Court Opinion

ID: 9895071
Source: CourtListenerOpinion
Date Created: 2023-11-04 00:00:35.624529+00
Date Added: 2024-06-11T09:10:44.765189
License: Public Domain

Case: 21-11225   Document: 00516956725   Page: 1   Date Filed: 11/03/2023

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

                           ____________                           FILED
                                                           November 3, 2023
                             No. 21-11225                    Lyle W. Cayce
                           ____________                           Clerk

   United States of America,

                                                   Plaintiff—Appellee,

                                versus

   Tammie L. Little; Laila N. Hirjee, Medical Doctor,

                                              Defendants—Appellants,

                        consolidated with
                          _____________

                            No. 21-11228
                          _____________

   United States of America,

                                                   Plaintiff—Appellee,

                                versus

   Mark E. Gibbs, Medical Doctor,

                                               Defendant—Appellant.
Case: 21-11225          Document: 00516956725              Page: 2      Date Filed: 11/03/2023

                       ______________________________

                      Appeals from the United States District Court
                           for the Northern District of Texas
                              USDC Nos. 3:17-CR-103-12,
                            3:17-CR-103-5 and 3:17-CR-103-6
                      ______________________________

   Before Richman, Chief Judge, and Stewart and Douglas, Circuit
   Judges.
   Per Curiam: *
           Three codefendants appeal their various convictions stemming from
   a multi-million-dollar healthcare conspiracy that involved fraudulent
   certification and recertification of patients as terminally ill and eligible for
   hospice care. Finding no reversible error, we affirm.
                                                 I
           Defendants challenge the sufficiency of the evidence to support their
   convictions. Our sufficiency review is highly deferential to the jury’s verdict,
   and “[a]s a result, the recounting of the evidence that follows is in the light
   most favorable to the jury’s verdict.” 1
           Novus was a hospice provider located in Dallas, Texas, and co-
   founded by Bradley Harris (Harris) and Amy Harris (Amy Harris) in 2012.
   Harris oversaw Novus’s operations. Drs. Mark E. Gibbs and Laila N. Hirjee
   were medical directors for Novus. Tammie L. Little was a registered nurse
   (RN). Melanie Murphey was an administrator who had no medical training.

           _____________________
           *
               This opinion is not designated for publication. See 5th Cir. R. 47.5.
           1
             United States v. Mesquias, 29 F.4th 276, 279 (5th Cir.) (citing United States v.
   Moreno–Gonzalez, 662 F.3d 369, 372 (5th Cir. 2011)), cert. denied sub nom. McInnis v. United
   States, 143 S. Ct. 115 (2022), and cert. denied sub nom. Mesquias v. United States, 143 S. Ct.
   269 (2022).

                                                 2
Case: 21-11225          Document: 00516956725           Page: 3   Date Filed: 11/03/2023

                                           No. 21-11225
                                         c/w No. 21-11228

          Under applicable regulations, hospice is a service for the “terminally
   ill” that provides palliative care rather than curative care. “Terminally ill”
   means “that the individual has a medical prognosis that his or her life
   expectancy is 6 months or less if the illness runs its normal course.” 2
   Hospice care is among the benefits covered by Medicare. Medicare pays
   hospice providers’ claims automatically in order to expedite reimbursement.
   A web of statutes and regulations governs whether Medicare will pay for
   hospice services.         For a hospice claim to be eligible for Medicare
   reimbursement, a medical director must have enrolled the patient after
   “certify[ing] in writing . . . that the individual is terminally ill . . . based on
   the physician’s or medical director’s clinical judgment regarding the normal
   course of the individual’s illness.” 3 The medical director can rely on the
   records and recommendation of the patient’s attending physician to certify a
   patient as terminally ill and admit him or her to hospice. A patient can be
   recertified after their first 90 days on hospice without a face-to-face visit. If
   a patient is still alive after 180 days, Medicare requires that a face-to-face visit
   accompany the medical director’s recertification for hospice. A face-to-face
   visit is also required for every following recertification, which must occur no
   more than 60 days after the previous one.
          Novus exploited Medicare’s reimburse-first-verify-later system.
   Because Medicare pays a flat rate per day for patients who are receiving
   hospice care regardless of the amount of care provided or the resulting costs
   to the hospice, it can be profitable to have low-acuity patients who are
   designated as hospice patients for long periods of time. Novus’s business
   model was to target patients who had a medical diagnosis that would qualify

          _____________________
          2
              42 C.F.R. § 418.3.
          3
              42 U.S.C. § 1395f(a)(7)(A)(i)(II).

                                                   3
Case: 21-11225      Document: 00516956725          Page: 4   Date Filed: 11/03/2023

                                    No. 21-11225
                                  c/w No. 21-11228

   them for hospice but who were not “imminently dying.” Staff at Novus
   would market to these desirable types of patients, and, if those patients
   agreed to receive hospice services from Novus, the staff would then use pre-
   signed physician’s orders to enroll patients.
          As discussed above, Medicare has certain requirements for
   recertifying patients for hospice. Relevant here, the medical director’s 180-
   day recertification must be accompanied by a form attesting to the medical
   director’s face-to-face visit with the patient and a physician’s narrative
   explaining “why the clinical findings of that face-to-face encounter support a
   life expectancy of six months or less.” At Novus, the medical directors used
   nurses’ notes to fill out the narrative section of the face-to-face forms, and
   Harris told them what dates to put on the forms. Face-to-face visits by the
   directors did not occur.
          Ultimately, Novus’s business model had inherent limitations.
   Medicare imposes an aggregate cap on the amount of money it will pay a
   hospice in a year. When Medicare has paid a hospice provider more than its
   cap allows, it claws back the excess payments. Novus exceeded its cap in
   2012 and 2013, and, by its calculations, it had exceeded its cap by millions in
   mid-2014. To avoid liability for the excess payments, Novus needed to
   increase the number of patients who were hospice patients for a short time.
   Bluntly, Novus needed patients who would die quickly or who could be
   discharged before the end of their first 90-day benefits period.
          To meet these needs, Harris entered into an agreement with Ali Rizvi,
   the owner of Express Medical. Rizvi provided Little with login credentials to
   Express Medical’s electronic records database. Little and Harris used
   Express Medical’s database to look for patients who had been diagnosed with
   a disease that would qualify them for hospice care. Little or Amy Harris
   would then contact those patients and try to enroll them with Novus.

                                         4
Case: 21-11225       Document: 00516956725         Page: 5     Date Filed: 11/03/2023

                                      No. 21-11225
                                    c/w No. 21-11228

            In 2015, the Centers for Medicare and Medicaid Services (CMS)
   suspended payments to Novus because of “credible allegations of fraud.”
   Harris, Amy Harris, and Dr. Gibbs responded by transferring some of
   Novus’s patients to another hospice company, Dependable. Dr. Gibbs
   served as Dependable’s medical director until CMS suspended payments to
   Dependable.
            A grand jury indicted Harris, Amy Harris, Rizvi, Murphey, Dr. Gibbs,
   Dr. Hirjee, Little, and others for conspiracy to commit healthcare fraud and
   other crimes. Little and Drs. Hirjee and Gibbs proceeded to trial. Harris and
   Murphey, among others who had been indicted, pled guilty and testified at
   trial.
            The jury found each defendant guilty of the allegations in Count One,
   conspiracy to commit healthcare fraud. The jury also found: (1) Dr. Gibbs
   guilty of Counts Five and Six, substantive healthcare fraud, but acquitted him
   on a third count, and guilty of Count Fifteen, conspiracy to obstruct an
   administrative proceeding; (2) Dr. Hirjee guilty of Counts Eight, Nine, and
   Ten, substantive healthcare fraud, and guilty of Count Fourteen, unlawful
   distribution of a controlled substance; and (3) Little guilty of Counts Two,
   Three, and Four, substantive healthcare fraud. The district court sentenced
   Dr. Gibbs to 156 months of imprisonment; Dr. Hirjee to 120 months; Little
   to 33 months. The district court ordered Dr. Gibbs to pay $27,978,903 in
   restitution jointly and severally with other coconspirators; and Little to pay
   $366,493.12 jointly and severally with other coconspirators. The defendants
   timely appealed.
            We first address challenges to the sufficiency of the evidence—first to
   the conspiracy counts, then to the substantive healthcare fraud counts, and
   finally to the defendant-specific counts of distribution of a controlled
   substance and conspiracy to obstruct justice. We then address issues relating

                                           5
Case: 21-11225           Document: 00516956725              Page: 6       Date Filed: 11/03/2023

                                            No. 21-11225
                                          c/w No. 21-11228

   to the conduct of trial, including the jury instructions given on two counts,
   the denial of a motion for a new trial, and the admission of evidence. Finally,
   we address challenges to restitution and sentencing.
                                                  II
           We review sufficiency of the evidence challenges de novo, but we
   remain “highly deferential to the verdict.” 4 “[T]he relevant question is
   whether, 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.” 5 “The evidence is viewed in the
   light most favorable to the verdict, accepting all credibility choices and
   reasonable inferences made by the trier of fact which tend to support the
   verdict,” 6 and we resolve any conflict in the evidence “in favor of the jury’s
   verdict.” 7 “We will not second guess the jury in its choice of which witnesses
   to believe.” 8 We begin by addressing the sufficiency of the evidence as to the
   conspiracy to commit healthcare fraud counts; then the substantive
   healthcare fraud counts; then the distribution of a controlled substance count
   for Dr. Hirjee; and last the conspiracy to obstruct justice count for Dr. Gibbs.

           _____________________
           4
            Moreno–Gonzalez, 662 F.3d at 372 (quoting United States v. Harris, 293 F.3d 863,
   869 (5th Cir. 2002)).
           5
               Jackson v. Virginia, 443 U.S. 307, 319 (1979).
           6
            Moreno–Gonzalez, 662 F.3d at 372 (quoting United States v. Asibor, 109 F.3d 1023,
   1030 (5th Cir. 1997)).
           7
               Id. (citing United States v. Duncan, 919 F.2d 981, 990 (5th Cir. 1990)).
           8
            United States v. Zuniga, 18 F.3d 1254, 1260 (5th Cir. 1994) (citing United States v.
   Jones, 839 F.2d 1041, 1047 (5th Cir. 1988)).

                                                   6
Case: 21-11225           Document: 00516956725                Page: 7       Date Filed: 11/03/2023

                                             No. 21-11225
                                           c/w No. 21-11228

                                                   A
           “A person commits health care fraud by ‘knowingly and willfully
   execut[ing] a scheme to defraud a government health care program like
   Medicare.’” 9 “A person is guilty of conspiring to commit health care fraud
   when he knowingly agrees to execute the fraud scheme with the intent to
   further its unlawful purpose.” 10 To prove a conspiracy to commit healthcare
   fraud, the Government must show that: (1) two or more people made an
   agreement to commit healthcare fraud; (2) the defendant knew of the
   unlawful purpose of the agreement; and (3) the defendant joined in the
   agreement with the intent to further the unlawful purpose. 11 We first address
   Dr. Gibbs’s arguments, then Dr. Hirjee’s, and last, Little’s.
                                                    1
           Dr. Gibbs argues that the Government failed to establish that he
   “agreed to commit healthcare fraud.” He provides two theories.
           First, Dr. Gibbs contends that the Government did not present
   evidence proving he “knowingly participated in a scheme where he knew
   patients were certified for hospice when they were not hospice appropriate
   or that patients were kept in hospice when that was no longer appropriate.”
   This argument misconstrues the theory of fraud underlying these charges.
   The fraud is the false certification of patients as terminally ill to enroll them
   as hospice patients and the false recertification to keep them as receiving
           _____________________
           9
             United States v. Mesquias, 29 F.4th 276, 280 (5th Cir.) (alteration in original)
   (quoting United States v. Sanjar, 876 F.3d 725, 745 (5th Cir. 2017)), cert. denied sub nom.
   McInnis v. United States, 143 S. Ct. 115 (2022), and cert. denied sub nom. Mesquias v. United
   States, 143 S. Ct. 269 (2022).
           10
                Id. (citing United States v. Njoku, 737 F.3d 55, 63 (5th Cir. 2013)).
           11
            United States v. Hamilton, 37 F.4th 246, 257-58 (5th Cir.), cert. denied, 143 S. Ct.
   450 (2022).

                                                    7
Case: 21-11225         Document: 00516956725               Page: 8      Date Filed: 11/03/2023

                                          No. 21-11225
                                        c/w No. 21-11228

   hospice care. Those certifications and recertifications are false because Dr.
   Gibbs did not know whether the patients were eligible for hospice care, but
   he lent his signature to attest to Medicare that they were. 12 Another medical
   director following Medicare’s requirements might have placed or kept
   certain patients in a hospice program, but that is not the point. Falsely
   certifying a patient who happens to be eligible does not make the certification
   less false.
           Second, Dr. Gibbs avers that the Government failed to put on proof of
   an agreement, and “[t]here is no way to distinguish lax medical practices with
   participation in the common scheme.” Contrary to this assertion, the
   Government did introduce evidence of an agreement between the
   coconspirators, as well as evidence supporting a conclusion that Dr. Gibbs’s
   actions amounted to willful participation, not just haphazard medical
   practices.
           The jury heard a recording of Dr. Gibbs, Murphey, Harris, and Amy
   Harris after CMS suspended payments to Novus. Murphey recorded the
   conversation without the others knowing. Amy Harris described moving
   Novus hospice patients to another hospice company, Optim, and that “we
   don’t think that they’re going to come after Optim because they’re gonna

           _____________________
           12
               See United States v. Ramirez, 979 F.3d 276, 278 (5th Cir. 2020) (“Ramirez
   defrauded Medicare. He falsely certified that Medicare beneficiaries needed a specialized
   form of nursing care called ‘home health services.’ Medicare pays for such services only
   where a physician certifies that he evaluated the patient face-to-face and decided that home
   health services were medically necessary. Ramirez signed hundreds of those certifications.
   But he did so without meeting the patients, much less evaluating them.”); United States v.
   Sanjar, 876 F.3d 725, 746 (5th Cir. 2017) (“The circumstantial evidence of fraudulent
   intent in this case is similar to what courts have found sufficient in other health care fraud
   schemes. [Defendants] had employees falsify patient files to comport with [partial
   hospitalization program] requirements, feigned participation in patient evaluations, and, as
   the owners of [Provider], reaped substantial profits from the scheme.”).

                                                 8
Case: 21-11225      Document: 00516956725           Page: 9     Date Filed: 11/03/2023

                                     No. 21-11225
                                   c/w No. 21-11228

   have to be able to find . . . a reason to do that. If they did, by that time, like
   worst-case scenario, we could then move to this other hospice that our names
   are not associated with.” Dr. Gibbs then explained, “[T]he Optim thing is
   going to be tricky because, like we talked about earlier, they’re going to really
   notice 200.” Murphey clarified at trial that Dr. Gibbs was referring to
   Medicare noticing 200 Novus patients being moved to another company.
   The group then discussed “Plan C,” which was to move Novus patients to
   Dependable, a hospice company owned by an associate of Harris, and which
   had no patients. Dr. Gibbs posed, “So your next question is: Is this kind of
   shady? And the answer is: Yes, absolutely, but we’ve worked in the gray areas
   for years and everybody does.” Dr. Gibbs did assure Murphey that “we
   haven’t done anything illegal at all,” but Murphey testified that she believed
   he was trying to convince her to stay because, as Dr. Gibbs phrased it, she
   was “vital.” Dr. Gibbs’s involvement in planning the next steps after the
   CMS suspension, moving the Novus patients to Dependable, and
   acknowledgment of having “worked in the gray area for years” support a
   reasonable inference that Dr. Gibbs had been willfully participating in a
   scheme to defraud Medicare.
          Aside from this recording, the jury also heard testimony about actions
   taken by Dr. Gibbs that indicate he was working in concert with the
   coconspirators to achieve the goals of the conspiracy. Murphey testified to
   receiving pre-signed documents from Dr. Gibbs, including physician’s orders
   and face-to-face forms. Murphey, who was not a medical professional, used
   those pre-signed physician’s orders to enroll new patients in hospice. Harris
   and Murphey testified to witnessing Dr. Gibbs complete face-to-face forms
   without visiting the patients in person. Harris explained at trial that he and
   Dr. Gibbs would go through patients’ medical records, and Dr. Gibbs would
   write a physician narrative based on the recent nurse’s notes. In order to
   make it difficult “to prove that he didn’t do the visits,” Harris instructed Dr.

                                           9
Case: 21-11225         Document: 00516956725               Page: 10         Date Filed: 11/03/2023

                                           No. 21-11225
                                         c/w No. 21-11228

   Gibbs to date the face-to-face certifications when Dr. Gibbs came to Novus’s
   clinic and his other office was closed.
          “In the vast majority of concert of action cases, the Government
   presents an insider with direct evidence of the conspiratorial scheme who
   testifies to the individual actions she completed and the actions the defendant
   took to meet their common unlawful goal.” 13 “Such testimony of a co-
   conspirator, as long as it is not incredible, is alone sufficient to support a
   conviction.” 14       Here, the jury heard the testimony of coconspirators
   Murphey and Harris, both of whom described the actions Dr. Gibbs took to
   further the conspiracy. Those actions evidence his agreement to join in the
   scheme to defraud Medicare. The jury also heard the recording of Dr. Gibbs
   describing how he and the others had been working in the “gray area.”
          Viewing this evidence in the light most favorable to the verdict, a jury
   could reasonably infer that Dr. Gibbs willfully joined in the conspiracy to
   defraud Medicare.
                                                  2
          Dr. Hirjee argues that the Government failed to prove that there was
   a conspiracy and, if there was, that Dr. Hirjee willfully participated in it.
          Like Dr. Gibbs, Dr. Hirjee argues that “the Government failed to
   show that between 2012 and 2014, Novus doctors and employees willfully
   certified any ineligible patients for hospice care.” She concedes that “the
   Government presented evidence that Dr. Hirjee and other Novus doctors
   signed blank hospice admission forms and Murphey filled in the
   information,” but she asserts “there is no evidence that any blank form

          _____________________
          13
               United States v. Ganji, 880 F.3d 760, 771 (5th Cir. 2018).
          14
               Mesquias, 29 F.4th at 282.

                                                 10
Case: 21-11225          Document: 00516956725          Page: 11   Date Filed: 11/03/2023

                                          No. 21-11225
                                        c/w No. 21-11228

   signed by Dr. Hirjee resulted in the admission of an ineligible patient.”
   Again, this misconstrues the underlying theory of fraud. Under Dr. Hirjee’s
   interpretation, so long as Murphey happened to enroll only eligible patients,
   then no fraud occurred. That is not the fraud theory the Government
   presented to the jury. The fraud theory presented by the Government was
   supported by evidence—Harris testified about Novus’s overarching business
   model, and he and Murphey testified about how individuals, including Dr.
   Hirjee, fit into the mechanics of that model in order to defraud Medicare.
          Dr. Hirjee continues on to argue that, if there was a conspiracy, the
   Government failed to prove that she willfully agreed to it. She makes three
   assertions: (1) she was not intimately involved in Novus; (2) the Government
   failed to prove she falsely certified that she visited patients; and (3) the
   Government proved at most lax practices.
          First, Dr. Hirjee likens her situation to that of the defendants in United
   States v. Ganji. 15 There, the Government’s concerted-action evidence fell
   short because the witnesses “admitted to their own fraud, [but] they did not
   implicate [the defendant].” 16 Ganji is inapposite. Here, Harris and Murphey
   testified as to their own fraudulent actions and how they carried out those
   actions with Dr. Hirjee. The jury heard evidence of Dr. Hirjee pre-signing
   physician’s orders used to admit patients to hospice; receiving patient
   narratives for face-to-face forms along with requests to date the forms as
   Harris directed; and leaving pre-signed, blank prescriptions for Harris or
   Murphey to retrieve. Dr. Hirjee also points to evidence that she refused to
   certify ineligible patients for hospice, and claims that she “hardly earned the
   sort of money that might tempt a doctor of her stature into risking decades in

          _____________________
          15
               880 F.3d 760 (5th Cir. 2018).
          16
               Id. at 770.

                                               11
Case: 21-11225       Document: 00516956725              Page: 12       Date Filed: 11/03/2023

                                         No. 21-11225
                                       c/w No. 21-11228

   federal prison.” But the jury did not credit this evidence or make these
   inferences, and we will not second-guess the jury. 17                  Ultimately, the
   Government needed to prove beyond a reasonable doubt that Dr. Hirjee
   willfully joined in a conspiracy to defraud Medicare, not that she was a key
   player or intimately involved.
           Second, Dr. Hirjee argues that the Government failed to prove that
   she falsified face-to-face forms for recertification of hospice patients. Dr.
   Hirjee primarily re-presents evidence that the jury heard at trial. She points
   to witness testimony that she did complete face-to-face visits and visited her
   patients’ facilities weekly. She suggests that while “the Government no
   doubt showed that Dr. Hirjee was on vacation on two dates on which she
   supposedly saw [three patients]” for face-to-face visits, “the Government
   did not show that she had not seen the patients on or about those dates—in
   other words, that the precise dates on the forms were not simply mistakes.”
   She also suggests that “[i]t would make no sense to lie about something so
   simple and convenient.” These are possible inferences that the jury could
   have drawn, but they are not the inferences it drew.
           The Government responds by pointing to the evidence cutting the
   other way. Harris testified that Dr. Hirjee fraudulently certified that she
   conducted face-to-face visits that never occurred. As with Dr. Gibbs, Harris
   would instruct Dr. Hirjee to date the face-to-face certifications on days when
   it would be more difficult to prove that she had not performed the visit.
   Harris would fax Dr. Hirjee batches of narratives, written by nurses, along
   with blank face-to-face forms so that Dr. Hirjee could fill them out and then

           _____________________
           17
             See United States v. Asibor, 109 F.3d 1023, 1030 (5th Cir. 1997) (“The evidence
   is viewed in the light most favorable to the verdict, accepting all credibility choices and
   reasonable inferences made by the trier of fact which tend to support the verdict.” (citing
   United States v. Jimenez, 77 F.3d 95, 97 (5th Cir. 1996))).

                                               12
Case: 21-11225     Document: 00516956725          Page: 13     Date Filed: 11/03/2023

                                     No. 21-11225
                                   c/w No. 21-11228

   sign and date them as directed by Harris. Dr. Hirjee would sign the forms
   and put them under her doormat for Harris to retrieve. Further, as discussed
   in more detail below regarding the sufficiency of the evidence as to the
   substantive healthcare fraud counts, the Government produced three face-
   to-face forms, signed by Dr. Hirjee, attesting that the visits with the patients
   occurred on a date when Dr. Hirjee was out of the country. It was reasonable
   for the jury to infer from this evidence that Dr. Hirjee used the information
   provided by Harris to complete face-to-face forms rather than perform the
   encounters as Medicare requires.
          Third, Dr. Hirjee argues that the Government proved nothing more
   than her lax practices. She suggests that the evidence shows only that she
   “took it upon herself to defraud Medicare and Medicaid” because she was
   unaware that Harris did not care whether the face-to-face visits occurred. In
   other words, she was acting independently of the conspiracy. This argument
   ignores Harris’s testimony describing the process of faxing Dr. Hirjee patient
   narratives and blank face-to-face forms and retrieving them once they were
   completed. It also ignores the other evidence showing Dr. Hirjee worked in
   concert with the others, such as Murphey’s testimony explaining Dr. Hirjee
   provided pre-signed physician’s orders Murphey used to admit patients to
   hospice.
          On the topic of lax practices, Dr. Hirjee contends that her practice of
   pre-signing blank prescriptions for controlled substances does not support
   the conclusion that she willfully joined in the conspiracy. As it pertains to
   Count One, conspiracy to commit healthcare fraud, Dr. Hirjee’s practice of
   pre-signing blank prescription pads supports an inference that she willfully
   joined in the conspiracy. Dr. Hirjee suggests the jury could infer she pre-
   signed triplicates for other reasons—for instance, “so that drugs could be
   distributed quickly in the middle of the night,” otherwise “[t]hey all would
   have issued [sic] had nurses awakened Dr. Hirjee.” But we draw inferences

                                          13
Case: 21-11225          Document: 00516956725            Page: 14      Date Filed: 11/03/2023

                                            No. 21-11225
                                          c/w No. 21-11228

   in favor of the verdict. Further, even excluding from consideration Dr.
   Hirjee’s practice of pre-signing blank prescription pads, the jury was
   presented ample evidence on which it could find Dr. Hirjee guilty of the
   conspiracy count.
           Ultimately, the Government presented “insider[s] with direct
   evidence of the conspiratorial scheme who testifie[d] to the individual actions
   [they] completed and the actions the defendant took to meet their common
   unlawful goal.” 18         This testimony was “alone sufficient to support a
   conviction.” 19 Viewing the evidence and making inferences in the light most
   favorable to the verdict, a rational jury could have found that Dr. Hirjee
   knowingly participated in a scheme to defraud Medicare.
                                                 3
           Little argues that the Government failed to “prove with any sufficient
   evidence that Little knowingly and willfully joined any agreement for any
   illegal purpose and with the intent to defraud Medicare.” The Government
   charged Little with “conspiring with Harris, Rizvi, and Amy Harris to
   commit healthcare fraud by unlawfully (a) finding, (b) recruiting, and
   (c) enrolling ineligible patients in hospice.” These were separate means that
   independently support her conspiracy conviction, 20 and importantly, they

           _____________________
           18
                See Ganji, 880 F.3d at 771.
           19
                See Mesquias, 29 F.4th at 282.
           20
              See United States v. Moparty, 11 F.4th 280, 297 (5th Cir. 2021) (“The government
   presented two theories of fraud: one relating to the medical necessity and adequacy of the
   procedures performed, and another focused on how the procedures were billed. Moparty
   argues that Dr. Bungo’s testimony demonstrates that Moparty lacked the necessary
   training to determine whether any particular test was necessary. He misconstrues the
   inquiry, however, because the government could bear its burden against him with evidence
   on the fraudulent billing practices alone.”).

                                                 14
Case: 21-11225     Document: 00516956725          Page: 15       Date Filed: 11/03/2023

                                     No. 21-11225
                                   c/w No. 21-11228

   are distinct from the manner and means the Government alleged Drs. Gibbs
   and Hirjee employed in participating in the conspiracy.
          Little contends that the Government failed to prove she unlawfully
   found patients by invading their privacy in violation of the Health Insurance
   Portability and Accountability Act (HIPAA). She attacks the Government’s
   witnesses and their expertise on HIPAA, arguing that the jury did not have
   the background to decide whether Little violated patients’ rights to privacy
   in their medical records. Even if there was insufficient evidence as to
   whether Little violated HIPAA, the Government can bear its burden for the
   conspiracy conviction by providing sufficient evidence on either of the other
   two theories: recruiting and enrolling ineligible patients.
          As to those theories, the Government presented the following
   evidence. Harris testified that, after Novus realized the Medicare-cap issue
   in 2014, he and Little met with Rizvi to discuss generating new hospice
   referrals by using the Express Medical database. After Rizvi provided access
   to the database, Harris and Little searched for patients who could be enrolled
   and discharged after 90 days to offset Novus’s liability. Indeed, there was
   evidence that Harris directed Little to discharge patients from hospice before
   their initial 90-day period expired. Harris testified that Little received
   bonuses for patients located through Express Medical’s database, which was
   corroborated by text messages exchanged between Harris and Little.
          The Government points to three patients in particular: R.C., B.B., and
   J.M. For each of these patients, the Government presented evidence that
   their information was obtained through the Express Medical database.
   Evidence corroborated Little admitting these patients to Novus hospice and
   then discharging them after 90 days. R.C. was alive at the time of trial, seven
   years after being admitted to hospice. J.M. passed away in 2022, likewise
   years after being put on hospice. These patients’ longevity post-hospice

                                          15
Case: 21-11225       Document: 00516956725            Page: 16       Date Filed: 11/03/2023

                                        No. 21-11225
                                      c/w No. 21-11228

   admission is circumstantial evidence that they were ineligible for hospice.21
   A rational juror could infer that Little was enrolling patients who were not
   terminally ill, thereby defrauding Medicare.
          Other circumstantial evidence further supports the inference that
   Little was unlawfully recruiting patients for Novus hospice.                 Murphey
   testified that to attract desirable patients, Little and Amy Harris would
   contact prospective patients and Little “pretend[ed]” to work as a
   “representative” for another company, encouraging patients to go on
   hospice with Novus. The jury also saw evidence that Novus staff were
   instructed to avoid using the word “hospice” when delivering a cane to R.C.,
   which further supports the claim that Little was deceptive in her recruitment
   methods. Little testified in her defense, and she presented testimony that
   conflicted with the Government’s evidence for the jury to consider. She
   claimed that she did not provide Harris with her login credentials for the
   Express Medical database, she did not look through Express Medical for
   potential patients, and she believed Harris was communicating the medical
   directors’ orders when he directed her to discharge patients. It is the
   province of the jury to weigh such conflicting evidence and evaluate the
   credibility of witnesses, and it did not credit Little’s testimony.
          Viewing the evidence in the light most favorable to the verdict, there
   was sufficient evidence of Little’s willful and knowing participation in the
   scheme to sustain her conviction.

          _____________________
          21
              See Mesquias, 29 F.4th at 282 (“[A]mple circumstantial evidence backed up the
   co-conspirators’ testimony. The named patients were in hospice for an average of three
   years, a far cry from Medicare’s six-months-to-live eligibility requirement.”).

                                             16
Case: 21-11225          Document: 00516956725           Page: 17   Date Filed: 11/03/2023

                                           No. 21-11225
                                         c/w No. 21-11228

                                                B
          A person commits healthcare fraud by knowingly and willfully
   executing a scheme to defraud a government healthcare program such as
   Medicare. 22 Under 18 U.S.C. § 1347(a), a person is guilty of healthcare fraud
   if he or she knowingly and willfully executes a scheme or artifice to
   (1) defraud any healthcare benefit program or (2) obtain, by means of false or
   fraudulent pretenses, representations, or promises, any healthcare benefit
   program’s money in connection with the delivery of or payment for
   healthcare services. 23 We first address Little’s arguments, then Dr. Gibbs’s,
   and last, Dr. Hirjee’s.
                                                1
          The jury found Little guilty of three substantive counts of healthcare
   fraud for her role in illegally finding, recruiting, and enrolling the three
   patients discussed above, R.C., B.B., and J.M.              Little argues that the
   Government failed to prove she unlawfully recruited and admitted patients,
   raising many of the same points discussed above in Section II.A.3 as to
   Little’s conviction on Count One. In addition to the analysis above, we
   provide the following.
          Little suggests that the Government put on no evidence establishing
   that the three patients were ineligible for hospice when Little enrolled them.
   This is not the case. For instance, the Government introduced physician’s
   notes from three weeks before B.B. was enrolled on hospice. Those notes
   indicated that B.B. was “[d]oing great; no active issue; vitally stable; not on
   any medicines; [and] walk[ing] with assistance.”                   B.B.’s doctor

          _____________________
          22
               Id. at 280.
          23
               Ganji, 880 F.3d at 777.

                                                17
Case: 21-11225          Document: 00516956725               Page: 18       Date Filed: 11/03/2023

                                            No. 21-11225
                                          c/w No. 21-11228

   recommended that she “continue low salt diet” and follow up with home
   healthcare. Likewise, for J.M., the notes from the physician visit one week
   before J.M. was enrolled on hospice indicated that J.M. was “alert” and had
   “no complaints.” As mentioned above, J.M. was discharged after 90 days
   and lived until 2022. This evidence supports the claim that these patients
   were not terminally ill when enrolled on hospice. To the extent Little argues
   expert testimony was required, we have “decline[d] to impose such a
   requirement” in other healthcare fraud cases, and we decline to impose one
   here. 24 Little’s arguments do not show that the jury lacked evidence to find
   her guilty.
                                                   2
           The jury found Dr. Gibbs guilty on Counts Five and Six, which
   charged him with falsely certifying that he had conducted face-to-face visits
   with S.D. It found him not guilty on Count Seven, which charged him with
   the same conduct as to E.O. Dr. Gibbs argues that the Government failed to
   produce evidence establishing that the documents relating to S.D. were
   (1) authentic and (2) submitted to Medicare.
           First, the Government did put on evidence establishing that the
   documents were authentic. Murphey testified that the signature on S.D.’s
   face-to-face certification belonged to Dr. Gibbs and that she watched him
   sign it. The jury was permitted to credit that testimony. 25 Dr. Gibbs is
   correct that the evidence generally established that “non-physicians at
   Novus forged documents, altered documents, and fraudulently worked

           _____________________
           24
                See United States v. Sanjar, 876 F.3d 725, 745 (5th Cir. 2017).
           25
              See United States v. Zuniga, 18 F.3d 1254, 1260 (5th Cir. 1994) (“We will not
   second guess the jury in its choice of which witnesses to believe.” (citing United States v.
   Jones, 839 F.2d 1041, 1047 (5th Cir. 1988))).

                                                  18
Case: 21-11225       Document: 00516956725              Page: 19       Date Filed: 11/03/2023

                                         No. 21-11225
                                       c/w No. 21-11228

   around the physicians,” but, for this document in particular, the
   Government presented evidence that Dr. Gibbs signed it. The jury could
   have reasonably concluded from Murphey’s testimony that Dr. Gibbs signed
   S.D.’s face-to-face certification form, and we resolve conflicts in favor of the
   jury’s verdict. 26
           Second, Dr. Gibbs’s argument that “there was absolutely no evidence
   that the documents that the government used to tie Dr. Gibbs to S.D. were
   ever submitted to Medicare” also fails. The jury heard testimony that the
   face-to-face forms for S.D. were “uploaded into the [electronic medical
   record] and provided as part of the certification for continued eligibility for
   payment” from Medicare. The Government introduced an exhibit showing
   that Novus submitted claims and received payments from Medicare during
   the time periods when the face-to-face forms for S.D. bearing Dr. Gibbs’s
   signature were dated. The jury also heard that such face-to-face forms were
   a condition of payment without which Medicare would not have paid claims.
   As the Government puts it, the face-to-face forms bearing Dr. Gibbs’s
   signature were part of the “package” Novus used to bill Medicare for S.D.
   The Government did not need to prove that the document was submitted
   directly to Medicare to prove beyond a reasonable doubt that Dr. Gibbs
   committed healthcare fraud. 27 There was sufficient evidence to convict Dr.
   Gibbs of healthcare fraud.

           _____________________
           26
              See United States v. Moreno–Gonzalez, 662 F.3d 369, 372 (5th Cir. 2011) (“[A]ny
   conflict in the evidence must be resolved in favor of the jury’s verdict.” (citing United
   States v. Duncan, 919 F.2d 981, 990 (5th Cir. 1990))).
           27
              See United States v. Umawa Oke Imo, 739 F.3d 226, 235 (5th Cir. 2014) (“A
   defendant need not have actually submitted the fraudulent documentation to Medicaid in
   order to be guilty of health care fraud or conspiracy to commit health care fraud.” (citing
   United States v. Girod, 646 F.3d 304, 313 (5th Cir. 2011))).

                                               19
Case: 21-11225      Document: 00516956725         Page: 20    Date Filed: 11/03/2023

                                     No. 21-11225
                                   c/w No. 21-11228

                                          3
            The jury found Dr. Hirjee guilty on Counts Eight, Nine, and Ten,
   which charged her with fraudulently certifying face-to-face visits for D.P.,
   J.M., and J.F. Dr. Hirjee reiterates several of the arguments she made in
   challenging the sufficiency of the evidence for Count One, which fail for the
   same reasons discussed above, as well as the additional reasons discussed
   below.
            First, Dr. Hirjee argues that the Government failed to prove that she
   did not see the patients, “instead proving only that she did not see them on
   specific, immaterial dates.”     The Government presented the following
   evidence. For J.M.: On October 29, 2013, Harris faxed Dr. Hirjee a narrative
   and blank face-to-face form for J.M. At the top of the narrative was written,
   “[J.M.] Date 10/24.” The completed face-to-face form for J.M. states that
   “I confirm that I had a face-to-face encounter with [J.M.] on 10/24/13” and
   is signed by Dr. Hirjee. Testimony at trial established that Dr. Hirjee was in
   Hawaii on October 24, 2013. For D.P. and J.F.: On April 29, 2014, Murphey
   faxed Dr. Hirjee narratives and blank face-to-face forms for D.P. and J.F. The
   fax includes the request, “[P]lease date all of these 4/19/14.”          The
   completed face-to-face forms for D.P. and J.F. state the encounters occurred
   on “4/19/14.” Testimony at trial established that Dr. Hirjee was in Mexico
   on April 19, 2014. Dr. Hirjee’s argument presents another possible inference
   the jury could have drawn from the evidence, but it is not the inference the
   jury ultimately drew.
            Second, Dr. Hirjee argues that the “Government failed to prove that
   [these patients] were not eligible for hospice care and that the face-to-face
   certifications were material.” As discussed with respect to Count One
   above, the Government’s fraud theory did not turn on whether the patients
   were ineligible. The fraud turned on Dr. Hirjee attesting to Medicare that

                                         20
Case: 21-11225        Document: 00516956725               Page: 21        Date Filed: 11/03/2023

                                           No. 21-11225
                                         c/w No. 21-11228

   she performed face-to-face encounters that she did not actually perform.
   Had Dr. Hirjee performed the encounters, she may have legitimately
   recertified the patients for hospice—the problem, according to the
   Government, is that she did not perform the encounters but filled out the
   face-to-face forms anyway. As to the materiality of the face-to-face forms,
   the Government introduced evidence showing that face-to-face forms were a
   condition of payment without which Medicare would not have paid claims.
           Viewing the evidence and inferences in the light most favorable to the
   verdict, a rational jury could have concluded that Dr. Hirjee did not perform
   the face-to-face visits she attested to Medicare she performed, thereby
   defrauding Medicare.
                                                 C
           Count Fourteen charged Dr. Hirjee with unlawfully distributing and
   dispensing hydromorphone to L.V. outside the usual course of professional
   practice and not for a legitimate medical purpose in violation of 21 U.S.C.
   § 841(a). To convict Dr. Hirjee, the Government was required to prove that
   (1) she distributed or dispensed a controlled substance; (2) she acted
   knowingly and intentionally; and (3) she did so other than for a legitimate
   medical purpose and in the usual course of her professional practice. 28 “[A]
   practitioner is unauthorized to dispense a controlled substance if the
   prescription either lacks a legitimate purpose or is outside the usual course of
   professional practice.” 29 After Dr. Hirjee’s trial, the Supreme Court decided

           _____________________
           28
              United States v. Brown, 553 F.3d 768, 780-81 (5th Cir. 2008); see also United States
   v. Norris, 780 F.2d 1207, 1209 (5th Cir. 1986).
           29
              United States v. Bennett, 874 F.3d 236, 245 (5th Cir. 2017) (quoting United States
   v. Armstrong, 550 F.3d 382, 397 (5th Cir. 2008), overruled on other grounds by United States
   v. Balleza, 613 F.3d 432 (5th Cir. 2010) (per curiam)).

                                                 21
Case: 21-11225            Document: 00516956725             Page: 22       Date Filed: 11/03/2023

                                            No. 21-11225
                                          c/w No. 21-11228

   Ruan v. United States, 30 holding that “[a]fter a defendant produces evidence
   that he or she was authorized to dispense controlled substances, the
   Government must prove beyond a reasonable doubt that the defendant knew
   that he or she was acting in an unauthorized manner, or intended to do so.” 31
           Generally, a preserved sufficiency challenge is reviewed de novo. 32
   However, if a defendant “asserts specific grounds for a specific element of a
   specific count for a Rule 29 motion, [s]he waives all others for that specific
   count.” 33 Dr. Hirjee’s counsel argued orally and in writing for acquittal
   because the Government failed to prove beyond a reasonable doubt that the
   L.V. prescription was outside the usual course of professional practice and
   not for a legitimate medical purpose. She did not challenge the sufficiency of
   the evidence as to the mens rea element, and we review this unpreserved
   challenge for plain error. 34
           The Government presented the following evidence: Dr. Hirjee pre-
   signed “triplicates,” the form that physicians use to prescribe schedule-II
   controlled substances like oxycontin, hydromorphone, morphine, and
   fentanyl. A triplicate is also known as a “C-II.” The jury heard testimony
   from Harris and Murphey that Dr. Hirjee supplied pre-signed C-IIs, which
   were used to medicate Novus’s hospice patients. Once Murphey had used
   all of Dr. Hirjee’s triplicates, Murphey would text Dr. Hirjee that she needed
   more.        The jury also saw messages between Dr. Hirjee and Harris

           _____________________
           30
                142 S. Ct. 2370 (2022).
           31
                Id. at 2375.
           32
                See United States v. Harris, 740 F.3d 956, 962 (5th Cir. 2014).
           33
                United States v. Herrera, 313 F.3d 882, 884 (5th Cir. 2002) (en banc) (per
   curiam).
           34
                See id.

                                                  22
Case: 21-11225        Document: 00516956725               Page: 23       Date Filed: 11/03/2023

                                          No. 21-11225
                                        c/w No. 21-11228

   demonstrating how Dr. Hirjee pre-signed C-IIs and left them under her
   doormat for retrieval. As to L.V. in particular, Murphey testified to using a
   triplicate pre-signed by Dr. Hirjee to order hydromorphone, a painkiller, for
   L.V. Text messages corroborated Murphey’s testimony.
           As to Dr. Hirjee’s preserved challenges, she first argues that “there is
   no evidence that [L.V.]’s [h]ydromorphone prescription was for an
   illegitimate purpose.” Dr. Hirjee points to testimony establishing that
   hydromorphone is dispensed to treat L.V.’s condition. The logic of this
   interpretation is flawed. As the Government points out, “[u]nder Hirjee’s
   theory, an office[] manager could write millions of prescriptions for hospice
   patients, and the doctor who pre-signed those prescriptions would be
   immune from prosecution unless the government could prove that the office
   manager chose a drug for which the patient had no need.” The Government
   cites the Sixth and Eleventh Circuits, which reject Dr. Hirjee’s
   interpretation. 35 We agree with those circuits. The question is whether Dr.
   Hirjee herself prescribed hydromorphone to L.V. for an illegitimate purpose,
   and a rational jury could conclude from the evidence that she did.
           Dr. Hirjee further argues that it was not outside the usual course of
   professional practice for a doctor to pre-sign prescription forms. She points
   to “multiple defense witnesses [who] testified that hospice agencies use pre-

           _____________________
           35
              See United States v. Chaney, 921 F.3d 572, 590-91 (6th Cir. 2019) (“As the district
   court made abundantly clear, a doctor prescribing opioid painkillers to anyone walking
   through the door is not saved if a person happens to have an underlying condition that could
   justify the prescription; likewise, a doctor who acts in good faith and with all due care but
   nevertheless issues a prescription to a patient who was merely faking symptoms is
   nevertheless acting with a legitimate medical purpose. To say otherwise would be
   absurdity.”); United States v. Abovyan, 988 F.3d 1288, 1306 (11th Cir. 2021) (“The
   question is not whether a doctor could prescribe buprenorphine for legitimate medical
   addiction treatment actually being rendered, but whether Abovyan himself did prescribe
   buprenorphine for such actual addiction treatment.”).

                                                23
Case: 21-11225        Document: 00516956725               Page: 24       Date Filed: 11/03/2023

                                          No. 21-11225
                                        c/w No. 21-11228

   signed prescription forms” although this violates Texas medical regulations.
   As the Government explains, those witnesses testified to leaving pre-signed
   triplicates with properly designated nurses, not with anyone working for the
   hospice provider. In addition, multiple witnesses testified that they would
   not pre-sign triplicates, full stop. It is the province of the jury to weigh
   conflicting evidence. Resolving inferences in favor of the verdict, the jury
   had sufficient evidence to conclude Dr. Hirjee acted outside the usual course
   of professional practice.
           Last, as mentioned above, although Dr. Hirjee preserved her
   sufficiency of the evidence challenge to this count, she did not preserve her
   mens rea argument, meaning we review for plain error. 36 Dr. Hirjee argues
   that “the Government failed to show that she knew she was acting in an
   unauthorized manner or intended to do so,” as Ruan requires. “[W]e have
   summarized the plain-error test’s application to unpreserved insufficiency
   claims by stating that the court will reverse only if there is a manifest
   miscarriage of justice.” 37 Dr. Hirjee has not shown that her conviction on
   this count was a manifest miscarriage of justice. She signed prescription pads
   for schedule II drugs—drugs like morphine, cocaine, and oxycodone—and
   left them under her doormat. Non-medical professionals then used pre-
   signed triplicates to order medication for hospice patients.
           We conclude that the evidence was sufficient to convict Dr. Hirjee on
   Count Fourteen.

           _____________________
           36
              See Herrera, 313 F.3d at 884 (“Where, as here, a defendant asserts specific grounds
   for a specific element of a specific count for a Rule 29 motion, he waives all others for that
   specific count.”).
           37
             United States v. Huntsberry, 956 F.3d 270, 283 (5th Cir. 2020) (alteration and
   emphasis in original) (quoting United States v. Delgado, 672 F.3d 320, 331 (5th Cir. 2012)
   (en banc)).

                                                24
Case: 21-11225          Document: 00516956725            Page: 25       Date Filed: 11/03/2023

                                         No. 21-11225
                                       c/w No. 21-11228

                                               D
           The superseding indictment charged Dr. Gibbs with conspiring with
   Harris and others to violate 18 U.S.C. § 1505 by moving Novus’s operations
   and payments to a different hospice company to “circumvent the CMS
   suspension.”          The Government was required to establish beyond a
   reasonable doubt (1) the existence of an agreement to violate § 1505;
   (2) knowledge and intent to join the conspiracy; and (3) an overt act
   constituting actual participation in the conspiracy. 38 Section 1505 makes it a
   criminal offense to “corruptly . . . obstruct[], or impede[] or endeavor[] to
   influence, obstruct, or impede the due and proper administration of the law
   under which any pending proceeding is being had before any department or
   agency of the United States.” 39            To prove a violation of § 1505, the
   Government must prove that (1) there was an agency proceeding; (2) the
   defendant was aware of that proceeding; and (3) the defendant intentionally
   endeavored corruptly to influence, obstruct, or impede the pending
   proceeding. 40
           Dr. Gibbs argues that there is “no testimony or evidence that [he]
   destroyed evidence, shredded paper, etc.” He also suggests that “[t]he
   transfer of money could be a qualifying event if the records showing the
   transfer were deliberately obscured or destroyed,” but “there was no effort
   to obliterate, alter, or amend” the bank records. This argument misconstrues
   the requirements of the offense. We have noted that § 1505 was “drafted
   with an eye to the variety of corrupt methods by which the proper
           _____________________
           38
                See 18 U.S.C. § 371.
           39
                Id. § 1505.
           40
              See United States v. Warshak, 631 F.3d 266, 325 (6th Cir. 2010); United States v.
   Quattrone, 441 F.3d 153, 174 (2d Cir. 2006); United States v. Bhagat, 436 F.3d 1140, 1147
   (9th Cir. 2006).

                                               25
Case: 21-11225          Document: 00516956725            Page: 26       Date Filed: 11/03/2023

                                           No. 21-11225
                                         c/w No. 21-11228

   administration of justice may be impeded or thwarted.” 41 Indeed, the
   Government points to two cases, one unpublished from our circuit 42 and one
   published from the Sixth Circuit, 43 involving similar facts and denying
   sufficiency challenges to § 1505 convictions.
           As discussed with respect to Dr. Gibbs’s conviction on Count One,
   the jury heard a recording of Dr. Gibbs’s attempts to recruit Murphey in the
   plan to move Novus patients to Dependable, a different hospice company.
   Moving patients in order to continue billing Medicare would circumvent the
   CMS suspension of payments, which was an aspect of the CMS proceeding
   relating to the allegations of fraud leveled against Novus. 44 Dr. Gibbs in
   particular raised concerns about Medicare “noticing” 200 patients being
   moved. The Government also presented evidence that Dr. Gibbs and Harris
   succeeded in moving some patients, before Medicare suspended payments to
   Dependable as well. The jury could conclude from this evidence that Dr.
   Gibbs and others agreed to circumvent the CMS proceedings in violation of
   § 1505.

           _____________________
           41
               United States v. Rainey, 757 F.3d 234, 245 (5th Cir. 2014) (quoting United States
   v. Griffin, 589 F.2d 200, 206 (5th Cir. 1979)).
           42
             United States v. Veasey, 843 F. App’x 555, 563-64 (5th Cir. 2021) (per curiam)
   (unpublished).
           43
                Warshak, 631 F.3d at 325-26.
           44
              See Rice v. United States, 356 F.2d 709, 712 (8th Cir. 1966) (explaining that, for
   § 1505, “[p]roceedings before a governmental department or agency simply mean
   proceeding in the manner and form prescribed for conducting business before the
   department or agency, including all steps and stages in such an action from its inception to
   its conclusion”); see also Rainey, 757 F.3d at 245 (citing Rice approvingly in interpreting
   § 1505 generally).

                                                26
Case: 21-11225          Document: 00516956725              Page: 27       Date Filed: 11/03/2023

                                            No. 21-11225
                                          c/w No. 21-11228

                                                 III
           Drs. Gibbs and Hirjee allege various errors committed by the district
   court at trial. Dr. Gibbs argues that the jury charge on Count Fifteen,
   conspiracy to obstruct justice, constructively amended the superseding
   indictment. Dr. Hirjee challenges the denial of her motion for a new trial, the
   jury charge on Count Fourteen, and an evidentiary ruling. She also argues
   that, taken together, these errors deprived her of a fair trial.
                                                  A
           Dr. Gibbs argues that the jury charge on Count Fifteen constructively
   amended the superseding indictment. We review a preserved claim of
   constructive amendment de novo, and an unpreserved claim for plain error. 45
   Dr. Gibbs did not raise his constructive amendment arguments in the district
   court, so our review is for plain error. 46 Because the district court properly
   instructed the jury to consider the crime as charged in the superseding
   indictment, Dr. Gibbs has not shown plain error.
           A constructive amendment occurs “when the government changes its
   theory at trial, allowing the jury to convict on a broader basis than that alleged
   in the indictment, or when the government proves an essential element of the
   crime on an alternate basis authorized by the statute but not charged in the
   indictment.” 47 “In this circuit, a constructive amendment occurs when the
   court ‘permits the defendant to be convicted upon a factual basis that
           _____________________
           45
                United States v. Chaker, 820 F.3d 204, 210, 213 (5th Cir. 2016).
           46
              See United States v. Dupre, 117 F.3d 810, 816 (5th Cir. 1997) (“[U]nder Rule 30
   of the Federal Rules of Criminal Procedure, these proposed instructions do not preserve
   error on appeal, absent an objection specific to the counts at issue.”); United States v.
   Rosenthal, 805 F.3d 523, 530 (5th Cir. 2015).
           47
              United States v. Stanford, 805 F.3d 557, 566 (5th Cir. 2015) (citing United States
   v. Girod, 646 F.3d 304, 316 (5th Cir. 2011)).

                                                  27
Case: 21-11225        Document: 00516956725              Page: 28       Date Filed: 11/03/2023

                                         No. 21-11225
                                       c/w No. 21-11228

   effectively modifies an essential element of the offense charged’ or upon ‘a
   materially different theory or set of facts than that which [the defendant] was
   charged.’” 48      “In evaluating whether a constructive amendment has
   occurred, we consider ‘whether the jury instruction, taken as a whole, is a
   correct statement of the law and whether it clearly instructs jurors as to the
   principles of the law applicable to the factual issues confronting them.’” 49
           As discussed above with respect to the sufficiency of the evidence for
   this count, to prove a violation of § 1505 the Government must prove that
   (1) there was an agency proceeding; (2) the defendant was aware of that
   proceeding; and (3) the defendant intentionally endeavored corruptly to
   influence, obstruct, or impede the pending proceeding. 50 The jury was
   charged with the following instruction:
                   First:           That there was an agency proceeding;
                   Second:          That the Defendant was aware of that
                                    agency proceeding;
                   Third:           That the Defendant intentionally
                                    endeavored to influence, obstruct or
                                    impede that proceeding; and
                   Fourth:          That the Defendant’s act was done
                                    “corruptly,” that is, the Defendant acted
                                    knowingly and dishonestly, with the
                                    specific intent to subvert or undermine
                                    the due administration of justice.

           _____________________
           48
             Chaker, 820 F.3d at 210 (alteration in original) (quoting United States v.
   McMillan, 600 F.3d 434, 451 (5th Cir. 2010)).
           49
             United States v. Jara–Favela, 686 F.3d 289, 299-300 (5th Cir. 2012) (quoting
   United States v. Guidry, 406 F.3d 314, 321 (5th Cir. 2005)).
           50
              See United States v. Warshak, 631 F.3d 266, 325 (6th Cir. 2010); United States v.
   Quattrone, 441 F.3d 153, 174 (2d Cir. 2006); United States v. Bhagat, 436 F.3d 1140, 1147
   (9th Cir. 2006).

                                               28
Case: 21-11225     Document: 00516956725         Page: 29     Date Filed: 11/03/2023

                                    No. 21-11225
                                  c/w No. 21-11228

   Dr. Gibbs argues that the charge “impermissibly broadened the allegations
   from the indictment” by failing to specify (1) the ways in which Dr. Gibbs
   was alleged to have influenced, obstructed, or impeded that proceeding and
   (2) the CMS proceeding as the agency proceeding.
          The district court instructed the jury to consider the jury instructions
   in light of the crimes charged in the superseding indictment.             The
   superseding indictment was read to the jury at the beginning of trial, and a
   redacted copy was provided to the jury for use during deliberations. The jury
   instructions stated that “[n]o Defendant is on trial for any act, conduct, or
   offense not alleged in the Superseding Indictment.” As to Count Fifteen, the
   charge stated that the jury “must be convinced that the Government has
   proven . . . beyond a reasonable doubt” that Dr. Gibbs “and at least one other
   person made an agreement to commit the crime of obstruction of justice as
   charged in Count Fifteen of the Superseding Indictment.” The superseding
   indictment stated that Dr. Gibbs “caus[ed] Medicare to pay for hospice
   services through [Dependable’s] provider number, so that they and Novus
   could continue to receive Medicare funds despite being on notice that Novus
   was the subject of a pending proceeding and suspended from receiving
   Medicare monies by CMS.” The superseding indictment listed Dr. Gibbs’s
   acts as “discuss[ing] the best way to circumvent the CMS suspension and
   continue receiving payment for hospice services rendered by Novus” and
   “agree[ing] to and serv[ing] as the medical director of [Dependable].”
   Further, the only agency proceeding mentioned in the superseding
   indictment is the CMS proceeding. The charge also explained that “[a]n
   investigation by the Centers for Medicare and Medicaid Services constitutes
   an agency proceeding.”

                                         29
Case: 21-11225          Document: 00516956725               Page: 30        Date Filed: 11/03/2023

                                            No. 21-11225
                                          c/w No. 21-11228

          Because jurors are presumed to follow the court’s instructions, 51 and
   the district court properly instructed the jury to consider the crime as
   charged in the superseding indictment, we find no plain error here. As there
   is no error, we decline to address the Government’s argument that Dr. Gibbs
   invited the error.
                                                   B
          Dr. Hirjee raises three claims of error relating to the conduct of her
   trial, and she further argues that these errors, taken cumulatively, deprived
   her of a fair trial. First, she argues that the district court erred by denying her
   motion for a new trial. Second, she argues that, based on Supreme Court
   precedent decided after her trial but before this appeal, her jury instruction
   was plainly erroneous. Third, she argues that the district court erred by
   admitting certain evidence over her objection. We find no error.
                                                   1
          We review the district court’s decision to deny a motion for new trial
   “only for an abuse of discretion.” 52 “A judge’s power to grant a new trial
   based on a different assessment of the evidence must be ‘exercised with
   caution’ and ‘invoked only in exceptional cases.’” 53
          Dr. Hirjee argues that the “evidence here preponderates heavily
   against the verdict, such that it would be a miscarriage of justice to let the
   verdict stand.” She points to much the same evidence she cited for her
   challenges to the sufficiency of the evidence. As discussed above, there was

          _____________________
          51
               See United States v. Bieganowski, 313 F.3d 264, 288 (5th Cir. 2002).
          52
               United States v. Crittenden, 46 F.4th 292, 297 (5th Cir. 2022) (en banc).
          53
               Id. (quoting United States v. Sinclair, 438 F.2d 50, 51 n.1 (5th Cir. 1971)).

                                                  30
Case: 21-11225          Document: 00516956725             Page: 31        Date Filed: 11/03/2023

                                           No. 21-11225
                                         c/w No. 21-11228

   sufficient evidence presented at trial to support the jury’s verdicts. The
   district court did not abuse its discretion in denying the motion for a new trial.
           Aside from her evidentiary arguments, Dr. Hirjee also suggests that a
   new trial is warranted because “the Government may have tried and failed to
   find an expert to testify that Dr. Hirjee referred ineligible patients to hospice
   care, and the Government did not disclose as much to the defense.” Dr.
   Hirjee did not raise this argument in the district court, and we decline to
   consider it on appeal. 54
                                                 2
           Next, Dr. Hirjee argues that, based on the Supreme Court’s decision
   in Ruan v. United States, the jury charge on Count Fourteen was erroneous
   because it failed to require the correct mens rea. “[W]hen a defendant fails
   to object to jury instructions, we review for plain error.” 55
           As an initial matter, the Government argues that Dr. Hirjee waived
   this argument by inviting the error. Generally, the invited-error doctrine
   applies to jury instructions. 56 The Government states that Dr. Hirjee
   “proposed nearly the exact instruction that she challenges now, including the
   instruction of good faith,” precluding our review of this claim. Dr. Hirjee
   responds that “the invited-error doctrine does not apply when a party relied
   [below] on settled law that changed while the case was on appeal.” For this

           _____________________
           54
                See Grogan v. Kumar, 873 F.3d 273, 277 (5th Cir. 2017).
           55
              United States v. Huntsberry, 956 F.3d 270, 282 (5th Cir. 2020) (quoting United
   States v. Vasquez, 677 F.3d 685, 692-93 (5th Cir. 2012) (per curiam)).
           56
              United States v. Baytank (Houston), Inc., 934 F.2d 599, 606-07 (5th Cir. 1991)
   (explaining that this court “has made clear that the invited error doctrine applies to jury
   instructions” and collecting cases).

                                                 31
Case: 21-11225          Document: 00516956725               Page: 32       Date Filed: 11/03/2023

                                            No. 21-11225
                                          c/w No. 21-11228

   proposition, she cites two published out-of-circuit cases 57 and one
   unpublished out-of-circuit case, 58 and at least one other circuit appears to
   take Dr. Hirjee’s position. 59 As explained below, Dr. Hirjee cannot show
   plain error. Accordingly, we decline to decide the applicability of invited
   error here. 60
           Because Dr. Hirjee did not object to the jury instructions on this basis
   in the district court, we review for plain error. 61 “A jury charge is plain error
   if: (1) it was erroneous; (2) the error was plain; and (3) the plain error affected
   the substantial rights of the defendant.” 62 If those conditions are met, “we
   have discretion to correct the error; discretion we will exercise if the error

           _____________________
           57
              United States v. Titties, 852 F.3d 1257, 1264 n.5 (10th Cir. 2017); United States v.
   Nasir, 982 F.3d 144, 173 n.35 (3d Cir. 2020) (en banc), cert. granted, judgment vacated, 142
   S. Ct. 56 (2021).
           58
                United States v. Coffelt, 529 F. App’x 636, 639 (6th Cir. 2013) (unpublished).
           59
              See, e.g., United States v. Andrews, 681 F.3d 509, 517 n.4 (3d Cir. 2012) (“[W]e
   have previously held that ‘[w]here a defendant submits proposed jury instructions in
   reliance on current law’ and while his case is on direct appeal, the law is found to be
   constitutionally problematic, we will not apply the ‘invited error’ doctrine. Instead, we
   review for plain error. This is consistent with the Supreme Court’s definition of waiver as
   the ‘intentional relinquishment or abandonment of a known right.’” (citations omitted)).
           60
             See United States v. Martinez–Vega, 471 F.3d 559, 563 n.4 (5th Cir. 2006)
   (“Additionally, because we conclude that Appellant has failed to satisfy the plain error test,
   we need not reach the question of whether Appellant’s admission constituted invited
   error.”).
           61
              See United States v. Percel, 553 F.3d 903, 908-09 (5th Cir. 2008) (“Generally,
   incorrect jury instructions are not considered structural errors, and because neither
   [defendant] objected to the jury instruction in the district court, we review the instruction
   for plain error.” (footnotes omitted)).
           62
                United States v. Daniels, 252 F.3d 411, 414 (5th Cir. 2001).

                                                  32
Case: 21-11225             Document: 00516956725             Page: 33      Date Filed: 11/03/2023

                                              No. 21-11225
                                            c/w No. 21-11228

   ‘seriously affect[s] the fairness, integrity or public reputation of judicial
   proceedings.’” 63
              In Ruan, the Supreme Court held that “[a]fter a defendant produces
   evidence that he or she was authorized to dispense controlled substances, the
   Government must prove beyond a reasonable doubt that the defendant knew
   that he or she was acting in an unauthorized manner, or intended to do so.” 64
   “In other words, the defendant must subjectively understand the illegitimate
   nature of the distribution they facilitate to commit an offense under [21
   U.S.C.] § 841(a).” 65 The jury instructions on Count Fourteen instructed the
   jury that the culpable mental state attached only to whether Dr. Hirjee
   dispensed or distributed a controlled substance. Accordingly, the district
   court plainly erred with this jury charge. 66 The Government concedes that
   Dr. Hirjee can show the first and second prongs of plain error. The following
   discussion focuses on the third and fourth prongs.
              As to the third prong, “[Dr. Hirjee] has the burden of showing that, if
   the District Court had correctly instructed the jury on the mens rea element
   of a [distribution-of-a-controlled-substance] offense, there is a ‘reasonable
   probability’ that [s]he would have been acquitted.” 67 Dr. Hirjee argues that
   the “Government here entirely failed to show that Dr. Hirjee knew she was
              _____________________
              63
                   Id. (alteration in original) (quoting United States v. Olano, 507 U.S. 725, 736
   (1993)).
              64
                   142 S. Ct. 2370, 2375 (2022).
              65
             United States v. Ajayi, 64 F.4th 243, 247 (5th Cir. 2023) (per curiam) (citing
   Ruan, 142 S. Ct. at 2381).
              66
             See United States v. Escalante–Reyes, 689 F.3d 415, 423 (5th Cir. 2012) (en banc)
   (“[W]here the law is unsettled at the time of trial but settled by the time of appeal, the
   ‘plainness’ of the error should be judged by the law at the time of appeal.”).
              67
           See Greer v. United States, 141 S. Ct. 2090, 2097 (2021) (quoting United States v.
   Dominguez Benitez, 542 U.S. 74, 83 (2004)).

                                                    33
Case: 21-11225     Document: 00516956725          Page: 34     Date Filed: 11/03/2023

                                     No. 21-11225
                                   c/w No. 21-11228

   acting in an unauthorized manner or intended to do so.” She refers the court
   to the discussion of sufficiency of the evidence as to Count Fourteen. The
   Government responds that Dr. Hirjee “cannot show any chance—let alone
   a reasonable probability—that a properly instructed jury would have found
   that she believed that she was acting in [an] authorized manner when she pre-
   signed the blank prescription that Murphey used to order hydromorphone
   for L.V.” The Government goes on to argue that Dr. Hirjee “falls back on
   the argument that pre-signing prescriptions was a widespread practice among
   hospices,” which “conflates the practice of pre-signing prescriptions for use
   by designated nurses employed by the doctor with Hirjee’s practice of pre-
   signing prescriptions for use by Harris and Murphey.”
          The Government makes the stronger argument. Both Harris and
   Murphey testified about Dr. Hirjee, a medical doctor, leaving pre-signed,
   blank prescription pads for controlled substances under her doormat. In one
   exchange, Dr. Hirjee told Harris the pre-signed triplicates were “outside in
   [N]ordstrom bag,” and Harris responded, “[I] am going to have [N]ick pick
   it up. He’s my assistant since back to [previous company] we can trust him.”
   In another exchange with Harris, Dr. Hirjee texted, “Hope triplicates are still
   there lol.” Given the evidence presented on Count Fourteen, had the jury
   been properly instructed on mens rea, Dr. Hirjee has not shown a reasonable
   probability that she would have been acquitted.
          Even if Dr. Hirjee satisfies the first three prongs, we will only exercise
   our discretion to correct the error if the error seriously affects the fairness,
   integrity, or public reputation of judicial proceedings. Dr. Hirjee contends
   that the fourth prong is “easily satisfied” because she “is or could be
   innocent.” According to the Government, it would be a miscarriage of
   justice to reverse Dr. Hirjee’s conviction. The Government again highlights
   Dr. Hirjee’s “own text messages,” which reveal she was “beyond cavalier
   with her prescription pad.” It also points to the conclusion in the Pre-

                                          34
Case: 21-11225        Document: 00516956725              Page: 35        Date Filed: 11/03/2023

                                          No. 21-11225
                                        c/w No. 21-11228

   Sentencing Report (PSR) that “[a] review of 485 triplicates pre-signed by
   Hirjee showed that 344 of them were filled in by a coconspirator.” 68
           Dr. Hirjee has not shown that her rights were substantially affected by
   the jury instruction on Count Fourteen, nor that allowing any error to stand
   would seriously affect the fairness, integrity, or public reputation of judicial
   proceedings.
                                                3
           At trial, the Government introduced Exhibit 32, a chart and graphs
   showing when Dr. Hirjee’s patients were admitted to hospice and how long
   they lived thereafter. Dr. Hirjee objected under Federal Rule of Evidence
   403, arguing that the evidence had little probative value. The district court
   overruled this objection and allowed Dr. Hirjee to cross-examine the
   Government’s witnesses on the evidence.
           “A district court’s ruling as to Rule 403 is reviewed ‘with an
   especially high level of deference to the district court, with reversal called for
   only rarely and only when there has been a clear abuse of discretion.’” 69
   “[T]he application of Rule 403 must be cautious and sparing. Its major
   function is limited to excluding matter of scant or cumulative probative force,
   dragged in by the heels for the sake of its prejudicial effect.” 70 Further,
   “[a]ny error in admitting such evidence is subject to harmless error review,

           _____________________
           68
               See id. at 2098 (“This Court has repeatedly stated that an appellate court
   conducting plain-error review may consider the entire record—not just the record from the
   particular proceeding where the error occurred.”).
           69
              United States v. Sims, 11 F.4th 315, 323 (5th Cir. 2021) (quoting United States v.
   Dillon, 532 F.3d 379, 387 (5th Cir. 2008)), cert. denied, 142 S. Ct. 827 (2022).
           70
             United States v. Fields, 483 F.3d 313, 354 (5th Cir. 2007) (alteration in original)
   (quoting United States v. Pace, 10 F.3d 1106, 1116 (5th Cir. 1993)).

                                                35
Case: 21-11225        Document: 00516956725                Page: 36     Date Filed: 11/03/2023

                                          No. 21-11225
                                        c/w No. 21-11228

   and reversal is not required unless there is a reasonable possibility that the
   improperly admitted evidence contributed to the conviction.” 71
           Dr. Hirjee argues that Exhibit 32 had minimal probative value because
   the “Government did not allege that any of Dr. Hirjee’s patients were
   ineligible for hospice care.” This argument assumes that Exhibit 32 was
   introduced to show that Dr. Hirjee admitted and recertified patients who
   were ineligible for hospice. Rather, as the Government explains, Exhibit 32
   was probative because it tended to establish that Dr. Hirjee “enabled Harris
   to enroll the patients he chose by pre-signing physician’s orders for
   admittance.” In other words, Exhibit 32 tended to prove that the scheme
   operated as the Government described—“profitable” patients were
   admitted to Novus. Further, we have recognized that hospice patients
   outliving    the    “six-months-to-live           eligibility   requirement”      can     be
   circumstantial evidence which corroborates coconspirators’ testimony that
   certifications were fabricated. 72
           Dr. Hirjee also argues that Exhibit 32 misled the jury by suggesting
   that Dr. Hirjee placed patients on hospice who were not eligible. As
   discussed for the sufficiency of the evidence challenges in Section II.A.2, the
   theory of fraud was not that Dr. Hirjee enrolled ineligible patients, but that
   she lent her signature so that non-medical staff could admit patients to

           _____________________
           71
             Sims, 11 F.4th at 323 (quoting United States v. Williams, 620 F.3d 483, 492 (5th
   Cir. 2010)).
           72
              See United States v. Mesquias, 29 F.4th 276, 282 (5th Cir.), cert. denied sub nom.
   McInnis v. United States, 143 S. Ct. 115 (2022), and cert. denied sub nom. Mesquias v. United
   States, 143 S. Ct. 269 (2022).

                                                36
Case: 21-11225           Document: 00516956725               Page: 37   Date Filed: 11/03/2023

                                                No. 21-11225
                                              c/w No. 21-11228

   hospice. While Exhibit 32 may have risked misleading the jury, that risk did
   not substantially outweigh the probative value of the evidence. 73
            Even if the district court erred in admitting Exhibit 32, we will not
   reverse unless there is a reasonable possibility that Exhibit 32 contributed to
   the conviction. 74 Dr. Hirjee argues that “[i]t’s at least reasonably possible
   that the Government’s suggestion tipped the scales and that the jury
   concluded that improper hospice admissions rendered Dr. Hirjee guilty
   despite the Government’s failure to prove that she cut any corners.” She
   also points out that the Government mentioned Exhibit 32 in closing. Given
   the substantial evidence supporting the verdict, we cannot say that Exhibit
   32 contributed to Dr. Hirjee’s conviction.
            The district court did not abuse its discretion in admitting Exhibit 32
   over Dr. Hirjee’s Rule 403 objection. Further, even if the district court did
   err, any error was harmless given the other evidence presented at trial.
                                                     4
            Last, Dr. Hirjee argues that the district court’s combined errors—
   “erroneously instructing the jury in the charge, admitting a chart and graphs
   showing how long many of Dr. Hirjee’s patients lived, and providing the jury
   with a transcript of a portion of a witness’s testimony”—denied her a fair
   trial.
            “‘Cumulative error’ justifies reversal only when errors ‘so fatally
   infect the trial that they violated the trial’s fundamental fairness.’” 75
            _____________________
            73
              See Fields, 483 F.3d at 354 (“[T]o warrant exclusion, the danger of unfair
   prejudice . . . must substantially outweigh the probative value of the evidence.”).
            74
                 See Sims, 11 F.4th at 323.
            75
             United States v. Delgado, 672 F.3d 320, 344 (5th Cir. 2012) (en banc) (quoting
   United States v. Fields, 483 F.3d 313, 362 (5th Cir. 2007)).

                                                    37
Case: 21-11225        Document: 00516956725              Page: 38       Date Filed: 11/03/2023

                                          No. 21-11225
                                        c/w No. 21-11228

   “Though this is possible in theory, arguments for cumulative error are
   ‘practically never found persuasive.’” 76 “Because we have found that the
   district court did not commit reversible error in any of the issues presented
   in this case, ‘there are no errors that we could aggregate to find cumulative
   error.’” 77
                                               IV
           Dr. Gibbs and Little raise challenges to their sentences. Dr. Gibbs
   argues that the restitution ordered against him is improper. Little likewise
   challenges her restitution order, as well as various other adjustments applied
   by the district court.
                                                A
           Dr. Gibbs challenges his restitution amount by “incorporat[ing] his
   arguments for the sufficiency of the evidence and appl[ying] them to the
   nearly twenty-eight million dollars in restitution that the trial court ordered.”
   Because his sufficiency challenges fail as explained above in Sections II.A.1,
   II.B.2, and II.D, we do not further address the propriety of Dr. Gibbs’s
   restitution order.
                                                B
           Little argues that the district court miscalculated the applicable
   restitution and sentencing range under the 2021 U.S. Sentencing Guidelines

           _____________________
           76
              United States v. Nicholson, 961 F.3d 328, 339 (5th Cir. 2020) (quoting United
   States v. De Nieto, 922 F.3d 669, 681 (5th Cir. 2019)).
           77
             United States v. Herman, 997 F.3d 251, 275 (5th Cir. 2021) (quoting United States
   v. Eghobor, 812 F.3d 352, 361 (5th Cir. 2015)), cert. denied, 142 S. Ct. 787 (2022); see also
   Delgado, 672 F.3d at 344 (“Because we have rejected [defendant’s] other allegations of
   error, and non-errors have no weight in a cumulative error analysis, there is nothing to
   accumulate.”).

                                                38
Case: 21-11225          Document: 00516956725             Page: 39       Date Filed: 11/03/2023

                                           No. 21-11225
                                         c/w No. 21-11228

   Manual by determining an incorrect loss amount and erroneously applying
   multiple adjustments.             The specific adjustments she challenges are
   (1) obstruction of justice enhancement under § 3C1.1; (2) vulnerable victim
   enhancement under § 3A1.1(b)(1); and (3) minor/minimal role reduction
   under § 3B1.2.
           The district court determined that Little’s Guidelines range was 41 to
   51 months of imprisonment, and it sentenced her to 33 months, a below-
   Guidelines sentence. The PSR initially recommended $1,382,899 be ordered
   in restitution, but the district court ultimately ordered Little to pay
   $366,493.12 in restitution jointly and severally with several codefendants.
   Although Little’s term of imprisonment has ended, her challenges to her
   sentence are not moot because she remains subject to a term of supervised
   release, an element of the overall sentence. 78
           We first address the restitution order and then the Guidelines
   adjustments. We review the district court’s application of the Guidelines de
   novo and its factual findings for clear error. 79

           _____________________
           78
               See United States v. Lares–Meraz, 452 F.3d 352, 355 (5th Cir. 2006) (per curiam)
   (citing United States v. Clark, 193 F.3d 845, 847 (5th Cir. 1999)); see also United States v.
   Vega, 960 F.3d 669, 674 (5th Cir. 2020) (describing Lares–Meraz as holding that “a
   defendant may challenge his term of imprisonment as long as he remains under an active term
   of supervised release”); Greene v. Underwood, 939 F.3d 628, 628 (5th Cir. 2019) (“On July
   19, 2019, during the pendency of this appeal, Greene was released from BOP custody.
   Nevertheless, because ‘a district court may exercise its discretion to modify an individual’s
   term of supervised release, taking into account that an individual has been incarcerated
   beyond the proper expiration of his prison term,’ this appeal is not moot.” (quoting Johnson
   v. Pettiford, 442 F.3d 917, 918 (5th Cir. 2006) (per curiam))).
           79
                United States v. Mahmood, 820 F.3d 177, 192 (5th Cir. 2016).

                                                 39
Case: 21-11225          Document: 00516956725                Page: 40    Date Filed: 11/03/2023

                                                No. 21-11225
                                              c/w No. 21-11228

                                                     1
           Little argues that the district court determined an incorrect loss
   amount, resulting in an incorrect restitution order and an incorrect offense
   level for calculating the sentencing range.                   Section 2B1.1(b)(1) of the
   Guidelines provides that the amount of loss resulting from a crime involving
   fraud is a specific offense characteristic that increases a defendant’s base
   offense level. A sentencing “court need only make a reasonable estimate of
   the loss,” 80 but the amount of loss must account for “the fair market value
   of the . . . services rendered, by the defendant or other persons acting jointly
   with the defendant, to the victim before the offense was detected.” 81 “The
   district court’s loss calculation is generally a factual finding [reviewed] for
   clear error.” 82 “There is no clear error if the district court’s finding is
   plausible in light of the record as a whole.” 83 “[W]e review ‘de novo how the
   court calculated the loss, because that is an application of the guidelines,
   which is a question of law.’” 84
           The district court adopted the PSR’s findings as to the total loss
   amount. The PSR determined the total loss to be $366,493.12, which was
   based on the amount Medicare paid for seventeen patients who were found
   via the Express Medical database. Little argues that the district court erred
   in failing to (1) exclude eight claims for patients who died within four years
   of being enrolled as hospice patients, and (2) offset the remaining nine
           _____________________
           80
                U.S.S.G. § 2B1.1 cmt. n.3(C).
           81
                Id. § 2B1.1 cmt. n.3(E)(i).
           82
                Mahmood, 820 F.3d at 192.
           83
              United States v. Mathew, 916 F.3d 510, 516 (5th Cir. 2019) (quoting United States
   v. Harris, 597 F.3d 242, 250 (5th Cir. 2010)).
           84
             Mahmood, 820 F.3d at 192 (quoting United States v. Klein, 543 F.3d 206, 214 (5th
   Cir. 2008)).

                                                    40
Case: 21-11225          Document: 00516956725             Page: 41    Date Filed: 11/03/2023

                                             No. 21-11225
                                           c/w No. 21-11228

   patients’ claims by the amount Medicare would have paid for home health
   services.
           First, Little argues that the loss amount should not include the
   patients who lived fewer than four years after being admitted to hospice. As
   she puts it, the eight patients she identified should be excluded from the loss
   calculation because “[a]ll eight passed well within the expected timeframe of
   four years stated by the government’s expert witness in her testimony of
   possible life expectancy after hospice admission.” Little does not cite
   authority for this proposition, and the Government argues that Little waived
   her arguments on this point due to inadequate briefing. The district court
   did not err in including all of the patients for the loss-amount calculation.
           Second, Little argues that the loss amount should be offset by the
   value of the services provided. In healthcare fraud cases, a defendant is
   entitled to have Medicare’s actual loss amount offset by the value of
   legitimate services provided to the patients. 85 To be entitled to such an offset
   for purposes of restitution, the defendant must establish that (1) the services
   she provided to Medicare beneficiaries were legitimate, and (2) Medicare
   would have paid for those services but for her fraud. 86 “The defendant has
   the burden of proof to establish each of these factors.” 87

           _____________________
           85
             United States v. Ricard, 922 F.3d 639, 658-59 (5th Cir. 2019); see also Mahmood,
   820 F.3d at 193-94.
           86
                Mathew, 916 F.3d at 521.
           87
                Id. (citing Mahmood, 820 F.3d at 194).

                                                 41
Case: 21-11225         Document: 00516956725              Page: 42      Date Filed: 11/03/2023

                                            No. 21-11225
                                          c/w No. 21-11228

          In United States v. Mahmood, 88 we compared two cases to guide the
   analysis: United States v. Klein 89 and United States v. Jones. 90 Those two
   examples are relevant here.                 In Klein, “even though the defendant
   fraudulently billed services related to the medications, neither party disputed
   that the patients needed those medications or that the insurance companies
   would have had to pay for the medications had the defendant not fraudulently
   billed them.” 91 In Jones, “we concluded that ‘Medicare pays for treatments
   that meet it[s] standards’ and that the defendants’ treatments using
   unlicensed personnel did not meet those standards.” 92 Little’s case is more
   like Jones. The seventeen patients identified for calculating Medicare’s
   losses were “categorically ineligible for the hospice benefit because they were
   not terminally ill, and/or . . . were enrolled in hospice using falsified
   admittance orders.” The Government met its burden of showing that
   Medicare would not have paid for these claims because they do not meet
   Medicare’s standards, and so Little is not entitled to any offset for the
   services provided.
          In light of the record, the district court made a reasonable estimate of
   the loss amount. We find no error.
                                                      2
          Little next argues that that district court erred by applying the
   obstruction-of-justice enhancement. The Supreme Court has instructed
   sentencing courts to address each element of the alleged perjury in a separate
          _____________________
          88
               820 F.3d 177 (5th Cir. 2016).
          89
               543 F.3d 206 (5th Cir. 2008).
          90
               664 F.3d 966 (5th Cir. 2011).
          91
               Mahmood, 820 F.3d at 193 (citing Klein, 543 F.3d at 214-15).
          92
               Id. (citing Jones, 664 F.3d at 984).

                                                  42
Case: 21-11225          Document: 00516956725              Page: 43   Date Filed: 11/03/2023

                                            No. 21-11225
                                          c/w No. 21-11228

   and clear finding when applying this enhancement. 93 Here, the PSR adopted
   the Government’s objection, and the district court adopted the PSR. This
   satisfies the requirement of separate and clear findings. Further, based on
   our review of the record, it is plausible that Little committed perjury; the
   district court did not clearly err in applying the enhancement.
           Little preserved her objection to the obstruction-of-justice
   enhancement.           Section 3C1.1 of the Guidelines imposes a two-level
   enhancement if
           (1) the defendant willfully obstructed or impeded, or
           attempted to obstruct or impede, the administration of justice
           with respect to the investigation, prosecution, or sentencing of
           the instant offense of conviction, and (2) the obstructive
           conduct related to (A) the defendant’s offense of conviction
           and any relevant conduct; or (B) a closely related offense. 94
   “Generally, we review the district court’s interpretation and application of
   the guidelines de novo and its ‘factual findings, such as a finding of
   obstruction of justice, for clear error.’” 95 A factual finding is not clearly
   erroneous so long as it is plausible in light of the record as a whole. 96
           Initially, the PSR did not recommend a sentencing enhancement for
   obstruction of justice. The Government objected, contending that Little
   provided false and perjurious testimony at trial. The PSR was amended to
   reflect a two-level enhancement for obstruction of justice. Little objected,

           _____________________
           93
                United States v. Dunnigan, 507 U.S. 87, 95 (1993).
           94
                U.S.S.G. § 3C1.1.
           95
              United States v. Perryman, 965 F.3d 424, 426-27 (5th Cir. 2020) (quoting United
   States v. Huerta, 182 F.3d 361, 364 (5th Cir. 1999)).
           96
                See Huerta, 182 F.3d at 364.

                                                 43
Case: 21-11225           Document: 00516956725          Page: 44      Date Filed: 11/03/2023

                                           No. 21-11225
                                         c/w No. 21-11228

   and the second addendum to the PSR retained the enhancement over her
   objection. This issue was not addressed at sentencing.
           First, Little argues that the district court failed to comply with the
   Supreme Court’s instruction in United States v. Dunnigan 97 that trial courts
   applying § 3C1.1 enhancements make clear findings of perjury. In Dunnigan,
   the Court explained that “it is preferable for a district court to address each
   element of the alleged perjury in a separate and clear finding.” 98 A § 3C1.1
   enhancement survives review when a trial court makes a single finding that
   “encompasses all of the factual predicates for a finding of perjury.” 99 “The
   trial court may make such a finding by adopting a PSR that contains adequate
   findings.” 100
           Here, the Government submitted “lengthy, detailed objections to the
   PSR,” several of which were included in the PSR addendum. The district
   court adopted the PSR. This amounted to the district court making a finding
   of an obstruction that encompasses all of the factual predicates for a finding
   of perjury. The district court did not violate Dunnigan.
           Second, Little argues that the Government did not “prove
   prosecutable perjury.” “In determining what constitutes perjury, we rely
   upon the definition that has gained general acceptance and common
   understanding under the federal criminal perjury statute.” 101 “A witness
   testifying under oath or affirmation violates this statute if she gives false

           _____________________
           97
                507 U.S. 87 (1993).
           98
                Id. at 95.
           99
                Id.
           100
              United States v. Ajayi, 64 F.4th 243, 251 (5th Cir. 2023) (per curiam) (citing
   United States v. Perez–Solis, 709 F.3d 453, 470 (5th Cir. 2013)).
           101
                 Dunnigan, 507 U.S. at 94.

                                               44
Case: 21-11225         Document: 00516956725             Page: 45         Date Filed: 11/03/2023

                                           No. 21-11225
                                         c/w No. 21-11228

   testimony concerning a material matter with the willful intent to provide false
   testimony, rather than as a result of confusion, mistake, or faulty
   memory.” 102 Little contends that “[a]ny alleged inconsistencies in [her]
   testimony were certainly the result of a clouded memory after years from the
   initial events and trial, her confusion over an exceedingly complex series of
   legal and factual issues, and the high-stress environment that accompanies
   testifying in one’s own defense when facing felony charges at a federal level.”
          The Government provides at least five instances of Little perjuring
   herself at trial. Having reviewed Little’s testimony at trial and the relevant
   exhibits, we conclude that the district court did not clearly err in imposing
   the enhancement.           Little’s testimony was on matters central to her
   substantive healthcare fraud counts, and the Government provided examples
   of evidence directly refuting the claims Little made at trial.
          Last, Little gestures to constitutional issues. She did not raise these
   constitutional arguments when she objected to the obstruction-of-justice
   enhancement. Because Little raises these objections for the first time on
   appeal, we decline to reach them. 103
                                                 3
          Next, Little argues that the district court erred in applying the
   vulnerable-victim enhancement. The district court did not err. Little’s fraud
   potentially harmed patients by exposing them to palliative care rather than
   curative care, making them victims for purposes of this enhancement.
   Further, it is plausible that other victims—individuals who could reasonably
   qualify for hospice care—were vulnerable to Little’s fraud.

          _____________________
          102
                Id.
          103
                See Grogan v. Kumar, 873 F.3d 273, 277 (5th Cir. 2017).

                                                45
Case: 21-11225           Document: 00516956725               Page: 46       Date Filed: 11/03/2023

                                              No. 21-11225
                                            c/w No. 21-11228

            Little preserved this argument. Section 3A1.1(b)(1) of the Guidelines
   imposes a two-level increase when “the defendant knew or should have
   known that a victim of the offense was a vulnerable victim.” 104 We have
   “drawn a distinction between fraud schemes that ‘benefitted’ patients”
   versus those in which patients were potentially harmed by the fraud
   scheme. 105 In a fraud scheme that exposes the patients to needless or
   unnecessary medical treatments, the patients are victims. 106                        “The
   determination that a victim is vulnerable is a factual finding which the district
   court is best suited to make,” 107 and we review that determination for clear
   error.
            In applying this enhancement, the PSR cited the use of pre-signed
   triplicates by those without medical licenses to prescribe medication to
   Novus patients.            It concluded that a “preponderance of the evidence
   indicates that the hospice care patients were exposed to medication that was
   potentially unnecessary and/or physically harmful to their health.” Little
   argues that she was unaware of the practice of using pre-signed triplicates to
   provide patients with prescription medication, and in any event, “all of [her]

            _____________________
            104
                  U.S.S.G. § 3A1.1(b)(1).
            105
                  United States v. Valdez, 726 F.3d 684, 693 (5th Cir. 2013).
            106
              See id. at 693-94; United States v. Burgos, 137 F.3d 841, 844 (5th Cir. 1998) (per
   curiam) (“[A] reasonable fact finder could conclude that the patients were the victims of
   Burgos’s fraudulent scheme. They were often admitted to the hospital needlessly or their
   stays in the hospital were extended beyond what was necessary . . . .”); United States v.
   Sidhu, 130 F.3d 644, 655 (5th Cir. 1997) (“Gifford’s patients were often debilitated by pain
   or depression, and easily became addicted to the treatment proffered by Gifford to support
   his fraud. The record supports the conclusion that Gifford preyed upon vulnerable patients
   by addicting them to morphine in order to support his fraudulent billing scheme.”); see also
   United States v. Mazkouri, 945 F.3d 293, 306 n.4 (5th Cir. 2019).
            107
              Burgos, 137 F.3d at 843 (citing United States v. Rocha, 916 F.2d 219, 244-45 (5th
   Cir. 1990)).

                                                   46
Case: 21-11225     Document: 00516956725          Page: 47     Date Filed: 11/03/2023

                                     No. 21-11225
                                   c/w No. 21-11228

   patients were benefit[t]ed by the services they received . . . and none were
   harmed or victimized in any way.”
          The district court did not clearly err in imposing the vulnerable-victim
   enhancement. As explained at trial, hospices provide palliative care, not
   curative care. By recruiting patients for Novus hospice and then admitting
   them without the requisite involvement of a medical director, Little risked
   exposing patients to the wrong type of medical treatments.             This is
   distinguishable from other cases involving healthcare fraud and the
   vulnerable-victim enhancement in which we pointed to “needless or
   unnecessary” medical treatments as the potential harm to patients. Here,
   the potential harm stems from the lack of needed or necessary treatments
   because hospice provides a fundamentally different type of care. Placing
   ineligible patients on hospice potentially exposes them to harm, making them
   victims for purposes of § 3A1.1(b)(1). It is plausible in light of the record as
   a whole that these victims were vulnerable—Little and Harris were by design
   targeting patients who had common hospice diagnoses. In other words, these
   patients suffered from serious medical conditions, and it is plausible that this
   made them susceptible to Little’s conduct.
          Little acknowledges that the following issues are foreclosed under this
   circuit’s precedents, but she preserves them for further review:
   (1) “whether, if there are vulnerable victims in this case, the enhancement
   would be proper, since there is no nexus in this case between the vulnerability
   of the victims and the success of the criminal activity,” and (2) “that there
   were actually no vulnerable victims at all.”
                                          4
          Last, Little argues that the district court erred in granting only a two-
   level reduction, rather than a four-level reduction, for Little’s role in the
   offense. Little preserved this argument. Whether a defendant was a minor

                                         47
Case: 21-11225        Document: 00516956725              Page: 48       Date Filed: 11/03/2023

                                          No. 21-11225
                                        c/w No. 21-11228

   or minimal participant for purposes of § 3B1.2 is a “factual determination
   reviewed for clear error.” 108 “A factual finding is not clearly erroneous if it
   is plausible in light of the record read as a whole.” 109 “As a preliminary
   matter, § 3B1.2 ‘does not provide an affirmative right to a [mitigating role]
   reduction to every actor but the criminal mastermind.’” 110 Little “bore ‘the
   burden of proving by a preponderance of the evidence that the adjustment
   [was] warranted.’” 111
           Originally, the PSR did not recommend a reduction for Little’s
   minor/minimal role in the offense. Little objected, arguing she (i) had a
   “paltry understanding of the scope and structure” of the conspiracy; (ii) had
   minimally participated in the planning, organization, or implementation of
   the conspiracy; (iii) possessed no decision-making authority and held no
   influence over Harris or Rizvi; (iv) minimally participated in the acts
   constituting the offense conduct; and (v) received only approximately $1,750
   for her role. The Government responded that “Little illegally recruited
   patients for hospice service; recruited other individuals to work for Novus;
   worked as both a marketer and a nurse; worked as a case manager; opened a
   branch office in Greenville; and was involved in the criminal conduct from
   April 2014 until October 2015.” The PSR addendum declined to apply the
   reduction. Little again objected, reiterating her previous arguments. At

           _____________________
           108
              United States v. McElwee, 646 F.3d 328, 346 (5th Cir. 2011) (citing United States
   v. Villanueva, 408 F.3d 193, 204 (5th Cir. 2005)).
           109
              United States v. Castro, 843 F.3d 608, 612 (5th Cir. 2016) (quoting Villanueva,
   408 F.3d at 203).
           110
             United States v. Bello–Sanchez, 872 F.3d 260, 264 (5th Cir. 2017) (alteration and
   emphasis in original) (quoting United States v. Gomez–Valle, 828 F.3d 324, 331 (5th Cir.
   2016)).
           111
             Castro, 843 F.3d at 612 (alteration in original) (quoting United States v. Miranda,
   248 F.3d 434, 446 (5th Cir. 2001)).

                                                48
Case: 21-11225           Document: 00516956725            Page: 49   Date Filed: 11/03/2023

                                             No. 21-11225
                                           c/w No. 21-11228

   sentencing, the Government and Little presented argument. The district
   court granted a two-level reduction.
            The district court did not err in granting only a two-level reduction for
   Little’s minor role in the offense. It is plausible in light of the record as a
   whole that, while Little was “less culpable than most other participants in the
   criminal activity,” she was not “plainly among the least culpable of those
   involved in the conduct of a group.” 112 Little did not bear her burden of
   showing otherwise.
                                           *       *     *
            For the foregoing reasons, we AFFIRM the judgment of the district
   court.

            _____________________
            112
                  U.S.S.G. § 3B1.2 cmt. nn.4, 5.

                                                   49