Court Opinion

ID: 9352172
Source: CourtListenerOpinion
Date Created: 2023-01-05 16:00:39.041586+00
Date Added: 2024-06-11T16:58:18.835060
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USCA11 Case: 17-12653   Document: 177-1      Date Filed: 01/05/2023   Page: 1 of 18

                                                           [PUBLISH]
                                    In the
                 United States Court of Appeals
                         For the Eleventh Circuit

                           ____________________

                                 No. 17-12653
                           ____________________

        UNITED STATES OF AMERICA,
                                                       Plaintiff-Appellee,
        versus
        XIULU RUAN,
        JOHN PATRICK COUCH,

                                                  Defendants-Appellants.

                           ____________________

                  Appeal from the United States District Court
                     for the Southern District of Alabama
                    D.C. Docket No. 1:15-cr-00088-CG-B-2
                           ____________________
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        2                         Opinion of the Court                      17-12653

            ON REMAND FROM THE SUPREME COURT OF THE
                         UNITED STATES

        Before WILSON, NEWSOM, Circuit Judges, and COOGLER,* Chief
        District Judge.
        PER CURIAM:
               This case returns to our court on remand from the Supreme
        Court. Ruan v. United States, 142 S. Ct. 2370 (2022) (Ruan II). We
        ordered supplemental briefing to address whether the mens rea
        jury instruction used in this case was error and whether any such
        error was harmless. After careful consideration, we conclude that
        the jury instruction used in this case is inconsistent with the Su-
        preme Court’s guidance and did not convey an adequate mens rea
        to the jury for the substantive drug convictions under 21 U.S.C.
        § 841. We further find that this error was not harmless beyond a
        reasonable doubt for Dr. Xiulu Ruan’s and Dr. John Couch’s (col-
        lectively, the defendants) substantive drug charges. However, we
        conclude that the instructional error was harmless as to the other
        convictions in this case. Accordingly, we VACATE in part and
        AFFIRM in part the defendants’ convictions. 1

        * Honorable L. Scott Coogler, United States Chief District Judge for the North-
        ern District of Alabama, sitting by designation.
        1 In the defendants’ original appeal, they raised a number of other challenges,
        including sufficiency of the evidence, evidentiary, and sentencing challenges.
        On remand these issues were not re-briefed, and nothing in the Supreme
        Court’s decision alters our consideration of those issues. Accordingly, we
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        17-12653                   Opinion of the Court                               3

                                               I.
               The factual and procedural history at trial were thoroughly
        recounted in our prior panel opinion, United States v. Ruan, 966
        F.3d 1101, 1119–36 (11th Cir. 2020) (Ruan I). Among other things,
        the defendants challenged the jury instructions used for their sub-
        stantive drug convictions under 21 U.S.C. § 841(a), which prohibits
        the “knowing[] or intentional[]” dispensing of controlled sub-
        stances “[e]xcept as authorized.” The relevant drugs in this case
        are only “authorized” to be dispensed pursuant to a prescription,
        and an effective prescription must be made for a “legitimate medi-
        cal purpose by an individual practitioner acting in the usual course
        of his professional practice.” 21 C.F.R. § 1306.04(a). The defend-
        ants requested that the jury be instructed that their good faith be a
        defense to an allegation that they acted outside the “usual course
        of professional practice.”
               In Ruan I, we affirmed on all but Count 16 2 and held that we
        were bound by prior Eleventh Circuit precedent to reject the de-
        fendants’ request for a good-faith instruction. See, e.g., United
        States v. Joseph, 709 F.3d 1082 (11th Cir. 2013); United States v.

        adopt the reasoning of the previous panel opinion, but not the discussion re-
        lating to the good-faith instruction in Part C.1. See United States v. Ruan, 966
        F.3d 1101 (11th Cir. 2020).
        2 We remanded the remaining counts for resentencing and after the district
        court resentenced the defendants they appealed again. Those appeals are cur-
        rently pending and stayed awaiting resolution of this case.
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        4                      Opinion of the Court                17-12653

        Tobin, 676 F.3d 1264 (11th Cir. 2012); United States v. Merrill, 513
        F.3d 1293 (11th Cir. 2008); United States v. Williams, 445 F.3d 1302
        (11th Cir. 2006). We reaffirmed that the “usual course of profes-
        sional practice” prong was evaluated using an objective standard,
        not a subjective one. Ruan I, 966 F.3d at 1167. Accordingly, good
        faith was irrelevant to the question of whether a doctor acted in the
        usual course of professional practice; though it was relevant to
        whether the doctor prescribed a controlled substance for a “legiti-
        mate medical purpose.” See id. The defendants then petitioned
        for, and the Supreme Court granted, certiorari to consider whether
        good faith is a defense on the usual course of professional practice
        prong. See Ruan v. United States, 142 S. Ct. 457 (2021).
                The Supreme Court reversed. It reasoned that § 841(a)’s sci-
        enter provision (requiring the defendant to act “knowingly or in-
        tentionally”) applied not only to the statute’s actus reus—here dis-
        pensing—but also to the “except as authorized” exception. Ruan
        II, 142 S. Ct. at 2378. Thus, to obtain a conviction under this sec-
        tion, the government must prove beyond a reasonable doubt that
        a defendant (1) knowingly or intentionally dispensed a controlled
        substance; and (2) knowingly or intentionally did so in an unau-
        thorized manner. Id. at 2382. The Court held that an objective
        standard would inappropriately import a civil negligence standard
        into a criminal prosecution. See id. at 2381. Instead, what matters
        is the defendant’s subjective mens rea. Id. at 2382.
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        17-12653               Opinion of the Court                        5

               The Supreme Court expressly declined to apply its new
        standard to the facts in this case and remanded to this court to con-
        sider the issue in the first instance. Id.
                                         II.
               We review de novo whether a challenged jury instruction
        “misstated the law or misled the jury to the prejudice of the object-
        ing party.” United States v. Cochran, 683 F.3d 1314, 1319 (11th Cir.
        2012). Jury instructions need not be perfect, and we review the
        instructions in light of the “entire charge” and do not isolate indi-
        vidual statements in order to contrive error. Id.
               Where the error is the omission of an element of the crime
        we will reverse unless it can be shown the error was harmless be-
        yond a reasonable doubt. Neder v. United States, 527 U.S. 1, 15–
        16 (1999).
                                        III.
               The district court in this case followed then-binding Elev-
        enth Circuit precedent and denied the defendants’ request for a
        good-faith instruction reflecting their subjective intent. Instead,
        the district court gave an alternative instruction on good faith:
              A controlled substance is prescribed by a physician in
              the usual course of a professional practice and, there-
              fore, lawfully, if the substance is prescribed by him in
              good faith as part of his medical treatment of a patient
              in accordance with the standard of medical practice
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        6                      Opinion of the Court                 17-12653

              generally recognized and accepted in the United
              States.
               The government argues in its supplemental briefing that this
        instruction, read together with the whole charge, adequately in-
        structed the jury that it had to find the defendants acted with
        knowledge or intent in order to convict them under § 841(a). We
        disagree for three reasons.
               First, the passing reference to “good faith” excerpted above
        is inadequate. The Supreme Court recognized that § 841 “uses the
        familiar mens rea words ‘knowingly or intentionally.’ It nowhere
        uses words such as ‘good faith’ . . . .” Ruan II, 142 S. Ct. at 2381.
        The Supreme Court then explicitly rejected the government’s prof-
        fered compromise instruction that objective good faith or “honest
        effort” should govern the usual course of professional practice
        prong. Id. Instead, it is the defendant’s subjective intent that mat-
        ters. The government argues that our cases have conceptually
        linked “good faith” and “knowledge” in the past, and that this in-
        struction gave the “functional equivalent of a knowledge instruc-
        tion.” But, at best, even if the concepts are linked, good faith is an
        imprecise proxy for knowledge.
                Without further qualification, the phrase “good faith” en-
        compasses both subjective and objective good faith. In the context
        of § 841 though, as the Supreme Court has explicitly held, only the
        subjective version is appropriate. The instruction given by the dis-
        trict court did not contain any qualification to make this clear to
        the jury. And, of course, the instruction did not contain this
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        17-12653               Opinion of the Court                         7

        qualification. The district court’s instruction is substantially iden-
        tical to one this court first approved in Williams. See 445 F.3d at
        1309. Over the next fifteen years we reaffirmed this language re-
        peatedly because it comported with our understanding that the
        “usual course of his professional practice must be evaluated based
        on an objective standard.” See, e.g., Joseph, 709 F.3d at 1097. At
        the same time, we consistently rejected attempts by defendants to
        change this language and introduce other formulations that had a
        subjective character. Id.; Tobin, 676 F.3d at 1283; Merrill, 513 F.3d
        at 1306. Based on all of this, we conclude this phrase on its own
        inadequately conveyed the required mens rea.
               Second, even viewing this phrase in the context of the “en-
        tire charge,” the remaining jury instructions did not help convey
        that a subjective analysis was required for the “except as author-
        ized” exception. The district court enumerated the elements of a
        § 841(a) charge: (1) the defendant dispensed the controlled sub-
        stance; (2) “the [d]efendant did so knowingly and intentionally;”
        and (3) the defendant did not have authorization. Grammatically,
        the “did so” phrase links the mens rea element to the preceding
        element describing the actus reus of dispensing the controlled sub-
        stance, but not to the “except as authorized” exception.
                Third and finally, the summary of the charge also did not
        help to convey the required mens rea. The district court essentially
        repeated the language from 21 C.F.R. § 1306.04(a) without linking
        it to any requirement that the jury find a lack of good faith or sci-
        enter for this exception.
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        8                       Opinion of the Court                  17-12653

               Therefore, we conclude that the district court’s instruction
        for the substantive drug charges inadequately conveyed the re-
        quired mens rea to authorize conviction under § 841(a).
                                          IV.
              We turn now to whether the error in the jury instructions
        was harmless beyond a reasonable doubt. Neder, 527 U.S. at 15–
        16. The Supreme Court has held that while the omission of an el-
        ement from the jury instruction is unconstitutional, “most consti-
        tutional errors can be harmless.” Id. at 8 (quoting Arizona v. Ful-
        minante, 499 U.S. 279, 306 (1991)).
                In McDonnell v. United States, the Supreme Court held that
        the erroneous omission of limiting language for the definition of
        “official act” under the federal bribery statute was not harmless.
        579 U.S. 550, 577–80 (2016). In that case, extensive evidence was
        presented both of acts that arguably fell within the overinclusive
        instruction, and of acts that would still qualify as “official acts” had
        the proper limiting instruction been given. Id. at 577. Under this
        circumstance, the Supreme Court held that the jury may have con-
        victed the defendant “for conduct that [was] not unlawful,” and
        therefore the error was not harmless beyond a reasonable doubt.
        Id. at 579–80.
               Here, the district court did not adequately instruct the jury
        that the defendants must have “knowingly or intentionally” pre-
        scribed outside the usual course of their professional practices. At
        a minimum, as discussed above, without the limiting qualification
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        17-12653               Opinion of the Court                        9

        that only subjective good faith was sufficient for conviction, the
        jury was authorized to convict under the sort of objective good
        faith or honest effort standard rejected by the Supreme Court.
                For Dr. Ruan, both sides presented expert evidence about
        the appropriate standard of care. In his defense, Dr. Ruan intro-
        duced witnesses who testified to his practices and procedures at the
        clinic to guard against abuse. He also testified in his own defense
        about how he always centered the patient’s medical needs. Dr.
        Couch also introduced both expert witnesses who testified to the
        standard of care and lay witnesses who testified to his activities at
        the clinic. Like Dr. Ruan, Dr. Couch testified that he believed his
        actions to be in accord with the applicable standard of care.
               The jury could have weighed all of this evidence and con-
        cluded that Dr. Ruan and Dr. Couch subjectively believed their
        conduct was in accord with the appropriate standard of care. But
        under the erroneous instruction that was given, the jury could con-
        vict the defendants if they found that a reasonable doctor would
        not have believed the conduct was in accord with the appropriate
        standard. In other words, a properly instructed jury may not have
        convicted the defendants had it known that Dr. Ruan’s and Dr.
        Couch’s subjective beliefs that they were acting properly was a de-
        fense to these charges. Similar to McDonnell, under the erroneous
        instruction in this case the jury was authorized to convict the de-
        fendants for conduct that was lawful. Thus, we cannot conclude
        that these errors were harmless. We therefore vacate the defend-
        ants’ substantive drug convictions under § 841(a).
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         10                     Opinion of the Court                 17-12653

                                          V.
                Given that we have found error in the district court’s in-
         structions for the § 841(a) charges, all that remains is to decide
         which, if any, of the other charges must also be vacated.
                                           1.
                 We begin with the conspiracy to violate the Controlled Sub-
         stances Act charges, violations of 21 U.S.C. § 846. To violate § 846
         the government must prove: “(1) there was an agreement between
         two or more people to commit a crime (in this case, unlawfully
         dispensing controlled substances in violation of § 841(a)(1)); (2) the
         defendant knew about the agreement; and (3) the defendant volun-
         tarily joined the agreement.” United States v. Azmat, 805 F.3d
         1018, 1035 (11th Cir. 2015).
                Because a conviction under § 846 requires the jury to find
         that the defendants knew of the illegal nature of the scheme and
         agreed to participate in it, the erroneous jury instruction for the
         substantive charges has a limited impact here. Consider what a
         jury who voted to convict under § 846 would have to find. The
         jury would need to find that the defendant knew the illegal object
         of the conspiracy. For a defendant to know that the aim of their
         agreement was illegal in this context means that they would need
         to know both that (1) they were dispensing a controlled substance
         and (2) that they were doing so in an unauthorized manner. If the
         jury concluded that the defendant did not know either of these
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         17-12653               Opinion of the Court                       11

         things, then they could not conclude the defendant knew the illegal
         object of the conspiracy and could not vote to convict.
                In this circumstance, the inadequate substantive jury in-
         struction would have no effect on the jury’s analysis for the con-
         spiracy counts. The jury did not need an additional instruction clar-
         ifying between subjective and objective good faith for the “except
         as authorized” exception, because the conspiracy instructions al-
         ready required them to find that the defendant acted with subjec-
         tive knowledge.
                Here, the jury instructions for the drug conspiracy charges
         tracked our precedent and conveyed the adequate mens rea. The
         jurors in this case were instructed to convict only if they found
         “two or more people in some way agreed to try and accomplish a
         shared unlawful plan to distribute or dispense . . . the alleged con-
         trolled substance or substances.” Further, they were instructed to
         convict only if they found that the defendants “knew the unlawful
         purpose of the plan and willfully joined it.” The instructions told
         the jury that a person acts with willfulness only when they act “vol-
         untarily and purposefully . . . to do something the law forbids.”
         Had the jury in this case concluded that Dr. Ruan or Dr. Couch
         believed their actions to be for a legitimate medical purpose they
         could not have found the defendants made an “unlawful plan” and
         “knew” its “unlawful purpose,” nor could they have concluded
         they “willfully” joined that plan. The jury was properly instructed
         on these counts, and considering all the evidence, voted to convict.
         So the instructions for the drug conspiracy charges were not
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         12                     Opinion of the Court                17-12653

         erroneous, and any error in the substantive drug charges was harm-
         less to these convictions.
                                          2.
                 Next, the inadequate instruction does not affect the defend-
         ants’ convictions for conspiracy to commit health care fraud in vi-
         olation of 18 U.S.C. §§1347 and 1349. A health care fraud conspir-
         acy is fundamentally about the submission of false medical claims
         to health care benefit programs. United States v. Gonzalez, 834
         F.3d 1206, 1214 (11th Cir. 2016). Here, the government proceeded
         on four distinct factual theories, that the defendants conspired to:
         (1) falsely certify that some patients had cancer when they did not;
         (2) bill office visits with nurse practitioners as if Dr. Couch con-
         ducted them; (3) bill insurers for medically unnecessary drug tests;
         and (4) bill insurers for office visits that prescribed medically un-
         necessary drugs. See Ruan I, 966 F.3d at 1142–44 (summarizing
         charges and evaluating sufficiency of the evidence).
                None of these theories is affected by the inadequate jury in-
         struction for the substantive drug charges. The jury was properly
         instructed by the district court for the health care fraud conspiracy
         charges, and the defendants do not challenge the jury instructions
         for these charges. They argue nonetheless that United States v.
         Ignasiak, 667 F.3d 1217 (11th Cir. 2012), requires us to consider the
         substantive drug charges and the fraud counts “together” because
         in that case we stated such charges may be “inextricably inter-
         twined.” Id. at 1235. But the defendants overstate Ignasiak. In that
         case we considered the sufficiency of the evidence for substantive
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         17-12653                Opinion of the Court                         13

         drug convictions under § 841 and convictions for health care fraud
         under 18 U.S.C. § 1347. Id. at 1219. The government’s theory of
         the case for the drug charges turned on whether the prescriptions
         were legitimate, and submitting the illegitimate prescriptions was
         the fraud perpetrated on the health care benefit programs. Id. at
         1227. Thus, in the context of a sufficiency of the evidence chal-
         lenge, both sets of charges rose and fell together. Had the defend-
         ant in that case shown the evidence was insufficient for the jury to
         find the prescriptions were illegitimate, then both the substantive
         drug charges and the fraud counts would fall. This is all Ignasiak
         was saying; it was not announcing any broader principle about how
         the two types of charges relate to one another.
                 Here, whether or not the defendants had subjective
         knowledge that their prescriptions were outside the “usual course”
         is irrelevant to whether or not the defendants also (1) falsely certi-
         fied that patients had cancer; (2) falsely billed for office visits when
         the doctor was not present; (3) falsely billed insurers for unneces-
         sary medical tests; or (4) falsely billed insurers for office visits to
         prescribe unnecessary drugs. Thus, the inadequate jury instruction
         was harmless as to the health care fraud conspiracy convictions.
                                            3.
                Nor are the defendants’ convictions under Count 17 for con-
         spiring to violate the Anti-Kickback Statute, 18 U.S.C. § 371 and 42
         U.S.C. § 1320a-7b, affected by the inadequate instruction. The de-
         fendants were convicted of willfully receiving compensation from
         the pharmaceutical company InSys in exchange for increased
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         14                     Opinion of the Court                17-12653

         prescriptions of InSys branded fentanyl. By doing so the jury found
         that the defendants willfully received compensation from the phar-
         maceutical company InSys in exchange for increased prescriptions
         of fentanyl. Like the health care fraud charges, the jury was
         properly instructed on this count. For the reasons previously
         stated for the health care fraud conspiracy charges, the inadequate
         instruction is equally irrelevant to the defendants’ conviction under
         the Anti-Kickback Statute.
                                          4.
                The defendants were convicted of two counts of conspiracy
         to commit mail or wire fraud, in violation of 18 U.S.C. §§ 1341,
         1343, and 1349. Three different theories were used to convict the
         defendants, none of which is affected by the inadequate instruction.
         Two theories overlapped with the health care fraud conspiracy
         charges: (1) falsely billing insurers for visits with a nurse practi-
         tioner at the higher rate for a visit with a doctor; and (2) falsely
         certifying that patients had cancer to justify prescribing expensive
         drugs. These theories are unaffected by the jury instructions for
         the same reasons stated previously. Unique to this count, the gov-
         ernment’s third theory alleged that the defendants selected more
         expensive drugs to stock in their workers’ compensation dispen-
         sary and made decisions about which drug to prescribe based on
         the profit generated by the higher reimbursement for these drugs
         rather than medical need. Again, the jury was properly instructed
         on this count. The mens rea instructions for the § 841 conviction
         have nothing to do with these theories.
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         17-12653               Opinion of the Court                        15

                                           5.
                The defendants were charged with one count of conspiring
         to violate the Racketeer Influenced and Corrupt Organizations Act
         (RICO). 18 U.S.C. § 1962(d). RICO requires the government to
         prove a “pattern of racketeering activity” which generally means
         the commission of two or more predicate offenses. 18 U.S.C.
         § 1962(a); id. § 1961(1), (5). In this case, the government identified
         21 U.S.C. § 841 (substantive drug charges); 21 U.S.C. § 846 (conspir-
         acy drug charges); 18 U.S.C. § 1341 (mail fraud); and 18 U.S.C.
         § 1343 (wire fraud) as the predicate offenses. To prove a RICO con-
         spiracy, the government need only prove that the defendants
         agreed to participate in the enterprise and that there was an agree-
         ment to preform the predicate offenses. United States v. Pepe, 747
         F.2d 632, 660 n.44 (11th Cir. 1984). There is no requirement that
         the predicate offenses even occur, just that the defendants agreed
         to commit them.
                 As an initial matter, we have already held that the inade-
         quate instruction for the substantive drug charges did not affect the
         defendants’ convictions for conspiracy to violate the Controlled
         Substances Act and conspiracy to commit mail or wire fraud. To
         the extent the jury relied on these charges, the inadequate instruc-
         tion was harmless to the RICO conspiracy conviction. But even
         had the jury been relying entirely on the substantive drug charges
         as the predicates for the RICO conspiracy, the inadequate instruc-
         tion is still harmless. Similar to the § 846 charges, in order to con-
         vict the defendants for RICO conspiracy, the jury was instructed it
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         16                     Opinion of the Court                17-12653

         had to find “the Defendant[s] had the specific intent either to per-
         sonally participate in committing . . . or else to participate in the
         enterprise’s affairs, knowing that other members of the conspiracy
         would commit” the predicate offenses. Thus, if the jury relied en-
         tirely on the § 841 charges, they would still have made a finding
         that the defendants intended to violate § 841, which means that the
         defendants would have to have known their acts were unauthor-
         ized. For these reasons we hold the inadequate jury instruction for
         the substantive drug charges was harmless to the RICO conspiracy
         conviction.
                                          6.
                 Finally, turning to Dr. Ruan’s money laundering convic-
         tions, these were also unaffected by the inadequate instruction. He
         was convicted of two counts of substantive money laundering of-
         fenses in violation of 18 U.S.C. § 1957(a) and one count of conspir-
         acy to commit money laundering in violation of 18 U.S.C.
         § 1956(h).
                Substantive money laundering under § 1957 criminalizes the
         knowing execution of “monetary transaction[s]” over $10,000 that
         use money “derived from specified unlawful activity.” 18 U.S.C.
         § 1957(a). Here, the government alleged that the health care con-
         spiracies (18 U.S.C. § 1347); the Anti-Kickback Statute conspiracies
         (18 U.S.C. § 371; 42 U.S.C. § 1320a-7b); and the drug conspiracies
         (21 U.S.C. § 846) were the specified unlawful activity. As we have
         previously said, these convictions were unaffected by the inade-
         quate instruction for the substantive drug charges. Therefore, the
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         17-12653               Opinion of the Court                      17

         inadequate instruction was harmless to the substantive money
         laundering convictions under § 1957(a).
                 Conspiracy to commit money laundering criminalizes those
         who conspire to violate either of the two money laundering sec-
         tions, 18 U.S.C. §§ 1956 and 1957. Because we hold that the instruc-
         tion was harmless to the substantive money laundering convictions
         it cannot possibly affect the money laundering conspiracy convic-
         tion.
                                         VI.
                For the reasons stated above we VACATE in part and
         AFFIRM in part the defendants’ convictions. We VACATE both
         of the defendants’ sentences on all counts consistent with our ordi-
         nary practice in multi-indictment cases. See United States v.
         Fowler, 749 F.3d 1010, 1017–18 (11th Cir. 2014) (collecting cases
         and noting “we have always . . . presumed that sentences on each
         count of a multi-count indictment are part of a package”). We re-
         mand to the district court for further proceedings consistent with
         the following instructions:
               (1) We VACATE Dr. Ruan’s convictions under 21 U.S.C.
                   § 841 in Counts 8, 9, 11, and 12. We REMAND for new
                   trial.
               (2) We VACATE Dr. Couch’s convictions under 21 U.S.C.
                   § 841 in Counts 5, 6, 7, 13, and 14. We REMAND for
                   new trial.
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         18                  Opinion of the Court             17-12653

              (3) We AFFIRM the defendants’ convictions on all remain-
                  ing counts.
              (4) We VACATE the defendants’ sentence for all counts and
                  REMAND for resentencing on the surviving counts.