Court Opinion

ID: 6353098
Source: CourtListenerOpinion
Date Created: 2022-06-23 20:00:35.107353+00
Date Added: 2024-06-11T09:13:54.089908
License: Public Domain

NOT RECOMMENDED FOR PUBLICATION
                                File Name: 22a0253n.06

                             Case Nos. 20-5891/5897/5920/5946/6010

                           UNITED STATES COURT OF APPEALS                                FILED
                                FOR THE SIXTH CIRCUIT                              Jun 23, 2022
                                                                               DEBORAH S. HUNT, Clerk

                                                        )
UNITED STATES OF AMERICA,
                                                        )
       Plaintiff-Appellee,                              )        ON APPEAL FROM THE
                                                        )        UNITED STATES DISTRICT
v.                                                      )        COURT FOR THE EASTERN
                                                        )        DISTRICT OF TENNESSEE
JAYSON MONTGOMERY, et al.,                              )
       Defendants-Appellants.                           )                                  OPINION
                                                        )

Before: McKEAGUE, STRANCH, and BUSH, Circuit Judges.

       McKEAGUE, Circuit Judge. This case is about a get-rich-quick pyramid scheme. Five

defendant drug marketers extracted $35 million in two years from public and private insurers by

convincing friends and family to order prescription creams and wellness tablets that they didn’t

need, and then pocketing a cut of the insurance reimbursement for themselves. The government

caught on, and the defendants were charged with and convicted of various counts of healthcare

fraud, conspiracy to commit healthcare fraud, wire fraud, mail fraud, paying and receiving illegal

kickbacks, and money laundering. Despite carefully targeting insurance companies that would

reimburse without scrutiny, hiring a nurse practitioner to sign prescriptions without asking

questions, inducing people to order creams by giving them a cut of the commission, and charging

insurance companies thousands of dollars for creams with ingredients that could be purchased over

the counter for a fraction of the price, the defendants claim that their convictions should be vacated
Nos. 20-5891/5897/5920/5946/6010, United States v. Montgomery, et al.

because of their belief that all of this was perfectly legal. In the alternative, they argue that even

if what they did was fraudulent, they should not be held accountable at sentencing for the total loss

because at least some prescriptions were legitimate, though they don’t identify which ones or

explain why.

       Because a rational factfinder could infer intent to defraud from the defendants’ actions, and

because the defendants did not establish the legitimacy of any part of their operation, we affirm

the convictions and sentences of all defendants.

                                                 I.

                                                 A.

       The scheme perpetrated here was built to exploit a prescription drug insurance system

dependent upon intermediary gatekeepers. Generally, health insurance pays for prescription

medications needed by those covered under their plans. Typically, a patient meets with their

doctor, the doctor assesses their medical needs, and the doctor prescribes medication if necessary.

The doctor then sends that prescription to a pharmacy, and the pharmacy fills the prescription. The

patient often pays a co-payment when picking up the prescription. The pharmacy then submits a

reimbursement claim for the remaining cost to the insurer through an intermediary called a

pharmacy benefit manager.        Reimbursements are often approved automatically, although

expensive or uncommon medications may require preauthorization.

       Before the passage of the Affordable Care Act, insurers reimbursed pharmacies for only

one ingredient per prescription to keep costs down. Compound drugs—drugs with multiple

ingredients that are prescribed when a standard medication can’t meet a patient’s specialized

medical needs—often required preauthorization. After the passage of the Act, some insurers

changed their coverage to include reimbursement for compound medications without

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preauthorization. One of those insurers was Tricare, a health benefit program for military

personnel.

                                               B.

       With some insurers adapting their coverage to reimburse for compound medications

without prior scrutiny, the defendants saw an opportunity. At the front end, they negotiated

agreements with several pharmacies to receive a 30–40% cut of the insurance reimbursement for

compound drugs they marketed. Then they paid a pharmacist, Jared Schwab, to help them devise

compound drug formulas that used the most expensive ingredients to maximize

their reimbursement. They took those pre-set formulas and made pre-printed pads of order

forms—even though compound drugs are meant to be tailored to a patient’s individual needs.

       In the next stage, they identified family, friends, coworkers, and military service members

whom they knew had insurance that would reimburse for compound medications without

preauthorization and encouraged those people to order compound creams and pills whether or not

they needed or wanted them. They did so primarily by offering to pay customers. The defendants

told customers that they were being paid for evaluating the creams as part of a clinical trial. But

no clinical trial or survey about the products was ever conducted. And there is no evidence that

the defendants planned or intended to conduct a survey. Any such clinical trial would have

required approval by the insurance company prior to any benefits being paid. The defendants also

persuaded people to order creams they didn’t need by assuring them that they would pay nothing

for the medications, and then ensuring that outcome by either paying co-pays for them or seeking

waivers. To increase their sales, the defendants added medications to customers’ order forms that

they did not request and sought refills for customers without their consent.

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       Once the prescription order forms were completed, they gave them to a nurse practitioner,

Candace Michele Craven. The defendants paid Craven to sign prescriptions without evaluating

patients, or they simply stamped her signature without her knowledge. Then they faxed the

prescriptions to the pharmacies, who in turn sought reimbursement from the insurers. The

compound medications were very expensive, ranging from $4,000 to $15,000 per cream. Some

customers’ insurance providers were billed hundreds of thousands of dollars for the unnecessary

medications. When the defendants received their commissions from the pharmacies, they gave a

cut of those commissions to the lower-level marketers whom they had recruited to sell the creams

on their behalf. In total, the scheme extracted approximately $35 million from government and

private insurers.

                                              C.

       Jerry Wayne Wilkerson was at the top of the pyramid scheme. He negotiated with the

compounding pharmacies to be paid a 30–40% commission of the insurance reimbursement for

each prescription they marketed. On the next step down were Wilkerson’s recruits: Michael

Chatfield, Billy Hindmon, and Kasey Nicholson, whom Wilkerson in turn paid approximately half

of the commission he received. On the next step was Hindmon’s recruit, Jayson Montgomery,

whom Hindmon paid approximately half of his commissions. The group set up LLCs to receive

the commission payments and make the enterprise appear legitimate. Each of the defendants

recruited their own subordinate marketers, referred to as “downlinks,” by offering them a cut of

their commissions. The defendants advised and helped downlinks set up LLCs to receive the

commissions via wire transfer.

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                                                D.

       Jerry Wayne Wilkerson

       As the instigator and leader of the scheme, Wilkerson negotiated the commission

arrangement with the pharmacies. He set up Top Tier, LLC to receive the commission and paid

his downlinks via wire transfer from Top Tier. Working with his downlinks, he identified insurers

covering compound medications and targeted customers who had such insurance. In an email to

Chatfield, Hindmon, Nicholson, and others, Wilkerson shared the news that Tricare would

continue paying for compound medication and wrote, “It’s money making time. Saddle up.”

R. 374, P. 6190–91.

       Wilkerson paid Schwab, the pharmacist, to consult on creating a pre-printed prescription

pad with pre-set formulas for the compound creams. They chose the formulas by “put[ting] the

most expensive ingredients in the medication[,]” rather than by considering medical efficacy.

R. 313, P. 2750–51.

       Wilkerson also paid Craven, the nurse practitioner, to sign prescriptions without evaluating

patients. Craven was working at a facility called Balanced Life at the time and was not Wilkerson’s

employee when he began paying her for these services. Wilkerson eventually hired Craven to

work at the spa he opened, Karma Wellness. Craven estimated that she signed prescriptions

without seeing patients on ten occasions; writing multiple prescriptions each time. Wilkerson

instructed his downlinks to make a stamp with Craven’s signature and directed employees to stamp

prescriptions without her consent. When Craven confronted him about this, Wilkerson said, “It’s

okay. Everything’s under control.” R. 313, P. 2804. Craven testified that it was not typical

practice for a medical provider to prescribe medications for patients referred directly by marketers,

and this arrangement was the only time she had done so.

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       Hunter Magnuson worked the front desk at Balanced Life when Wilkerson established his

arrangement with Craven. Although he didn’t work there, Wilkerson frequently visited Balanced

Life to speak with Craven. After the visits, he left stacks of prescriptions with Magnuson to be

faxed to the pharmacy. Magnuson remembers faxing stacks of prescriptions that were an inch to

an inch-and-a-half thick on multiple occasions.         Sometimes Wilkerson brought stamped

prescriptions to Magnuson to be faxed without visiting with Craven first.

       Heather Fryar worked the front desk at Karma Wellness, owned by Wilkerson. While she

was working there, Wilkerson discussed the nonexistent clinical trial. He directed Fryar to stamp

Craven’s signature on a stack of prescriptions, and when she asked why, he said it was her “job”

to do so. R. 361, P. 4639–40. Fryar also marketed creams as a downlink, earning $33,000 in

commission for sales she made to one person in just half an hour.

       Wilkerson’s downlinks included Rich and Kim Terry, Wilkerson’s cousin, and his wife.

Together, Rich and Kim Terry received over $120,000 in commission from Wilkerson for creams

they ordered for themselves and creams they sold to family members and co-workers. Just before

receiving a $93,649 payment from Wilkerson, Rich Terry opened a bank account under the name

“Terry Transport.” The Terrys paid a cut of those commissions to the relatives and friends who

were their customers. Dawn Steele, who ordered creams from the Terrys, testified that she did not

need the creams and simply ordered them to “help [Wilkerson] get his company going.” R. 361,

P. 4328. Her husband, Nelson Steele, believed that they were being compensated because they

would be participating in the clinical trial. Although Craven signed the prescriptions, Nelson never

spoke to her about the medications before receiving them. The Steeles were signed up for refills

of the medications without requesting them.

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       Another of Wilkerson’s downlinks was a longtime friend and retired Marine, Josh Linz

(also downlinked from Hindmon). Wilkerson advised him to open an LLC, and he did so under

the name AFA Consulting. His purpose in establishing the LLC was “to receive payment for

[him]self for the topical creams.” R. 369, P. 5710–11. In total, he received approximately $99,000

for ordering his own creams, and selling creams to his roommate.

       Wilkerson opened an LLC for one of his downlinks, Amanda Booker. Although Wilkerson

set it up, the name of the LLC was Booker’s initials. He told her that she “had to have an LLC to

receive the wire transfers.” R. 370, P. 5813.

       When one of Chatfield’s downlinks, Ryan McGowan, found out he had a co-pay on the

medications, Chatfield assured him that “Wayne” “would pay it.” R. 370, P. 5911–12. Wilkerson

met McGowan in a post office parking lot and gave him $2,000 cash; McGowan took the money

inside, purchased money orders, and mailed the co-pays to the pharmacy.

       In text messages with Kirtis Green (who was prosecuted in a separate case for his

involvement), Wilkerson said, “We will just set up an online fax account and feed scripts to

Michelle [Craven] constantly,” to which Green responded, “Perfect. She said she will sign 500 a

time once Karma opens.” R. 375, P. 6444. Two days later Wilkerson texted Green again: “Hey

forgot about what I had to pay for Michelle [Craven] and Jared [Schwab] and I am splitting that

up between me, you, and Beaver [Chatfield] . . . [s]o it’s 4k apiece. We can settle that up in

Florida.” R. 375, P. 6445. Wilkerson later deducted $4,000 from the May commission checks he

paid to Green, Chatfield, Hindmon, and Nicholson. On June 3, 2014, just days after Blue Cross

Blue Shield of Tennessee stopped covering compound medications without preauthorization,

Wilkerson texted Green and said, “Talked to Jared. He’s gonna . . . backdate the scripts from

yesterday and Christi added some refills to May.” R. 375, P. 6446. A few months later, Wilkerson

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texted Green asking for a map of military bases for marketing to those with Tricare insurance, and

Green responded with a map and said, “[a]ll I see is $$$,” to which Wilkerson replied, “Damn

straight.” R. 375, P. 6446.

       Wilkerson earned $13 million from the approximately two-year enterprise.

       Michael Chatfield

       Chatfield worked directly under Wilkerson. His family business, Diversified Printing,

printed the pre-set compound formula prescription pads the marketers used. He also acquired the

stamp of Craven’s signature. Craven and Schwab were paid out of funds from Chatfield’s

commission.

       Chatfield recruited his own customers and downlinks. When recruiting downlinks, he

informed them that the “process” of selling these creams involved telling people that they would

be paid for “[t]heir participation in a survey regarding the creams.” R. 368, P. 5292. His customers

included his aunt, uncle, and cousin. His uncle testified that he had no need for the creams, and

he couldn’t recall speaking to a medical provider before ordering the creams. Chatfield gave his

uncle a $6,200 check, which seemed strange to him because he hadn’t done anything.

       Chatfield also sold the medications to friends of his brother, the Bowling family. He

pitched the sale to them as a “business opportunity, which was filling out this form with [their]

insurance information, and that it was basically kind of like a survey type thing where [they] would

get some creams to try, and [they] would be sent a survey, then [they] would be paid for that

survey.” R. 361, P. 4446–47. Chatfield said that “if [they] signed up more people in [their] family

that [they] would receive a larger sum of money.” R. 361, P. 4453–54. The Bowlings ordered

creams for other family members as well and testified later that they did not need the creams, did

not request the creams, and did not speak to a medical provider before receiving them. Emma

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Bowling testified that she received scar, wound, antiaging, wrinkle, and stretch mark creams even

though she was a teenager with no need for those creams and had not requested them.

       Chatfield also ordered medications in the names of his wife’s parents without them

requesting the medications or giving him permission to do so. In fact, his wife’s parents never

spoke to Craven about the creams. The creams were shipped to Chatfield’s address and the order

listed his wife’s phone number.

       One of Chatfield’s downlinks was former Marine Josh Morgan. Chatfield promised

Morgan $300 for ordering creams for himself and told him to offer the same deal to fellow Marines

to get them to order creams. Morgan testified that the purpose of the fabricated clinical trial was

“[b]asically, to get [customers] to sign up for the cream.” R. 369, P. 5649. Chatfield told Morgan

not to bother with people who didn’t have Tricare insurance. He also told Morgan to form an LLC

to receive the commissions Chatfield was paying him. Morgan received $314,000 from Chatfield

despite never meeting him in person.

       Another of Chatfield’s downlinks was George Striker. Chatfield advised Striker that his

“role would be to approach people, to ask them to sign up for these creams, to participate in a

study, and that they would be paid $100 per person that signed up.” R. 368, P. 5283. He said that

those ordering creams “wouldn’t have to pay anything out of pocket.” R. 368, P. 5284. Striker

ordered creams for himself, his wife, daughter, stepchildren, ex-wife, father, uncle, cousins, and

cousins’ kids. Like the others, Striker repeatedly cut corners. Striker’s stepdaughter, for example,

never spoke to a medical provider. Instead, Chatfield joked that “every kid has scars from growing

up and things like that, so, [they] just added the scar cream” to the stepdaughter’s order. R. 368,

P. 5305. Chatfield informed Striker that they could not order a medication with fluticasone in it

because of his stepson’s age, so they “put him down for something else.” R. 368, P. 5307–08.

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Striker testified that he understood the purpose for ordering the creams was “Commission.

Revenue.” R. 331, P. 3413.

       In a series of text messages between Chatfield and Striker, the two discussed how much

each family member’s orders would net and which medications would bring the highest returns.

For example, one text said that the “wound creams” could get them “17 to 20k.” R. 368, P. 5313–

14. He told Striker that he “made 17k total for August and as long as you don’t lose anyone and

refills keep going through . . . you’re over 21k.” R. 368, P. 5335. Chatfield also texted Striker

that “at least we got Hamby to get his wound and wellness come Monday that’s 20k in revenue.”

R. 368, P. 5337–38. Chatfield asked Striker if the “Walter family [would] be okay with wellness

tablets?” and when he said they would, Chatfield responded, “[s]end all four of them wellness

tablets. 25k in revenue extra.” R. 368, P. 5343. Chatfield explained that Striker would be getting

“a total of 40–42k revenue from your family at Central [pharmacy].” R. 368, P. 5349–50.

       When the cream scheme came under investigation, Striker surreptitiously recorded a

February 10, 2015, phone conversation between himself, Chatfield, and another marketer,

regarding what to say if contacted by law enforcement. In that call, they discussed why there was

no clinical trial or survey in place although they had been telling people they were being paid for

evaluating the products. Chatfield said they could tell customers, “[H]ey, we got an approved

evaluation now. Go back and fill it out” because they “would have to cover [their] butt to have

them do an evaluation after the fact.” R. 368, P. 5388, 5399. Striker told Chatfield that the agent

asked who referred him for the creams, and Chatfield said, “[S]ay someone from work told you.

Say I can’t remember. Say one of my customers told me. It’s been months ago. I don’t

remember.” R. 368, P. 5391. When they discussed reimbursing customers for co-pays, Chatfield

said, “That’s not—that’s not how you word it though.” R. 368, P. 5396. Insurers were billed for

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over $7.6 million for prescriptions sold by Chatfield through Striker. In the conversation, Chatfield

referred to activity happening at the Willow pharmacy—the pharmacy where their consultant Jared

Schwab was employed—as “fraud.” R. 368, P. 5392.

       In a series of text messages with Kirtis Green, Chatfield said, “I’m having 16 script pads

made up of the Karma Wellness Spa with the corrections that Jared told me to make. That includes

giving .05 Fluticasone to antiaging and age spots . . . . I figured that would be the best way to

make money and we can ignore Billy’s dermatologist, if she doesn’t want Fluticasone, we will

give her her own pad.” R. 375, P. 6420–21. He went on to say that “if antiaging bills out [$]2,000

and age spots [$]2500 or [$]7,000, I’ll take the second all day . . . . It was billing out [$]4800 with

.025 then when Billy changed it, it went down to [$]2000[,] now Jared said to go to .05 so it should

be around [$]7,000. I have too many people getting those creams for them to be billing out at

[$]2,000.” R. 375, P. 6422. When Green asked Chatfield what the insurers would be billed for

the creams, he said, “Stretch [$]10, Scar [$]11, Wound [$]12–14, Acne–[$]6500, Psoriasis

[$]5500, Wrinkle and age spots [$]4800.” R. 375, P. 6437. He said that “[w]ellness is [$]6K,”

and “antifungal is [$]13 and eczema is [$]10.” R. 375, P. 6404. Chatfield joked about adjusting

the formula on the prescription pads to 10 percent fluticasone which would make the cream cost

$60,000. In discussing one of the creams, Chatfield said, “One of my patient’s kids got a burn

from it. Luckily I knew him.” Green responded, “[g]otcha. LOL. No more [$]8K haha,” and

Chatfield said, “nope, even Jared admitted he shouldn’t have done that.” R. 375, P. 6402.

       When Blue Cross Blue Shield insurance set a June 2, 2014, deadline to stop covering

compound medications, Chatfield texted Green about backdating prescriptions saying, “[d]o you

see all of those refills they are doing 10 days early for our Blue Cross Blue Shield people LOL . . . .

Yeah. Jared said he was going to put lost or stolen and override LOL.” R. 375, P. 6426–27.

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Around the same timeframe, Chatfield also asked Green, “[a]ny word from our e-mails and

refills?” and Green said, “[y]es, both are solid. Jared is backdating and fixing today.” R. 375,

P. 6434.

       In February 2015, because the scheme was being investigated, Chatfield sold his “book of

business” to Jimmy Collins for $1.5 million. Overall, Chatfield earned approximately $5.4 million

from the scheme.

       Billy Hindmon

       Hindmon worked directly under Wilkerson, and he, too, recruited customers and

downlinks, including Jayson Montgomery. Hindmon started out trying to market to doctors, but

soon began marketing directly to patients because Wilkerson had “a nurse on staff” who would

sign prescriptions, allowing them to “bypass the gatekeeper so to speak.” R. 360, P. 4079, 4081.

Wilkerson withheld $4,000 from Hindmon’s commission check to cover payments to Craven and

Schwab.

       Hindmon also recruited Adam Staten as a downlink, advised him to form an LLC, and

helped him do so. He sent Staten a “consent form” that stated marketers would not receive

commissions for sales to customers whose insurance did not cover compound medications and

those customers would not receive their “participation compensation.” R. 360, P. 4136–38.

Hindmon knew Staten was paying his customers, numbering at least twenty, to order creams and

loaned him money on at least one occasion to do so. Both Hindmon and Staten told customers

they would be paid as part of a clinical trial. And when customers complained about not being

paid for their participation in the trial, Hindmon paid them. Hindmon and Staten tried to recruit

additional nurse practitioners to join the scheme.

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       One of Staten’s customers was Rachel Franklin, who ordered scar cream; Staten added

eczema, stretch mark, wart, and wound creams to her order as well, although she hadn’t requested

them and was never contacted by a medical provider. Franklin contacted Staten crying because

her healthcare savings account had been depleted from cream orders. Staten called Hindmon who

assured him that he would “get it fixed.” R. 360, P. 4128–29. Franklin called Hindmon directly,

and Hindmon said he would pay her in cash if he couldn’t get it taken care of.

       Hindmon earned over $1 million from the scheme.

       Kasey Nicholson

       Nicholson worked directly under Wilkerson and was also his girlfriend. Her commission

money was used to pay Craven and Schwab. But Nicholson also recruited her own customers and

downlinks. Heather Fryar testified that, like the others, Nicholson was encouraging customers to

order creams by telling them they’d be paid as part of a (nonexistent) clinical trial. One of her

customers was her close friend, Sydney Patterson. Nicholson offered Patterson part of her

commission to order creams. Patterson didn’t want to order refills because she “didn’t think they

worked,” but Nicholson persuaded her to order more before the June 2, 2014, Blue Cross Blue

Shield deadline. R. 313, P. 2764–66. Nicholson’s payments to Patterson included $1,000 that she

used to go to a music festival and a $1,000 “birthday” check.

       Nicholson also recruited Navy sailor Matthew Perkins as a downlink. Nicholson contacted

Perkins to see if he wanted “to sign up for the medication to get money.” R. 313, P. 2672, 2680.

They discussed how “they just put the most expensive ingredients in the medication” to make more

money. R. 313, P. 2750–51. She told him how she “paid somebody’s insurance for the year and

gave them $10,000 in cash because she would make that money back” in two months’ commission.

R. 313, P. 2719. Perkins ordered wellness pills, scar cream, stretch mark cream, and pain cream

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for himself and for his wife. Perkins was unaware of the cost of the medications until he received

his Explanation of Benefits (EOB) from his insurer, which showed that Tricare was billed $67,000

for his medications in December alone, and an additional $60,000 for his wife’s creams that month.

Upset, he called Nicholson, and she assured him, “that’s how much the insurance company pays

for the creams, that it’s not a big deal.” R. 313, P. 2700. Perkins’s EOB showed that Tricare paid

$6,038.20 for the wellness pills alone, and the defendants’ expert agreed that the ingredients in

those pills could be purchased at Walmart for “[$]10 to $20, $30 each.” R. 380, P. 7544–45.

       Nicholson informed Perkins that she would pay him $4,000 to $5,000 for each person he

could get to sign up to order compound medications, but she later lowered the commission to

$1,000. Perkins recruited approximately 30 fellow shipmates to order creams by paying them or

taking them out for drinks. Nicholson instructed Perkins to “do whatever [he] ha[s] to do to get

people to sign up” for the creams and encouraged him to sell the creams that garnered the highest

reimbursement. R. 313, P. 2678, 2742. She advised Perkins to set up an LLC because “the bank

wires were going to be so large and [he] was banking with Navy Federal, so it just wouldn’t look

good.” R. 313, P. 2703. Nicholson paid Perkins approximately $40,000 a month for several

months. When the scheme came under investigation, Nicholson contacted Perkins via Snapchat

and told him not to speak to law enforcement. Perkins testified that he thought things were legal

in the beginning, but later knew it was a fraud.

       Nicholson earned nearly $1 million from the scheme.

       Jayson Montgomery

       Montgomery was a downlink of Hindmon. His commission money was used to pay Craven

and Schwab. His first customer and downlink of his own was his mother, Dawn Montgomery.

She testified that Jayson knew she had Blue Cross Blue Shield insurance that covered compound

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medications. He told her that she would be paid $200–$300 for each cream she ordered and that

she would not have to pay any co-pays. He also told her that she would be paid $100 for every

person she signed up to order creams. She ordered creams for herself and her grandchildren. She

was never contacted by a medical professional until she was asked if she wanted to refill her

prescriptions. Jayson paid her the commissions.

       Dawn sold the creams to her supervisor, Maria Valdez, telling her that she would get $100

per order. Valdez ordered creams for herself and six of her family members. She was never

contacted by a doctor before receiving the medications. When Valdez received bills for co-pays

and complained, Dawn contacted Jayson, who went with Hindmon to get money orders and came

to their workplace to pay Valdez back. When Valdez complained that she also had not received

her $100 per order that she was promised, Hindmon paid her $700 cash on the spot. Valdez’s

insurance company was billed more than $230,000 for the creams.

       When Jayson asked his mother if she wanted to be a marketer of the creams herself, she

declined because “[t]hey were making a lot of money quickly” and she didn’t have a good feeling

about it. R. 363, P. 5086.

       Montgomery ordered creams for an acquaintance, Katie Callaway, who mentioned once in

a group of friends that she had a scar from a car accident. Montgomery offered her a “free sample”

of a scar cream, and she allowed him to take a picture of her insurance card. Montgomery ordered

scar cream, antiaging cream, and stretch cream for her, although she did not request those

medicines and had no need for them at 24 years old. She did not know the creams were prescription

medications and was not contacted by a medical provider. Montgomery ordered her 12 months of

automatic refills that she did not request. Later, a federal agent who was investigating the scheme

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contacted Callaway, and Montgomery told her not to meet with him and tried to convince her that

she had spoken with a doctor before receiving the medications.

       Montgomery also targeted service members, including Zac Rice. He induced Rice to order

the creams by telling him he would receive payment as part of a clinical trial, but he never received

a survey to evaluate the product. Montgomery added wellness tablets to Rice’s order form even

though he did not request them. When confronted, Montgomery said they were “just part of the

order.” R. 362, P. 4601. Montgomery offered Rice commission to sell creams to other service

members. Montgomery and Hindmon advised Rice to form an LLC and paid the setup cost.

Because service members’ family would have to pay co-pays, Montgomery instructed Rice to

order the medications in the service member’s name.

       Rice sold creams to 23 people and was paid more than $80,000 in commissions. Some of

the service members Rice sold to had agreed to order the creams because they felt they had no

choice, as Rice was their superior. No medical provider had contacted them, and creams and

wellness pills that they had not requested were ordered in their name. Tricare insurance paid

$1,345,812 for these medically unnecessary prescriptions. Rice was discharged from the Army

for his participation in the scheme.

       Montgomery earned nearly $340,000 overall from the scheme.

                                                E.

       The government charged the five defendants with healthcare fraud, mail fraud, wire fraud,

conspiracy to commit healthcare fraud, and paying and receiving illegal kickbacks. Wilkerson and

Chatfield were also charged with money laundering. The parties agreed to a bench trial and did

not request that the court make specific findings of fact. Before rendering a verdict, the court held

a hearing to discuss the legal standards that should be applied. The court agreed to consider a good

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faith defense to all charges and declined to consider fraud solely through the lens of a strict

standard of fraud by omission.

       After an eleven-week trial, the court found Wilkerson, Chatfield, Hindmon, and Nicholson

guilty of healthcare fraud, mail and/or wire fraud, and paying and receiving illegal kickbacks. The

court also found Wilkerson, Chatfield, and Hindmon guilty of conspiracy to commit healthcare

fraud, and found Wilkerson and Chatfield guilty of money laundering. Montgomery was found

guilty on two counts of receiving illegal kickbacks and acquitted on all other counts.

                                               F.

       When setting the defendants’ Sentencing Guidelines ranges, the court applied

enhancements for their respective roles in the scheme, number of victims, and loss caused. The

court calculated loss amounts using the amount paid by insurers that was attributable to each

defendant’s conduct. The defendants objected to this method of calculating loss. Nicholson and

Montgomery reached an agreement with the government regarding loss amount, and the court

overruled the remaining objections on that issue. Ultimately, the court imposed below-Guidelines

sentences for all defendants: Wilkerson was sentenced to a 165-month term of imprisonment,

Chatfield to a 108-month term, Hindmon to a 51-month term, Nicholson to a 30-month term, and

Montgomery to a 24-month term.

       The defendants timely appealed their convictions. Wilkerson, Chatfield, and Hindmon also

appealed the method used to calculate loss amounts for sentencing. The court granted the

defendants bond pending appeal.

                                                II.

       The posture of this case means that our review is highly deferential. The parties waived a

jury trial and did not request that the district court make specific findings of fact under Federal

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Nos. 20-5891/5897/5920/5946/6010, United States v. Montgomery, et al.

Rule of Criminal Procedure 23(a) and (c). We therefore review the district court’s verdict for

sufficiency of the evidence alone, inferring from the record the “facts which are relevant to

the issues here” that the trial court “could have found.” United States v. Beckley, 335 F.2d 86, 87

(6th Cir. 1964); United States v. Vance, 956 F.3d 846, 853 (6th Cir. 2020) (“[I]f, from the facts

found, other facts may be inferred which will support the judgment, such inferences should be

deemed to have been drawn by the District Court.”) (quoting Grover Hill Grain Co. v. Baughman-

Oster, Inc., 728 F.2d 784, 793 (6th Cir. 1984)).

       What’s more, defendants seeking to overturn their convictions for insufficient evidence

already face a “high bar.” United States v. Persaud, 866 F.3d 371, 379–80 (6th Cir. 2017).

Reviewing de novo, we ask if “after viewing the evidence in the light most favorable to the

prosecution, any rational trier of fact could have found the essential elements of the crime beyond

a reasonable doubt.” United States v. Alebbini, 979 F.3d 537, 543 (6th Cir. 2020) (emphasis in

original) (quoting Jackson v. Virginia, 443 U.S. 307, 319 (1979)). In doing so, we cannot “weigh

the evidence, assess the credibility of witnesses, or substitute our judgment for that of the [trier of

fact].” Id. (alterations in original). “We must resolve all conflicts in the testimony in the

government’s favor and draw every reasonable inference from the evidence in favor of the

government.” United States v. Bashaw, 982 F.2d 168, 171 (6th Cir. 1992). “Circumstantial

evidence alone is sufficient to sustain a conviction and such evidence need not remove every

reasonable hypothesis except that of guilt.” United States v. Spearman, 186 F.3d 743, 746 (6th

Cir. 1999) (quoting United States v. Vannerson, 786 F.2d 221, 225 (6th Cir. 1986)).

       All five defendants challenge their convictions for sufficiency of the evidence as to the

mens rea element of their offenses. They argue that they lacked criminal intent because they

thought their actions were legal. Our task, then, is to determine whether, after viewing the evidence

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Nos. 20-5891/5897/5920/5946/6010, United States v. Montgomery, et al.

in the light most favorable to the prosecution and accepting all reasonable inferences that would

support the judgment, any rational factfinder could evaluate the defendants’ actions and decide

that they knew their actions were unlawful. Under this deferential standard, we affirm the

defendants’ convictions.

                                                   III.

       All defendants except Montgomery were convicted of healthcare fraud, along with mail

and/or wire fraud. Healthcare fraud requires proof of three elements: “(1) the defendant knowingly

and willfully executed a scheme to defraud a health-care benefit program or to obtain its money or

property by fraudulent pretenses, representations, or promises; (2) the scheme related to or

included a material misrepresentation or concealment of material fact; and (3) the defendant had

the intent to defraud.” United States v. Sosa-Baladron, 800 F. App’x 313, 318 (6th Cir. 2020);

Sixth Circuit Pattern Jury Instruction 10.05(1).

       Similarly, mail and wire fraud “each comprise three elements: first, ‘that the defendant

devised or willfully participated in a scheme to defraud’; second, that ‘he used or caused to be

used’ an ‘interstate wire communication’ or the United States mail in furtherance of the scheme;

and third, ‘that he intended to deprive a victim of money or property.’” United States v. Maddux,

917 F.3d 437, 443 (6th Cir. 2019) (quoting United States v. Faulkenberry, 614 F.3d 573, 580–81

(6th Cir. 2010)).

       The defendants’ fraud convictions rise or fall based on whether they had intent to defraud.

Fraud “is not defined according to a technical standard.” United States v. Van Dyke, 605 F.2d 220,

225 (6th Cir. 1979); United States v. Moore, 29 F. App’x 222, 225 (6th Cir. 2002). Instead, fraud

is measured by its departure from “moral uprightness, [ ] fundamental honesty, fair play and right

dealing in the general and business life of members of society.” Van Dyke, 605 F.2d at 225

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Nos. 20-5891/5897/5920/5946/6010, United States v. Montgomery, et al.

(quoting United States v. Bruce, 488 F.2d 1224, 1229 (5th Cir. 1973)). Direct evidence of fraud

can be scarce, so a factfinder “may consider circumstantial evidence of fraudulent intent and draw

reasonable inferences therefrom.” United States v. Davis, 490 F.3d 541, 549 (6th Cir. 2007)

(quoting United States v. Cooper, No. 02-40069, 2004 WL 432236, at *4 (D. Kan. Feb. 10, 2004)).

For example, fraudulent intent “can be inferred from efforts to conceal the unlawful activity, from

misrepresentations, from proof of knowledge, and from profits.” Id. (quoting Cooper, 2004 WL

432236, at *4); United States v. Bailey, 973 F.3d 548, 565 (6th Cir. 2020); see, e.g., United States

v. Bertram, 900 F.3d 743, 748–51 (6th Cir. 2018). Importantly, “the question of intent is generally

considered to be one of fact to be resolved by the trier of the facts . . . and the determination thereof

should not be lightly overturned.” United States v. White, 492 F.3d 380, 394 (6th Cir. 2007)

(quoting United States v. Wagner, 382 F.3d 598, 612 (6th Cir. 2004)).

        At every turn, these defendants demonstrated their intent to defraud. They targeted family,

friends, coworkers, and service members who had insurance that wouldn’t scrutinize compound

drug prescriptions; they paid customers to order the creams and pills by misrepresenting that

they were part of a nonexistent clinical trial, paying direct commissions, or paying the customers’

co-pays; they created pre-set order pads with drug formulas tailored to maximize profit rather than

medical efficiency; they persuaded customers to order unneeded and unwanted creams; they

ordered extra creams and refills for customers without their knowledge or consent; they paid

medical providers to sign prescriptions without seeing patients and stamped the providers’

signature without consent; they directed pharmacists to backdate prescriptions to fall within the

period before insurers stopped covering compound drugs; and these drugs were excessively

expensive relative to their demonstrated benefit, netting the defendants millions of dollars in just

two years.    A reasonable factfinder could easily conclude that these actions constitute an

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intentional, comprehensive scheme to defraud and establish the defendants’ guilt beyond a

reasonable doubt.

       The defendants try to hide behind the complexity of the healthcare system, arguing that

they were “merely advertising prescriptions,” and so the healthcare providers and pharmacies are

responsible for any wrongdoing as gatekeepers between marketers and insurance companies. But

potential wrongdoing by other parties does not excuse the defendants from the consequences of

their actions here. See, e.g., United States v. Grow, 977 F.3d 1310, 1321 (11th Cir. 2020)

(“A doctor’s prescription is not a get-out-of-jail-free card.”); United States v. Svete, 556 F.3d 1157,

1165 (11th Cir. 2009) (“A perpetrator of fraud is no less guilty of fraud because his victim is also

guilty of negligence.”).    And the evidence shows that these gatekeepers were deliberately

commandeered by the marketers’ scheme. The defendants co-opted the role of the healthcare

provider by paying Craven to sign prescriptions without creating any doctor/patient relationship

and in many cases without evaluating the patients whatsoever. In some instances, the defendants

circumvented the role of the healthcare provider altogether by obtaining a stamp of Craven’s

signature and using it to approve prescriptions without her knowledge. The defendants also

undermined the role of the pharmacy by paying a pharmacist, Jared Schwab, to consult with them

to create pre-set drug formulas designed for maximum profit rather than medical efficacy and to

backdate prescriptions. They did all these things knowing that the insurers of their targeted

customers would cover compound drugs without preauthorization. These actions were the essence

of a scheme by which the defendants intended to—and in fact did—extract massive profits from

the marketing of medically unnecessary drugs. Even if these actions taken in isolation could have

a plausible innocent explanation, when taken together, a reasonable factfinder could easily

conclude that they establish an intentional scheme to defraud. See United States v. Jones, 641 F.3d

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706, 710 (6th Cir. 2011); Davis, 490 F.3d at 547 (referring to “the paradigm health care fraud case”

as one “consisting of claims for pharmaceuticals or supplies in the obvious absence of medical

need”).

          It is true that the defendants engaged in the various actions comprising the scheme in

differing degrees, and some of these actions were accomplished indirectly through downlinks. Yet

there is more than sufficient evidence from which a rational trier of fact could infer that each

defendant understood the essence of the scheme; that they either knew the actions their downlinks

were taking or even directed the downlinks to take those actions. Seeing as the myriad of

downlinks engaged in substantially similar conduct, a rational factfinder could infer that these

actions were in fact part of the “process” of marketing these creams and were the essence of the

scheme itself. See Grow, 977 F.3d at 1321 (holding that evidence of healthcare fraud was

sufficient where marketers recruited people to order prescriptions and insurance was billed for pain

creams, scar creams, and vitamins that were not medically necessary).

          Nicholson argues that because she was not found guilty of conspiracy, that necessarily

means that she wasn’t part of the scheme to defraud. Not so. The crimes require proof of different

elements: a person can perpetrate a scheme to defraud without being part of a conspiracy. See,

e.g., United States v. Myint, 455 F. App’x 596, 603 (6th Cir. 2012) (affirming defendant’s

conviction for conspiracy to commit healthcare fraud despite acquittal for substantive healthcare

fraud). A court could have a myriad of reasons for not convicting on the conspiracy charge aside

from lack of sufficient evidence. And on Nicholson’s challenge to her fraud conviction, we ask

only whether the evidence was sufficient to support a conviction on that charge.

          The defendants’ half-hearted assertion that they consulted attorneys does not prove that

they thought their actions were legal, as they did not assert a formal advice of counsel defense and

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Nos. 20-5891/5897/5920/5946/6010, United States v. Montgomery, et al.

offered no evidence of what they told their attorneys in those conversations. United States

v. Lindo, 18 F.3d 353, 356–57 (6th Cir. 1994) (without providing evidence of full disclosure of all

pertinent facts to counsel, defendant could not rely on advice of counsel defense).

       In a final effort to undermine their fraud convictions, the defendants attempt to recast the

evidence of affirmative misrepresentations detailed above as omissions, and then dismiss them by

arguing that they had no duty to disclose. But this argument does not absolve them because a

defendant can be guilty of fraud through the concealment of material information in the absence

of a positive legal duty to disclose that information. Bertram, 900 F.3d at 748–51; Maddux, 917

F.3d at 443–44; United States v. Colton, 231 F.3d 890, 898–99 (4th Cir. 2000); see also United

States v. Keplinger, 776 F.2d 678, 697–98 (7th Cir. 1985) (“[O]missions or concealment of

material information can constitute fraud . . . without proof of a duty to disclose the information

pursuant to a specific statute or regulation.”) (collecting cases).

       The defendants attempted to conceal the nature of their scheme from insurers. By paying

a medical provider to sign the prescriptions without seeing patients, they concealed that they were

the ones soliciting the cream orders rather than the prescriptions originating out of the typical

doctor/patient consultation process. By creating a pre-set compound formula order form, they

concealed that the formulas were created to maximize profit rather than tailored by a doctor for

unique patient needs. And by fabricating a clinical trial, paying customers commissions to order

creams, and paying customers’ co-pays, they concealed that they were inducing customers to order

creams rather than the prescriptions originating from medical necessity and consultation with a

doctor. These concealments are material because insurers testified that if they knew any of this

information, they would not have approved payment for the creams. But even without this

concealment, the affirmative misrepresentations alone can sustain the defendants’ fraud

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Nos. 20-5891/5897/5920/5946/6010, United States v. Montgomery, et al.

convictions. The bottom line is that these customers would not have ordered these medically

unnecessary prescription medications without the fraudulent actions of the defendants, and the

defendants reaped substantial profits from convincing them to do so.

       In short, there is ample evidence for a rational factfinder to infer intent to defraud.

                                                IV.

       Next, Wilkerson, Chatfield, and Hindmon challenge their convictions for conspiracy to

commit healthcare fraud on evidence sufficiency grounds. To establish a conspiracy to commit

healthcare fraud, the government must prove “(1) the existence of an agreement to violate the law;

[and] (2) knowledge and intent to join the conspiracy.” Bailey, 973 F.3d at 564–65 (quoting United

States v. Hughes, 505 F.3d 578, 593 (6th Cir. 2007)).

       The defendants do not challenge the existence of an agreement itself or that they

individually joined such an agreement. Instead, they argue only that their underlying actions were

not unlawful and so they never agreed to violate the law. But, as discussed above, there is

sufficient evidence for a rational factfinder to determine that the defendants engaged in a scheme

by which they intended to defraud insurers. And the evidence shows that Wilkerson, Chatfield,

and Hindmon were working together to carry out that scheme. They coordinated to figure out

which insurers were covering the compound creams, they used the same pre-set order forms to

maximize their profits, their process of recruiting customers by telling them they would be paid

for participating in a clinical trial was the same, their orders were often signed by the same

healthcare provider, and they were all getting paid commissions from the same source. Because

their underlying scheme was intentionally fraudulent and they agreed together to accomplish that

scheme, there is sufficient evidence to support the defendants’ conspiracy convictions. See United

States v. Bryant, 849 F. App’x 565, 570–71 (6th Cir. 2021).

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                                                 V.

       Wilkerson and Chatfield next challenge their money laundering convictions for sufficiency

of the evidence. A person is guilty of money laundering if they “[1] knowingly engage[] or

attempt[] to engage in a monetary transaction [2] in criminally derived property [3] of a value

greater than $10,000 and [4] is derived from specified unlawful activity.” 18 U.S.C. § 1957.

       Neither defendant challenges that they knowingly derived more than $10,000 from

transactions involving their drug marketing activities. The only argument they advance is, again,

that their underlying conduct was not criminal. Thus, as with conspiracy, the money laundering

convictions rise or fall based on the fraud convictions. See United States v. Whitfield, 663 F. App’x

400, 406–07 (6th Cir. 2016). Because there is sufficient evidence that Wilkerson and Chatfield

intentionally defrauded insurers, there is sufficient evidence to support their convictions for money

laundering.

                                                 VI.

       Wilkerson, Chatfield, Hindmon, and Nicholson were convicted of paying and receiving

illegal kickbacks, and Montgomery was convicted of receiving illegal kickbacks. Again, they

challenge their convictions on sufficiency of the evidence grounds. Nicholson also argues that her

kickback payment conviction and wire fraud conviction are multiplicitous.

       To establish a violation of the anti-kickback statute, the government must prove that a

defendant (1) knowingly and willfully offered or paid remuneration (2) to induce that person to

refer an individual (3) for the furnishing of any item or service for which payment may be made

under a federal healthcare program, 42 U.S.C. § 1320a-7b(b)(2), or that a defendant (1) knowingly

and willfully solicited or received remuneration (2) in return for referring an individual to a person

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(3) for the furnishing or arranging for the furnishing of any item or service for which payment may

be made under a federal healthcare program, 42 U.S.C. § 1320a-7b(b)(1).

       Wilkerson, Chatfield, Hindmon, and Nicholson. Here, again, the defendants argue that

their conduct was not fraudulent and so they did not knowingly and willfully do something the law

forbids. They assert that commission arrangements like the ones they had were standard for the

industry, and so they did not believe their conduct was unlawful. Because there is sufficient

evidence that Wilkerson, Chatfield, Hindmon, and Nicholson participated in a scheme with intent

to defraud, the intent requirement is satisfied here as well.

       Montgomery. More needs to be said about Montgomery, since he was not convicted of

fraud. In evaluating the sufficiency of the evidence of Montgomery’s convictions, we ask only

whether there is sufficient evidence for a rational factfinder to find him guilty of the crimes for

which he was convicted: receipt of illegal kickbacks. We do not inquire why the district court

didn’t find him guilty on the fraud counts. The evidence shows that Montgomery engaged in many

of the same activities the court deemed fraudulent. He recruited his own downlinks by promising

them commissions. He told his downlinks to offer commissions to customers to order creams.

And he instructed them to say the customers were being paid as part of a clinical trial that was

nonexistent. He helped pay customers’ co-payments. He encouraged people to order creams they

did not want or need. He also ordered creams for customers without their knowledge or consent

and instructed his downlinks to do the same. According to the government, Montgomery made

$338,391 from the scheme. And he set up an LLC to receive those payments. A rational factfinder

could infer from those actions that he knew his conduct was unlawful, and therefore he had the

requisite mens rea in that he knowingly and willfully received unlawful kickbacks. See Bailey,

973 F.3d at 566–67.

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Nos. 20-5891/5897/5920/5946/6010, United States v. Montgomery, et al.

       Nicholson. In addition to contesting mens rea, Nicholson argues that her convictions for

receiving illegal kickbacks and wire fraud are multiplicitous. We review such claims de novo.

United States v. Vichitvongsa, 819 F.3d 260, 273 (6th Cir. 2016). Multiplicity is “charging a single

offense in more than one count in an indictment” in violation of double jeopardy. United States

v. Swafford, 512 F.3d 833, 844 (6th Cir. 2008) (quoting United States v. Lemons, 941 F.2d 309,

317 (5th Cir.1991)). To assess multiplicity, we use the test set forth in Blockburger v. United

States, 284 U.S. 299, 304 (1932), asking “whether each charge requires proof of a fact that the

other charge does not; if each charge does, then the charges accuse different crimes and are

therefore not multiplicitous.” United States v. Myers, 854 F.3d 341, 355 (6th Cir. 2017).

       The two convictions at issue here are based on a single monetary transaction—a 12/5/14

check to Matthews Consulting LLC. But the question is not whether the charges are based on the

same conduct, but whether the charges each require proof of an element the other does not.

A kickback violation does not require proof of using the wires; a kickback could be paid in cash,

could be an exchange of goods or services in person, or could be accomplished by various other

non-wire means. See, e.g., United States v. Martinez, 921 F.3d 452, 467 (5th Cir. 2019) (kickback

payment made via envelopes of cash). Meanwhile, wire fraud does not require proof that a

payment was intended to induce someone to refer another person for federal healthcare services.

See, e.g., United States v. Kozerski, 969 F.3d 310, 312 (6th Cir. 2020) (wire fraud based on

obtaining government contracts by impersonating a disabled veteran). So both offenses require

proof of an element the other does not, and the charges are not multiplicitous. See United States

v. Tahir, No. 15-20351, 2016 WL 795884, at *6–7 (E.D. Mich. Feb. 29, 2016).

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                                                VII.

        Wilkerson, Chatfield, and Hindmon argue that even if their convictions are affirmed, the

district court erred in calculating the loss amount for sentencing. The district court calculated loss

as the total amount paid by insurers for creams sold by each defendant and their downlinks. The

defendants argue that the cost of “legitimate” claims should have been subtracted from that

amount.

        We review de novo the district court’s method of calculating loss and review any related

factual findings for clear error. United States v. Chaney, 921 F.3d 572, 579 (6th Cir. 2019). The

Guidelines instruct courts to calculate the loss amount as “the greater of actual loss or intended

loss.” U.S.S.G. § 2B1.1, cmt. n.3(A). The court “does not have to ‘establish the value of the loss

with precision,’” United States v. Poulsen, 655 F.3d 492, 513 (6th Cir. 2011) (quoting United

States v. Nelson, 356 F.3d 719, 723 (6th Cir. 2004)), but rather, “a reasonable estimate” will

suffice, U.S.S.G. § 2B1.1 cmt. n. 3(C)). The loss amount need only be proven by a preponderance

of the evidence. United States v. Washington, 715 F.3d 975, 984 (6th Cir. 2013). Because the

district court is in a “unique position to assess the evidence and estimate the loss based on that

evidence,” the “loss determination is entitled to appropriate deference.” U.S.S.G. § 2B1.1 cmt. n.

3(C).

        When healthcare fraud is perpetrated against a government program, “the aggregate dollar

amount of fraudulent bills submitted to the Government health care program . . . is evidence

sufficient to establish the amount of the intended loss, if not rebutted.” U.S.S.G. § 2B1.1, cmt.

n.3(F)(viii); see, e.g., Bryant, 849 F. App’x at 571–72 (defendants failed to rebut loss amount

because they didn’t “meet their burden in providing the specific value by which the loss amount

should be reduced”). In cases of fraud against private insurers as well, it is permissible for a court

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Nos. 20-5891/5897/5920/5946/6010, United States v. Montgomery, et al.

to “conclude[ ] that the intended loss amount was best represented by the amount billed.” Bertram,

900 F.3d at 752. This is especially true where “[t]he Government proved that the defendants

engaged in a pervasive health care fraud conspiracy” and the defendants do not present evidence

“to distinguish legitimate claims from fraudulent ones.” United States v. Lovett, 764 F. App’x

450, 460 (6th Cir. 2019); Bryant, 849 F. App’x at 572; Washington, 715 F.3d at 985; United States

v. Mahmud, 541 F. App’x 630, 635–36 (6th Cir. 2013).               This reflects a court’s “modest

requirement” to make a reasonable estimate of the loss. Bertram, 900 F.3d at 752–53.

       The defendants assert that United States v. Mehmood establishes that legitimate claims

should be subtracted from the aggregate amount. 742 F. App’x 928, 941 (6th Cir. 2018). But that

unpublished case only holds that legitimate claims should be offset “if established.” Id. Here, the

court found that the entire pervasive scheme was fraudulent by a preponderance of the evidence.

Once the court made its reasonable estimate of the loss, it was up to the defendants to establish the

legitimacy of the prescriptions they claim weren’t fraudulent and to present the court with a

valuation of those legitimate prescriptions. See Bertram, 900 F.3d at 752–53. But the defendants

presented no contrary evidence to set apart or establish the legitimacy of any claims here, much

less a valuation of such claims. Instead, they argue that the district court didn’t allow them to offer

such evidence, but nothing in the record indicates that the defendants were precluded from doing

so, only that they chose not to. In response to the court’s request for such evidence, the defendants’

only contention was that there was no fraudulent scheme in the first place. Because we affirm the

defendants’ fraud convictions, this argument is unavailing.

                                                VIII.

       For these reasons, we affirm the convictions and sentences of all defendants.

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