Court Opinion

ID: 9375336
Source: CourtListenerOpinion
Date Created: 2023-02-27 16:00:49.939808+00
Date Added: 2024-06-11T17:16:57.954951
License: Public Domain

Case: 21-11273   Document: 00516654596      Page: 1   Date Filed: 02/23/2023

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

                                                                      FILED
                                                               February 23, 2023
                             No. 21-11273                        Lyle W. Cayce
                                                                      Clerk

   United States of America,

                                                      Plaintiff—Appellee,

                                versus

   Leah Hagen,

                                                  Defendant—Appellant,

                        consolidated with
                          _____________

                            No. 21-11279
                          _____________

   United States of America,

                                                      Plaintiff—Appellee,

                                versus

   Michael Hagen,

                                                  Defendant—Appellant.
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                                     No. 21-11273
                                   c/w No. 21- 11279

                    Appeals from the United States District Court
                         for the Northern District of Texas
                              USDC No. 3:19-CR-146-1
                              USDC No. 3:19-CR-146-2

   Before Higginbotham, Southwick, and Higginson, Circuit
   Judges.
   Stephen A. Higginson, Circuit Judge:
          Leah and Michael Hagen were convicted by a jury of conspiring to
   defraud the United States and to pay and receive health care kickbacks, in
   violation of 18 U.S.C. § 371 and 42 U.S.C. § 1320a-7b(b)(1), (b)(2), and
   conspiring to commit money laundering, in violation of 18 U.S.C.
   § 1956(a)(2)(A), (h). The district court sentenced each defendant to 151
   months of imprisonment to be followed by three years of supervised release
   and ordered the defendants to pay, jointly and severally, $27,104,359 in
   restitution. The Hagens now appeal, arguing that the district court erred in
   excluding certain evidence, refusing to instruct the jury about an affirmative
   defense, imposing a sentencing enhancement for sophisticated money
   laundering, and ordering restitution. For the reasons stated below, we
   AFFIRM the Hagens’ convictions and sentences.
                                          I.
                                          A.
          Medicare Part B is a federal healthcare program that provides durable
   medical equipment (“DME”) like wheelchairs, walkers, and braces to
   qualifying individuals, among other benefits. Medicare Part C, which is
   administered by private health insurance companies, also covers DME for
   beneficiaries.
          A beneficiary of Medicare Parts B or C needs a doctor’s order to
   obtain covered equipment. To write such an order, Medicare requires that

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   the doctor have treated or examined the patient. But when a patient lives in
   a rural area where there is limited access to medical care, Medicare accepts
   an electronic “telehealth” meeting between the doctor and patient as a
   substitute. Still, telehealth appointments must include real time audio and
   visual communication and patients must go to a medical facility like a
   doctor’s office or hospital for telehealth calls.
          After a patient gets a doctor’s order, an equipment supply company
   fills it. Then, the supplier submits a claim to Medicare for the equipment. A
   claim is only eligible for payment under Part B if the supplier is enrolled in
   Medicare.
          To enroll in Medicare, a supplier must agree to comply with pertinent
   laws and regulations, including the federal Anti-Kickback Statute (“AKS”),
   42 U.S.C. § 1320a-7b. That statute “criminalizes the payment of any funds
   or benefits designed to encourage an individual to refer another party to a
   Medicare provider for services to be paid for by the Medicare program.”
   United States v. Miles, 360 F.3d 472, 479 (5th Cir. 2004). Medicare does not
   reimburse claims that are based on prohibited kickbacks.
          The Hagens are a married couple that owned and operated two DME
   supply companies, Metro DME Supply (“Metro DME”) and Ortho Pain
   Solutions (“OPS”).
          In 2006, the Hagens enrolled Metro DME as a provider under
   Medicare Part B. On February 7, 2013, the Hagens applied to recertify Metro
   DME as a Part B provider. In that application, the Hagens stated that they
   would comply with the AKS. The Hagens recertified that statement in 2016
   and 2017. But the Hagens terminated Metro DME’s Part B certification on
   September 30, 2017.

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           At trial, the Hagens testified that they founded OPS in 2014 to sell
   wholesale braces to doctors. As discussed below, the Hagens used OPS to
   bill private insurers for equipment through Medicare Part C.
                                          B.
          Between March 2016 and January 2019, almost all the Hagens’
   business was generated through two companies called Chronos Strategies
   HLK Corp. (“Chronos”) and Pantheon Concepts HLK Co. (“Pantheon”).
   Herb Kimble owned those companies with his wife, Claire Reyes Kimble, and
   operated them out of the Philippines. Chronos and Pantheon purported to
   offer marketing and business process outsourcing (“BPO”) services to the
   Hagens.
          Kimble testified that the Hagens visited him in the Philippines in 2017
   and 2018. During those trips, the Hagens visited Kimble’s call center and
   observed his operations.
          To help the Hagens get equipment orders, Kimble’s companies ran
   advertisements targeting senior citizens who had pain or discomfort. Those
   advertisements directed targets to contact a call center, also operated by
   Kimble, where an “opener” would make sure the target was Medicare
   eligible. Next, the call would be transferred to a “closer” to confirm the
   caller’s eligibility and upsell the caller on additional braces. The closer would
   then transfer the caller to a telemedicine doctor who would sign an
   equipment order. Kimble’s companies would upload the order to an online
   portal where the Hagens’ DME companies could access them to bill
   Medicare.
          More than eighty percent of Kimble’s callers were told they needed
   two or more braces. And almost seventy percent were persuaded to get what

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   Kimble called an “iron man package,” meaning three or more braces—for
   example, shoulder, back, knee, and wrist braces.
          At trial, Kimble testified that he was introduced to the Hagens on a
   phone call in March 2016. 1 During the call, the Hagens allegedly told Kimble
   that they had been unhappy with a prior marketing deal where they paid for
   leads on doctors’ orders. Those leads often did not result in completed
   orders. So Kimble proposed that he would sell the Hagens completed orders
   that they could immediately fill and submit to Medicare for reimbursement.
   Under this arrangement, the Hagens would prepay Kimble for a certain
   number of brace orders at a set price per order and “get a guaranteed result.”
   The Hagens agreed to give it a shot. According to Kimble, the Hagens
   negotiated prices for different types of brace orders over email and signed
   contracts with Chronos and Pantheon.
          An email exchange shortly after the Hagens signed the contracts
   supports Kimble’s story. Leah emailed that Metro DME wanted to fill back
   brace orders. Claire Kimble answered at Herb’s direction. Since Kimble’s
   companies would not be able to “monetize” all “inbound leads and calls”
   “with just [b]ack [b]race” orders, they would charge at least $375 per back
   brace order. Michael responded, “[t]his is not what was agreed upon. I made
   notes during the first call with Herb and there was no mention of strings
   attached.” He also seemed to complain that Claire had mentioned the
   alleged kickback scheme in writing: “[W]hy are you emailing about this?? We
   are NOT paying per referral! This is not a good start!” But Leah also emailed
   back, “[l]et’s start with [ten] back and [five] wrist if we can please.”

          1
            Kimble testified that this call was in March 2015. Despite Kimble’s testimony,
   the government asserts that the call happened in March 2016. Given the timing of
   subsequent emails in the record, Kimble likely misspoke.

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          Other evidence was consistent with Kimble’s account of the deal.
   Leah’s emails and Skype messages to Kimble’s companies often referred to
   specific quantities of orders. When the Hagens missed a payment, Kimble
   did not send them orders. And when an order did not result in payment by
   Medicare, the Hagens asked for replacement orders, which they called
   “credits.”
          As a result of the deal with Kimble, the Hagens’ business grew
   exponentially. In 2015, Metro DME billed between 100 and 200 claims, and
   in 2016, it billed over 6,000 claims. From January 2015 to February 2016,
   Metro DME received $135,000 from Medicare. In January 2017 alone, Metro
   DME cleared about $1 million in Medicare payouts. OPS had similar returns
   in 2018. Meanwhile, the geographic scope of the Hagens’ business expanded
   from the Dallas area to nationwide.
          To cover up the scheme, Kimble testified that the Hagens signed
   contracts for legitimate business services. Marketing contracts between
   Metro DME and Pantheon and OPS and Chronos said that Kimble’s
   companies would provide the Hagens’ companies with “[r]aw [l]eads” on
   potential customers. Those contracts explained that raw leads were “not
   referrals” or guaranteed customers. BPO contracts between Metro DME
   and Chronos and OPS and Pantheon required the Hagens’ companies to pay
   Kimble’s companies on an hourly basis, and Kimble’s companies would
   “submit properly documented invoices . . . on a weekly basis for the
   [s]ervices performed the previous week.” Those services included handling
   inbound calls and making outbound calls to potential customers. All the
   contracts said that the parties would comply with the AKS. And Kimble
   testified that in case of an audit, Kimble or the Hagens could point to the
   contracts to prove that they were not paying for doctors’ orders.

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           Consistent with those contracts, Kimble’s companies billed the
   Hagens for marketing and BPO services. But Kimble testified that the
   invoices were used to disguise the scheme. Each week, the total amount
   owed for doctors’ orders would be divided into 75 and 25 percent portions
   and invoiced as a marketing fee and hourly BPO fee, respectively.
           Despite the guise of separate marketing and BPO fees, Kimble’s
   companies started charging a “standardized brace cost of $280 per brace” in
   September 2016. From that point on, the Hagens wired Kimble’s companies
   weekly payments in amounts divisible by $280.
           The Hagens tried to shield their employees from the scheme.
   Employees of the Hagens testified that Kimble’s companies sent doctors’
   orders, medical records, and recordings of patient conversations to the
   Hagens’ office.     But the Hagens did not permit those employees to
   communicate with Kimble’s companies or to listen to the recordings.
           Between March 2016 and January 2019, the Hagens’ companies billed
   Medicare Part B and Medicare Part C insurers almost $59,976,900. They
   were paid about $27 million, around $15 million of which was wired to
   Kimble’s companies. Those wires were sent in pairs, to Chronos and
   Pantheon in the Philippines. The Hagens also wired $5 million of their gains
   to their overseas accounts. They used some of that money to renovate a
   home in Spain.
           However, Medicare took note of the Hagens’ unusual billing activity.
   Medicare denied claims because braces were not medically necessary, not
   enough time had elapsed since the patient had received the same brace, or
   the patient had passed away. One denial letter said that the doctor ordered
   so much equipment for the patient that the patient would be a “walking
   mummy.” Sometimes, Medicare denied hundreds of the Hagens’ claims at
   once.

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          In August 2017, a Medicare contractor suspended payments to Metro
   DME. The Hagens terminated Metro DME’s Medicare Part B enrollment
   at the end of September 2017. Kimble testified that he advised the Hagens to
   start billing private insurers through Medicare Part C, and they did so with
   OPS. Those insurance companies denied OPS’s claims almost every day.
   Humana audited OPS, and Aetna stopped payments to OPS altogether.
          At trial, the Hagens told a different story. Leah testified that Kimble
   did not explain the scheme in their first call. To the contrary, Leah testified
   that Kimble only described the marketing, advertising, and BPO services that
   he could provide. Leah said she thought those services were legitimate and
   asserted that the Hagens never had access to Kimble’s internal operations,
   including telehealth doctors or doctor-patient consultations.         Michael
   confirmed that they never entered into an agreement to buy doctors’ orders
   from Kimble.
          Instead, both Leah and Michael testified that Kimble told them about
   a formula that allowed him to calculate the likely number of doctors’ orders
   produced by a given number of leads. They would give Kimble a target
   number of doctors’ orders, and Kimble would estimate how many raw leads
   they needed to buy to meet the target. The Hagens prepaid for leads, but
   doctors’ orders were not guaranteed.         Kimble’s $280 cost per brace
   represented internal advertising costs and nothing more. As to credits that
   the Hagens demanded from Kimble, Michael testified the Hagens were
   merely asking for invalid or duplicate leads to be regenerated.
          In addition, Leah testified that Kimble never told them that the
   contracts were a sham to disguise their illegal scheme. She maintained that
   they had agreed to pay $8 per hour for BPO services and $7.50 per raw lead.
   Yet Michael testified that they never saw any raw leads. Michael also
   testified that Kimble told him that the contracts had been “vetted” and

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   “reviewed” by attorneys. But the Hagens did not have their own attorneys
   review the contracts.
          The jury also heard evidence that Kimble said the Hagens were
   clueless about the scheme. On cross-examination, defense counsel refreshed
   Kimble’s recollection with a report from an interview with a government
   agent on December 5, 2018. Kimble admitted that he told the agent that the
   Hagens believed “[t]hat the system they were operating in” was “[l]egal.”
   On redirect, Kimble clarified that he did not write the interview report and
   did not know the context for the statement in the report.
                                         C.
          The Hagens were charged in a two-count superseding indictment.
   The first count alleged that the Hagens conspired to defraud the United
   States and to pay and receive healthcare kickbacks, see 18 U.S.C. § 371; 42
   U.S.C. § 1320a-7b(b)(1), (b)(2), and the second count alleged that they
   conspired to commit money laundering, see 18 U.S.C. § 1956(a)(2)(A), (h).
          After an eight-day trial, the jury found Leah and Michael Hagen guilty
   on both counts. The Hagens filed a joint motion for a new trial, which the
   district court denied.
          The district court sentenced each defendant to 151 months of
   imprisonment to be followed by three years of supervised release and ordered
   the defendants to pay, jointly and severally, $27,104,359 in restitution.
          The Hagens have timely appealed.
                                         II.
          The Hagens first challenge the district court’s decision to exclude the
   testimony of an attorney, Joshua Skora, with whom Kimble consulted. This
   testimony was not relevant and was cumulative with testimony elicited on

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   Kimble’s cross-examination. Accordingly, the district court did not abuse its
   discretion in excluding it. 2
                                            A.
          Where a defendant preserves an objection to the exclusion of
   evidence, we review the district court’s ruling for an abuse of discretion and
   harmless error. United States v. Njoku, 737 F.3d 55, 73 (5th Cir. 2013); United
   States v. Saldana, 427 F.3d 298, 306 (5th Cir. 2005). “A district court abuses
   its discretion if it bases its decision on an error of law or a clearly erroneous
   assessment of the evidence.” United States v. Portillo, 969 F.3d 144, 168 (5th
   Cir. 2020). But a district court “has the power to exclude . . . witness
   testimony that would be cumulative and marginally relevant.” United States
   v. Alaniz, 726 F.3d 586, 606 (5th Cir. 2013) (citation omitted). We give the
   trial court “wide discretion in assessing the relevance and prejudicial effect
   of evidence.” Id. (citation omitted); see United States v. Gonzalez-Lira, 936
   F.2d 184, 191 (5th Cir. 1991) (trial judge’s balancing of probative value and
   prejudicial effect given “great deference on review”).
          An error in excluding evidence is harmless “unless it affected the
   defendant’s substantial rights.” United States v. Johnson, 880 F.3d 226, 231
   (5th Cir. 2018) (citation omitted). The question of for us is whether,
   “consider[ing] the other evidence in the case[,] . . . the improperly excluded
   evidence, if admitted, would have had a substantial impact on the jury’s
   verdict.” Id. (citation omitted).

          2
             The Hagens also argue that the district court erred in excluding documentary
   evidence of Kimble’s communications with his attorneys. For similar reasons as concern
   Skora’s testimony, see infra Section II.C, any error in excluding these documents was
   harmless.

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                                           B.
         In the Hagens’ pretrial witness and exhibit lists, they named four of
   Kimble’s attorneys, including Skora, and included hundreds of documents
   pertaining to Kimble’s communications with his legal team.                 The
   government moved in limine to exclude those witnesses and evidence on
   notice and relevance grounds.        The district court denied that motion,
   permitting the Hagens “to call as witnesses four former attorneys of . . .
   Kimble    and   to     present     evidence     of   Kimble’s    attorney-client
   communications, if admissible.”
         At trial, the defense tried to cross-examine Kimble about whether he
   told the Hagens that his “operations were . . . vetted by healthcare and
   regulatory lawyers.”     The government objected.           “[I]n abundance of
   caution,” the district court let the defense ask Kimble whether law firms
   created the contracts so long as the defense also asked Kimble whether he
   told the Hagens that the contracts had been vetted. The court permitted the
   defense to show certain emails to Kimble but sustained the government’s
   objection to admitting those emails on hearsay grounds.
         On cross-examination, Kimble testified that templates for the
   Hagens’ contracts had been prepared by an attorney at King & Spalding.
   Kimble also testified that he consulted with lawyers at K&L Gates. However,
   Kimble said that he did not share his communications with those firms with
   the Hagens. The defense then cross-examined Kimble about the meaning of
   different terms and provisions in the contracts between Kimble’s and the
   Hagens’ companies.
         After the cross-examination, the Hagens submitted a trial brief
   arguing that defendants’ proposed exhibits 147-238, 247, 258-330, 349-68,
   370, 374-76, and 383-88 should be admitted. At a bench conference, the
   defense argued that the evidence was relevant because it showed that Kimble

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   explained his business to his lawyers in the same way that the Hagens claimed
   he explained it to them. The government responded that the evidence was
   hearsay, confusing, misleading, and irrelevant. The district court excluded
   the documentary evidence on hearsay and relevance grounds but permitted
   the defense to recall Kimble and ask him about his communications with his
   lawyers.
          The defense chose not to recall Kimble, and instead made a proffer of
   Skora’s testimony outside the presence of the jury. Skora testified that
   Kimble was a former client who had retained K&L Gates to provide
   regulatory compliance advice for Chronos and Pantheon with respect to
   “prospective activities that the companies wanted to do with third-party
   companies.”    To help “get[] to know a new client,” Skora reviewed
   marketing and BPO service agreements dated October 11, 2017, between
   Kimble’s companies and a third-party company called Rego Medical.
   Kimble never told Skora that Kimble sold doctors’ orders to clients, and
   Skora’s impression was that Kimble’s prospective activities with third
   parties would be in compliance with federal law.
          The district court excluded Skora’s testimony. The government did
   not dispute and the court accepted that the Rego Medical contracts were
   identical to those entered into by the Hagens’ companies, but the court
   would not permit Skora to testify. The court explained that if Skora’s
   testimony concerned the contracts between Kimble and the Hagens, Skora’s
   testimony might be admissible. And the court stated that if the defense could
   call a lawyer who had reviewed the two contracts at issue in the Hagens’ case,
   then the court would entertain the admissibility of such a witness. The
   Hagens did not call such a lawyer as a witness.
          After the jury returned a verdict, the Hagens moved for a new trial
   based on the district court’s exclusion of Skora’s testimony and the

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   documentary evidence of Kimble’s attorney-client communications. The
   district court denied the motion.
          The district court rejected the Hagens’ argument that Skora’s
   testimony “would have bolstered their position that Kimble misled them by
   concealing the illegal nature of his operation.” The fact that Skora never
   heard Kimble mention the sale of doctors’ orders was not “key exculpatory
   information,” as the defense suggested. Rather, Kimble hired Skora after the
   Hagens signed their contracts with Kimble, rendering Skora’s testimony
   irrelevant to the contracts at issue in the case. And the district court noted
   that the Hagens elicited similar testimony from Kimble on cross-
   examination.
          For the same reasons, the district court concluded that the
   documentary evidence was inadmissible. The district court also explained
   that the Hagens did not identify “any specific document . . . that would have
   impacted the jury’s verdict” or how the documents would have impacted the
   verdict.
                                          C.
          The district court did not abuse its discretion in excluding Skora’s
   testimony because the proffered testimony was irrelevant and needlessly
   cumulative. In any event, exclusion of Skora’s testimony was harmless error
   in light of the other evidence in the case.
          Under Federal Rule of Evidence 401, evidence is relevant if “it has
   any tendency to make a fact more or less probable than it would be without
   the evidence” and “the fact is of consequence in determining the action.”
   Fed. R. Evid. 401; see United States v. Jones, 664 F.3d 966, 975 (5th Cir.
   2011) (“Evidence is relevant if it tends to prove the point . . . for which it is

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   offered . . . and if the point . . . counts in the case.” (citation omitted)).
   “Irrelevant evidence is not admissible.” Fed. R. Evid. 402.
           The Hagens’ theory is that Skora’s testimony makes it more likely
   that they believed they were buying legitimate marketing and BPO services
   from Kimble, not doctors’ orders. And if that were true, the Hagens may
   have lacked the necessary criminal intent to act “with bad purpose either to
   disobey or disregard the law,” United States v. Ricard, 922 F.3d 639, 648 (5th
   Cir. 2019) (citation omitted), for the government to prove a conspiracy to
   violate the AKS, see United States v. Sanjar, 876 F.3d 725, 746 (5th Cir. 2017);
   Njoku, 737 F.3d at 64. 3
           But the fact that Kimble did not tell Skora that he sold doctors’ orders
   to suppliers does not have “any tendency to make [it] more or less probable”
   that Kimble also did not tell the Hagens that he was selling them doctors’

           3
             In relevant part, the Anti–Kickback Statute, 42 U.S.C. § 1320a-7b(b), “is violated
   when a defendant knowingly and willfully gives or receives a benefit for referring a party to
   a health care provider for services paid for by a federal health care program.” Sanjar, 876
   F.3d at 746. The government must prove beyond a reasonable doubt that the defendant
   “(1) solicited or received renumeration, (2) in return for referring an individual for a
   service, (3) that may be paid under a federal health care program, and (4) that the defendant
   acted knowingly and willfully.” Ricard, 922 F.3d at 647.
            To obtain a conviction for a conspiracy to violate the AKS, the government must
   prove an agreement to violate that law, knowing and voluntary participation in the
   conspiracy, and an overt act by one member of the conspiracy in furtherance of the unlawful
   goal. Id.; Njoku, 737 F.3d at 64 (citation omitted). “The government must prove the same
   degree of criminal intent as is necessary for proof of the underlying substantive offense.”
   United States v. Peterson, 244 F.3d 385, 389 (5th Cir. 2001) (citation omitted). Thus, the
   government has to prove that a defendant intended to further an unlawful objective and
   acted willfully, “with the specific intent to do something the law forbids,” Njoku, 737 F.3d
   at 64 (citation omitted), meaning a “bad purpose either to disobey or disregard the law,”
   Ricard, 922 F.3d at 648 (citation omitted). But a defendant need not be aware of the specific
   law that the defendant is charged with violating. United States v. Nora, 988 F.3d 823, 830
   n.3 (5th Cir. 2021).

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   orders, or that the Hagens did not know about the true nature of their
   relationship. See Fed R. Evid. 401(a). That Kimble kept a secret from an
   attorney retained to analyze one business partner does not have any bearing
   on whether Kimble kept the same secret from a different business partner.
   Indeed, the Hagens had nothing to do with Skora’s engagement. Skora
   reviewed contracts that Kimble signed with a separate third party. He did
   not testify that Kimble asked him to review the Hagens’ contracts or the
   arrangement that Kimble had struck with them. And Kimble engaged Skora
   more than a year after the alleged scheme had begun, after the Hagens had
   signed all their contracts.
          While the Hagens argue that “the point of the testimony” was “to
   show how Kimble misled both healthcare attorneys and the Hagens about the
   nature of the operation,” it does not follow that Kimble would have disclosed
   his deal with the Hagens in an unrelated conversation about a different
   company. Even assuming Kimble had the same deal with Rego Medical that
   he did with the Hagens, there is no reason why Kimble would have asked
   Skora to review the illegal aspects of his operations. After all, the purpose of
   the marketing and BPO services contracts was to give Kimble’s operation a
   veneer of legitimacy.
          Construed liberally, the Hagens’ argument is that because a
   healthcare attorney could not discern an undisclosed, illegitimate part of
   Kimble’s business from the contracts, it is more likely that a DME supplier
   given the same information would also be unaware of the hidden kickback
   scheme. But this argument rests on an unsubstantiated premise that Skora
   was given the same information as the Hagens, even though he consulted
   with Kimble about a different third-party company long after Kimble and the
   Hagens started doing business, and even though Kimble retained Skora for
   compliance advice. The district court did not abuse its discretion in deciding

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   that this lawyers-to-partners comparison is too remote and speculative to
   make the Hagens’ innocent state of mind more probable. 4
           True, the contracts that Skora reviewed were the same as those that
   the Hagens signed. This would tend to make it more likely that the Hagens’
   contracts were legitimate, since Skora concluded that Kimble’s prospective
   contracts with Rego Medical would be legitimate. But the legitimacy of the
   Hagens’ contracts was not a disputed fact at trial. Kimble testified that the
   purpose of the contracts was to cover up the kickback scheme. The contracts
   needed to be legitimate so that if Kimble or the Hagens were audited, nothing
   would appear to be amiss. And the case turned on whether those contracts
   accurately represented Kimble’s business with the Hagens. In other words,
   the fact that the Hagens’ contracts were approved by a lawyer is irrelevant to
   whether those contracts accurately represented the Hagens’ dealings with
   Kimble.
           Even if Skora’s testimony had some relevance to the Hagens’
   scienter, the district court did not take a clearly erroneous view of the
   evidence in finding its probative value “substantially outweighed by a danger
   of . . . needlessly presenting cumulative evidence” under Rule 403. Fed. R.
   Evid. 403. The district court permitted the defense to elicit compelling
   testimony from Kimble on cross-examination. Kimble testified that his
   attorney at King & Spalding, Seth Lundy, prepared the template contracts

           4
             The Hagens also argue that Skora’s testimony would have shown that the way
   Kimble talked about “his business operation to outside parties was inconsistent with the
   way he described his business operation at trial.” But Skora is not the same kind of outside
   party as the Hagens: he was a lawyer retained to evaluate the contracts for regulatory
   compliance, not a business partner being brought in on the deal. So Skora’s “point of view
   with respect to Kimble’s operation” was not the same as the Hagens’, and Kimble did not
   “deceive[] a knowledgeable and experienced healthcare attorney in a similar way” to the
   Hagens.

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                                      No. 21-11273
                                    c/w No. 21- 11279

   that the Hagens signed. The defense then cross-examined Kimble about how
   he later sought advice from K&L Gates about the templates.               It was
   unnecessary to call Skora to corroborate Kimble’s testimony that K&L Gates
   had reviewed those contracts. And since Kimble testified that the specific
   contracts that the Hagens used had been generated by his legal team, it would
   have been needlessly cumulative to offer testimony from a different lawyer
   confirming that those contracts, used in the context of a separate business
   relationship, were legitimate.
          The Hagens rely on United States v. Lowery, but that case is inapposite.
   135 F.3d 957 (5th Cir. 1998) (per curiam). There, the government indicted
   and tried the owner of a gentleman’s club for obstruction of justice in
   connection with an earlier trial of the owner’s girlfriend for tax evasion. Id.
   at 958-59. The defendant argued as an affirmative defense that he had merely
   tried to encourage one of his employees and the employee’s son to tell the
   truth at the girlfriend’s trial. Id. at 959. The district court excluded evidence
   from the tax-evasion trial on the ground that it was irrelevant. Id. Our court
   reversed, finding that the exclusion of “evidence from and with reference to
   the . . . trial” was harmful error because the defendant could not develop his
   affirmative defense without eliciting testimony about the government’s
   conduct in the trial—evidence that the district court’s order excluded. Id. at
   959-60. In effect, the district court “left [the defendant] little more than the
   ability to make unsubstantiated and . . . unprovable claims on the witness
   stand.” Id. at 960.
          This case is different from Lowery. Skora’s testimony would not have
   allowed the Hagens to argue that they were ignorant about the scope of
   Kimble’s operation, which was the lynchpin of their defense. Instead,
   Skora’s analysis of Kimble’s later arrangement with an unrelated third-party
   would have only made it more likely that the Hagens’ contracts were legal—

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                                          No. 21-11273
                                        c/w No. 21- 11279

   not that those contracts represented the extent of their deal. And the district
   court did not restrict all references to the legitimacy of the contracts. Rather,
   the district court permitted the defense to cross-examine Kimble about
   whether lawyers had vetted the contracts. And based on the resulting cross-
   examination, the defense argued at closing that the “contracts were vetted
   and prepared . . . by healthcare regulatory attorneys . . . at the international
   law firm of King & Spalding.” The Hagens’ claims that they believed the
   contracts to be legitimate were not left unsubstantiated and unprovable by
   the district court’s evidentiary ruling. 5
           Regardless, any error by the district court in excluding Skora’s
   testimony did not have a substantial impact on the jury’s verdict. See
   Johnson, 880 F.3d at 231. Even if Skora’s testimony made it more likely that
   Kimble misled the Hagens, ample evidence supported Kimble’s testimony
   that the Hagens knew they were purchasing doctors’ orders. The Hagens
   objected to Kimble’s wife mentioning referrals over email, requested specific
   quantities of doctors’ orders, did not receive orders when they failed to pay
   Kimble, and asked for orders to be credited to their account when Medicare

           5
             United States v. Garber proves the point. 607 F.2d 92 (5th Cir. 1979). In Garber,
   a defendant charged with tax evasion for not paying income taxes on money she received
   for donating blood plasma testified that she subjectively believed that plasma sales were not
   taxable. Id. at 99. But the district court did not permit expert testimony that a recognized
   legal theory supported her belief. Id. Under those circumstances, our court held that the
   district court improperly “deprived the defendant of evidence showing her state of mind
   to be reasonable.” Id. Setting aside the minimal probative value of Skora’s testimony
   compared to the tax expert’s testimony in Garber, here, the district court permitted cross-
   examination on what the defense argued was an exculpatory fact: the creation and vetting
   of the contracts by outside lawyers. If the Garber defendant had been permitted to cross-
   examine a phlebotomist at the plasma center about how the technician had vetted a tax-free
   pay-for-plasma deal with a lawyer, the court very well may have decided the case
   differently. Given Kimble’s cross-examination and nature of Skora’s testimony, the
   district court did not withhold a fact that had a “powerful impact on the issue of [the
   Hagens’] willfulness . . . from the jury,” see id.

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                                    No. 21-11273
                                  c/w No. 21- 11279

   refused reimbursement. The jury also heard evidence that the Hagens and
   Kimble used a contrived formula to make invoices conform with their
   contracts and adopted a standard price per brace. The Hagens’ employees
   testified that they were not allowed to interact with Kimble’s companies, the
   Hagens’ business exploded as soon as they started working with Kimble, and
   the Hagens’ claims were frequently rejected by Medicare and private
   insurers. If that were not enough, Kimble’s brother testified that he had a
   similar kickback deal with Kimble. Given the strength of this evidence
   showing that the Hagens willingly participated in the kickback scheme—a
   scheme that was not disclosed to Skora—testimony that Kimble’s operations
   seemed legitimate to Skora would not have impacted the verdict.
          Ultimately, the jury did hear evidence that lawyers created the
   Hagens’ contracts, a point which the defense argued to the jury in closing.
   Faced with this argument and the evidence supporting it, the jury rejected
   the defense theory that the Hagens thought Kimble’s business was
   legitimate.   Skora’s testimony that Kimble’s operations, including the
   template contracts, seemed legitimate was too attenuated from the Hagens’
   deal and too repetitive of evidence the jury already heard to make a
   difference. See United States v. Mejia, 844 F.2d 209, 215 (5th Cir. 1988)
   (exclusion of testimony harmless where cumulative); United States v.
   Rajwani, 476 F.3d 243, 248 (5th Cir. 2007) (exclusion of testimony harmless
   where cumulative and other evidence of guilty knowledge was extensive).
                                        III.
          Next, the Hagens argue that the district court abused its discretion in
   refusing to give the jury a proposed instruction concerning a safe-harbor
   defense to the AKS violations. But the Hagens did not put forward sufficient
   evidence to warrant such an instruction, and any error in refusing to give the
   instruction was harmless.

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                                          A.
          We review a district court’s refusal to give a requested jury instruction
   for abuse of discretion. United States v. Martinez, 921 F.3d 452, 477 (5th Cir.
   2019); see United States v. Gibson, 875 F.3d 179, 195 (5th Cir. 2017). “The
   district court abuses its discretion by refusing to include a requested
   instruction only if that instruction: (1) is substantively correct; (2) is not
   substantially covered in the charge given to the jury; and (3) concerns an
   important point in the trial so that the failure to give it seriously impairs the
   defendant’s ability to present effectively a particular defense.” United States
   v. Simkanin, 420 F.3d 397, 410 (5th Cir. 2005).
          A defendant is generally entitled “to an instruction as to any
   recognized defense for which there exists evidence sufficient for a reasonable
   jury to find in his favor.” Mathews v. United States, 485 U.S. 58, 63 (1988);
   see United States v. Bradfield, 113 F.3d 515, 522 (5th Cir. 1997) (reiterating the
   standard from Mathews “that evidence in support of a defensive theory must
   be sufficient for a reasonable jury to rule in favor of the defendant on that
   theory”). It follows that a district court may refuse “to give a requested
   instruction which . . . is without foundation in the evidence.” United States
   v. Tannehill, 49 F.3d 1049, 1057 (5th Cir. 1995) (citation omitted).
          A trial court’s failure to give a requested safe-harbor instruction “is
   subject to harmless error review.” United States v. Turner, 561 F. App’x 312,
   319 (5th Cir. 2014) (unpublished) (quoting United States v. Aldawsari, 740
   F.3d 1015, 1019 (5th Cir. 2014)); see United States v. Nguyen, 493 F.3d 613,
   623 (5th Cir. 2007); see also United States v. Chen, 913 F.2d 183, 192 (5th Cir.
   1990); United States v. Bernal, 814 F.2d 175, 184 (5th Cir. 1987). Even if the
   jury instructions were erroneous on account of an improperly omitted
   instruction, “we will not reverse if we determine, based on the entire record,

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   that the challenged instruction could not have affected the outcome of the
   case.” Nguyen, 493 F.3d at 623 (citation omitted).
                                               B.
           As we explained, the AKS is violated when a defendant knowingly and
   willfully gives or receives “remuneration” for referring a party to a health
   care provider for services paid for by a federal health care program. 42 U.S.C.
   § 1320a-7b(b)(1), (b)(2); see Sanjar, 876 F.3d at 746. The Department of
   Health and Human Services (“DHHS”) has promulgated regulations that
   exclude certain types of remuneration from criminal liability under the
   statute. See 42 C.F.R. § 1001.952(b), (d), (f). Relevant here, these “safe-
   harbor” provisions include an exception for “personal services” contracts
   where “payment [is] made by a principal to an agent as compensation for the
   services of the agent” and certain conditions are met. 6 Id. § 1001.952(d).
           For the personal services safe harbor to apply:
           (1) the agreement must be “set out in writing and signed by the
           parties”;

           6
             Between January 20, 2016, and January 18, 2021, the personal services safe harbor
   remained the same and its conditions were codified at 42 C.F.R. § 1001.952(d)(1)-(7). In
   2021, DHHS amended the applicable conditions for application of the personal services
   safe harbor and recodified the amended conditions at 42 C.F.R. § 1001.952(d)(1)(i)-(vi).
   See 85 Fed. Reg. 77,887 (Dec. 2, 2020). The parties do not take positions on whether the
   old or new safe-harbor regulations apply in this case. While the government appears to cite
   the 2021 amendments, the defendants’ proposed instruction, filed with the trial court on
   July 5, 2021, more closely tracks the language of the pre-2021 regulations. This opinion
   applies the pre-2021 regulations that were in effect when the Hagens entered and
   performed the contracts at issue. In any event, whether we apply the new or old regulations
   does not affect the disposition of this issue.

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          (2) the agreement must “cover[] all of the services the agent provides
          to the principal for the term of the agreement and specif[y] the
          services to be provided by the agent”;
          (3) if the agreement provides for services on less than a full-time basis,
          the agreement must specify “exactly the schedule of such intervals,
          their precise length, and the exact charge for such intervals”;
          (4) the agreement’s term “is for not less than one year”;
          (5) “[t]he aggregate compensation paid to the agent over the term of
          the agreement is set in advance, is consistent with fair market value in
          arms-length transactions and is not determined in a manner that takes
          into account the volume or value of any referrals or business otherwise
          generated between the parties for which payment may be made in
          whole or in part under Medicare, Medicaid or other Federal health
          care programs”;
          (6) services performed under the agreement do not involve counseling
          or promoting an activity that violates state or federal law; and
          (7) “[t]he aggregate services contracted for do not exceed those which
          are reasonably necessary to accomplish the commercially reasonable
          business purpose of the services.”
   42 C.F.R. § 1001.952(d)(1)-(7) (2016).
          The parties agree that the safe-harbor provision is an affirmative
   defense. See United States v. Robinson, 505 F. App’x 385, 387 (5th Cir. 2013)
   (unpublished) (per curiam); United States v. Turner, 561 F. App’x 312, 319
   (5th Cir. 2014) (unpublished); see also Sanjar, 876 F.3d at 742.
          At the charge conference, the Hagens maintained their initial request
   for an instruction on the personal services safe harbor, as well as for a

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                                  c/w No. 21- 11279

   preliminary instruction explaining that the defendant would have to prove
   the safe-harbor affirmative defense by a preponderance of the evidence. The
   government objected that the Hagens had not put forward sufficient evidence
   that the agreements covered all services to the agent and specified those
   services, 42 C.F.R. § 1001.952(d)(2), did not take into account the volume or
   value of referrals, 42 C.F.R. § 1001.952(d)(5), and were not consistent with
   fair market value, 42 C.F.R. § 1001.952(d)(5). After hearing argument, the
   district court did not give the requested personal services safe-harbor
   instruction. However, the district court did give an instruction on a good
   faith defense, as the Hagens requested.
                                         C.
          The Hagens did not present sufficient evidence on the fifth element
   of the personal services safe-harbor instruction for a reasonable jury to find
   in their favor on the defense. Mathews, 485 U.S. at 63; see Bradfield, 113 F.3d
   at 522. The district court accordingly did not abuse its discretion in declining
   to give a safe-harbor instruction. See Tannehill, 49 F.3d at 1057; United States
   v. Vega, 813 F.3d 386, 397 (1st Cir. 2016); United States v. Norton, 17 F. App’x
   98, 102 (4th Cir. 2001) (unpublished) (per curiam).
          On appeal, the Hagens argue that the personal services safe harbor
   applied to the BPO contracts and do not argue that the defense covered the
   marketing services contracts. But the evidence did not show that either
   contract was “consistent with fair market value in arms-length transactions”
   or was “not determined in a manner that takes into account the volume or
   value of any referrals” in accordance with the safe-harbor provision’s fifth
   element. 42 C.F.R. § 1001.952(d)(5).
          To begin, the record is devoid of evidence that the marketing or BPO
   agreements paid “aggregate compensation” to Kimble that was “consistent
   with fair market value in arms-length transactions.”                42 C.F.R.

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                                    No. 21-11273
                                  c/w No. 21- 11279

   § 1001.952(d)(5). The marketing contracts refer to price terms set in a
   “Campaign Insertion Order,” and it appears that the Hagens were invoiced
   $7.50 per raw lead. The BPO contracts set a rate of $8 per hour. On appeal,
   the Hagens do not point to any evidence that those rates satisfied the fair
   market value standard set in the safe-harbor provision. Our inquiry could
   stop here—the Hagens failed to introduce sufficient evidence for a jury to
   find all the requirements for the safe-harbor defense. See Tannehill, 49 F.3d
   at 1057.
          The contracts also accounted for the volume of referrals. 42 C.F.R.
   § 1001.952(d)(5). The Hagens agree that the marketing contracts pegged
   compensation on the number of raw leads generated, which they admit
   disqualifies those contracts from the safe harbor. But they argue that the BPO
   contracts charged $8 per hour for BPO services irrespective of raw leads.
          Whatever the BPO contracts said on their face, the Hagens
   acknowledge in their reply that “the money they remitted for BPO services
   was connected to the number of ‘raw leads.’” And that concession is
   consistent with their own theory of how the contract worked in practice. The
   Hagens testified that they prepaid for marketing and BPO services, that the
   amounts they prepaid were divided on a fixed basis, 75 percent for marketing
   and 25 percent for BPO, and that the total amount invoiced was based on a
   target number of raw leads. So it stands to reason that the amount paid
   pursuant to the BPO contract took into account the volume of raw leads—
   after all, the prepaid BPO services fee was calculated as a function of the raw
   leads that the Hagens wanted to procure. And just because those raw leads
   weren’t guaranteed, or so the Hagens testified, does not mean that the BPO
   fee was determined without reference to referral volume, as the safe-harbor
   provision requires. See 42 C.F.R. § 1001.952(d)(5).

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                                     No. 21-11273
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          Under the Hagens’ own understanding of the BPO contract, hourly
   compensation was determined in a manner that accounted for the volume of
   referrals. If the Hagens were right that a defendant could omit from a
   contract the real way the parties calculated an hourly fee—which is to say, by
   deciding in advance how many referrals would be generated and then
   charging the hourly fee necessary to get those referrals—the safe-harbor
   provision would shield pretextual agreements from criminal liability. But
   how a contractual rate is implemented is relevant in determining whether the
   rate is set by referral volume. See United States v. Nagelvoort, 856 F.3d 1117,
   1125-26 (7th Cir. 2017) (affirming jury verdict on sufficiency of the evidence
   challenge where recorded conversations revealed that a putative hourly rate
   might have been based on referrals). Here, the defendants’ own testimony
   as to how the BPO contract worked puts the contract outside the protection
   of the safe harbor. In light of this testimony, a reasonable jury could not have
   found that the BPO contract was referral-agnostic, and so the district court
   did not abuse its discretion in declining the instruction on this basis, either.
          Moreover, any error by the district court in declining to give a safe-
   harbor instruction for the BPO contracts was harmless because, taken by
   itself, the proposed personal services safe-harbor instruction as to the BPO
   contracts could not have impacted the jury’s verdict.
          Although the Hagens argued that the BPO and marketing services
   contracts were both covered by the safe harbor at trial, on appeal, they drop
   their challenge to the omitted instruction as to the marketing services
   contracts. That leaves the instruction for the BPO contracts. Assuming the
   district court erred in declining the safe-harbor instruction with respect to
   the BPO contracts, the jury may have found the personal services safe harbor
   applied to those contracts. If the jury did reach that conclusion, the Hagens’

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                                     No. 21-11273
                                   c/w No. 21- 11279

   payment practices under those contracts would not give rise to criminal AKS
   violations. See 42 C.F.R. § 1001.952.
          However, by accepting that the district court properly withheld the
   safe-harbor instruction as to the marketing contracts, the Hagens concede
   that the jury could have convicted them for their payment practices under
   those contracts. Indeed, the Hagens state that had the jury found the BPO
   contracts subject to the safe harbor, then the jury would “have focused on
   the Hagens’ intent with respect to the marketing agreement.” And given the
   evidence the jury heard about how the Hagens covered up their purchase of
   doctors’ orders, a reasonable jury could have convicted the Hagens of taking
   kickbacks anyway. Put differently, because of the structure of the kickback
   scheme in which the Hagens paid for doctors’ orders under the guise of the
   marketing and BPO services contracts, the Hagens needed safe-harbor
   instructions on both contracts to have hoped for acquittal.
                                         IV.
          The Hagens attack their sentences on the ground that the district
   court clearly erred in imposing a two-level sentencing enhancement for
   sophisticated money laundering. This challenge is meritless.
                                          A.
          We review the district court’s interpretation and application of the
   Sentencing Guidelines de novo and its factual determinations for clear error.
   United States v. Charon, 442 F.3d 881, 887 (5th Cir. 2006). Here, the parties
   agree that we review a district court’s finding of a sophisticated money
   laundering enhancement for clear error. See id. at 890. “If the district
   court’s account of the evidence is plausible in light of the record viewed in its
   entirety,” we will not reverse under the clear error standard even if we
   “would have weighed the evidence differently” had we been the factfinder.

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                                    No. 21-11273
                                  c/w No. 21- 11279

   Id. at 890-91. Reversal is appropriate only if we are “left with the definite
   and firm conviction that a mistake has been committed.” Id. at 891.
                                         B.
          Section 2S1.1(b)(3) of the Sentencing Guidelines imposes a two-level
   sentencing enhancement where the defendant was convicted under 18
   U.S.C. § 1956 and “the offense involved sophisticated laundering.”
   U.S.S.G. § 2S1.1(b)(3).        The commentary defines “sophisticated
   laundering” as “complex or intricate offense conduct pertaining to the
   execution or concealment of the 18 U.S.C. § 1956 offense,” and explains that
   “[s]ophisticated laundering typically involves the use of” (i) “fictitious
   entities,” (ii) “shell corporations,” (iii) “two or more levels” or “layering”
   “of transactions . . . involving criminally derived funds that were intended to
   appear legitimate,” or (iv) “offshore financial accounts.” Id. § 2S1.1 cmt.
   n.5(A). Those factors are not exclusive. See United States v. Fish, 731 F.3d
   277, 280 (3d Cir. 2013); United States v. Ada, 700 F. App’x 689, 690 (9th Cir.
   2017) (unpublished). But when the offense conduct includes one or more of
   those four factors, “the commentary clearly subjects an individual to the
   sophisticated laundering enhancement.” United States v. Miles, 360 F.3d
   472, 482 (5th Cir. 2006).
          Application Note 5(B) to Section 2S1.1 instructs courts not to apply
   the sophisticated laundering enhancement where “the conduct that forms
   the basis for an enhancement under the guideline applicable to the underlying
   offense is the only conduct that forms the basis for application of [the
   sophisticated laundering enhancement].” U.S.S.G. § 2S1.1 cmt. n.5(B).
          The amended pre-sentence reports (“PSR”) for the Hagens
   calculated their base offense level as 8. Probation recommended a 20-level
   increase based on the amount of the improper benefit conferred less the
   direct costs of braces, or $24,620,325.63. See U.S.S.G. §§ 2B4.1(b)(1),

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   2B1.1(K). Pursuant to § 2S1.1(b)(2)(B), the PSRs imposed a two-level
   increase because the Hagens were convicted under 18 U.S.C. § 1956. Finally,
   the PSRs applied a two-level enhancement for sophisticated laundering
   because the Hagens “sent unlawfully derived gains from Medicare fraud to
   Kimble’s bank account in the Philippines” to “promote and continue the
   Medicare fraud,” and “sent unlawfully derived gains . . . to their personal
   bank accounts in Spain and Austria” to build a second home. Based on a total
   offense level of 32 and a category I criminal history, the PSRs calculated the
   guidelines range as 121 to 151 months’ imprisonment.
          At sentencing, the Hagens objected to the sophisticated laundering
   enhancement. The Hagens argued that their laundering activity consisted of
   “open and transparent wire payments” without an “attempt to conceal or
   divert” the activity. In addition, the Hagens claimed that the enhancement
   “essentially underlines the . . . conviction related to money laundering [and]
   unfairly penalizes [them]” because the overseas transfers were not used to
   conceal the funds. The Hagens also pointed to Application Note 5(B)’s
   direction not to apply the enhancement where “the conduct that forms the
   basis for an enhancement under the guideline applicable to the underlying
   offense is the only conduct that forms the basis for application of [the
   sophisticated laundering enhancement].” Id. § 2S1.1 cmt. n.5(B). They
   argued that because their conviction for conspiracy to commit money
   laundering was predicated on transferring money overseas, see 18 U.S.C. §
   1956(a)(2)(A), the conduct that formed the basis for the sophisticated
   laundering enhancement was the same conduct as the underlying offense.
          The government responded that the Hagens made payments to
   offshore accounts that were “sent in two parts” and “reverse engineered
   based on the sham invoices . . . to conceal the nature of the payments.” The

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   government also emphasized that the Hagens prepaid the wires “to further
   conceal the nature of the payments.”
          After hearing argument, the district court overruled the Hagens’
   objection and applied the two-level enhancement for sophisticated
   laundering.
                                         C.
          The district court did not err in imposing the sophisticated laundering
   enhancement since the Hagens manipulated their wire transfer payments to
   conceal the kickback scheme. And because the Hagens’ conduct with respect
   to the marketing and BPO services invoices did not form the basis of another
   enhancement under the Guidelines, Application Note 5(B) does not
   foreclose a sophisticated laundering enhancement.
          In applying the sophisticated laundering enhancement, the district
   court did not commit a definite mistake. See Charon, 442 F.3d at 887. The
   district court took a plausible view of the evidence in concluding that the
   Hagens’ offense conduct pertaining “to the execution or concealment” of
   the laundering crime was sufficiently “complex or intricate.” U.S.S.G.
   § 2S1.1 cmt. n.5(A). Here, the underlying offense was conspiracy to transmit
   money from the United States to a place outside the United States to
   promote unlawful activity. See 18 U.S.C. § 1956(a)(2)(A). The Hagens’
   efforts to disguise their purchase of illegal kickbacks by structuring their
   payments as multiple prepaid invoices for legitimate services meets the
   standard for complex or intricate conduct. On a weekly basis, the Hagens
   wired two sets of funds to Kimble’s companies in the Philippines as
   prepayment for marketing and BPO services invoices. Those invoices
   appeared legitimate. But the sum of the invoices equaled the total charge for
   a set number of doctors’ orders. Kimble calculated the net price for the
   doctors’ orders and then charged the Hagens in two separate invoices by

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                                         No. 21-11273
                                       c/w No. 21- 11279

   dividing the total between marketing and BPO services. As a result, the dual
   wire transfers disguised the illegal sale of doctors’ orders.
           In sum, the Hagens’ (i) division of illegal kickbacks into two invoices,
   (ii) mislabeling of those divided invoices as relating to legitimate services, and
   (iii) prepayment of those mislabeled invoices to further conceal the kickbacks
   are sufficiently “complex or intricate” to warrant the sophisticated
   laundering enhancement. U.S.S.G. § 2S1.1 cmt. n.5(A); cf. United States v.
   Chon, 713 F.3d 812, 822-23 (5th Cir. 2013) (“Maintaining two sets of books,
   skimming income on a daily basis, and disguising . . . proceeds . . . to make
   the criminally derived funds appear legitimate are sufficiently complex to
   support the enhancement.”). 7
           Relying on Application Note 5(B), the Hagens argue first, that the
   district court clearly erred in applying the sophisticated laundering
   enhancement even though some of the conduct supporting the enhancement
   was conduct charged in the underlying offense, and second, that
   sophisticated laundering enhancement was improperly based on the same

           7
              The cases upon which the Hagens rely do not involve the § 2S1.1(b)(3)
   enhancement.         United States v. Valdez, 726 F.3d 684, 695 (5th Cir. 2013)
   (§ 2B1.1(b)(9)(C)); United States v. Conner, 537 F.3d 480, 492 (5th Cir. 2008) (same);
   United States v. Clements, 73 F.3d 1330, 1340 (5th Cir. 1996) (§ 2T1.1(b)(2)); United States
   v. Charroux, 3 F.3d 827, 837 (5th Cir. 1993) (same). Even assuming any of those cases are
   persuasive in the context of § 2S1.1(b)(3), all except United States v. Valdez affirmed the
   district court’s finding of sophisticated means and did not set a factual floor for such a
   finding. And in Valdez, we reversed because the defendant “used no false names, fictitious
   entities, shell companies or complicated financial transactions, or any other particularly
   sophisticated means to hide or conceal the assets.” 726 F.3d at 695. Specifically, the
   defendant “took money directly deposited from Medicare into his operating account,
   which was in his name, and moved it into his investment accounts, which were also in his
   name.” Id. The Hagens went far beyond Valdez in reverse-engineering mislabeled invoices
   to disguise their illegal activity.

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   conduct giving rise to the twenty-level improper benefit enhancement.
   Neither argument is a reason to reverse the district court.
          The Hagens’ first argument misapprehends the plain language of
   Application Note 5(B). This comment directs the district court to not apply
   the sophisticated laundering enhancement if “the conduct that forms the
   basis for an enhancement under the guideline applicable to the underlying offense
   is the only conduct that forms the basis for application of [the sophisticated
   laundering enhancement].” U.S.S.G. § 2S1.1 cmt. n.5(B) (emphasis added).
   The relevant question is whether the only conduct supporting the
   sophisticated laundering enhancement also forms the basis for a different
   enhancement for the underlying offense, not whether the only conduct
   supporting the sophisticated laundering enhancement is the conduct charged
   in the underlying offense.
          Because 18 U.S.C. § 1956(a)(2)(A) criminalizes “transport[ing],
   transmit[ting], or transfer[ring]” money from a place “in the United States”
   to “a place outside the United States,” many if not all § 1956(a)(2)(A)
   charges will involve the use of offshore accounts.              At least some
   § 1956(a)(2)(A) convictions—those that involve offshore accounts as
   opposed to sacks of money being shipped to a stash house, for example—will
   almost always warrant a sophisticated laundering enhancement.                See
   U.S.S.G. § 2S1.1 cmt. n.5(A)(iv). The Sentencing Guidelines contemplate
   this result.    Section 2S1.1 predicates the sophisticated laundering
   enhancement on a violation of 18 U.S.C. § 1956 and includes offshore
   accounts as a defined example of qualifying conduct. Cf. United States v.
   Reyes, 781 F. App’x 965, 969 (11th Cir. 2019) (unpublished) (per curiam)
   (Application Note 5(B) “is designed to prevent a defendant from receiving
   the same enhancement both for the underlying offense and for the
   sophisticated laundering.”); United States v. Mehmood, 742 F. App’x 928,

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   943 (6th Cir. 2018) (unpublished) (analyzing double counting of
   enhancements, not underlying charged offense); United States v. Rubashkin,
   718 F. Supp. 2d 953, 977 n.14 (N.D. Iowa 2010) (same).
           But even setting aside the offshore accounts, the district court was
   justified in applying the enhancement because the Hagens bifurcated,
   mislabeled, and prepaid the invoices. 8
           The Hagens’ second argument, that the same conduct gives rise to the
   sophisticated laundering and improper benefit enhancements, is also
   incorrect. In addition to the sophisticated laundering enhancement, the
   district court applied a twenty-level enhancement based on “the value of the
   . . . improper benefit.” U.S.S.G. § 2B4.1(b)(1). But as the government notes,
   the improper benefit enhancement was based on the volume of the fraud,
   while the sophisticated laundering enhancement was based on the manner in
   which the fraud was executed. In other words, the sophisticated laundering
   enhancement was triggered by the Hagens’ conduct executing and
   concealing the fraud—not the dollar amount of the Hagens’ profit from the
   Medicare fraud. Cf. United States v. Small, 210 F. App’x 776, 783 (10th Cir.
   2006) (unpublished) (rejecting double counting challenge to application of
   sophisticated means enhancement with amount of loss enhancement because
   “the method by which the money was obtained or concealed is irrelevant” to
   enhancements “concerned solely with amounts of money”).
           The Hagens insist that the amount of the fraud and the manner of the
   fraud is conduct all the way down. They reason that the conduct giving rise
   to the improper benefit, wire transfers, is the same conduct that counts as

           8
            The Hagens argue that prepayment formed the basis of the underlying conviction,
   too. They do not explain why this is true. But accepting the argument, the division and
   mislabeling of the invoices were still enough for the district court to apply the enhancement,
   and the Hagens do not appear to argue that those actions were charged under § 1956.

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   sophisticated laundering. Their theory defies the plain language of the
   Sentencing Guidelines, which direct a court to look only at the value of an
   improper benefit in § 2B4.1(b)(1) and only at the nature of laundering activity
   in § 2S1.1 cmt. n.5(A). And if their theory were true, a court could almost
   never apply the improper benefit and sophisticated laundering enhancements
   at the same time, because the sophisticated laundering conduct would
   probably have been related to the accumulation of the improper benefit.
          For those reasons, the sophisticated laundering enhancement is
   affirmed.
                                         V.
          Finally, the Hagens argue that the district court’s restitution order
   pursuant to the Mandatory Victims Restitution Act (“MVRA”), 18 U.S.C.
   § 3663A, is unlawful. The Hagens contend that the crimes for which they
   were convicted, conspiracy to defraud the United States and to pay and
   receive kickbacks and conspiracy to commit money laundering, are not
   “offense[s] against property [under Title 18], . . . including any offense
   committed by fraud or deceit” within the meaning of the MVRA. See id.
   § 3663A(c)(1)(A)(ii). Specifically, the Hagens maintain that this provision,
   § 3663A(c)(1)(A)(ii), should be interpreted according to a “categorical
   approach.” Rather than look at how a crime was committed in deciding
   whether the crime counts as an “offense against property . . . committed by
   fraud or deceit,” courts applying the categorical approach would consider the
   elements of the offense. Applying the categorical approach, the Hagens
   conclude that because their crimes of conviction do not contain the elements
   of a crime against property by fraud or deceit, the restitution order was not
   authorized by the statute.
          Three of our sister circuits have rejected application of the categorical
   approach to § 3663A(c)(1)(A)(ii). See United States v. Razzouk, 984 F.3d 181,

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   187-89 (2d Cir. 2020); United States v. Ritchie, 858 F.3d 201, 208-10 (4th Cir.
   2017); United States v. Collins, 854 F.3d 1324, 1333-35 (11th Cir. 2011). The
   Hagens give us no reason to depart from those well-reasoned opinions.
   Today, we join those circuits in holding that the categorical approach does
   not control the analysis of whether a Title 18 offense is “against property”
   for purposes of the MVRA. Instead, the factual circumstances of the crime
   of conviction determine whether the crime is an “offense against property”
   requiring mandatory restitution.
                                          A.
          The parties dispute whether our review of an illegal restitution order
   is de novo or for plain error where, as here, the defendants failed to preserve
   their challenge.
          Our cases are split on what standard of review applies to an
   unpreserved challenge against the legality of a restitution order. Usually,
   when a party fails to preserve a legal argument, our review is for plain error.
   See, e.g., United States v. Leal, 933 F.3d 426, 431 (5th Cir. 2019). And in some
   cases, we have taken a plain-error approach with respect to attacks on the
   legality of restitution orders. See id.; United States v. Rosbottom, 763 F.3d 408,
   419 (5th Cir. 2014). But more recently, we have reviewed “de novo the
   legality of a restitution order, regardless of whether the defendant raised this
   objection at sentencing,” “[b]ecause a restitution order that exceeds the
   court’s statutory authority is an illegal sentence . . . [that] always constitutes
   plain error.” United States v. Penn, 969 F.3d 450, 458 (5th Cir. 2020), cert.
   denied, 141 S. Ct. 2526 (2021); United States v. Nolen, 472 F.3d 362, 382 (5th
   Cir. 2014) (same).
          Here, we need not decide whether de novo or plain-error review
   applies because the result is the same under either standard.

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                                     No. 21-11273
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                                          B.
            The MVRA imposes mandatory restitution if a defendant commits
   “an offense against property . . . including any offense committed by fraud or
   deceit” and “an identifiable victim . . . suffered a physical injury or pecuniary
   loss.”     18 U.S.C. § 3663A(c)(1)(A)(ii), (c)(1)(B); see United States v.
   Tarnawa, 26 F.4th 720, 723 (5th Cir. 2022). When the district court finds
   those conditions satisfied, it must “order restitution to each victim in the full
   amount of each victim’s losses as determined by the court and without
   consideration of the economic circumstances of the defendant.” 18 U.S.C.
   § 3664(f)(1)(A)); see Tarnawa, 26 F.4th at 723.
            The Hagens argue that in determining whether a crime of conviction
   is an “offense against property . . . committed by fraud or deceit,” courts
   must use a categorical approach and focus on the elements of the offense
   rather than facts about how it was committed. The Hagens borrow the
   concept of a categorical approach from the interpretation of the Armed
   Career Criminal Act (“ACCA”), 18 U.S.C. § 924(e). As relevant here,
   ACCA imposes a sentencing enhancement for certain firearms offenses
   where the defendant had been previously convicted of three violent felonies,
   including burglary. See id. In determining whether a prior offense counted
   as burglary and triggered the ACCA enhancement, the Supreme Court in
   Taylor v. United States held that sentencing courts “must look only to the
   statutory definitions of prior offenses . . . and not to the particular facts
   underlying those convictions.” 495 U.S. 575, 600 (1990). Along similar
   lines, the Hagens imagine a categorical approach to the MVRA that would
   consider whether the crime of conviction has the elements of an “offense
   against property,” including such an offense “committed by fraud or
   deceit.”

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                                    No. 21-11273
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          The Hagens are wrong. The text, structure, and purpose of the
   MVRA permit a sentencing court to consider the factual circumstances in
   which an offense was committed in deciding whether the offense was against
   property.
          Start with the text. Section 3663A(c)(1)(A)(ii) says that a Title 18
   “offense against property” includes “any offense committed by fraud or
   deceit.” 18 U.S.C. § 3663A(c)(1)(A)(ii). The statute says that the way the
   offense is “committed” may bring it within the meaning of the offense-
   against-property provision. See Razzouk, 984 F.3d at 187. Indeed, it was
   significant in Taylor that ACCA referred to a person who “has three previous
   convictions” for violent felonies, not “a person who has committed” violent
   felonies. 495 U.S. at 600 (emphasis added). The absence of “committed”
   from ACCA supported “the inference that Congress intended the sentencing
   court to look only to the fact that the defendant had been convicted of crimes
   falling within certain categories, and not to the facts underlying the prior
   convictions.” Id. The presence of “committed” in the offense-against-
   property provision leads to the opposite conclusion: facts matter here.
          Section 3663A(c)(1)(A)(ii) also lacks any affirmative textual clues that
   Congress meant courts to consider the elements of property offenses. No
   language in § 3663A(c)(1)(A)(ii) directs courts to the elements of Title 18
   statutory offenses. Nor does the statute include a representative list of
   property offenses that refer to generic crimes. Ritchie, 858 F.3d at 210.
          Elsewhere in the MVRA, Congress did call for a categorical approach.
   In the preceding subsection, § 3663A(c)(1)(A)(i), Congress designated “a
   crime of violence, as defined in section 16” of Title 18 as triggering
   mandatory restitution. And the language of § 16 “unmistakably uses an
   ‘elements’ formulation, defining a ‘crime of violence’ as one that has as ‘an
   element the use, attempted use, or threatened use of physical force against

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   the person or property of another.’” Razzouk, 984 F.3d at 187 (quoting 18
   U.S.C. § 16). Accordingly, under § 16, courts “look to the elements and the
   nature of the offense of conviction, rather than to the particular facts relating
   to petitioner's crime.” Leocal v. Ashcroft, 543 U.S. 1, 7 (2004). 9 Congress
   could have made a similar choice in § 3663A(c)(1)(A)(ii) but did not. The
   difference “shows that Congress intended subsection (c)(1)(A)(ii) to cover a
   broader range of prior offenses than those reached by subsection
   (c)(1)(A)(i).” Ritchie, 858 F.3d at 210 (cleaned up).
           Finally, a fact-based approach is consonant with the remedial purpose
   of the MVRA. The primary goal of the MVRA is “to ensure that the loss to
   crime victims is recognized, and that they receive the restitution that they are
   due.” S. Rep. No. 104-179, at 12–13 (1995), reprinted in 1996 U.S.C.C.A.N.
   924, 925–27. Congress intended the MVRA to “expand the number of
   identifiable victims entitled to full, mandatory restitution,” but the
   categorical approach would illogically exclude “those unfortunate victims
   who suffer property loss as a result of an offense that doesn’t contain as an
   element a reference to ‘property.’” Ritchie, 858 F.3d at 210.
           The Hagens do not launch a coherent attack on the district court’s
   restitution order under a fact-based approach. Any such challenge would be
   futile. The trial court heard sufficient evidence to find that the Hagens used
   fraud to derive an unlawful benefit in the amount of $27,104,359 from the
   Medicare program. This is enough to establish an “offense against property
   . . . committed by fraud or deceit” under the MVRA.                      18 U.S.C. §

           9
            The Hagens argue in reply that because Leocal was decided after enactment of the
   MVRA, Congress could not have been aware that the § 3663A(c)(1)(A)(i) inquiry would
   necessarily involve a categorical analysis of violent crimes. But as we explained, the
   language of § 16 is clear and shows that Congress could have used the “elements” formula
   in § 3663A(c)(1)(A)(ii) but did not. See Razzouk, 984 F.3d at 187.

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   3663A(c)(1)(A)(ii); see Collins, 854 F.3d at 1331 (offenses against property
   “includes situations where the defendant seeks to derive an unlawful benefit
   from another’s property or otherwise deprive a person of his property”).
                                       VI.
         For those reasons, the Hagens’ convictions and sentences are
   AFFIRMED.

                                        38