Court Opinion

ID: 4680502
Source: CourtListenerOpinion
Date Created: 2021-04-23 15:04:56.179508+00
Date Added: 2024-06-11T08:03:55.634065
License: Public Domain

IN THE SUPREME COURT OF THE STATE OF KANSAS

                                        No. 118,710

                                    STATE OF KANSAS,
                                        Appellee,

                                             v.

                                 JASMON DEVAR WATSON,
                                       Appellant.

                              SYLLABUS BY THE COURT

1.
       It is improper for a prosecutor to attempt to shift the burden of proof to the
defendant, but prosecutors are granted wide latitude to address the arguments and
weaknesses of the defense.

2.
       A prosecutor does not shift the burden of proof to the defendant by pointing out a
lack of evidence to support a defense or to corroborate a defendant's argument regarding
deficiencies in the State's case. Likewise, a prosecutor does not shift the burden of proof
when he or she poses a general question about a lack of evidence to rebut the State's
witnesses.

3.
       A prosecutor falls outside the wide latitude afforded the State in conducting its
case when he or she misstates the law or argues a fact or factual inference with no
evidentiary foundation.

                                              1
4.
        An intent to defraud is an essential element of Medicaid fraud under K.S.A. 2019
21-5927(a).

5.
        When evaluating a claim of cumulative error, appellate courts look to the totality
of the circumstances to determine if the errors substantially prejudiced the defendant and
denied him or her a fair trial.

        Review of the judgment of the Court of Appeals in an unpublished opinion filed August 2, 2019.
Appeal from Wyandotte District Court; BILL KLAPPER, judge. Opinion filed April 23, 2021. Judgment of
the Court of Appeals affirming the district court is reversed. Judgment of the district court is reversed, and
the case is remanded with directions.

        Jennifer C. Roth, of Kansas Appellate Defender Office, argued the cause and was on the brief for
appellant.

        Kristafer Ailslieger, deputy solicitor general, argued the cause, and Rachel L. Pickering, assistant
solicitor general, and Derek Schmidt, attorney general, were with him on the brief for appellee.

The opinion of the court was delivered by

        WALL, J.: The State charged Jasmon Devar Watson with one count of making a
false claim to the Medicaid program (i.e., Medicaid fraud), in violation of K.S.A. 2019
Supp. 21-5927(a)(1)(B), and one count of felony theft, in violation of K.S.A. 2019 Supp.
21-5801(a)(2), after discovering Watson had submitted inaccurate times sheets as part of
his employment with Best Choice Home Health Care Agency, a home health-care agency
enrolled with Medicaid. At trial, Watson admitted his time sheets did not accurately
record the exact times of day he delivered services to Medicaid beneficiaries as a Best

                                                      2
Choice employee. However, Watson testified that he worked the total number of hours
recorded on the time sheets and delivered all the services billed to the Medicaid program.

       The jury convicted Watson of Medicaid fraud but was unable to reach a verdict on
the theft charge. Based on his Medicaid fraud conviction, the district court ordered
Watson to pay $13,077.22 in restitution. Watson appealed both his conviction and the
district court's restitution order.

       On review, the Court of Appeals found one instance of prosecutorial error and one
instance of instructional error but concluded the errors were harmless and affirmed
Watson's conviction. State v. Watson, No. 118,710, 2019 WL 3511827 (Kan. App. 2019)
(unpublished opinion). But the panel vacated the restitution order, concluding it was
supported by insufficient evidence. Watson petitioned for review, arguing the panel erred
by affirming his conviction.

       Upon thorough review of the record and the parties' briefing, we conclude the
State committed two errors during closing argument. The prosecutor misstated the
evidence by arguing Watson failed to provide any proof that he had worked the total
hours recorded on his time sheets, an argument that disregarded Watson's own testimony.
The prosecutor also misstated the law by arguing Watson was guilty of Medicaid fraud
based solely on his submission of inaccurate timesheets, without regard to whether
Watson had acted with intent to defraud. These errors substantially diminished, or
effectively eliminated, an essential element of the crime of conviction—the defendant's
intent to defraud Medicaid. Simultaneously, the errors undermined Watson's central
defense to this charge—that he acted without intent to defraud.

                                             3
       The prosecutorial errors substantially prejudiced Watson and deprived him of a
fair trial. An additional instructional error contributed to this prejudice. Accordingly, we
reverse the judgment of the Court of Appeals, reverse the judgment of the district court
based on the jury verdict, and remand the case for a new trial.

                         FACTS AND PROCEDURAL BACKGROUND

       Between February 2013 and August 2014, Watson worked two different jobs in
Kansas City, Kansas. First, he worked as a transitional living skills (TLS) assistant with
Best Choice, a home healthcare agency owned and managed by his aunt and uncle. In
that position, Watson provided TLS services to individuals with traumatic brain injuries
to help them develop or relearn skills necessary to optimize independence and enhance
their quality of life. Best Choice contracted with Medicaid to provide these TLS services
to Medicaid beneficiaries. In turn, Medicaid reimbursed Best Choice for services
delivered each billing cycle through a claim submission and review process. Best Choice
relied on its employees' time sheets and case notes to prepare its claim submissions to
Medicaid.

       In addition to his job at Best Choice, Watson also worked part-time as a store clerk
for QuikTrip. At the time of trial, Watson had worked at QuikTrip for six years. During
this tenure, Watson worked part-time, averaging 20-25 hours per week, with no set
schedule. His manager knew Watson had another job but never had to change Watson's
schedule to accommodate his employment with Best Choice.

       Based on Watson's dual employment, Special Agent Darren Brown in the
Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office launched an
investigation into possible Medicaid fraud. Agent Brown collected Watson's personnel
files from both QuikTrip and Best Choice, which contained QuikTrip timecards and
timesheets from Best Choice. From these time entry records, the Attorney General's

                                              4
Office had its research analyst, Cindy Ludwig, identify Watson's overlapping work hours
between QuikTrip and Best Choice. Ludwig's summary showed a total of 247 instances
where time reported on Watson's QuikTrip time sheets overlapped with the scheduled
work hours reported on Watson's Best Choice time sheets. Assuming all overlapping
hours were devoted to QuikTrip, rather than Medicaid beneficiaries, Ludwig concluded
that Medicaid had been overbilled and paid fraudulent claims totaling $13,077.22.

       The State charged Watson with one count of Medicaid fraud and one count of
felony theft. At trial, the State presented four witnesses: Kim Reynolds, a traumatic brain
injury program manager for the Kansas Department for Aging and Disability Services;
Special Agent Brown; Corey Hanover, Watson's manager at QuikTrip; and Ludwig. The
State also introduced Ludwig's table of overlapping hours and Watson's personnel records
from his employers. The State acknowledged its case was "based on these records"
showing the overlapping hours in the time sheets from Watson's two employers.

       Watson took the stand in his defense. He admitted that it was not unusual for his
two work schedules to overlap, and he did not disagree that it happened over 200 times,
as the State alleged. However, he insisted that everyone at Best Choice knew his work
schedules overlapped on paper, but the flexible nature of his duties at Best Choice
allowed him to work around his QuikTrip schedule. He testified adamantly that he always
worked the total number of hours documented on his Best Choice time sheet, but not
necessarily during the schedule reflected in those records.

       Watson explained his flexible work schedule was made possible, in part, due to
the State's guidelines that restricted the amount of TLS services that could be provided to
beneficiaries. Under these guidelines, TLS providers could deliver no more than 15 hours
of TLS services per week and no more than 4 hours per day for any client. Thus, in any
24-hour period, Watson only had 4 hours to work with a client to assist with varying
transitional living activities, skills, and goals. To illustrate how his flexible work schedule

                                              5
operated, Watson explained he might go help one of his Best Choice clients with a
morning-oriented goal, such as waking up with an alarm clock, making coffee, and
starting one's day. Then, he could go to work at QuikTrip to work his scheduled hours.
When his shift ended at QuikTrip, he could finish out the day reviewing and assessing
daily progress with a Best Choice client. Through this flex time approach, Watson
claimed he always worked the total hours reported, even though he delivered the TLS
services outside the schedule reflected on his Best Choice time sheet.

       Watson acknowledged that each Best Choice time sheet contained the warning,
"any misrepresentation or falsification will result in Medicaid fraud and will be
punishable to the full extent of the law." But Watson insisted he discussed with Best
Choice the variance between the work schedule reflected on his Best Choice time sheets
and the hours he actually worked outside this schedule. Watson said Best Choice never
took issue with this discrepancy. Watson testified that he asked Best Choice to change his
schedule to reflect the times he delivered services, but Best Choice told him changing the
schedule would "throw their coordination off."

       Watson also explained that Best Choice required all time sheets be accompanied
by case notes. The case notes described all TLS services Watson provided to clients each
day and how these services related to the clients' overall goals. Best Choice strictly
enforced its case notes requirement and refused to pay TLS providers if they did not
submit case notes with their time sheets. Watson's case notes were not submitted as
evidence, but he testified that his clients signed off on all his time sheets to verify the
total hours worked and the content of the case notes, and he never missed a paycheck for
failing to provide the required case notes. Watson admitted his case notes did not itemize
the hours worked with each client but did contain the total number of hours worked and
other details tending to corroborate that he delivered the TLS services billed to Medicaid.

                                               6
       Following Watson's testimony, the defense rested, and the district court held a jury
instruction conference. Watson objected to jury instruction No. 10, which stated:

               "It is not a defense that others who participated in the commission of the crime
       have or have not been convicted of the crime, any lesser degree of the crime, or some
       other crime based on the same act."

       Watson objected on the grounds that no one else had been charged with a crime.
The district court overruled his objection because Watson testified that others may have
been involved in the commission of a crime.

       The jury convicted Watson on the first count of making a false claim to Medicaid
but could not reach a verdict on the second count of felony theft. The district court
sentenced Watson to probation with an underlying prison term of five months. The court
also ordered restitution in the amount of $13,077.22.

       On appeal, Watson claimed several trial errors. He argued the prosecutor erred
during closing argument by trying to shift the burden of proof to the defense and
misstating the law and evidence. He also claimed the district court committed
instructional error by giving jury instruction No. 10, and cumulative error deprived him
of a fair trial. Finally, he argued insufficient evidence supported the restitution order.

       The Court of Appeals concluded the prosecutor did not shift the burden of proof or
misstate the law during closing argument but did err by misstating the evidence. 2019
WL 3511827, at *2-6. The panel also held that the district court erred by giving jury
instruction No. 10 because it was not factually appropriate. 2019 WL 3511827, at *6-8.
However, the panel concluded these errors, both individually and cumulatively, were
harmless. 2019 WL 3511827, at *5-6, 8-9. Finally, the panel vacated the restitution order,
holding it was supported by insufficient evidence. 2019 WL 3511827, at *9-10.

                                                   7
       Watson petitioned for review of the Court of Appeals' decision regarding his
claims of prosecutorial, instructional, and cumulative error. The State cross-petitioned,
challenging the Court of Appeals' decision to vacate the restitution order. We granted
review of Watson's petition and denied the State's cross-petition.

                                                 ANALYSIS

The State Committed Prosecutorial Error During Closing Argument

       Watson argues the State committed three acts of prosecutorial error during closing
argument, including: (1) improperly shifting the burden of proof to him by repeatedly
remarking on the lack of evidence to support his defense; (2) misstating the evidence by
declaring Watson offered no proof he delivered the services charged or worked the hours
reported on the Best Choice time sheets; and (3) misstating the law by arguing Watson
was guilty of Medicaid fraud based solely on his submission of an inaccurate time sheet.
Watson argues the Court of Appeals erred in finding only one of these claims constituted
prosecutorial error and by concluding the error was not prejudicial.

       Standard of Review and Relevant Legal Framework

       We evaluate claims of prosecutorial error through a two-step process that includes
both error and prejudice analysis:

       "To determine whether prosecutorial error has occurred, the appellate court must decide
       whether the prosecutorial acts complained of fall outside the wide latitude afforded
       prosecutors to conduct the State's case and attempt to obtain a conviction in a manner that
       does not offend the defendant's constitutional right to a fair trial. If error is found, the
       appellate court must next determine whether the error prejudiced the defendant's due
       process rights to a fair trial. In evaluating prejudice, we simply adopt the traditional

                                                      8
       constitutional harmlessness inquiry demanded by Chapman [ v. California, 386 U.S. 18,
       87 S. Ct. 824, 17 L. Ed. 2d 705 (1967)]. In other words, prosecutorial error is harmless if
       the State can demonstrate 'beyond a reasonable doubt that the error complained of will
       not or did not affect the outcome of the trial in light of the entire record, i.e., where there
       is no reasonable possibility that the error contributed to the verdict.' State v. Ward, 292
       Kan. 541, Syl. ¶ 6, 256 P.3d 801 (2011), cert. denied [565 U.S. 1221] (2012)." State v.
       Sherman, 305 Kan. 88, 109, 378 P.3d 1060 (2016).

       The Prosecutor Did Not Improperly Shift the Burden of Proof onto Watson

       We first address Watson's claim that the prosecutor erred by shifting the burden of
proof onto him.

       It is improper for the prosecutor to attempt to shift the burden of proof to the
defendant, but prosecutors are granted wide latitude to address the arguments and
weaknesses of the defense. State v Duong, 292 Kan. 824, 832, 257 P.3d 309 (2011). A
prosecutor does not shift the burden of proof to the defendant by pointing out a lack of
evidence to support a defense or to corroborate a defendant's argument regarding
deficiencies in the State's case. State v. Williams, 299 Kan. 911, 940, 329 P.3d 400
(2014). Likewise, a prosecutor does not shift the burden of proof by posing a general
question about the lack of evidence offered to rebut the State's witnesses. State v.
Peppers, 294 Kan. 377, 397-98, 276 P.3d 148 (2012). Moreover, "[t]he prosecutor's
comment must be evaluated in context and can be mitigated by jury instructions
regarding the burden of proof." 294 Kan. at 397.

       During closing argument, the State repeatedly commented on the lack of evidence
corroborating Watson's testimony, including the following remarks:

                                                      9
        "He admitted he didn't always work those hours that he put down on his time
sheets. He also indicated and talked a great deal about the case notes. Those case notes,
he admitted, were submitted at the same time as the time sheets. There's no additional
information in those case notes according to him that would give any other times or dates.
He's asking you to believe that he provided those services at some other time, but he has
provided no information, no proof, no evidence of when he provided those services. . . .

        ....

        "You also heard the testimony of Darren Brown, and he provided he was the one
who issued all the subpoenas and gathered up all of this information. And I admit this
case is mostly records, but all of these exhibits, this is the evidence that we have. Mr.
Watson can't provide any other written documentation of when and how and if he
provided services to these traumatic brain injured people. He testified how important
those services were to them, made a world of difference or should have made a world of
difference to them. That's the purpose of the program, it's to help them get out and get a
job and have all the things everyone would like to have. But if they weren't getting those
services or they weren't getting them at the times he said, how do we even know that
[they] got those services—that they got to receive them. There's nothing in the record that
would indicate that during those times when he had these overlaps that he could
somehow magically work two places at once. . . .

        ....

        "He agrees that those hours are false. He claims that he provided services and
that he was not allowed to change his time sheets. He also claims that he couldn't or
didn't actually provide any testimony about whether or not he could change his hours at
QuikTrip other than saying that they were very flexible so he could have done that at the
very least. He's provided no evidence that he has provided or attempted to provide or
could have provided services during those periods while he was working at QuikTrip and
that he reported he was working for these clients.

        ....

                                             10
               ". . . There is no way that he could have provided services to these individuals
       that he said he did. He's admitted there are two hundred—that it's correct he has 247
       overlaps between this time and the time that he worked at QuikTrip. He admits that's true.
       He admits that he put false hours on and he can't provide and has not provided any proof
       that he actually provided any services during that day that he charged for. . . .

               "And it's also his statements that he was working with a very vulnerable
       population that couldn't tell time. He knew that. He knew they needed care, that's why he
       was there. He was the service transitional living service coordinator. They relied on him
       to make sure that they got the services they deserved and the State relied on him. That
       was the purpose of that program, to provide those services. Provide those services and
       provide proof that he actually did it is why we're here today. And has he provided any
       proof that he actually provided those services? No. All he's done is submit time sheets
       that 247 times overlapped with times that he was working at QuikTrip. That's our
       contention. That's what we're asking you to find. . . .

               ....

               "And counsel wants to say there's no evidence here. State has presented plenty of
       evidence. The defendant has not. Thank you." (Emphases added.)

       Watson contends these statements shifted the burden of proof onto the defense. He
also argues the prejudicial force of these statements was exacerbated by the State's cross-
examination, during which the prosecutor repeatedly asked Watson if he had any
evidence proving he had worked all hours reported or that Best Choice knew he worked
flexible hours outside the schedule reflected in his time sheets.

       After careful examination of the arguments in their proper context, we conclude
the challenged comments fall within the wide latitude afforded the prosecution in
discussing the evidence. Watson testified that he worked the total number of hours
recorded and billed to Medicaid, but not necessarily during the schedule reflected on his
time sheets. He also claimed Best Choice was fully aware of these facts. Watson also

                                                    11
claimed his case notes would corroborate this testimony. While Watson's testimony
constituted lawful evidence, it was not corroborated by any other witness or exhibit.
During closing argument, the prosecutor merely highlighted this fact to the jury. The
prosecutor also argued Watson had neither provided any documentation to rebut the
records introduced by the State (showing overlapping hours worked for his two
employers), nor introduced any of the potentially exonerating evidence he described on
the stand (the case notes). These statements accurately described the trial evidence.

       Moreover, the prosecutor was not calling on the defense to disprove the
occurrence of a crime. See State v. Tosh, 278 Kan. 83, 92, 91 P.3d 1204 (2004) (finding
prosecutor improperly attempted to shift burden of proof when he asked: "'"[I]s there any
evidence that it didn't happen? Is there any evidence that the things [the victim] told you
didn't happen?"'"), overruled on other grounds Sherman, 305 Kan. 88. Even if Watson
had worked the total number of hours reported, rather than the specific hours, that would
not preclude a Medicaid fraud conviction. Instead, the prosecutor's remarks were fair
comment on the strength, or lack thereof, of Watson's defense—specifically, the lack of
evidence to corroborate Watson's testimony or to rebut the State's records. See, e.g.,
Duong, 292 Kan. at 832-33 (holding prosecutor's remarks about defendant's failure to
present evidence of misidentification were "mere comment on the weakness of [the
defendant's] defense"); State v. Cosby, 293 Kan. 121, 137, 262 P.3d 285 (2011)
(prosecutor's comment, asking jury if it had heard any evidence that suggested witness'
testimony was wrong, was within wide latitude granted prosecutors because it reflected
lack of evidence to rebut the State's witnesses).

       The prosecutor's comments were within the wide latitude afforded prosecutors in
discussing the weaknesses of the defense. This conclusion is bolstered by the fact that the
district court properly instructed the jury that "[t]he State has the burden to prove the
defendant is guilty. The defendant is not required to prove he is not guilty."

                                             12
Consequently, we agree with the Court of Appeals and hold the prosecutor did not
impermissibly shift the burden of proof onto Watson.

       The Prosecutor Erred by Misstating the Evidence and the Law

       Watson also argues the prosecutor misstated the evidence and the law during
closing. Prosecutors are afforded wide latitude to conduct the State's case and attempt to
obtain a conviction. See Sherman, 305 Kan. at 109. But a prosecutor errs by arguing a
fact or factual inference with no evidentiary foundation. State v. Moore, 311 Kan. 1019,
1040, 469 P.3d 648 (2020). Likewise, a prosecutor falls outside his or her wide latitude,
and thus commits error, if he or she misstates the law. State v. Ross, 310 Kan. 216, 221,
445 P.3d 726 (2019).

       More than once during closing argument, the prosecutor asserted that Watson had
not offered any proof that he delivered the services billed to Medicaid or worked the
hours reported in his Best Choice time sheets. For example, the prosecutor told the jury,
"[Watson] admits that he put false hours on and he can't provide and has not provided any
proof that he actually provided any services during that day that he charged for." The
prosecutor later stated, "And has he provided any proof that he actually provided those
services? No."

       During rebuttal, the prosecutor also made the following comments that reflected
upon the crime and elements of Medicaid fraud as charged under K.S.A. 2019 Supp. 21-
5927(a)(1)(B):

       "All he's done is submit time sheets that 247 times overlapped with times that he was
       working at QuikTrip. That's our contention. That's what we're asking you to find. And he
       was paid over $13,000 for time that he was working two places at once. And he wants

                                                  13
       you to believe that he is not deceptive. He wants you to believe that he had no intent to
       defraud. What?

               "The record is clear, and he's even admitted that each time he signed one of these
       time sheets he was aware of the statement any misrepresentation or falsification will
       result in Medicaid fraud and will be punishable to the full extent of the law. How many
       times does an individual commit a crime and have a warning each time they do it? In
       these cases, they do. Each time he signed off on one of these time sheets he was told don't
       put down false information, it could impact you, it could subject you to Medicaid fraud
       charges and yet he signed them, he submitted them, he attached the case notes to them."
       (Emphases added.)

       Watson takes issue with the prosecutor's comments that he failed to provide "any
proof" that he worked all hours reported, and therefore delivered all TLS services billed
to Medicaid, because he testified to these facts. He also argues the prosecutor's remarks
during rebuttal misstated the law by arguing Watson committed Medicaid fraud based
solely on his submission of inaccurate time sheets, regardless of whether Watson had
acted with intent to defraud. The State responds that these comments, when taken in
context, were within the wide latitude granted to prosecutors because they were
consistent with the evidence presented at trial and accurately reflected the law.

       The Court of Appeals agreed with Watson that the prosecutor erred by stating
Watson had not provided any proof that he worked all hours reported or delivered all
services billed to Medicaid. Watson, 2019 WL 3511827, at *5. But the panel concluded
the error was harmless because "the prosecutor's misstatement of fact did not bear on the
factual issue to be decided by the jury"—that is, "whether Watson submitted inaccurate
Medicaid time sheets to Best Choice." 2019 WL 3511827, at *6. As for Watson's claim
that the prosecutor had misstated the law, the Court of Appeals held the statements were
not improper. The panel reasoned that the prosecutor's comments regarding the warning
on Watson's time sheet invited the jury to infer that Watson had intended to defraud

                                                   14
Medicaid because he had been warned against submitting false statements or
misrepresentations. 2019 WL 3511827, at *5.

       We agree with the Court of Appeals that the prosecutor misstated the evidence
when she informed jurors there was "no proof" that Watson had worked all the hours
reported or delivered all services billed to Medicaid. The prosecutor used the term
"proof" to mean evidence. Watson testified to these facts, and his testimony constitutes
evidence, or "proof" the prosecutor claimed did not exist. Furthermore, Watson testified
that he would not have been paid if he had not submitted case notes detailing and
corroborating the TMS services delivered to clients, and the evidence showed Watson
never missed a Best Choice paycheck for failing to submit case notes.

       However, we disagree with the Court of Appeals' holding that the prosecutor's
argument did not misstate the law. During rebuttal, the prosecutor indicated Watson
completed the crime of Medicaid fraud by submitting inaccurate timesheets to Best
Choice, regardless of his intent in doing so. We find that these comments misstated the
essential elements of Medicaid fraud, specifically the intent to defraud element.

       The crime of Medicaid fraud, as charged in this case, is defined as follows:

               "(1) With intent to defraud, making, presenting, submitting, offering or causing
       to be made, presented, submitted or offered:

               ....

                       (B) any false or fraudulent statement or representation for use in
               determining payments which may be made, in whole or in part, under the
               medicaid program, whether or not the claim is allowed or allowable." K.S.A.
               2019 Supp. 21-5927(a)(1)(B).

                                                  15
       Under the plain language of this statute, proof that a defendant made false
statements or misrepresentations to Medicaid satisfies only one element of Medicaid
fraud. To secure a conviction, the State must also prove the defendant made such false
statements or misrepresentations with the "intent to defraud." An "[i]ntent to defraud"
means "an intention to deceive another person, and to induce such other person, in
reliance upon such deception, to assume, create, transfer, alter or terminate a right,
obligation or power with reference to property." K.S.A. 2019 Supp. 21-5111(o). As used
in this definition, "deception" means "knowingly creating or reinforcing a false
impression, including false impressions as to law, value, intention or other state of mind."
K.S.A. 2019 Supp. 21-5111(e).

       Together, these statutory definitions demonstrate the "intent to defraud" element of
K.S.A. 2019 Supp. 21-5927 requires the State to prove defendant made false statements
or false representations to deceive Medicaid and induce it to pay claims in reliance on
such falsehoods or misrepresentations. Whether Medicaid, in fact, pays the claim is
irrelevant. K.S.A. 2019 Supp. 21-5927(a)(1)(B). Instead, the false statement or
misrepresentation must be made with the intent to induce such payment.

       This construction finds further support in the plain language of K.S.A. 2019 Supp.
21-5927(a)(1)(B), which requires the State prove, as an element of Medicaid fraud, that
the statement or representation in question was not only "false or fraudulent," but also of
the type "use[d] in determining payments which may be made . . . under the Medicaid
program . . . ." This language reinforces the notion under K.S.A. 2019 Supp. 21-5111(e)
and (o) that defendant's false statement or misrepresentation must be material or relevant
to the claims review process and, therefore, calculated to induce payment from Medicaid
in reliance on the false statement or misrepresentation. And it was up to the jury to sort
that out in light of the evidence concerning the claim review process.

                                             16
       The prosecutor's argument misstated the law by informing jurors they could
convict Watson based solely on the submission of time sheets containing any
inaccuracy, regardless of whether he intended to defraud Medicaid in the process.
Perhaps the prosecutor only intended to argue that the warning on the timesheet
("any misrepresentation or falsification will result in Medicaid fraud and will be
punishable to the full extent of the law") was probative of Watson's state of mind,
as suggested by the Court of Appeals panel. However, the message the prosecutor
intended to communicate is irrelevant to our analysis. Instead, we must focus on
the actual message communicated to jurors. See State v. Thomas, 307 Kan. 733,
745, 415 P.3d 430 (2018) (in analyzing prejudice, appellate courts focus
exclusively on the error's impact on the verdict rather than considering the
prosecutor's motivation or intent); see also State v. Loughbom, 196 Wash. 2d 64,
76, 470 P.3d 499 (2020) ("The prosecutor's 'reasonable intentions' are irrelevant
because we do not assess a prosecutor's subjective intent when deciding whether
error occurred."); Lucas v. United States, 102 A.3d 270, 278 n.12 (D.C. 2014) (In
evaluating whether a prosecutor's comment constitutes error, the court employs an
objective test and does "not consider the intentions of the prosecutor.").

       And, here, the prosecutor's argument conveyed far more than some
attenuated inference that Watson knew his conduct was unlawful. More directly, it
provided an inaccurate and incomplete description of the elements necessary to
characterize the defendant's acts as unlawful in the first instance under K.S.A.
2019 Supp. 21-5927(a)(1)(B). In her closing remarks, the prosecutor argued the
warning on the Best Choice time sheets put Watson on notice that any inaccuracy
in these records constituted Medicaid fraud. Thus, according to the prosecutor,
each time Watson submitted a time sheet that did not accurately account for his
flexible work hours, he knew or should have known he was committing Medicaid
fraud. Through this argument, the prosecutor informed jurors that the warning on
the time sheet was not only a cautionary notice, but also provided an accurate and

                                             17
complete recitation of the elements of the crime. Further, the prosecutor signaled
to the jury it was free to convict Watson based solely on his submission of time
sheets that did not accurately report the time of day services were delivered,
regardless of whether Watson intended to defraud Medicaid through such "false or
fraudulent statement or representation." K.S.A. 2019 Supp. 21-5927(a)(1)(B). Of
course, to convict a defendant of Medicaid fraud, the State must prove the
defendant acted with such intent to defraud. The prosecutor's argument eliminated
this essential element and effectively converted the crime of Medicaid fraud into a
strict liability offense, contrary to the plain language of K.S.A. 2019 Supp. 21-
5927(a)(1)(B).

       Prosecutorial Error Resulted in Prejudice to Watson

       Having determined the prosecutor erred in closing argument by misstating the
evidence and the law, we must now consider whether those errors prejudiced Watson. In
evaluating prejudice, we must determine if the State has demonstrated beyond a
reasonable doubt that these errors did not affect the verdict. Sherman, 305 Kan. at 109.

       In conducting its prejudice analysis, the Court of Appeals erred by embracing and
perpetuating the same misstatement of the law advanced by the prosecutor during closing
argument. The panel acknowledged the prosecutor erred by claiming Watson had not
offered any proof that he worked the total hours recorded on his time sheets and delivered
all services billed to Medicaid. However, it concluded this error was harmless because
the jury could convict Watson of Medicaid fraud based solely on his submission of
inaccurate time sheets:

               "More importantly, however, is the fact that the prosecutor's misstatement of fact
       did not bear on the factual issue to be decided by the jury. The jury was charged with
       deciding whether Watson submitted inaccurate Medicaid time sheets to Best Choice.

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       Even if the jury had believed Watson's testimony that he worked all of the hours
       documented in his submission on each given day, just not at the times documented on the
       time sheet, his inaccurate submission still meets the elements of Medicaid fraud as
       charged. In fact, it appears that at least some members of the jury did believe Watson's
       testimony that he actually worked the hours at a different time because the jury ultimately
       could not come to a consensus on the theft charge, which the State ultimately dismissed."
       Watson, 2019 WL 3511827, at *6.

       Like the prosecutor's closing argument, the panel's analysis assumes that Watson's
"intent to defraud" was not a relevant consideration for the jury. To the contrary, our
statutory analysis confirms the defendant's intent to defraud is an essential element of the
crime of Medicaid fraud. Thus, to secure a conviction, the State needed to prove not only
that Watson submitted inaccurate timesheets, but also that he did so with the requisite
intent to defraud. The panel's prejudice analysis fails to account for this essential element,
and this omission constitutes legal error.

       When all essential elements of Medicaid fraud are incorporated into the analysis,
we are not convinced beyond reasonable doubt that the error did not affect the verdict. As
set forth above, "intent to defraud" is an essential element of Medicaid fraud, yet the
prosecutor's argument suggested this element was nonessential, if it even existed at all.
Therefore, the error opened the door for the jury to convict Watson of violating K.S.A.
2019 Supp. 21-5927(a)(1)(B), without regard to all essential elements of that crime.

       The prosecutor's misstatement of law not only eliminated an element of proof for
the State, but also substantially undermined Watson's defense. At trial, Watson admitted
his time sheets contained inaccuracies regarding the time of day services were delivered.
However, his defense focused on the materiality of the inaccuracies to contest the "intent
to defraud" element of the crime. Watson explained the time sheets accurately reflected
the total number of hours he worked and demonstrated he delivered all services billed to
Medicaid. If the jury accepted Watson's testimony, it supported a legally viable defense

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to Medicaid fraud—that he did not "submit[]" inaccurate time sheets "[w]ith intent to
defraud." K.S.A. 2019 Supp. 21-5927(a).

       Although the jury could have accepted Watson's testimony that he worked the total
hours he reported and still concluded his misrepresentations were intended to defraud
Medicaid, the prosecutor's missteps led the jury away from considering the nuances of
this element. The prosecutorial errors potentially affected the verdict in two different
respects. In misstating the evidence, the prosecutor undermined Watson's core trial
defense by suggesting it lacked any foundational, evidentiary support. Second, and more
damaging, by misstating the law, the prosecutor suggested Watson's defense—though by
no means a complete defense—was no defense at all, and the jury was free to convict him
based on the submission of time sheets containing any inaccuracy, regardless of Watson's
intent to defraud.

       The jury's verdict contributes to concerns about the influence of these errors on the
outcome of the proceedings. The jury convicted Watson of Medicaid fraud but could not
reach a verdict on the felony theft charge. The felony theft charge required the jury to
find Watson obtained control over Medicaid's property by deception and with the intent
to permanently deprive Medicaid of that property. See State v. Fritz, 261 Kan. 294, 299,
933 P.2d 126 (1997) (discussing elements of felony theft). Likewise, the Medicaid theft
charge required the jury to find Watson acted with intent to defraud. The Court of
Appeals acknowledged that the jury's failure to reach a verdict on the felony theft charge
demonstrated that "at least some members of the jury did believe" Watson's testimony
that he had worked the total number of hours recorded in the time sheets, confirming he
had delivered all services billed to Medicaid. Watson, 2019 WL 3511827, at *6. Yet this
testimony also supported Watson's defense to the "intent to defraud" element of the
Medicaid fraud charge.

                                             20
       The verdict leaves open the possibility the jury did not recognize or appreciate that
defendant's intent to defraud was an essential element of Medicaid fraud. And, like the
Court of Appeals, the jury may have been under the mistaken impression it "was
charged" solely "with deciding whether Watson submitted inaccurate Medicaid time
sheets to Best Choice" in arriving at a verdict on the Medicaid fraud charge, regardless of
whether he intended to defraud the program. 2019 WL 3511827, at *6. As established
above, the prosecutor's misstatement of the evidence and the law tended to contribute to
this legally erroneous assumption that Watson's "intent to defraud" was not a relevant
consideration in the jury's decision-making calculus. Additionally, the State's case
focused on the time entry records showing overlapping hours between Watson's work
schedules at QuikTrip and Best Choice. The State offered little evidence of Watson's
intent to defraud Medicaid.

       For these reasons, we hold that the prosecutor erred by misstating the facts and the
law. These errors prejudiced Watson's right to a fair trial, and the State has not
demonstrated beyond reasonable doubt that the errors did not affect the verdict in light of
the entire record.

Cumulative Error Deprived Watson of a Fair Trial

       While prosecutorial error alone entitles Watson to a new trial, Watson argues the
district court committed instructional error and that the cumulative effect of these trial
errors deprived him of a fair trial.

       The Court of Appeals found jury instruction No. 10 was factually inappropriate
because "the State failed to present 'specific evidence' at trial that Best Choice had not
been convicted of Medicaid fraud, had been acquitted of Medicaid fraud, or had been
convicted of some other crime based on the facts presented at trial to support a Medicaid
fraud conviction against Watson." 2019 WL 3511827, at *8. Consequently, the panel

                                             21
concluded the district court erred by giving jury instruction No. 10. Neither party
challenges this finding on review. Thus, we proceed to Watson's claim that cumulative
error deprived him of a fair trial.

       Standard of Review and Relevant Legal Framework
       ,
       When evaluating a claim of cumulative error, we look to the totality of the
circumstances to determine if the errors substantially prejudiced the defendant and denied
him or her a fair trial. In making this determination, "an appellate court examines the
errors in context, considers how the district court judge addressed the errors, reviews the
nature and number of errors and whether they are connected, and weighs the strength of
the evidence." State v. Thomas, 311 Kan. 905, 914, 468 P.3d 323 (2020) (citing State v.
Holt, 300 Kan. 985, 1007-08, 336 P.3d 312 [2014]). No prejudicial error may be found
under this rule if the evidence against the defendant is overwhelming. Holt, 300 Kan. at
1007-08. "If any of the errors being aggregated are constitutional, the constitutional
harmless error test of Chapman applies, and the party benefitting from the errors must
establish beyond a reasonable doubt that the cumulative effect of the errors did not affect
the outcome." Thomas, 311 Kan. at 914. Because the Chapman standard applies to the
prosecutorial errors, we must determine if the cumulative errors here are harmless under
that standard. See Chapman v. California, 386 U.S. 18, 87 S. Ct. 824, 17 L. Ed. 2d 705
(1967).

       Instructional Error Compounded the Prosecutorial Error, Depriving Watson of a
       Fair Trial

       Here, the instructional error added to the prejudice arising from the prosecutorial
error. Jury instruction No. 10 told the jury that "[i]t is not a defense that others who
participated in the commission of the crime have or have not been convicted of the crime,
any lesser degree of the crime, or some other crime based on the same act." The jury

                                              22
could have inferred from jury instruction No. 10 that Best Choice had been convicted of
Medicaid fraud or a similar crime based on the same acts that gave rise to Watson's
charges. But in contrast to Watson, who signed and submitted the time sheets containing
the inaccuracies, Best Choice did nothing more than pass Watson's time sheets on for
payment. If the jury inferred from this instruction that Best Choice had been found guilty
of Medicaid fraud for simply forwarding time sheets, such an inference would suggest
that Watson certainly must be guilty for his more extensive role.

       The Court of Appeals determined that the cumulative effect of the prosecutorial
and instructional errors was harmless. This conclusion rested on the panel's premise that
"[a]t its core, the factual issue presented for the jury to decide was whether Watson
submitted inaccurate Medicaid time sheets to Best Choice," and because "Watson
repeatedly admitted during his testimony that he submitted inaccurate time sheets," his
admission alone supports the jury's conviction of Medicaid fraud as charged. Watson,
2019 WL 3511827, at *9. But again, the panel's harmlessness analysis suffers the same
legally erroneous premise advanced by the prosecutor during closing argument—that
Watson could be convicted of Medicaid fraud for submitting a time sheet containing any
inaccuracy, regardless of his intent to defraud. For the reasons established above, this
conclusion is legally erroneous.

       By misstating the evidence and the law during closing argument, the prosecutor
effectively negated the intent to defraud element from the jury's consideration. Further,
these errors undermined Watson's central trial defense, which challenged the mens rea
element of K.S.A. 2019 Supp. 21-5927(a)(1)(B). The instructional error, even if harmless
in isolation, exacerbated this prejudice by suggesting Best Choice, who appeared less
culpable than Watson based on the evidence presented at trial, may have been convicted
of a crime arising from the same acts. As a result, we find the cumulative effect of these
trial errors deprived Watson of a fair trial.

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       The Court of Appeals judgment affirming the district court is reversed, and the
district court judgment based on the jury verdict is reversed and the case is remanded for
a new trial.

       STANDRIDGE, J., not participating.

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