Court Opinion

ID: 9408858
Source: CourtListenerOpinion
Date Created: 2023-07-13 21:00:57.312973+00
Date Added: 2024-06-11T17:20:47.280821
License: Public Domain

USCA11 Case: 20-14264    Document: 96-1      Date Filed: 07/13/2023   Page: 1 of 29

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

                           ____________________

                                 No. 20-14264
                           ____________________

        UNITED STATES OF AMERICA,
                                                       Plaintiﬀ-Appellee,
        versus
        SEBASTIAN AHMED,

                                                    Defendant-Appellant.

                           ____________________

                  Appeal from the United States District Court
                      for the Southern District of Florida
                     D.C. Docket No. 0:19-cr-60200-FAM-2
                           ____________________

        Before ROSENBAUM, BRANCH, and BRASHER, Circuit Judges.
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        2                      Opinion of the Court                20-14264

        BRASHER, Circuit Judge:
                A jury convicted Sebastian Ahmed of healthcare fraud, wire
        fraud, and money laundering in a trial that took place during the
        initial days of the coronavirus pandemic. Ahmed appeals his con-
        viction, raising a number of constitutional, evidentiary, and proce-
        dural challenges. Ahmed argues that he was deprived of his Fifth
        and Sixth Amendment rights because, among other things, his law-
        yer, fearing coronavirus exposure, refused to visit him in jail
        throughout the trial. He also posits that the government commit-
        ted prosecutorial misconduct by improperly questioning one of his
        witnesses. On top of all that, Ahmed contends that the district court
        abused its discretion and violated his right to present a defense by
        making erroneous evidentiary rulings. Ahmed believes the district
        court’s cumulative errors denied him a fundamentally fair trial. We
        disagree and affirm.
                                       I.

                We start with the facts of the case. Ahmed’s conviction
        stems from his ownership of two substance abuse treatment cen-
        ters, Jacob’s Well and Medi MD, LLC. Ahmed also operated multi-
        ple residential sober homes—collectively known as Serenity Ranch
        Recovery or Serenity Treatment Centers—intended to provide
        safe, drug-free residences for Jacob’s Well and Medi MD patients.
               Ahmed and his co-defendants concocted a scheme for Seren-
        ity to submit insurance claims for substance abuse treatment ser-
        vices never rendered. Serenity would recruit young patients using
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        20-14264               Opinion of the Court                         3

        gimmicks like free flights, phones, vapes, and cigarettes. After en-
        rolling patients, Serenity would provide shoddy treatment services,
        doling out drugs in plastic baggies and allowing behavior health
        technicians to engage in sexual relationships with the patients. Liv-
        ing conditions at Serenity deteriorated into squalor, and several pa-
        tients overdosed. Between July 2016 and July 2019, Serenity sub-
        mitted over $37,000,000 in fraudulent claims to insurance compa-
        nies, eventually receiving more than $6,000,000.
               The government charged Ahmed with conspiracy to com-
        mit healthcare fraud and wire fraud, in violation of 18 U.S.C.
        § 1349; ten counts of healthcare fraud, in violation of 18 U.S.C.
        § 1347; conspiracy to commit money laundering, in violation of 18
        U.S.C. § 1956; and eleven counts of money laundering, in violation
        of 18 U.S.C. § 1957. Ahmed’s trial commenced in February 2020
        and continued through the first days of the coronavirus pandemic,
        ending in late-March 2020.
               Central to this appeal, Ahmed’s counsel orally moved for a
        mistrial a couple of weeks into the trial, expressing concern that the
        emerging coronavirus would impact the jury and prevent him
        from visiting Ahmed in jail. The district court denied the motion.
        Ahmed’s counsel renewed the motion for mistrial twice more, ech-
        oing his previous concerns. The district court denied the motions.
        At the close of evidence, the jury unanimously voted to deliberate,
        despite the evolving coronavirus situation.
              Ahmed raised a slew of other concerns during the trial. A
        few days into the trial, the district court learned that the jail was
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        4                       Opinion of the Court                   20-14264

        not providing Ahmed with his prescribed Adderall. After an in cam-
        era competency hearing, the district court found Ahmed responsive
        enough to proceed. Still, the district court took steps to ensure Ah-
        med received his medication, such as allowing him to take it at the
        beginning of court each day and reminding the jail to give it to him
        on the weekend. Ahmed also expressed concern about injuries sus-
        tained in a slip-and-fall accident at the jail, shackles cutting into his
        ankles during the trial, and the jail’s confiscation of his legal mate-
        rials.
               A few other issues relevant to this appeal arose as well. One
        related to the government’s characterization of Florida law during
        cross-examination of one of Ahmed’s witnesses. The others in-
        volved the district court’s exclusion of certain documentary and
        testimonial evidence.
                After a twenty-five-day trial, a jury convicted Ahmed of one
        count of conspiracy to commit healthcare fraud and wire fraud,
        five counts of healthcare fraud, one count of conspiracy to commit
        money laundering, and eleven counts of money laundering. The
        district court sentenced Ahmed to 210 months’ imprisonment. Ah-
        med timely appealed.
                                        II.

               This appeal turns on several standards of review. We review
        claims of constitutional error at a criminal trial de novo. United States
        v. Cavallo, 790 F.3d 1202, 1213 (11th Cir. 2015).
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        20-14264                Opinion of the Court                          5

               If a criminal defendant does not object to a district court’s
        shackling determination, we review for plain error. United States v.
        Moore, 954 F.3d 1322, 1329 (11th Cir. 2020). Plain error requires “(1)
        error, (2) that is plain, and (3) that affects substantial rights.” Id.
        (quoting United States v. Baker, 432 F.3d 1189, 1203 (11th Cir. 2005).
        And we may notice the error only if it “seriously affects the fairness,
        integrity, or public reputation of judicial proceedings.” Id. (quoting
        Baker, 432 F.3d at 1203).
               We uphold a district court’s decision not to grant a mistrial
        unless we detect an abuse of discretion. United States v. Newsome,
        475 F.3d 1221, 1227 (11th Cir. 2007). A district court should grant a
        mistrial “if the defendant’s substantial rights are prejudicially af-
        fected.” Id.
               When a district court allows a witness to invoke the Fifth
        Amendment right against self-incrimination, we review its decision
        for abuse of discretion. United States v. Perez, 661 F.3d 568, 580 (11th
        Cir. 2011). We usually review a district court’s evidentiary rulings
        for abuse of discretion too. United States v. Todd, 108 F.3d 1329, 1331
        (11th Cir. 1997).
                                        III.

               Ahmed raises three groups of issues on appeal. First, he ar-
        gues that the coronavirus pandemic impacted his ability to com-
        municate with counsel, meaningfully participate at trial, and con-
        front the witnesses against him. He believes the district court’s re-
        fusal to grant a mistrial on those grounds violated his Fifth and
        Sixth Amendment rights. Second, he contends the government
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        6                      Opinion of the Court                 20-14264

        committed prosecutorial misconduct by alleging that one of his
        witnesses violated Florida prescription drug law. The district court
        allowed the testimony and later found that any mischaracteriza-
        tions of Florida law by the government did not seriously under-
        mine Ahmed’s defense. Third, Ahmed posits that the district court
        committed several evidentiary errors, depriving him of his ability
        to present a defense. These cumulative errors, he argues, denied
        him a fundamentally fair trial. We address each group of issues in
        turn.
                                       A.

               We start with the coronavirus. Ahmed argues that the
        emerging coronavirus pandemic pervaded his trial and deprived
        him of his Fifth and Sixth Amendment rights. Specifically, he con-
        tends that he could not meaningfully participate in his defense, con-
        front witnesses against him, or benefit from effective assistance of
        counsel because of several incidents that transpired during trial. He
        believes the district court should have granted his many motions
        for a mistrial. We disagree.
                                            1.

               Ahmed’s lawyer, supposedly fearing coronavirus infection,
        said on the record during trial that he would not visit his client in
        jail during overnight recess. Ahmed argues that this refusal de-
        prived him of his Sixth Amendment right to counsel under Geders
        v. United States, 425 U.S. 80 (1976), because he could not effectively
        communicate with his lawyer. We disagree.
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        20-14264                Opinion of the Court                          7

                The Sixth Amendment to the Constitution provides that
        “[i]n all criminal prosecutions, the accused shall enjoy the right . . .
        to have the Assistance of Counsel for his defence.” U.S. Const.
        amend. VI. Applying the Sixth Amendment in Geders, the Supreme
        Court held that a court cannot preclude defense counsel from com-
        municating with a defendant “about anything” during an overnight
        recess. 425 U.S. at 91. The Supreme Court has recognized that
        “[n]ot every restriction on counsel’s time or opportunity to inves-
        tigate or to consult with his client or otherwise to prepare for trial
        violates a defendant’s Sixth Amendment right to counsel.” Morris
        v. Slappy, 461 U.S. 1, 11 (1983). But the Court has observed that
        overnight “recesses are often times of intensive work, with tactical
        decisions to be made and strategies to be reviewed.” Geders, 425
        U.S. at 88. The overnight recess period “gives the defendant a
        chance to discuss with counsel the significance of the day’s events.”
        Id. Thus, a court order prohibiting a defendant from consulting
        counsel “about anything” during an overnight recess conflicts with
        the Sixth Amendment. Id. at 91.
                For our part, we have held that a court must provide a de-
        fendant with a “reasonable opportunity” to communicate with
        counsel. United States v. Vasquez, 732 F.2d 846, 848 (11th Cir. 1984).
        That is, “a court may not deny a defendant all opportunity to consult
        counsel.” Id. (emphasis added). A Geders violation “presum[es] prej-
        udice” when “an unconstitutional statute or court order” hinders
        “a defense attorney . . . [from] rendering assistance of counsel to
        his client.” United States v. Roy, 855 F.3d 1133, 1148 (11th Cir. 2017)
        (en banc). Still, “a criminal defendant must demonstrate that he
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        8                      Opinion of the Court                 20-14264

        and his counsel actually intended to confer during the recess and
        would have done so” but for an interference by the court, govern-
        ment, or criminal justice system. United States v. Nelson, 884 F.3d
        1103, 1109 (11th Cir. 2018).
                Ahmed argues that a Geders violation occurred because his
        attorney refused to visit him in jail due to coronavirus fears. Not
        so. To secure a reversal under Geders, Ahmed must establish that
        the government or a court—not his own lawyer—deprived him of
        the opportunity to communicate. See Roy, 855 F.3d at 1148. But
        neither the government nor the court nor the criminal justice sys-
        tem prohibited overnight communication. Instead, Ahmed’s law-
        yer informed the district court that, out of concern for his own
        health, he would not meet with Ahmed at the jail during the over-
        night recess. Moreover, there is no evidence on this record that Ah-
        med’s lawyer “actually intended to confer” with his client during
        the overnight recess, irrespective of the pandemic concerns. See
        Nelson, 884 F.3d at 1109. For instance, Ahmed’s lawyer also told the
        district court that he did not have time to visit the jail.
                Finally, we note that the district court went to great lengths
        to facilitate communication between Ahmed and his lawyer. It al-
        lowed them to communicate in writing during the trial and while
        Ahmed was incarcerated at the county jail. And nothing precluded
        Ahmed’s lawyer from attempting to communicate electronically
        or via telephone with his client. Ahmed’s lawyer even acknowl-
        edged that he was able to consult with Ahmed during the overnight
        recess period once, though he did not specify how he did so.
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        20-14264               Opinion of the Court                        9

               The district court did not deny Ahmed “all opportunity to
        consult counsel” and provided him with a “reasonable oppor-
        tunity” to strategize with his lawyer. See Vasquez, 732 F.2d at 848.
        The communication deficiencies about which Ahmed complains
        resulted from his lawyer’s caprice, not from the court, govern-
        ment, or criminal justice system. Accordingly, no Geders violation
        occurred.
                                         2.

               As an alternative to his Geders claim, Ahmed argues that his
        lawyer’s failure to communicate with him (among other things)
        amounted to ineffective assistance of counsel under Strickland v.
        Washington, 466 U.S. 668, 686 (1984). That claim is not properly be-
        fore us.
                The right to counsel means “the right to the effective assis-
        tance of counsel.” Strickland, 466 U.S. at 686 (quoting McMann v.
        Richardson, 397 U.S. 759, 771 n.14 (1970)) (emphasis added). But a
        defendant usually cannot claim ineffective assistance of counsel for
        the first time on direct appeal without a sufficiently developed rec-
        ord. See United States v. Griffin, 699 F.2d 1102, 1107–09 (11th Cir.
        1983); accord United States v. Bender, 290 F.3d 1279, 1284 (11th Cir.
        2002) (holding that we generally do not consider ineffective-assis-
        tance-of-counsel claims on direct appeal “where the district court
        did not entertain the claim nor develop a factual record”). Though
        an insufficient record may bar direct appeal, a defendant may chal-
        lenge the effectiveness of counsel in a federal habeas corpus pro-
        ceeding, where the district court may grant an evidentiary hearing
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        10                     Opinion of the Court                 20-14264

        to develop the record. See Griffin, 699 F.2d at 1109 (citing 28 U.S.C.
        § 2255).
                Ahmed never raised ineffective assistance of counsel at the
        district court. He advances the argument for the first time on ap-
        peal, but there is no record to support his claims. Although Ah-
        med’s lawyer made statements on the record about communica-
        tion, these statements were not made under oath, they were not
        subject to cross-examination, and there is no way to assess whether
        any communication difficulty prejudiced Ahmed’s defense. Be-
        cause there is no relevant record from the district court related to
        this challenge, we cannot consider the merits of Ahmed’s claim on
        direct appeal. See id. at 1107–09.
               Citing United States v. Rodriguez, Ahmed contends that an ex-
        ception applies to our presumption against direct appeal for inef-
        fective assistance claims when the case involves a conflict of inter-
        est. 982 F.2d 474 (11th Cir. 1993). According to Ahmed, an irrecon-
        cilable conflict doomed his case because his lawyer had to choose
        between zealous advocacy for his client and protecting his own
        health. We need not plumb the merits of that contention because
        Ahmed misreads Rodriguez. In Rodriguez, we rejected two defend-
        ants’ claims that joint representation created a conflict of interest
        and violated their right to effective counsel. Id. at 476–78. We
        reached that conclusion based on the transcript from the pretrial
        hearing at which both defendants consented to joint representa-
        tion. Id. at 475–77. In other words, the record from the district
        court was sufficiently developed to review the defendants’ direct
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        20-14264                Opinion of the Court                         11

        appeal. Cf. Griffin, 699 F.2d at 1107–09; Bender, 290 F.3d at 1284.
        Notably, we declined to address another conflict-of-interest issue
        that the defendants failed to raise at the district court because it was
        not “developed factually.” Rodriguez, 982 F.2d at 476 n.3.
                Ahmed cannot direct us to any developed portion of the rec-
        ord that would allow us to review the merits of his ineffective as-
        sistance claim. Thus, without prejudice to a future Section 2255 pe-
        tition, the claim is not properly before us, and we refuse to consider
        it.
                                           3.

                Finally, Ahmed raises a panoply of miscellaneous com-
        plaints—lack of Adderall, slip-and-fall injuries, confiscated legal ma-
        terials, tight shackles, and an unengaged jury—that he believes
        compounded the district court’s supposed error in denying a coro-
        navirus-based mistrial. These complaints lack merit. We will ad-
        dress each in turn.
               The Fifth Amendment’s “Due Process Clause guarantees a
        defendant’s ‘right to be present at any stage of the criminal pro-
        ceeding that is critical to its outcome if [the defendant’s] presence
        would contribute to the fairness of the procedure.’” United States v.
        Brown, 879 F.3d 1231, 1236 (11th Cir. 2018) (quoting Kentucky v.
        Stincer, 482 U.S. 730, 745 (1987)). The right to be present includes
        the right to confront witnesses too. See U.S. Const. amend. VI;
        United States v. Gagnon, 470 U.S. 522, 526 (1985). A defendant’s Sixth
        Amendment right to confront witnesses ordinarily applies during
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        12                     Opinion of the Court                 20-14264

        the government’s case-in-chief, whereas the Fifth Amendment sup-
        plements that right with a broader protection for a defendant’s
        presence at all critical stages of the criminal proceeding. See United
        States v. Novaton, 271 F.3d 968, 997–98 (11th Cir. 2001) (tracing the
        root of a criminal defendant’s right to be present to the Sixth
        Amendment’s Confrontation Clause, the Fifth Amendment’s Due
        Process Clause, and Rule 43 of the Federal Rules of Criminal Pro-
        cedure).
               First, Ahmed argues that he could not meaningfully partici-
        pate in his defense or confer with counsel because the jail would
        not administer his prescribed Adderall. Ahmed claims that he did
        not receive his medication until the seventh day after trial com-
        menced and never received it on the four weekends during the
        trial.
               Ahmed’s intermittent access to Adderall did not violate his
        Fifth or Sixth Amendment rights. As soon as the district court
        learned that Ahmed was not receiving his medication, it took sev-
        eral steps to remedy the situation. For starters, the district court
        held an in camera competency hearing, finding that Ahmed was re-
        sponsive despite his lack of Adderall. Still, the district court asked
        marshals to administer Ahmed’s Adderall at the jail, allowed Ah-
        med to take his medication at the beginning of court each day, and
        personally contacted the jail about the issue.
               Ahmed argues that the Supreme Court’s holding in Riggins
        v. Nevada supports his argument. 504 U.S. 127 (1992). But Ahmed’s
        case is not like Riggins. In Riggins, the Supreme Court held that a
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        20-14264               Opinion of the Court                         13

        defendant cannot receive a full and fair trial when forced to take an
        antipsychotic drug. Id. at 133–38. Here, the opposite occurred. Ah-
        med requested the Adderall—the district court acquiesced and rec-
        tified his inability to access it, so no Fifth or Sixth Amendment vio-
        lation occurred.
                Second, Ahmed asserts that he sustained injuries to his back,
        shoulder, and wrist after a slip-and-fall accident at the jail. He as-
        serts that the jail failed to treat him, which hindered his ability to
        focus at trial, participate in his defense, and consult his lawyer. Af-
        ter Ahmed’s lawyer alerted the district court to these injuries, the
        district court, via the marshal service, instructed the jail to conduct
        a medical examination of Ahmed. A healthcare provider examined
        Ahmed shortly thereafter. Nothing in the record suggests that Ah-
        med’s injuries impacted his ability to concentrate, participate in his
        defense, or communicate with his lawyer. Again, no constitutional
        violation occurred.
               Third, Ahmed contends that the jail confiscated his high-
        lighted legal materials, which impeded his ability to participate in
        his defense and violated his due process right to be apprised of the
        evidence against him. But Ahmed’s lawyer told the district court
        that he—not Ahmed—annotated those materials. And Ahmed
        could still review his lawyer’s copy of those materials during trial.
        The district court even dispatched marshals to retrieve the confis-
        cated documents immediately upon learning of the seizure. This
        argument is meritless.
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        14                     Opinion of the Court                 20-14264

               Fourth, Ahmed argues that his shackling at trial interfered
        with his ability to confer with his lawyer and participate in his de-
        fense. Ahmed separately posits that the district court abused its dis-
        cretion by allowing him to remain shackled, entitling him to a new
        trial.
               Shackles “may confuse the defendant, impair his ability to
        confer with counsel, and significantly affect the trial strategy he
        chooses to follow.” Zygadlo v. Wainwright, 720 F.2d 1221, 1223 (11th
        Cir. 1983); accord Deck v. Missouri, 544 U.S. 622, 631–32 (2005). Re-
        straints, if visible, may prejudice the jury. United States v. Durham,
        287 F.3d 1297, 1305 (11th Cir. 2002). We grant a district court “rea-
        sonable discretion to decide whether to shackle or otherwise re-
        strain the defendant.” Zygadlo, 720 F.2d at 1223. Ordinarily, “the
        record should reflect why restraints are necessary.” Moore, 954 F.3d
        at 1330.
               Ahmed concedes that he did not object to his shackling at
        the district court, so we review for plain error. Id. at 1329. Plain
        error requires Ahmed to establish (1) error that is (2) plain and (3)
        impacted his substantial rights. See id. Even if Ahmed establishes all
        three conditions, the forfeited error must have “seriously affect[ed]
        the fairness, integrity, or public reputation of judicial proceedings”
        for us to notice it. Id. (quoting Baker, 432 F.3d at 1203).
               Ahmed’s shackles were not visible to the jury during trial,
        and the district court had them removed before Ahmed testified.
        Though the district court did not memorialize on the record its rea-
        sons for shackling Ahmed, it did not plainly err because the jury
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        20-14264               Opinion of the Court                         15

        never saw the restraints. See id. at 1329–30 (holding that the district
        court did not plainly err by restraining the defendant without stat-
        ing its reasoning on the record mainly because nonvisible shackles
        did not affect the defendant’s substantial rights). In this sense, even
        if the district court should not have restrained Ahmed during the
        trial, the shackling did not affect Ahmed’s substantial rights—such
        as the presumption of innocence—or prejudice the jury because
        the shackles were never visible. Nor did it impact his decision to
        testify. To be sure, Ahmed says that the shackles hurt his ankles
        when he was not wearing socks. But nothing in the record indicates
        that this transient discomfort prevented him from communicating
        with his lawyer or participating in his defense. Accordingly, the de-
        cision to restrain Ahmed with nonvisible restraints during trial was
        not plain error.
               In a final salvo, Ahmed speculates that the jury could not
        devote adequate attention to the proceedings because of anxiety
        related to the coronavirus pandemic. Here too, the record belies
        Ahmed’s contention. In response to Ahmed’s concerns about con-
        tinuing the trial in March of 2020, the district court asked the jurors
        whether the evolving coronavirus situation would prevent them
        from focusing on the evidence or properly applying the law. No
        juror voiced concern. And at the close of evidence, the jury unani-
        mously voted to proceed with deliberations. There is no reason to
        believe that the jury was anything but attentive and engaged
        throughout the trial.
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        16                     Opinion of the Court                 20-14264

               In short, we cannot say the district court abused its discre-
        tion in denying Ahmed’s motions for a mistrial. On the contrary,
        we commend the district court for its wise, efficient, and patient
        administration of justice during the early days of the pandemic.
                                       B.

               Ahmed next argues that the government committed prose-
        cutorial misconduct. Ahmed’s prosecutorial misconduct claim re-
        quires him to establish that the prosecution (1) made an improper
        statement that (2) affected his substantial rights. United States v.
        Cooper, 926 F.3d 718, 739 (11th Cir. 2019). He says the government
        misrepresented Florida law during its questioning of defense wit-
        ness Kay Stevens, which suggested that she illegally prescribed psy-
        chotropic medication at Serenity. According to Ahmed, this insin-
        uation of illegality rebutted his defense that he hired competent
        medical staff to run Serenity, undermined the legitimacy of his op-
        eration, and denied him a fundamentally fair trial. Again, we disa-
        gree.
               Under Florida law, advanced practice registered nurses, like
        Stevens, may perform certain acts within their specialty. Fla. Stat.
        § 464.012(4). Relevant here, “psychiatric nurse[s] . . . may prescribe
        psychotropic controlled substances for the treatment of mental dis-
        orders.” Id. § 464.012(4)(e). Moreover, the state’s regulatory board
        must “establish a committee to recommend a formulary of con-
        trolled substances that an advanced practice registered nurse may
        not prescribe or may prescribe only for specific uses or in limited
        quantities.” Id. § 464.012(6)(a). That committee “may recommend
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        20-14264                Opinion of the Court                          17

        an evidence-based formulary applicable to all advanced practice
        registered nurses which is limited by specialty certification . . . or is
        subject to other similar restrictions.” Id. That formulary “must re-
        strict the prescribing of psychiatric mental health controlled sub-
        stances for children younger than 18 . . . to advanced practice reg-
        istered nurses who also are psychiatric nurses.” Id. It “must also
        limit the prescribing of Schedule II controlled substances . . . to a 7-
        day supply,” but that limitation “does not apply to controlled sub-
        stances that are psychiatric medications prescribed by psychiatric
        nurses.” Id. A psychiatric nurse “means an advanced practice regis-
        tered nurse . . . who has a master’s or doctoral degree in psychiatric
        nursing, holds a national advanced practice certification as a psy-
        chiatric mental advanced practice nurse, and has 2 years of post-
        master’s clinical experience under the supervision of a physician.”
        Id. § 394.455(36).
               During cross-examination, Stevens testified that she pre-
        scribed antipsychotics, like Seroquel and Subutex, and benzodiaze-
        pines to Serenity patients. The government asked Stevens whether
        she was aware that only psychiatric nurses could prescribe such
        drugs under Florida law. Stevens responded that the government
        misunderstood Florida’s limitations on nurse practitioners and that
        she was authorized to prescribe the medications at issue. The gov-
        ernment reprised this point about Stevens’s alleged lack of prescrip-
        tion authority during its cross-examination of Ahmed and closing
        argument. Ahmed argues that this line of questioning amounted to
        prosecutorial misconduct because the government misinterpreted
        Florida law and erroneously accused Stevens of illegality.
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        18                     Opinion of the Court                20-14264

               After trial, the district court concluded that the government
        had been wrong about Florida law but that the error was harmless.
        We need not probe the soundness of the district court’s interpreta-
        tion of Florida law because we agree that any error was harmless
        and did not prejudice Ahmed’s substantial rights. See Cooper, 926
        F.3d at 739.
               Ahmed’s defense did not hinge on Stevens’s prescription
        practices or whether they complied with Florida law. Instead, the
        crux of his defense was that, as a passive investor, he relied on the
        expertise of his medical team and other employees to operate Se-
        renity lawfully. The government undermined his defense by elicit-
        ing testimony from several witnesses that Ahmed called the shots
        at Serenity. Any intimation that a single advanced practice regis-
        tered nurse may have prescribed psychotropic drugs without au-
        thorization had little bearing on whether Ahmed and his co-con-
        spirators committed healthcare fraud. Moreover, Stevens re-
        sponded to the government’s questions by denying that her pre-
        scription practices violated Florida law, explaining to the jury that
        the government’s lawyer misunderstood Florida’s limitations on
        nurse practitioners. Even if the government improperly cross-ex-
        amined Stevens, the government’s statements did not prejudice
        Ahmed’s substantial rights. Accordingly, Ahmed’s prosecutorial
        misconduct claim fails.
                                       C.

              Ahmed posits that three evidentiary rulings by the district
        court deprived him of his right to present a defense. These rulings
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        20-14264                Opinion of the Court                          19

        concern the district court’s exclusion of testimony by Ahmed’s ex-
        pert, certain documentary evidence, and testimony by Ahmed’s
        former attorney. Once again, we disagree that the district court
        erred.
                “The Constitution guarantees criminal defendants a mean-
        ingful opportunity to present a complete defense.” United States v.
        Nunez, 1 F.4th 976, 991 (11th Cir. 2021). But that right remains “sub-
        ject to reasonable restrictions.” Id. (quoting United States v. Scheffer,
        523 U.S. 303, 308 (1998)). Still, “[a]n evidentiary ruling may violate
        the right if it ‘infringe[s] upon a weighty interest of the accused.’”
        Id. (quoting Holmes v. South Carolina, 547 U.S. 319, 324 (2006)) (sec-
        ond alteration in original). A district court “does not infringe a
        weighty interest” by excluding testimony that “only ‘would have
        been helpful.’” Id. (quoting United States v. Gillis, 938 F.3d 1181,
        1195 (11th Cir. 2019)). Nor does the district court’s exclusion of cu-
        mulative evidence violate the right to present a complete defense.
        See id. at 991–92. The Supreme Court has never held that applica-
        tion of “a federal rule of evidence violated a defendant’s right to
        present a complete defense.” United States v. Mitrovic, 890 F.3d 1217,
        1222 (11th Cir. 2018).
                We generally review a district court’s evidentiary ruling for
        abuse of discretion. Todd, 108 F.3d at 1331. If “a party failed to ob-
        ject to an evidentiary ruling at trial,” however, we conduct a plain-
        error review. United States v. Clotaire, 963 F.3d 1288, 1292 (11th Cir.
        2020). A district court’s interpretation of the Federal Rules of Evi-
        dence receives de novo review. Doe No. 1 v. United States, 749 F.3d
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        20                     Opinion of the Court                 20-14264

        999, 1003 (11th Cir. 2014). Even if the district court makes an incor-
        rect evidentiary ruling, we will not reverse harmless error. See
        United States v. Henderson, 409 F.3d 1293, 1300 (11th Cir. 2005); see
        also Fed. R. Evid. 103(a) (stating that “[a] party may claim error in
        a ruling to admit or exclude evidence only if the error affects a sub-
        stantial right of the party”).
                                          1.

                Ahmed argues that the district court erred by excluding the
        testimony of his expert, Lilliam Rodriguez, who invoked her Fifth
        Amendment right against self-incrimination. Ahmed sought to call
        Rodriguez to establish industry practice on a clinical director’s du-
        ties to safeguard medical records and to sign off on completed treat-
        ment services. Rodriguez invoked her Fifth Amendment privilege
        when questioned outside the presence of the jury about her past
        employment as clinical director of Holistic Recovery Services. Af-
        ter the proffer, the district court decided to exclude her testimony
        entirely. Because her expert qualifications were directly tied to her
        experience at Holistic, the district court concluded that her invoca-
        tion of the privilege prevented the government from vetting those
        qualifications and challenging her credibility.
               The Fifth Amendment provides that “[n]o person . . . shall
        be compelled in any criminal case to be a witness against himself.”
        U.S. Const. amend. V. A witness properly invokes this privilege
        when “reasonably apprehend[ing] a risk of self-incrimination,”
        even if the prosecution risk “is remote.” United States v. Cuthel, 903
        F.2d 1381, 1384 (11th Cir. 1990) (quoting In re Corrugated Container
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        20-14264               Opinion of the Court                       21

        Anti-Trust Litig., 620 F.2d 1086, 1091 (5th Cir. 1980)). “[W]e do not
        require a high showing to meet this reasonable cause standard.”
        Perez, 661 F.3d at 580. Generally, we resolve a conflict between a
        witness’s Fifth Amendment privilege and a defendant’s Sixth
        Amendment compulsory process right in favor of the witness. Cu-
        thel, 903 F.2d at 1384. A district court needs to “make a particular-
        ized inquiry, deciding, in connection with each specific area that
        the questioning party wishes to explore, whether or not the privi-
        lege is well-founded.” United States v. Argomaniz, 925 F.2d 1349,
        1355 (11th Cir. 1991) (quoting United States v. Melchor Moreno, 536
        F.2d 1042, 1049 (5th Cir. 1976)).
                Ahmed contends that (1) the district court did not conduct a
        particularized inquiry into the legitimacy and scope of the invoked
        privilege, (2) Rodriguez did not face a real and substantial risk of
        self-incrimination, and (3) the scope of the privilege honored by the
        district court was too broad. Alternatively, Ahmed argues that the
        district court should have allowed Rodriguez to invoke the privi-
        lege but still compelled her to testify. We disagree.
                First, the district court conducted a particularized inquiry
        and properly concluded, after hearing about thirty minutes of prof-
        fered testimony, that Rodriguez’s basis to invoke her Fifth Amend-
        ment privilege was well-founded. See id. The district court noted
        on the record the striking similarities between Holistic’s and Seren-
        ity’s respective business practices. It also explained that answering
        the government’s questions about her employment at Holistic
        could expose Rodriguez to criminal liability because Holistic’s
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        22                     Opinion of the Court                 20-14264

        owner was facing criminal charges for illegally brokering patients.
        Moreover, Serenity’s clinical directors—the same job title held by
        Rodriguez at Holistic—had already pleaded guilty to conspiring
        with Ahmed to bill insurance companies illegally.
                Second, Ahmed asserts that there was no basis for the district
        court to conclude that Rodriguez faced a real and reasonable risk
        of self-incrimination. Ahmed grounds this argument on the gov-
        ernment’s statements that it did not know the extent of Rodri-
        guez’s involvement with the apparently illegal patient brokering at
        Holistic. Just because the government was unaware of all the de-
        tails concerning the state’s investigation into Holistic does not
        mean Rodriguez lacked reasonable apprehension of criminal liabil-
        ity. We have never held that a witness may invoke the Fifth
        Amendment only if the government is already privy to the wit-
        ness’s involvement in the criminal activity at issue. Though no
        charges were pending against Rodriguez at the time of her proffer,
        her testimony would have established that she was a clinical direc-
        tor and responsible for the billing practices at Holistic, the owner
        of which faced serious criminal charges. Her fear of prosecution
        was far from remote. Cf. Cuthel, 903 F.2d at 1384.
                Third, Ahmed posits that the district court did not consider
        the scope of Rodriguez’s invocation and ultimately honored too
        broad a privilege. But Rodriguez did not assert a blanket Fifth
        Amendment privilege—she limited her invocation to questions
        about her previous employment at Holistic. In fact, her lawyer clar-
        ified that Rodriguez would assert the privilege only with respect to
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        20-14264               Opinion of the Court                         23

        Holistic, not the other matters in her expert report. Accordingly,
        Rodriguez appropriately tethered her invocation to a “specific
        area” of questioning, and the district court did not abuse its discre-
        tion by allowing her to plead the Fifth Amendment. See Argomaniz,
        925 F.2d at 1355; Perez, 661 F.3d at 580.
               Alternatively, Ahmed argues that, even if the district court
        correctly honored the privilege, it should have permitted Rodri-
        guez to testify and instructed the jury to consider the invocation
        when assessing her credibility. Though we review a district court’s
        Daubert rulings for abuse of discretion, “we must affirm unless we
        at least determine that the district court has made a ‘clear error of
        judgment,’ or has applied an incorrect legal standard.” McClain v.
        Metabolife Int’l, Inc., 401 F.3d 1233, 1238 (11th Cir. 2005) (quoting
        Piamba Cortes v. Am. Airlines, Inc., 177 F.3d 1272, 1306 (11th Cir.
        1999) (internal quotation omitted)).
                We do not detect “a clear error of judgment” here. Id. Under
        the Federal Rules of Evidence, “[a] witness who is qualified as an
        expert by knowledge, skill, experience, training, or education may
        testify in the form of an opinion or otherwise if” certain conditions
        are met. Fed. R. Evid. 702. When a witness relies primarily on ex-
        perience to form the basis of an expert opinion, “the witness must
        explain how that experience leads to the conclusion reached, why
        that experience is a sufficient basis for the opinion, and how that
        experience is reliably applied to the facts.” United States v. Frazier,
        387 F.3d 1244, 1261 (11th Cir. 2004) (quoting Fed. R. Evid. 702 ad-
        visory committee’s note to 2000 amendment); see also Daubert v.
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        24                     Opinion of the Court                 20-14264

        Merrell Dow Pharms., Inc., 509 U.S. 579, 589 (1993) (holding that a
        trial judge must ensure that all admitted expert testimony “is not
        only relevant, but reliable”). Admissibility of an expert opinion can-
        not “be established merely by the ipse dixit of an admittedly quali-
        fied expert.” Frazier, 387 F.3d at 1261.
               Rodriguez’s unwillingness to answer questions about her
        work at Holistic denied the district court the ability to assess her
        expertise and barred the government from challenging her qualifi-
        cations and probing her credibility. Besides Holistic, Rodriguez
        worked at two other substance abuse treatment centers, which had
        the same owner, for a total of three years. Due to Rodriguez’s lim-
        ited work history, her experience at Holistic went to the heart of
        her qualifications as an expert in medical records and substance
        abuse treatment centers. But, because Rodriguez invoked her Fifth
        Amendment right in response to any question about Holistic, it was
        unclear to what extent she based her expert opinions on her work
        there. The district court applied the correct legal standard and ap-
        propriately exercised its discretion to exclude Rodriguez’s testi-
        mony under Rule 702.
                                          2.

                Ahmed challenges the district court’s exclusion of certain
        documentary evidence: invoices, promissory notes, and hardship
        exemption forms. He argues that these documents are not hearsay,
        or, if they are, they fall within the business records exception.
               The Federal Rules of Evidence define “statement” as “a per-
        son’s oral assertion, written assertion, or nonverbal conduct, if the
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        20-14264                Opinion of the Court                          25

        person intended it as an assertion.” Fed. R. Evid. 801(a) (emphasis
        added). Under the hearsay rule, statements not made by the declar-
        ant “while testifying at the current trial or hearing” that “a party
        offers in evidence to prove the truth of the matter asserted in the
        statement” are not admissible, subject to several carveouts and ex-
        ceptions. Id. 801(c)–(d), 802; see id. 803–04. Relevant here, business
        records are excepted from the rule against hearsay if they satisfy
        certain conditions. See id. 803(6). This exception applies to any “rec-
        ord made at or near the time of an act by a person with knowledge
        if the record ‘was kept in the course of regularly conducted activity
        of a business’ and ‘making the record was a regular practice of that
        activity.’” United States v. Joseph, 978 F.3d 1251, 1265 (11th Cir. 2020)
        (quoting Fed. R. Evid. 803(6)(A)–(C)). The record’s proponent may
        rely on “the testimony of the custodian or another qualified wit-
        ness” to meet Rule 803(6)’s requirements. Id. (quoting Fed. R. Evid.
        803(6)(D)). In the end, admissibility under the business records ex-
        ception boils down to reliability, “and a trial judge has broad dis-
        cretion to determine the admissibility of such evidence.” Id. (quot-
        ing United States v. Bueno-Sierra, 99 F.3d 375, 378–79 (11th Cir.
        1996)).
               Ahmed sought to admit invoices, promissory notes, and
        hardship exemption documents at trial. After voir dire examina-
        tion, the district court concluded that these documents were inad-
        missible hearsay and sustained the government’s objections to
        them. We assume without deciding that Ahmed adequately pre-
        served these purported errors, so we give him the benefit of abuse-
        of-discretion review. See Todd, 108 F.3d at 1331.
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        26                     Opinion of the Court                 20-14264

                First, Ahmed argues that these documents are not hearsay
        because he did not offer them to prove their truth but to establish
        his efforts to bill patients in good faith, rebutting the government’s
        allegations that he provided improper incentives. This argument
        gains little, if any, traction. To be sure, an out-of-court statement
        not offered to prove its truth escapes the hearsay prohibition. Cf.
        Fed. R. Evid. 801(c). But using the documentary evidence to sup-
        port the conclusion that Ahmed properly billed patients presup-
        poses that the information in the documents is true. In other words,
        for the records to benefit Ahmed’s defense, the jury would need to
        believe that the invoices contained appropriate and truthful
        amounts for services rendered, the promissory notes reflected pa-
        tients’ actual promises to pay Serenity for those services, and the
        financial hardship documents accurately portrayed patients’ need.
        Accordingly, Ahmed offered these records for their truth.
                Second, Ahmed posits that, even if the records are hearsay,
        Rule 803 allows their admission as business records. This argument
        has a lot to commend it. Though Ahmed did not recall who exactly
        created each document, a “testifying witness does not need
        firsthand knowledge of the contents of the records, of their au-
        thors, or even of their preparation.” Curtis v. Perkins (In re Int’l
        Mgmt. Assocs., LLC), 781 F.3d 1262, 1268 (11th Cir. 2015). Nor must
        the witness know the precise circumstances under which the rec-
        ords were kept as long as enough circumstantial evidence “estab-
        lish[es] the trustworthiness of the underlying documents.” Id. Rule
        803 does not demand “that the one who kept the record, or even
        had supervision over [its] preparation, testify.” Id. at 1269 (quoting
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        20-14264               Opinion of the Court                         27

        United States v. Flom, 558 F.2d 1179, 1182 (5th Cir. 1977)) (alteration
        in original). In this sense, based on the record before us, Ahmed
        was a “qualifying witness” under Rule 803.
                Still, Ahmed testified that he did not know how much time
        elapsed between rendering services and creating invoices, casting
        doubt on whether the records were “made at or near the time [of
        treatment] by . . . someone with knowledge.” Fed. R. Evid.
        803(6)(A). Ahmed also testified that Serenity’s intake protocol in-
        cluded promissory notes and hardship exemption forms, but he
        lacked specifics on what that protocol entailed. Moreover, when
        the FBI executed a search warrant at Serenity, the agency found no
        hardship exemption forms or promissory notes, either in hard copy
        or electronic form. To be sure, the FBI did not search the transi-
        tional living facilities, where Ahmed claims the records were kept,
        but Ahmed still could not explain how the documents ended up in
        his lawyer’s hands. In this light, the circumstantial evidence indi-
        cates that the documents lack the indicia of trustworthiness re-
        quired by Rule 803. See id.; Curtis, 781 F.3d at 1268. And because
        we afford broad discretion to the district court “to determine the
        admissibility of such evidence,” we cannot say the district court
        abused its discretion by concluding that the invoices, promissory
        notes, and hardship exemption forms were inadmissible hearsay.
        See Frazier, 387 F.3d at 1259 (holding that, under the abuse-of-dis-
        cretion standard, “we must affirm unless . . . the district court has
        made a clear error of judgment, or has applied the wrong legal
        standard”); cf. Joseph, 978 F.3d at 1265 (holding that a district court
        did not abuse its discretion by admitting business records because
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        28                     Opinion of the Court                  20-14264

        litigant did not show qualified witness’s “testimony was otherwise
        unreliable”).
                                          3.

              Lastly, Ahmed argues that the district court should have al-
        lowed his former attorney, Justin Claud, to testify about Ahmed’s
        response to a deceptive advertising allegation and Ahmed’s efforts
        to ensure zoning compliance. The district court rejected that argu-
        ment, and so do we.
                Rule 404 of the Federal Rules of Evidence prohibits intro-
        ducing “[e]vidence of a person’s character or character trait . . . to
        prove that on a particular occasion the person acted in accordance
        with the character or trait.” Fed. R. Evid. 404(a)(1). But a defendant
        in a criminal case may offer evidence of the defendant’s “pertinent
        trait.” Id. 404(a)(2)(A). Evidence of pertinent traits like honesty and
        truthfulness are admissible in a fraud case. United States v. Hough,
        803 F.3d 1181, 1190–91 (11th Cir. 2015). Still, if evidence of a per-
        son’s character or character trait is admissible under Rule 404, it
        usually must “be proved by testimony about the person’s reputa-
        tion or by testimony in the form of an opinion.” Fed. R. Evid.
        405(a). Specific instances of conduct ordinarily may be used only
        “[w]hen a person’s character or character trait is an essential ele-
        ment of the charge.” Id. 405(b); see also 1 Robert P. Mosteller et al.,
        McCormick on Evidence § 187 (8th ed. July 2022 update) (illustrating
        Rule 405(b) with a defamation example and noting that, “because
        truth is a defense to defamation claim,” a defendant may introduce
        evidence of a plaintiff’s specific acts to prove that the challenged
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        20-14264               Opinion of the Court                         29

        statement was not defamatory). In other words, “[e]vidence of
        good conduct is not admissible to negate criminal intent.” United
        States v. Ellisor, 522 F.3d 1255, 1270 (11th Cir. 2008) (quoting United
        States v. Camejo, 929 F.2d 610, 613 (11th Cir. 1991)) (alteration in
        original).
               Claud’s testimony would have covered specific acts of Ah-
        med’s conduct to establish traits unrelated to the fraud charges. Ah-
        med would have used this evidence of supposed good conduct “to
        negate [his] criminal intent,” which makes it precisely the kind of
        evidence that Rules 404(a) and 405(b) prohibit. See Ellisor, 522 F.3d
        at 1270; Fed. R. Evid. 404(a), 405(b). Accordingly, the district court
        correctly excluded the testimony.
                                       D.

              Ahmed “has not established a single error, let alone the ag-
        gregation of many errors.” Joseph, 978 F.3d at 1265. Thus, his cu-
        mulative error claim lacks merit.
                                       IV.

               For these reasons, the district court is AFFIRMED.