard the fact that three defendants had already admitted their guilt
   in one form or another, we see no reason not to assume that the jury was also
   able to disregard the fact that a fourth defendant had pleaded guilty.”).
           Next, the district court correctly concluded that the second
   introduction of Sidhu’s plea lacked a proper evidentiary purpose. While the
   government could preemptively introduce the plea to thwart a defense
   strategy of painting Sidhu as the primary culprit, see United States v. Valley,

   or DR. MOPARTY’S guilt or innocence. As I instructed you during the trial, Dr. Sidhu’s
   guilty plea is not to be considered by you in any way as you decide whether the government
   has met its burden to prove beyond a reasonable doubt that DR. NARANG or DAYAKAR
   MOPARTY committed the crimes alleged in the indictment.”

                                              17
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                                          No. 19-20797

   928 F.2d 130, 133 (5th Cir. 1991), or to negate expected impeachment efforts,
   see United States v. Borchardt, 698 F.2d 697, 701 (5th Cir. 1983), by the time
   of Lammons’s testimony, it was clear that the government did not intend to
   call Sidhu nor did the defense strategy rely on his plea. This factor leans
   toward the defendants.
           Finally, the district court determined that neither reference was
   improperly emphasized or offered as substantive evidence. Both statements
   were made in the course of explaining why Sidhu, a frequently discussed
   participant in the scheme, was not present at the trial. Further, the jury was
   instructed that an opening statement is only a preview, not evidence. The
   second reference to Sidhu’s guilty plea was immediately followed by a
   limiting instruction. The district court, in light of its eight-day trial, found no
   bad faith by the government. This factor weighs in favor of the government.
           In sum, the first and third factors favor the government while the
   second and fourth favor the defendants. On balance, given the strength of
   the curative instructions, the factors lean toward denying the motion for
   mistrial. In addition, the district court assessed the prejudicial effect of
   statements “in the context of other evidence presented in order to determine
   whether its admission was harmless beyond a reasonable doubt.” Arizona v.
   Fulminante, 499 U.S. 279, 308, 111 S. Ct. 1246, 1264 (1991). Here, the court
   found that the admissible evidence “overwhelming eclipse[d]” the two
   references to Sidhu’s plea. The district court did not abuse its discretion in
   denying the motion for mistrial as to Sidhu’s pleas. 18

           18
               Additionally, Narang argues that referencing Sidhu’s plea violated the
   Confrontation Clause. “This court reviews claims of Sixth Amendment Confrontation
   Clause violations de novo and subject to a harmless-error analysis.” United States v. Gentry,
   941 F.3d 767, 781 (5th Cir. 2019). To establish a Confrontation Clause violation, “the
   defendant need only show that ‘a reasonable jury might have received a significantly
   different impression of the witness’s credibility had defense counsel been permitted to

                                                18
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                                          No. 19-20797

           2. Dr. Ahmed’s Health Care Fraud Conviction
           Dr. Grant, after being asked if he knew the doctor who supervised
   Narang’s technicians for Narang, stated: “Dr. Ahmed, as I Googled his
   name, I found that he’s a convicted felon for health care fraud in January of
   2017. Probably in this exact building is where that happened.” The court
   sustained the objection and immediately issued two curative instructions,
   stating first “[t]he jury will disregard the fact that Dr. Ahmed had a
   conviction” and also “[t]he jury is instructed there’s no evidence Dr. Narang
   [or Moparty] knew of the conviction.”
           Considering the motion for mistrial, the district court concluded that
   Grant’s statement lacked any proper evidentiary or impeachment purpose.
   We agree. But the error was harmless because introduction of an unrelated
   conviction did not prejudice the defense—especially in light of the curative
   instructions. See United States v. Williams, 620 F.3d 483, 492 (5th Cir. 2010)
   (“[R]eversal is not required unless there is a ‘reasonable possibility that the
   improperly admitted evidence contributed to the conviction.’” (citation
   omitted)); see also United States v. Medina-Arellano, 569 F.2d 349, 357 (5th
   Cir. 1978) (“Knowledge by the jury of a [conviction] to unrelated crimes did
   not hurt the defense’s position.”).

   pursue his proposed line of cross-examination.’” United States v. Templeton, 624 F.3d 215,
   223 (5th Cir. 2010). Because Lammons’s testimony referencing the guilty plea was
   excluded, the right to cross-examination was not implicated. See Davis v. Alaska, 415 U.S.
   308, 315–16, 94 S. Ct. 1105, 1110 (1974) (explaining that the “primary interest” the
   Confrontation Clause secures is “the right of cross-examination”).
            Narang further claims that the court impermissibly shifted the burden to him when
   it stated that he had the power to subpoena Sidhu. He seeks support in United States v.
   Bennett, 874 F.3d 236, 251 (5th Cir. 2017). That case involved comments reflecting a
   defendant’s failure to offer exculpatory evidence. It is irrelevant to a Confrontation Clause
   claim. Here, the court, not the prosecution, merely noted that Narang could call Sidhu if
   he wished.

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                                          No. 19-20797

   B. Testimony by Anderson
           Moparty argues that Anderson impermissibly testified on the ultimate
   issue of criminal intent when she labeled various transactions by Moparty as
   “money laundering.” 19 He describes this as a “calculated effort” by the
   government “to extract opinion testimony from an agent.” Further, he
   argues that Anderson was not presented as an expert witness and challenges
   the government’s repeated references to the “money laundering counts.”
   Moparty, however, did not object at trial to this testimony.
           This court reviews unobjected-to testimony for plain error. United
   States v. Coffman, 969 F.3d 186, 189 (5th Cir. 2020). “There are four steps
   to [the] plain-error analysis: whether (1) an error that was (2) clear or
   obvious (3) affects the defendant’s substantial rights, and if there was such
   an error, [the court has] discretion to remedy (4) if the error ‘seriously
   affect[ed] the fairness, integrity or public reputation of judicial
   proceedings.’” Id. (quoting United States v. Olano, 507 U.S. 725, 732, 734,
   113 S. Ct. 1770, 1777–79 (1993)).
           While portions of Anderson’s testimony may have approached the
   line of permissible statements, 20 this claim can be resolved on the third and
   fourth prongs of plain error. The challenged statements represent three

           19
            He also challenges Lammons’s testimony describing Trinity as a “shell
   company” and Grant’s description of a particular factual scenario as “fraudulent.”
           20
              Particularly troubling are Anderson’s describing certain transactions as “money
   laundering” and opining on the motivation for structuring the transactions in that manner.
   See United States v. Setser, 568 F.3d 482, 494–95 (5th Cir. 2009) (acknowledging error in
   allowing a witness to testify that certain activities constituted “security fraud” or a “Ponzi
   scheme” but finding it harmless). But see United States v. Evans, 892 F.3d 692, 715 (5th
   Cir. 2018) (“[U]nder Rule 701, a lay witness may state his ultimate opinion, provided that
   opinion is ‘based on personal perception,’ ‘one that a normal person would form from
   those perceptions,’ and ‘helpful to the jury.’” (citation omitted)).

                                                20
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                                       No. 19-20797

   snippets of testimony among a substantial number of documents and
   testimony from multiple witnesses. As this court stated in United States v.
   Lucas, “[g]iven the overwhelming quantum of evidence used to convict, any
   error did not affect [the defendant’s] substantial rights under the third prong
   of plain-error review and, in any event, under the fourth prong, the putative
   error would not ‘seriously affect[] the fairness, integrity, or public reputation
   of the proceedings.’” (citation omitted)). Lucas, 849 F.3d 638, 646 (5th Cir.
   2017).
   C. Expert Testimony from Insurance Representatives
            Moparty objects to aspects of the three insurance representatives’
   testimony, as he insists that the government elicited expert opinions without
   qualifying the witnesses or providing notice that they would offer expert
   testimony. 21
            If, after a timely trial objection, “a district court’s determination as to
   the admissibility of evidence is questioned on appeal, [the] applicable
   standard of review is abuse of discretion.” United States v. O’Keefe, 426 F.3d
   274, 280 (5th Cir. 2005). But under the harmless error standard, the court
   will not reverse “[u]nless there is a reasonable possibility that the improperly
   admitted evidence contributed to the conviction.” United States v. Mendoza-
   Medina, 346 F.3d 121, 127 (5th Cir. 2003). If there was no objection, review
   is for plain error. See Coffman, 969 F.3d at 189. Moparty preserved at trial
   his objections to certain statements by the Aetna and Blue Cross Blue Shield
   witnesses, but he objected to none of the Cigna representative’s testimony.

            21
              He objected to statements made by the Aetna and Blue Cross Blue Shield
   representatives. But as the government notes, much of the testimony went unobjected—
   including all testimony from the Cigna representative.

                                            21
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                                     No. 19-20797

   However, it is unnecessary to parse the record statement by statement
   because Moparty’s argument fails under the abuse of discretion standard.
          “Rule 701 does not exclude testimony by corporate officers or
   business owners on matters that relate to their business affairs, such as
   industry practices and pricing.” Nat’l Hispanic Circus, Inc. v. Rex Trucking,
   Inc., 414 F.3d 546, 551–52 (5th Cir. 2005); see also United States v. Kerley,
   784 F.3d 327, 337 (6th Cir. 2015) (“In a number of decisions from other
   circuits, courts have permitted witnesses to give lay opinion testimony about
   a business’s policies, practices, or procedures, based on an after-the-fact
   review or analysis of documents or facts, if the witness’s testimony derived
   from personal knowledge gained through participation in the business’s day-
   to-day affairs.” (collecting cases)).
          Here, the challenged testimony largely related to the procedures,
   policy terms, and fraud prevention protections at each insurance company.
   For example, the Blue Cross Blue Shield witness addressed how the company
   would handle various situations, how it interpreted terms and policies, and
   how their policies compared to those of the industry. Similarly, the Aetna
   representative’s testimony focused on Aetna’s policies and practices. These
   witnesses’ admissible testimony “provided factual information about the
   circumstances of the case.” United States v. McMillan, 600 F.3d 434, 456
   (5th Cir. 2010). To whatever small extent limited aspects of this testimony
   crept beyond the permissible bounds for a lay witness, there is no reasonable
   basis to find, in the context of the entire trial, that such testimony affected
   the verdict. Id.
   D. Sufficiency of the Evidence
          Moparty challenges the sufficiency of evidence supporting all twenty-
   one of his convictions. Specifically, he claims that the government failed to
   establish the prerequisite agreement on the conspiracy charge; failed to

                                           22
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                                     No. 19-20797

   establish that he had knowledge that the medical testing was unnecessary and
   inadequate; and failed to refute that Moparty attempted to legally set up an
   HOPD. According to Moparty, this means the government failed to establish
   that he knowingly or willingly participated in a conspiracy to commit health
   care fraud. Further, Moparty argues that since the government failed to
   prove his intent relevant to the conspiracy count, it failed to prove his intent
   to commit the counts of substantive health care fraud. Finally, he claims the
   money-laundering counts fail because they depend on the substantive fraud
   counts. Moparty timely moved for a judgment of acquittal, preserving these
   challenges.
          This court reviews “challenges to the sufficiency of the evidence de
   novo, applying the same standard as applied by the district court: could a
   rational jury find that all elements of the crime were proved beyond a
   reasonable doubt?” United States v. Chapman, 851 F.3d 363, 376 (5th Cir.
   2017). Review is “highly deferential to the verdict.” United States v.
   Beacham, 774 F.3d 267, 272 (5th Cir. 2014). The court “‘search[es] the
   record for evidence . . . support[ing] the convictions beyond a reasonable
   doubt’ and review[s] the evidence ‘in the light most favorable to the verdict,
   accepting all credibility choices and reasonable inferences made by the
   jury.’” Chapman, 851 F.3d at 376 (citations omitted).
          “[A] defendant seeking reversal on the basis of insufficient evidence
   swims upstream.” United States v. Mulderig, 120 F.3d 534, 546 (5th Cir.
   1997). The “conviction will be affirmed if ‘any rational trier of fact could
   have found the essential elements of the crime beyond a reasonable doubt.’”
   United States v. Gonzalez, 907 F.3d 869, 873 (5th Cir. 2018) (citation omitted
   and emphasis in original).      “Though the government cannot obtain a
   conviction by piling ‘inference upon inference,’ the defendants cannot obtain
   an acquittal simply by ignoring inferences that can logically be drawn from

                                         23
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                                    No. 19-20797

   the totality of the evidence.” United States v. Martinez, 921 F.3d 452, 466
   (5th Cir. 2019) (citation omitted).
          1. Conspiracy Conviction
          “The elements of healthcare-fraud conspiracy are (1) the existence of
   an agreement between two or more people to pursue the offense of fraud;
   (2) knowledge of the agreement; and (3) voluntary participation.” United
   States v. Emordi, 959 F.3d 644, 650 (5th Cir. 2020). “‘An agreement may be
   inferred from concert of action, voluntary participation may be inferred from
   a collocation of circumstances, and knowledge may be inferred from
   surrounding circumstances.’” United States v. Daniel, 933 F.3d 370, 377 (5th
   Cir. 2019) (quoting United States v. Bieganowski, 313 F.3d 264, 277 (5th Cir.
   2002)). The agreement may be silent and informal, and the government can
   use either direct or circumstantial evidence to prove it. United States v.
   Barson, 845 F.3d 159, 163–64 (5th Cir. 2016).
          Moparty doesn’t disagree that he and Narang had an agreement to
   process patient bills through ROH. Thus, this case boils down to whether
   that agreement had a fraudulent purpose or was a legitimate business
   arrangement in which Moparty innocently benefitted from Narang’s fraud.
   The government presented two theories of fraud: one relating to the medical
   necessity and adequacy of the procedures performed, and another focused on
   how the procedures were billed. Moparty argues that Dr. Bungo’s testimony
   demonstrates that Moparty lacked the necessary training to determine
   whether any particular test was necessary. He misconstrues the inquiry,
   however, because the government could bear its burden against him with
   evidence on the fraudulent billing practices alone.
          There was substantial evidence that Moparty and Narang agreed to
   process insurance reimbursement claims through ROH instead of North
   Cypress; that rejected claims were resubmitted through other entities

                                         24
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                                     No. 19-20797

   controlled by Moparty; and that millions of dollars flowed out of Trinity, in
   the form of rent and suspect real estate deals, and landed in the accounts of
   various entities owned by Narang and his wife.               The government
   demonstrated that Moparty had specific knowledge of all of the billing
   through emails sent by Warren.
          In contrast, Moparty asserts that he was attempting to run a legitimate
   HOPD and any payments to Narang represent “mere association,” the
   evidence of legitimate transactions. Ultimately, the jury was left largely with
   a credibility determination. That Moparty was aware of the ROH’s billing
   practices is beyond dispute. As to whether he had the requisite intent to
   conspire to commit fraud, part of the answer turns on whether the jury
   believed Moparty’s efforts to establish an HOPD in the North Cypress office.
   The emails submitted by the government demonstrate that Moparty did not
   receive authorization, and he was instead advised repeatedly to obtain
   counsel. This, coupled with Moparty’s authorization of “rebilling” rejected
   claims and his suspicious explanations for the large sums of money
   transferred to Narang’s entities, could lead a rational jury to conclude that he
   failed to organize a legitimate HOPD, and he and Narang conspired to
   commit health care fraud.
          2. Substantive Health Care Fraud
          Principally, Moparty repeats his arguments on the conspiracy count
   that the evidence also fails to establish his criminal intent to commit
   substantive health care fraud. To establish health care fraud, the government
   must prove that Moparty “‘knowingly and willfully execute[d], or
   attempt[ed] to execute, a scheme or artifice—(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, in

                                         25
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                                         No. 19-20797

   connection with the delivery of or payment for health care benefits, items, or
   services.’” United States v. Willett, 751 F.3d 335, 339 (5th Cir. 2014) (citation
   omitted). “It is enough for criminal liability if a defendant ‘associates with
   the criminal activity, participates in it, and acts to help it succeed.’” 22
   Martinez, 921 F.3d at 472 (quoting United States v. Delagarza-Villarreal,
   141 F.3d 133, 140 (5th Cir. 1997)).
           As detailed above, Moparty’s actions were the key to the second
   aspect of the scheme, billing Narang’s services and tests at the higher
   hospital or out-of-network rates. The government presented seventeen
   submitted claims, all of which reflected these grounds for overbilling.
   Whether Moparty “knowingly and willingly” defrauded the insurance
   companies was a quintessential jury question.                Based on the evidence
   presented, a rational fact finder could conclude that Moparty knew he was
   not operating a legal HOPD and otherwise knew the amounts billed were
   contrived to be illegally high.
           3. Money Laundering
           To sustain a conviction under 18 U.S.C. § 1957, the government must
   prove three elements: “(1) property valued at more than $10,000 that was
   derived from a specified unlawful activity, (2) the defendant’s engagement in
   a financial transaction with the property, and (3) the defendant’s knowledge
   that the property was derived from unlawful activity.” United States v. Fuchs,
   467 F.3d 889, 907 (5th Cir. 2006). Health care fraud is a qualifying unlawful
   activity. See Martinez, 921 F.3d at 476–77. Moparty argues that “since the
   evidence was legally insufficient to prove [his] participation in the . . .

           22
              The “[g]overnment must first ‘prove that someone committed the underlying
   substantive offense.’” United States v. Rufai, 732 F.3d 1175, 1190 (10th Cir. 2013). Here,
   the government proved that Narang committed substantive health care fraud—he does not
   challenge the sufficiency of his conviction on appeal.

                                              26
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                                       No. 19-20797

   conspiracy and . . . [the] scheme to defraud a health care benefit program, the
   convictions for money laundering should be reversed” because he lacked the
   requisite knowledge of the underlying illegality. Because his predicate
   arguments fail, so does this one.
   E. Cumulative Error
          Moparty argues that the government violated his right to a fair trial
   through repeated misconduct including:             (1) references to health care
   convictions of two people who didn’t testify; (2) impermissible witness
   testimony; (3) prejudicial comments referencing the “dark web,”
   “kickbacks,” and the transmission of confidential patient information to a
   third-party billing company in India.          According to Moparty, “[t]he
   cumulative prejudicial effect of these repeated acts of misconduct by
   prosecutors and government witnesses rendered impossible the jury’s ability
   to fairly review the evidence and return a just verdict.”
          “[T]he cumulative error doctrine . . . provides that an aggregation of
   non-reversible errors (i.e., plain errors failing to necessitate reversal and
   harmless errors) can yield a denial of the constitutional right to a fair trial,
   which calls for reversal.” United States v. Delgado, 672 F.3d 320, 343–44 (5th
   Cir. 2012) (en banc) (alteration in original and citation omitted). Reversal
   under the doctrine is rarely necessary—“‘the possibility of cumulative error
   is often acknowledged but practically never found persuasive.’” Id. at 344
   (quoting Derden v. McNeel, 978 F.2d 1453, 1456 (5th Cir. 1992) (en banc)).
   Instead, reversal is only justified “in the unusual case in which synergistic or
   repetitive error violates the defendant’s constitutional right to a fair trial.”
   Id. “[A]pplication is especially uncommon where . . . the government
   presents substantial evidence of guilt.” Id.

                                           27
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                                          No. 19-20797

           Moparty relies on Yates v. Evatt, 500 U.S. 391, 111 S. Ct. 1884 (1991),
   and United States v. Riddle, 103 F.3d 423 (5th Cir. 1997), 23 neither of which is
   directly applicable.       Yates involved jury instructions that applied an
   unconstitutional presumption, and the Court reversed the Supreme Court of
   South Carolina on its application of harmless error review. Yates, 500 U.S.
   at 402–07, 111 S. Ct. at 1892–95. That case says nothing about cumulative
   error which is premised on the repetition of individually harmless errors.
   Riddle involved testimony and evidence far outside the scope of the trial,
   prejudicial documents admitted into evidence, and the erroneous exclusion
   of the defendant’s expert. Riddle, 103 F.3d at 428–35. The court reasoned
   that, had those rulings come out differently, it would have been “a very
   different trial.” Id. at 434.
           The same cannot be said here. Any mistakes must be measured
   against the weight of the evidence presented. See United States v. Neal,
   27 F.3d 1035, 1051–52 (5th Cir. 1994) (sometimes “the cumulative effect of
   several incidents of improper argument or misconduct may require reversal,
   even though no single one of the incidents, considered alone, would warrant
   such a result,” but here, “we are not persuaded, in light of the substantial
   evidence of guilt adduced at trial, that the Defendants are entitled to reversal
   on the basis of cumulative error”). Moparty never objected to the jury
   instructions and there is no evidence the jury failed to follow them. The
   government offered hundreds of pages of documentary evidence and
   testimony      from     patients,     employees,       medical      experts,     industry
   representatives, and investigating agents. Moparty’s claimed errors lack the

           23
             Moparty also relies on an unpublished, nonprecedential opinion of this court.
   United States v. Houston, 481 F. App’x 188 (5th Cir. 2012). We allude to such opinions at
   most as persuasive, but Houston fails even that low bar because it involved more numerous
   and serious trial errors, which led to “confusion and prejudice that reached to the heart of
   the case—the identity of the perpetrator.” Id. at 195.

                                               28
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                                     No. 19-20797

   “synergistic” nature such that if none had occurred, he would have had “a
   very different trial.” Riddle, 103 F.3d at 434.
   F. Moparty’s Sentencing
            On appeal, Moparty argues that the district court erred in applying a
   two-level enhancement under U.S.S.G. § 3B1.3. That section applies “[i]f
   the defendant abused a position of public or private trust, or used a special
   skill, in a manner that significantly facilitated the commission or concealment
   of the offense.” U.S.S.G. § 3B1.3. Moparty preserved the issue. For
   preserved challenges, this court reviews the district courts application of the
   Guidelines de novo and its factual findings for clear error. United States v.
   Suchowolski, 838 F.3d 530, 532 (5th Cir. 2016). If the district court erred, the
   analysis shifts to whether the error was harmless. United States v. Halverson,
   897 F.3d 645, 652 (5th Cir. 2018).
            The abuse of trust enhancement is “a sophisticated factual
   determination” that this court reviews for clear error. United States v. Miller,
   607 F.3d 144, 148 (5th Cir. 2010). The enhancement is appropriate if
   (1) “the defendant occupies a position of trust” and (2) “the defendant
   abused her position in a manner that significantly facilitated the commission
   or concealment of the offense.” United States v. Kay, 513 F.3d 432, 459 (5th
   Cir. 2007). “A position of trust is characterized by (1) professional or
   managerial discretion (i.e., substantial discretionary judgment that is
   ordinarily given considerable deference), and (2) minimal supervision.”
   United States v. Ollison, 555 F.3d 152, 166 (5th Cir. 2009). This court will
   uphold the district court’s finding “as long as it is plausible in light of the
   record as a whole.” United States v. Ekanem, 555 F.3d 172, 175 (5th Cir.
   2009).
            Moparty rests his argument on the first prong—that he did not occupy
   a position of trust because he is not the owner of a hospital and the

                                         29
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                                    No. 19-20797

   government failed to meet its burden to prove the enhancement. He claims
   that according to trial testimony, his brother Roy Moparty was the sole
   owner. But, as the government points out, Moparty represented that he
   owned 50% in the signed licensing application and only his email address was
   listed. In fact, they were both signatories on ROH’s bank account. And
   Lammons testified that Moparty had a financial interest in and significant
   control over ROH. Moparty’s ownership position is a plausible view of the
   record.
          Moparty’s management position was thus excluded from close
   supervision, and it enabled him to direct Warren to bill for testing performed
   at North Cypress and “rebill” denied claims through other Moparty entities.
   Moparty’s managerial authority placed him in “a superior position . . . to
   commit the offense.” Kay, 513 F.3d at 459. The district court did not err in
   applying the enhancement.
   G. Narang’s Sentencing
          Narang argues that the district court erred in applying two sentencing
   enhancements. Section § 2B1.1(b)(2)(A)(i) adds two levels to the base
   offense level if the offense involved ten or more victims.          U.S.S.G.
   § 2B1.1(b)(2)(A)(i). Section 2B1.1(b)(11)(C)(i) adds another two levels if the
   offense involved “the unauthorized transfer or use of any means of
   identification unlawfully to produce or obtain any other means of
   identification.”     U.S.S.G. § 2B1.1(b)(11)(C)(i).    Narang filed written
   objections to both enhancements.
          1. Ten or More Victims—§ 2B1.1(b)(2)(A)(i)
          Narang argues that this enhancement is inapplicable because the only
   “victims” are the three insurance companies—Aetna, Blue Cross Blue
   Shield, and Cigna. Narang’s argument runs headlong into this circuit’s
   precedent.    In United States v. Barson, this court concluded that the

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                                          No. 19-20797

   enhancement applied because Medicare beneficiaries with falsely claimed
   benefits counted as “victims” since Application Note 4(E) defines a
   “victim” as “any individual whose means of identification was used
   unlawfully or without authority.” 845 F.3d 159, 167 (5th Cir. 2016) (quoting
   U.S.S.G. § 2B1.1 cmt. n.4(E)). 24 The only meaningful distinction here is that
   the benefits were paid by private insurance companies rather than Medicare.
   Application Note 4(E) applies to all cases, not just government health care
   programs, “involving means of identification.” 25 U.S.S.G. § 2B1.1 cmt.
   n.4(E). Since Narang used the patient’s “means of identification” to
   generate the fraudulent claims, precedent forecloses this argument.
           2. Means of Identification—§ 2B1.1(b)(11)(C)(i)
           Narang argues that “[t]he enhancement’s language does not call for a
   two-level increase merely because the offense involves a ‘means of
   identification’     from     which     another      ‘means      of   identification’      is
   unintentionally or tangentially created.” Again, this argument is foreclosed
   by circuit precedent. In United States v. Kalu, this court held that using a
   beneficiary’s Medicare information to generate a fraudulent health care claim
   satisfied the enhancement because the initial “means of identification” usage
   (the Medicare information) produced another means of identification—the
   Medicare claim number which “is unique and inextricably tied to a particular
   Medicare beneficiary.” 936 F.3d 678, 681–82 (5th Cir. 2020). Here, each

           24
              But see Barson, 845 F.3d at 168–170 (Jones, J., concurring in part and dissenting
   in part) (arguing that this enhancement and Application Note 4(E) are not applicable in
   these circumstances under the plain meaning of “victims” and the purpose of the 2009
   update to the Guidelines).
           25
              “Means of identification” is defined as “any name or number that may be used,
   alone or in conjunction with any other information, to identify a specific individual.” See
   U.S.S.G. § 2B1.1 cmt. n.1 (incorporating the quoted definition by cross-reference to
   18 U.S.C. § 1028).

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   patient’s personal information was used to generate a unique health care
   claim. 26 Accordingly, Kalu’s reasoning extends to the facts presented here.
                                   III. CONCLUSION
           Though we find no reversible error under the King factors or otherwise,
   we do not condone the government’s conduct in this case. Throughout the
   course of the trial, the government, at best, was careless in the testimony it
   elicited from its witnesses, its missteps salvaged only by the district court’s
   repeated and forceful curative instructions. Even though the trial court
   found no bad faith, such heedless behavior is unacceptable. With this said,
   we find no reversible error of fact or law.
           AFFIRMED.

           26
             Though Kalu involved Medicare rather than private insurance, Kalu approvingly
   discussed United States v. Gonzalez, 644 F. App’x 456 (6th Cir. 2016) (unpublished), which
   did involve private insurance. See Kalu, 936 F.3d at 682 (reciting the Gonzalez analysis and
   stating “[w]e see no reason to disagree”).

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