Court Opinion

ID: 3182120
Source: CourtListenerOpinion
Date Created: 2016-03-02 21:02:40.605803+00
Date Added: 2024-06-11T07:38:58.549549
License: Public Domain

United States Court of Appeals
                     For the First Circuit

No. 14-1794

                    UNITED STATES OF AMERICA,

                            Appellee,

                               v.

                          LUZ M. VEGA,

                      Defendant, Appellant.

          APPEAL FROM THE UNITED STATES DISTRICT COURT
                 FOR THE DISTRICT OF PUERTO RICO

          [Hon. Gustavo A. Gelpí, U.S. District Judge]

                             Before

                 Torruella, Lipez, and Thompson,
                         Circuit Judges.

     Rachel Brill, for appellant.
     Héctor E. Ramírez-Carbo, Assistant United States Attorney,
with whom Rosa Emilia Rodríguez-Vélez, United States Attorney,
Nelson Pérez-Sosa, Assistant United States Attorney, Chief,
Appellate Division, and Juan Carlos Reyes-Ramos, Assistant United
States Attorney, were on brief, for appellee.

                          March 2, 2016
          TORRUELLA, Circuit Judge.      A jury convicted defendant-

appellant Luz M. Vega of fifty-eight criminal counts stemming from

her participation in a Medicare fraud scheme.           Vega now appeals

her convictions from the United States District Court for the

District of Puerto Rico, alleging several procedural defects.

Additionally, although Vega does not challenge her Medicare fraud

convictions, she argues the Government did not present sufficient

evidence to convict her of identity theft and money laundering.

For the reasons that follow, we affirm.

                           I.   Background

          Vega was the director of Preferred Medical Equipment

("Preferred"), a supplier of durable medical equipment ("DME")

located in Arecibo.   DME are items used by individuals with certain

medical conditions outside of a hospital on regular basis, such as

wheelchairs,   walkers,   orthotics,   and   electric    hospital   beds.

Typically, a patient obtains DME through a DME supplier upon the

presentation of a physician order.      If the patient is a Medicare

beneficiary, the DME supplier can submit a claim to Medicare for

partial reimbursement.1

1  In the Medicare claim, the DME supplier states how much the
beneficiary was billed for the equipment. Up to a set price point,
Medicare will fully reimburse a DME supplier, factoring in an
expected twenty-percent copay by the beneficiary.

                                 -2-
           DME suppliers seeking reimbursement from Medicare must

submit documentation with their claim, including proof that the

DME ordered was medically necessary and prescribed by a physician.

Due to the volume of claims received, Medicare does not verify

every claim it receives beyond checking for paperwork showing that

the DME recipient was a Medicare beneficiary and the DME was

medically necessary.

           Preferred defrauded Medicare by submitting claims for

DME orders that were not medically necessary.             Rather than waiting

for   beneficiaries    to    come   with      physician   orders    to   fulfill,

"equipment coordinators" at Preferred would seek out Medicare

beneficiaries and persuade them to receive DME, often under the

pretense   that     the     equipment      was   free.        The   absence    of

documentation showing the DME ordered was medically necessary

would   normally    prevent     Medicare       reimbursement.       Preferred's

equipment coordinators circumvented this rule by paying a doctor,

Francisco A. Garrastegui-Bigas ("Garrastegui"), to provide the

required   documentation.           Garrastegui       would     either     create

documentation for DME already ordered, or accompany the equipment

coordinators on patient visits and prescribe DME on the spot.

           The     Government    jointly       indicted   Vega;     Garrastegui;

Preferred's secretary, María Elisa Pérez; and two of Preferred's

equipment coordinators, Lissette Acevedo-Rodríguez ("Acevedo") and

                                        -3-
Luisa Nieves, alleging that Preferred submitted ninety-five false

claims totaling $210,223.47 to Medicare between April 2010 and

March 2011.      For her role in this scheme, the Government charged

Vega with one count of conspiracy to commit Medicare fraud in

violation of 18 U.S.C. §§ 1347 and 1349 and twenty-four counts of

aiding   and   abetting     the     commission    of     health   care   fraud    in

violation of 18 U.S.C. §§ 2 and 1347.2

            Vega    also    faced    several     other    criminal   charges      in

connection with her participation in Preferred's fraud scheme.

For   payments     made    to   Preferred's      equipment    coordinators       and

Garrastegui, Vega was charged with twenty-eight counts of aiding

and abetting the solicitation and receipt of kickbacks in relation

to the Medicare program, in violation of 42 U.S.C. §§ 2 and 1320a-

7b(b)(1)(B).       Vega    paid     commissions    to    Preferred's     equipment

coordinators based on the type and quantity of DME they sold.

Additionally, Vega paid Garrastegui to visit Preferred's office in

late 2010 to create medical documentation for DME that Preferred

had sold without physician orders.3

2  These twenty-four counts were based on claims Preferred filed
for DME given to three different beneficiaries.
3  Count   29 was in regard to Vega paying Garrastegui for when he
visited    Preferred's office.    Counts 30-54 were in regards to
payments    Vega made to Acevedo.   Counts 55-56 were in regard to
payments   Vega made to Nieves.

                                        -4-
           The Government also charged Vega with three counts of

aiding and abetting aggravated identify theft in violation of 18

U.S.C. § 1028A(a)(1) and (2).       These aggravated identity theft

charges were in relation to Preferred obtaining the identification

information of three Medicare beneficiaries -- Juan Quiles-Medina

("Quiles"), José Figueroa-Class ("Figueroa"), and Efraín Toro-

Morales ("Toro") -- and continuing to bill Medicare on their behalf

even after they told Preferred they did not want the equipment.

           Finally, Vega was charged with two counts of transacting

in criminally derived property of a value greater than $10,000

(i.e., money laundering) because she used funds from Preferred's

bank account to pay for personal expenses (an auto loan and the

purchase of an official check).

           Garrastegui and Acevedo both pled guilty and testified

against Vega at trial.   The jury found Vega guilty of all counts.

The district court sentenced Vega to two years and one day of

imprisonment and three years of supervised release.     This timely

appeal followed.

                         II.   Napue Claims

           Vega first argues that the Government violated Napue v.

Illinois, 360 U.S. 264 (1959), and her right to due process by

allowing two of its witnesses to provide false testimony to the

jury.   Napue prohibits prosecutors from knowingly presenting false

                                  -5-
evidence, including false testimony, to the jury.          Id. at 269-70;

see also United States v. Flores-Rivera, 787 F.3d 1, 31 (1st Cir.

2015).   This prohibition applies even if the government does not

solicit the false testimony and merely fails to correct it.        Napue,
360 U.S. at 269.

            According   to   Vega,    two   of     Preferred's   equipment

coordinators who testified against her at trial, Acevedo and

Marcos A.    Sárraga-Montañez   ("Sárraga"),        underrepresented   the

benefits they received from their plea agreements.4         This in turn,

Vega argues, prevented the jury from fully assessing their bias

and credibility.   We reject Vega's Napue claims for two reasons.

            First, we note that Vega did not object to Acevedo's or

Sárraga's testimony, even though the Government entered their plea

agreements into evidence at trial and, as discussed in further

detail below, the plea agreements contained all of the information

Vega needed to impeach their testimony.          If a defendant has actual

knowledge of the false testimony and fails to correct it, absent

unusual circumstances, we assume the defendant did so for strategic

4  Acevedo and Sárraga were also involved in a similar Medicare
fraud scheme with a different DME supplier called Monte Mar.
Acevedo was charged in connection with Monte Mar and Preferred and
pled guilty to one count of conspiracy to commit health care fraud
in both cases and one count of aggravated identity theft in the
Preferred case. Sárraga was only charged in connection with Monte
Mar and pled guilty to one count of soliciting and receiving
kickbacks in relation to the Medicare program in that case.

                                     -6-
reasons and consider the Napue claim waived.                United States v.

Mangual-García, 505 F.3d 10, 10-11 (1st Cir. 2007).                    Given the

availability of the plea agreements, we do not think Vega has

reason to complain about either witness's testimony on appeal.

             Second, even if Vega's claims are reviewable, they are

meritless.

A.   Acevedo's Testimony

             Vega contests a portion of Acevedo's testimony elicited

on recross-examination.        Following Acevedo's statement that she

was repentant, Vega asked Acevedo if she "ha[d] to return the money

that [she] received" from her crimes; Acevedo, who had yet to be

sentenced, stated that she did not know.              The district court then

told the jury that Acevedo's plea agreement, whatever its terms,

was not binding and that the court "c[ould] order full restitution"

and it was "up to the Court, the amount of restitution."

             Vega argues that the prosecutors (and district court

with its comment) left the jury with an impression that Acevedo

did not receive a benefit from the Government by pleading guilty

because   restitution    was     still      up   to   the   district     court's

discretion.    This impression is false, according to Vega, because

discretionary restitution is a benefit.

             Vega premises her argument on the Mandatory Victim's

Restitution    Act   ("MVRA"),   18   U.S.C.      §   3663A,   which    requires

                                      -7-
defendants     to     pay   restitution     in   fraud   cases.        See   id.

§ 3663A(c)(1)(ii); United States v. Cheal, 389 F.3d 35, 53 (1st

Cir. 2004).    Vega argues that Acevedo's plea agreements must have

exempted her from the MVRA if the prosecutors and district court

viewed her restitution as a matter of court discretion.

             The problem with Vega's argument is that Acevedo's plea

agreements did not exempt her from the MVRA -- in fact, her plea

agreements explicitly state that the MVRA applied.                The benefit

Vega argues Acevedo lied about receiving simply does not exist.5

             We also find no falsity in Acevedo's statement that she

did not know the amount of restitution she would have to pay.

Restitution     has    a    precise   legal      definition.      It    is   not

unreasonable that Acevedo would not know this definition and thus

how the district court would calculate restitution or how much it

would order her to pay.        Finally, we fail to see how any problems

with Acevedo's testimony could not have been impeached by Vega

when Vega had a copy of Acevedo's plea agreement and the plea

agreement stated the terms of Acevedo's restitution and monetary

penalties.     Based on this review of the record, we conclude that

5  Vega seems to argue that because Acevedo ultimately did not pay
any restitution she must have been exempted from the MVRA. The
district court's restitution calculation is not before us and Vega
has failed to point us to any evidence suggesting that the plea
agreement terms were altered prior to sentencing. We therefore
assume the MVRA applied pursuant to the plea agreement's terms.

                                      -8-
Acevedo's testimony was not false and therefore did not violate

Napue.

B.   Sárraga's Testimony

            Our review of the record also leads us to conclude that

Sárraga's testimony did not violate Napue.              Sárraga's contested

testimony       came   during     his   redirect   examination    when    the

prosecution attempted to bolster his credibility following Vega's

attacks on cross-examination:

          PROSECUTOR: And you have already been sentenced . . .;
          is that correct?

          SÁRRAGA: Yes.

          PROSECUTOR: So what do you have to lose or win by
          coming here to testify?

          SÁRRAGA: From the very first time that I had contact
          with an agent, I decided that I was going to tell the
          truth and made a commitment to tell the truth and help
          them out.

          PROSECUTOR: Are you getting anything in return or do
          you fear something will happen to you by coming here
          and testifying today?

          SÁRRAGA: No.

Vega argues that Sárraga's statement that he was not receiving

anything in return for his testimony was false because he was still

on probation and was required to pay restitution and thus had an

incentive to "please the government with his testimony."

            Like Acevedo's testimony, we do not see any obvious

falsity    in    Sárraga's      statement.    Sárraga    had   already   been

                                        -9-
sentenced such that the main source of his bias -- wanting to

receive a favorable recommended sentence from the prosecution --

was mitigated.   The prosecution's ability to influence Sárraga's

probation and restitution seems attenuated at best.      Moreover,

even if Sárraga's statement that he was receiving nothing in return

for his testimony was misleading, Vega could easily cross-examine

his motives -- and in fact did so.    See United States v. Clark,

767 F. Supp. 2d 12, 67 (D.D.C. 2011) (stating conflicting testimony

between witnesses did not create Napue claim because even if a

witness's testimony contains falsehoods, "cross-examination and

jury instructions regarding witness credibility will normally

purge the taint of false testimony" (quoting United States v.

Joyner, 201 F.3d 61, 82 (2d Cir. 2000)).   Thus, even if Sárraga's

testimony could be construed as misleading, we do not find "any

reasonable likelihood" that the testimony could "have affected the

judgment of the jury.6   Mangual-García, 505 F.3d at 10 (quoting

6  We also reject Vega's argument that the district court made an
improper and misleading comment to the jury about plea agreements
generally.   While Sárraga was describing his plea agreement on
direct, the district court interjected and told the jury:

       You've heard other witnesses who are cooperating with
       the United States and have plea agreements, they have
       not yet been sentenced. The sentence is ultimately
       for the Court to decide, and the fact that [Sárraga]
       got 18 months is not indicative of how any of the
       other individuals will be sentenced that's ultimately
       a decision for the Court on a case-by-case-basis.

                               -10-
Giglio v. United States, 405 U.S. 150, 154 (1972)).              As a result,

we proceed to Vega's evidentiary claims.

                           III.   Evidentiary Issues

             Vega   next     argues   that    the   Government     improperly

introduced expert testimony without qualifying the witnesses as

experts.   Vega's claim relates to the testimony of two Government

witnesses: Jean Stone ("Stone") and Special Agent Michael Ayala

("Ayala").     We are dubious about the propriety of portions of

their   testimony,    but     ultimately     find   Vega's   alleged   errors

harmless given her theory of defense.

             Stone held a management position with the United States

Department of Health and Human Services, where she helped oversee

Medicare fraud prevention activities in New York, New Jersey,

Puerto Rico, and the Virgin Islands.            Stone did not assist with

the investigation of Vega or Preferred -- rather, the Government

gave Stone a copy of the indictment against Vega and asked Stone

to testify about the Medicare program generally.                  During the

Vega argues this statement was misleading because the witnesses
were assigned to the same judge and he ultimately gave other
witnesses the same sentence as Sárraga (eighteen months'
probation).   Vega claims the district court judge's statement
prevented her from arguing that other witnesses would not face
jail time. We do not see how the district court's statement was
false given that each sentence was up to the court's discretion.
And, similar to Vega's claim regarding Sárraga's testimony, we do
not see how Vega was prevented from making any arguments about
witness bias on cross-examination.

                                      -11-
course of her testimony, Stone described the structure of the

Medicare program; how DME was prescribed and could be obtained by

patients;   how    DME   suppliers      received      reimbursement;       and   how

Preferred's Medicare reimbursement claims showed conflicting DME

prescriptions.7

            On    appeal,      Vega   contests     the    portion    of    Stone's

testimony in which she described the anti-kickback statute.                   Stone

testified   that    a    DME    supplier      could   not   pay     an    equipment

coordinator commissions because the anti-kickback statute made it

illegal "to offer or receive anything of value for referrals of

Medicare or Medicaid patient [sic] to receive Medicare service or

equipment."

            Vega contests a similar statement made by Ayala, a U.S.

Secret Service agent who executed a search warrant of Preferred's

office in April 2011.       At trial, Ayala testified he found a chart

during the search that listed different DME, the price Preferred

paid for DME, the amount Medicare reimbursed for that DME, and a

column called "Rep. Payment."8          Ayala testified that he believed

7  For example, Stone stated that one of Preferred's claim forms
ordered both a pressure-reducing mattress -- used for immobile
patients who developed severe ulcers due to the pressure from their
bones pressing on their skin -- and a back brace -- used to help
patients' spines recover following surgery. As Stone explained,
it was not appropriate for a patient who was immobile to also have
a device used to stabilize a walking patient.
8   The chart contained some Spanish terms.              Translated versions of

                                       -12-
that (1) the chart showed Preferred paid its equipment coordinators

based   on    the     equipment    they   sold;   (2)   these   payments     were

kickbacks; and (3) kickbacks were prohibited by Medicare law.

             Vega argues that the Government needed to qualify Stone

and Ayala as expert witnesses pursuant to Federal Rule of Evidence

702 in order for them to testify about whether Preferred paid its

equipment coordinators commissions and whether such commissions

were prohibited by 42 U.S.C. § 1320a-7b(b)(1)(B).9                Federal Rule

of Evidence 701 limits opinion testimony by lay witnesses to

opinions that are "not based on scientific, technical, or other

specialized knowledge within the scope of Rule 702."                    Fed. R.

Evid. 701(c).       Vega argues Stone and Ayala's testimony was based

on technical or specialized knowledge.              The Government counters

it was not.

             In support of its view, the Government notes we have

allowed      police     officers    to    offer   opinions      based   on   the

"particularized knowledge [the officers had] by virtue of [their]

position[s]" without being qualified as experts.                 United States

these charts are part of the trial record.
9  The Government argues that Vega failed to preserve both of her
claims on appeal because she failed to contemporaneously object
during Stone or Ayala's testimony. We find the record ambiguous.
Because we find any error harmless even under the "manifest abuse
of discretion" standard, we do not address this point.     United
States v. Valdivia, 680 F.3d 33, 50 (1st Cir. 2012).

                                         -13-
v. Ayala-Pizarro, 407 F.3d 25, 28 (1st Cir. 2005) (quoting Fed. R.

Evid. 701, advisory committee's note on 2000 amendment).            The

Government argues that Stone and Ayala gained familiarity with the

anti-kickback statute through their jobs and thus their testimony

fit within the ambit of "particularized knowledge" gained "by

virtue of [their] positions."

           The Government reads too much into our precedent.         We

acknowledge that we have previously stated that Rule 701 "is meant

to admit testimony based on the lay expertise a witness personally

acquires through experience, often on the job."      United States v.

Maher, 454 F.3d 13, 24 (1st Cir. 2006).         We have not stated,

however,   that   all   job-based   knowledge   is   nontechnical    or

nonspecialized.    Rather, we have stated that lay experiential

expertise refers to those processes that are "well founded on

personal knowledge and susceptible to cross-examination."      Ayala-

Pizarro, 407 F.3d at 28 (quoting United States v. Vega-Figueroa,

234 F.3d 744, 755 (1st Cir. 2000)).      Such lay expertise is "the

product of reasoning processes familiar to the average person in

everyday life."   United States v. García, 413 F.3d 201, 215 (2d

Cir. 2005).   For example, a police officer noticing patterns of

behavior across criminal operations uses straightforward logic to

conclude a defendant's behavior fits within that pattern and thus,

does not need to be qualified as an expert.     See United States v.

                                -14-
Santiago, 560 F.3d 62, 66 (1st Cir. 2009) (holding that officer

could   testify     about    meaning    of    code    words    used    during     drug

transactions      based     on   hearing     same    language    in    other      drug

investigation as lay witness); Ayala-Pizarro, 407 F.3d at 28-29

(finding officer could testify as lay witness that defendant was

at "drug point" based on observation that location was heavily

guarded because no specialized expertise was required for officer

to reach the conclusion that "places which sell drugs are often

protected by people with weapons").

            The    testimony      in   this    case    helps    illustrate        this

distinction       between    experiential       knowledge       that     relies     on

reasoning   processes       familiar    to    the    average    person    and     more

specialized expertise.           On the one hand, Ayala's testimony about

his interpretation of the chart he found at Preferred could be

properly admitted as lay testimony.                  A jury could follow the

reasoning process Ayala used and understand why he interpreted a

chart listing medical equipment and containing a column reading

"Rep. payment" as evidence that Preferred's equipment coordinators

were paid based on the equipment they sold.              Such testimony relying

upon    logic   and   pattern      recognition       falls    within   Rule     701's

parameters for lay testimony.

            In contrast, we find that Stone's testimony and Ayala's

final conclusion that Preferred's commissions violated Medicare

                                       -15-
law fell outside the boundaries of lay expertise.                    Their opinions

were not based on the product of applying familiar reasoning

processes to their job experience -- rather, they could form their

opinions      only    by   understanding      technical    Medicare       laws   and

regulations.         Contrary to the Government's arguments, the fact

that Stone and Ayala had knowledge of Medicare law through their

occupations does not make it "personal knowledge" qualifying as

lay expertise under Rule 701.            As stated above, our use of the

term "personal knowledge" refers, generally, to the product of a

witness's     process      of   observing   patterns      and   drawing     logical

conclusions.         An understanding of what Medicare law allows and

forbids cannot be developed through this process.                When condemning

commission payments as illegal kickbacks, Stone and Ayala were not

relaying their personal observations for the jury to assess;

rather, they were lending the jury their knowledge of Medicare law

to provide definitive commentary on the matter.                      Other circuits

have reached similar conclusions concerning witnesses' testimony

about best practices and legal regulations in fraud cases.                   United

States v. White, 492 F.3d 380, 399-405 (6th Cir. 2007) (finding

Medicare auditors could not testify about meaning of certain

Medicare terms when testifying as lay witnesses); United States v.

Riddle, 103 F.3d 423, 428-29 (5th Cir. 1997) (finding bank auditor

needed   to    be    qualified    as   expert   in   order      to    testify    that

                                       -16-
defendant's    conduct   fell   outside   of   sound   banking   practices

because witness "functioned not as a witness relaying his own

observations so much as a knowledgeable bank examiner who could

provide the jury with an overview of banking regulations and

practices and who could authoritatively condemn [the defendant's]

actions").     We thus conclude it was error to admit Stone's and

Ayala's testimony that the payment of commissions to equipment

coordinators violated Medicare law without qualifying them as

expert witnesses.

             Nonetheless, we find any error in the admission of this

testimony harmless, meaning that we find it is "highly probable

that the error did not contribute to the verdict."         United States

v. Amador-Huggins, 799 F.3d 124, 129 (1st Cir. 2015) (quoting

United States v. Varoudakis, 233 F.3d 113, 125-26 (1st Cir. 2000)).

Vega's theory of defense at trial was that she was not aware of

the fraud or commission payments occurring at Preferred.           Vega's

closing argument focused on developing the theory that Acevedo,

who had participated in a separate Medicare fraud scheme prior to

Preferred, was the ringleader of the entire scheme.         Vega did not

contest at trial that Preferred paid commissions to its equipment

coordinators or that such actions were illegal.         Instead, the crux

of her argument was that Acevedo made the payments herself or had

Pérez (whom Acevedo knew prior to working at Preferred) prepare

                                  -17-
checks for Vega, who then signed the checks without knowing their

purpose.    Given Vega's trial strategy, we think it is highly

probable   that   Stone's   and   Ayala's    statements   that   commission

payments violated § 1320a-7b(b)(1)(B) did not contribute to the

verdict.   The issue that Vega posed to the jury was whether it

believed Vega was knowingly involved with Preferred's commissions,

not whether Preferred's scheme violated the law.                 Finding no

reversible error, we move to another of Vega's claims.

                         IV.   Jury Instructions

           Vega   next   argues    that     the   district   court's   jury

instructions regarding charges for aiding and abetting the receipt

of kickbacks were incomplete.       We reject these claims as well.

A.   The Anti-Kickback Instruction

           The Government charged Vega with violating the anti-

kickback statute pursuant to 42 U.S.C. § 1320a-7b(b)(1)(B).            That

statute makes it a crime to

        knowingly and willfully solicit[] or receive[] any
        remuneration (including any kickback, bribe, or
        rebate) directly or indirectly, overtly or covertly,
        in cash or in kind . . . in return for purchasing,
        leasing, ordering, or arranging for or recommending
        purchasing, leasing, or ordering any good, facility,
        service, or item for which payment may be made in
        whole or in part under a Federal health care program
        . . . .

42 U.S.C. § 1320a-7b(b)(1)(B).       The district court instructed the

jury that § 1320a-7b(b)(1)(B) "makes it a crime to . . . ask for

                                   -18-
or receive or pay or offer to pay any remuneration in connection

with referring patients or arranging for which [sic] payments may

be made under the federal healthcare program."                  It went on to

state that in order to convict Vega

        [T]he government must prove each of the following
        beyond a reasonable doubt:

        One, referring an individual to a person for the
        furnishing or arranging for the furnishing of an item
        or service that could be paid for, in whole or in part,
        by a federal healthcare program. Or, two, purchasing,
        leasing, ordering, or arranging for or recommending
        purchasing, leasing, or ordering any good, facility,
        service, or item that could be paid for, in whole or
        in part, by a federal healthcare program. And, third,
        that Ms. Vega did [so] knowingly and willfully.

           Vega argues for the first time on appeal that these

instructions were incomplete because they did not state that the

jury   needed    to    find   that     Vega    aided   or     abetted   in   the

"solicit[ation] or recei[pt] [of] any remuneration" and did not

define "remuneration."        When a defendant makes no objection to a

jury instruction at trial, this court reviews the instruction for

plain error.      United States v. Meadows, 571 F.3d 131, 145 (1st

Cir. 2009).       In order to establish plain error, "a criminal

defendant must show (1) that an error occurred (2) which was clear

or   obvious    and   which   not    only    (3)   affected   the   defendant's

substantial rights, but also (4) seriously impaired the fairness,

integrity, or public reputation of judicial proceedings."                United

States v. González-Vélez, 466 F.3d 27, 34-35 (1st Cir. 2006)

                                      -19-
(quoting United States v. Duarte, 246 F.3d 56, 60 (1st Cir. 2001)).

"[T]he plain error hurdle . . . nowhere looms larger than in the

context    of    alleged    instructional     errors."      United   States    v.

Paniagua-Ramos, 251 F.3d 242, 246 (1st Cir. 2001).

            The district court's instructions in this case do not

clear this hurdle.         While the district court's instruction may not

have been "letter perfect," we think that, "read[] against the

backdrop    of    the   charge    as    a   whole,"   the    district   court's

instruction was sufficient.            Id. at 246-47.       The district court

mentioned that Vega needed to aid or abet in the receipt of

remunerations before describing the elements the Government needed

to prove.        We think that this was sufficient for the jury to

understand that the charge also required evidence of a remuneration

and, thus, that absent a contemporaneous objection, it did not

constitute plain error.

            We also think the backdrop of the charge as a whole did

not necessitate a definition of the term "remuneration."                      The

Government's charges were not based on a novel conception of the

word "remuneration."         They were in reference to Preferred paying

Garrastegui and its equipment coordinators according to the amount

of DME they prescribed and ordered.               The term "remuneration"

referred to these payments.         Given this straightforward use of the

                                       -20-
term, we do not think it was plain error for the district court to

leave it undefined.

B.   Safe Harbor Instruction

             Vega has one preserved jury instruction claim.               While

discussing the jury instructions with the district court, Vega

requested that the court instruct the jury about the "safe harbor"

provisions promulgated by the Department of Health and Human

Services.      The district court denied this request.              When "a

criminal    defendant   seasonably      requests     an   instruction     on    a

particular theory of the case and the trial court flatly refuses

to submit that theory to the jury, our review is plenary."              United

States v. Ramos-Paulino, 488 F.3d 459, 463 (1st Cir. 2007).

             The   Department   of    Health   and    Human    Services    has

promulgated regulations stating that certain payments are not

"remunerations" in violation of § 1320a-7b(b)(1)(B).             Vega claims

she should have been allowed to argue to the jury that Preferred's

payments to its equipment coordinators fit within the safe harbor

described in 42 C.F.R. § 1001.952(d).              This regulation allows

principals, such as DME suppliers, to pay agents, such as equipment

coordinators, for their services if several provisions are met,

including:     that   the   payment    agreement     is   in   writing,        the

contractual relationship is for more than one year, and the agent's

payment is at a set salary.      Id. § 1001.952(d)(2), (4), (5).

                                      -21-
          "[T]o warrant a jury instruction on a specific theory of

defense, the evidence adduced at trial, taken in the light most

flattering to the accused, must plausibly support the theory."

Ramos-Paulino, 488 F.3d at 461 (emphasis in original).              "The

burden is on the defendant, as the proponent of the theory, to

identify evidence adduced during the trial that suffices to satisfy

this standard."   Id. at 462.

          Vega has not pointed us to any evidence showing that the

safe harbor provisions could have plausibly applied to her case.

Simply put, Vega did not even argue that Preferred met the basic

requirement   that   its   payment   agreements   with   its   equipment

coordinators were in writing -- let alone that these agreements

were for a period longer than one year and had a set salary.          On

this final point, Vega did not argue to the jury that Preferred

paid its equipment coordinators salaries.         As discussed in the

previous section, Vega's theory of defense was that she had no

knowledge of the commissions.        Given this trial record, we find

no error with the district court's denial of Vega's request for a

safe harbor instruction.

                           V.   Identity Theft

          Vega also raises two sufficiency challenges on appeal.

The first challenge regards her convictions for identity theft for

using the personal information of Medicare beneficiaries Figueroa,

                                   -22-
Quiles, and Toro to order equipment and submit claims to Medicare

without their permission.         A person commits aggravated identity

theft when that person "knowingly transfers, possesses, or uses,

without lawful authority, a means of identification of another

person" "during and in relation to any felony violation enumerated

in subsection (c)," which includes any fraud crime enumerated in

chapter 18 of the U.S. Code.        18 U.S.C. § 1028A(a)(1),(c)(4).

           Vega contests this final fraud element.              She notes that,

as   charged   in   the   indictment,      she    used    the   beneficiaries'

identities some time prior to December 2010.10               The timing, Vega

argues, is significant because in that month she (according to

Garrastegui's testimony) asked Garrastegui to visit Preferred's

office and fill out medical documentation that was missing from

Preferred's    medical    claim   files. 11      Vega    acknowledges   that   a

reasonable jury could conclude she knew of Preferred's fraud based

on this testimony, but argues this was the only evidence proffered

sufficient to prove her guilt.             If true, tying these threads

10 The specific dates are: May 7, 2010 (Quiles); August 17, 2010
(Toro); and September 21, 2010 (Figueroa).
11  Garrastegui did not testify that he came to Preferred in
December 2010 -- he could remember only that he visited in "the
latter part of 2010." The December 2010 date appears to come from
the testimony of an auditor Vega hired. This auditor testified
that when he visited Preferred in early December 2010, many of the
claims he saw lacked required medical documentation.

                                    -23-
together would mean that Vega did not know Preferred's claims were

fraudulent prior to December 2010 and thus, could not have used

the beneficiaries' personal information in connection with fraud

as required by the identity theft statute.

              We, however, reject Vega's premise that Garrastegui's

visit to Preferred was the only evidence proving her knowledge of

Preferred's fraud.        When reviewing a sufficiency of the evidence

claim,   we    must   "take   the     evidence   and   draw   all    reasonable

inferences     in   the   light   most   favorable     to   the   prosecution."

United States v. Rosado-Pérez, 605 F.3d 48, 52 (1st Cir. 2010).

"If a reasonable jury could find the defendants guilty beyond a

reasonable doubt of all elements of the charged offense, we must

affirm the conviction."       Id.12

              A reasonable jury could conclude that Vega knew of the

fraud occurring at Preferred prior to Garrastegui's visit.                 The

12  Moreover, Vega did not argue that the Government presented
insufficient evidence for the charges prior to December before the
district court. Vega's Rule 29 motions for acquittal argued only
that the Government failed to prove her awareness of Preferred's
fraud at any point during the conspiracy. As "a party is not at
liberty to articulate specific arguments for the first time on
appeal simply because the general issue was before the district
court," we review for plain error. Acosta-Colón, 741 F.3d at 210
(quoting United States v. Slade, 980 F.2d 27, 31 (1st Cir. 1992));
see also United States v. Christi, 682 F.3d 138, 140 (1st Cir.
2012) (applying plain error to sufficiency theory not articulated
in Rule 29 motion).    Nonetheless, we would reject Vega's claim
even if it was preserved and our discussion treats it as such.

                                       -24-
Government presented several strands of circumstantial evidence

through which a reasonable jury could infer knowledge, and a "jury

[is] entitled to rely on plausible inferences."   United States v.

Matthews, 498 F.3d 25, 31 (1st Cir. 2007).

           First, a reasonable jury could infer that Vega knew the

claims Preferred submitted on behalf of Figueroa, Quiles, and Toro

were fraudulent at the time of submission or soon thereafter.

Each of the beneficiaries (or a spouse or a relative) testified

that he or she told Preferred the beneficiaries did not want the

DME, one of whom stated she spoke with Vega directly.13   Moreover,

multiple witnesses testified that Vega had a large degree of

control over Preferred's operations.      Vega told an FBI agent

investigating her that nothing at Preferred was done without her

consent.   Additionally, as described by Acevedo, the DME orders

and Medicare claims did not go exclusively through the equipment

13  Quiles testified that he called Preferred asking someone to
pick up the DME, but his request was ignored. Yet Preferred billed
Medicare for equipment it claimed it rented to Quiles from at least
March 2010 to March 2011.      Toro's daughter testified that two
people from Preferred came to their house after her father called
their office saying he did not want the DME delivered. Preferred,
however, did not pick up the equipment and billed Medicare in
Toro's name from March 2010 through March 2011 and claimed he was
seen by Garrastegui. Figueroa's wife, Pascasia, testified that
she told someone who identified herself as Vega over the phone
that Figueroa did not need the equipment "[b]ecause the physician
who came over [and prescribed it] [was] not [her] husband's
attending physician."     Preferred picked up the equipment but
continued billing Medicare from August 2010 through October 2010.

                               -25-
coordinators.    Rather, once an equipment coordinator obtained a

patient's information, either Vega or her secretary would verify

that the patient was a Medicare beneficiary.            Given Vega's role

at Preferred, a jury could rationally find that Vega must have

known that the beneficiaries complained to Preferred they did not

want DME delivered to their houses and therefore any claims filed

after their complaints were fraudulent.

            Second,   the     testimony     of   Preferred's      equipment

coordinators suggested that Vega not only knew of the fraud, but

actively played a role in directing it.           Acevedo testified that

at Vega's instruction, Preferred did not fulfill DME orders that

came from individuals who were not Medicare beneficiaries or that

did not contain a motorized wheelchair (a high-priced item).              A

reasonable jury could infer that Vega was interested in fulfilling

orders only from Medicare beneficiaries because Medicare's honor

system made it easy to defraud.         Similarly, Vega's insistence on

orders   containing   a     motorized     wheelchair   creates    a   strong

inference that she did not care about whether the DME orders

fulfilled    served   a     legitimate     medical     purpose.       Vega's

indifference towards the medical legitimacy of Preferred's orders

is further bolstered by Acevedo's testifying that she told Vega

when she started working at Preferred (i.e., March 2010) that

Garrastegui would prescribe DME for patients he did not see.

                                   -26-
Sárraga also testified that he knew Vega was aware of this fact.

The fact that Vega allowed equipment coordinators to submit claims

with   Garrastegui      as   the   prescribing       doctor   also     supports      an

inference that she condoned Preferred's fraud.

           We    also    note      that    a     reasonable    jury    could       view

Preferred's commission payments to the equipment coordinators

(which Vega set and paid), taken with this record, as further

evidence that Vega had a role in directing the fraud.                        Standing

alone, this would not be sufficient to prove Vega knew of the

fraud, but it is further evidence that Vega was motivated to submit

as many claims as possible to Medicare, regardless of their

legitimacy.

           All   of     this   evidence        combined    convinces    us    that    a

reasonable jury could conclude Vega had knowledge of Preferred's

fraud beyond a reasonable doubt.                  We therefore reject Vega's

sufficiency challenge.

                             VI.   Money Laundering

           In    addition,      Vega      contests   the    sufficiency       of    the

Government's     evidence       proving        her   involvement       with    money

laundering.     In order to commit money laundering, a defendant must

"engage in a monetary transaction in criminally derived property

of a value greater than $10,000" that is in or affects interstate

or foreign commerce.         18 U.S.C. § 1957(a), (f)(1).          The Government

                                          -27-
charged Vega with money laundering based on her using money in

Preferred's bank account to make two transactions: to pay off an

$16,302.65 automobile loan in late December 2010 and to purchase

an official check in the amount of $34,121.16 in January 2011.

Vega   contests   the    sufficiency   of    the    Government's    evidence

regarding several elements of this crime.

             First, Vega argues that the Government did not present

sufficient    evidence   proving   that     she    knew   the   property    she

transacted in -- i.e., the money she used to pay her loan and

purchase a certified check -- was criminally derived.                      This

argument hinges on the point we rejected in considering her

identity theft claim -- that the Government did not provide

sufficient evidence to prove she knew of the theft at Preferred

prior to December 2010.     We also note that Vega's money laundering

charges correspond to transactions that occurred after the date

she concedes the Government proved she knew of the fraud (late

December 2010 and mid-January 2011).

             Second, Vega argues that the Government failed to prove

that the value of each transaction was greater than $10,000.               This

argument is also contingent on Vega's view that the Government did

not prove she knew of Preferred's fraud until December 2010.

According to Vega, Medicare paid only $9,633.98 to Preferred

following December 2010 and we should assume Vega used only "clean"

                                   -28-
funds to pay her loans.   Our finding that the Government presented

sufficient evidence that Vega knew of the fraud prior to December

2010 compels us to reject her argument.

          Finally, Vega argues that the Government failed to prove

that her transactions affected interstate commerce.    Vega points

to the fact that Preferred's bank account was with Banco Popular

and both of her transactions went to other Banco Popular accounts.

She argues that transferring money within the same bank cannot

affect interstate commerce.   This claim was considered sua sponte

by the district court and then rejected based on the Government's

arguments that a witness who worked for CIGNA, the processor that

paid out Medicare claims, stated CIGNA was located in Tennessee

and was the subsidiary of a South Carolina company.       Vega now

argues this ruling was erroneous because there was no testimony

that CIGNA was based in Tennessee and the location of CIGNA's

parent company was irrelevant.

          We reject Vega's argument.    Section 1957 requires only

a de minimus effect on interstate commerce.      United States v.

Benjamin, 252 F.3d 1, 10 (1st Cir. 2001).       We have previously

stated that a bank deposit affects interstate commerce if "the

source of that deposit actually affected interstate commerce to

any degree."   Id. at 11.     The crux of the Government's cases

against Vega was that she defrauded a federal health care program.

                                 -29-
We think it is uncontroversial to conclude the source of Vega's

funds   affected        interstate       commerce,     thereby   satisfying   the

interstate commerce element.             See United States v. Girod, 646 F.3d
304,    315    (5th     Cir.     2011)    (rejecting      defendant's     argument

government      failed    to     prove     interstate     commerce   affect   for

healthcare fraud charges because "Medicaid . . . is a federally

funded program that indisputably affects interstate commerce").

We thus find the Government presented sufficient evidence to

convict Vega of money laundering.

                                 VII.     Conclusion

              Finding     that    the     Government     presented      sufficient

evidence and any procedural defects were harmless, we affirm.

              Affirmed.

                                          -30-