Court Opinion

ID: 4655609
Source: CourtListenerOpinion
Date Created: 2021-01-29 01:00:17.674666+00
Date Added: 2024-06-11T08:00:24.470020
License: Public Domain

Case: 17-10665     Document: 00515724627          Page: 1    Date Filed: 01/28/2021

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

                                                                               FILED
                                                                        January 28, 2021
                                   No. 17-10665                           Lyle W. Cayce
                                                                               Clerk

   United States of America,

                                                             Plaintiff—Appellee,

                                       versus

   Wilbert James Veasey, Jr.; Charity Eleda, R.N.; Jacques
   Roy, M.D.; Cynthia Stiger,

                                                        Defendants—Appellants.

                  Appeal from the United States District Court
                      for the Northern District of Texas
                            USDC No. 3:12-CR-54

   Before Graves, Costa, and Engelhardt, Circuit Judges.
   Per Curiam:*
          This is a direct criminal appeal by four defendants convicted of
   multiple counts in a health care fraud case. On appeal, the defendants
   challenge their convictions and sentences. Finding no error, we AFFIRM

          *
            Pursuant to 5th Circuit Rule 47.5, the court has determined that this
   opinion should not be published and is not precedent except under the limited
   circumstances set forth in 5th Circuit Rule 47.5.4.
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                                          No. 17-10665

   the judgments in the district court as to all four appellants for the reasons
   stated herein.
                      FACTS AND PROCEDURAL HISTORY
          Wilbert James Veasey, Jr. and Cynthia Stiger were the owners and
   registered directors of Apple of Your Eye Health Care Services, a home
   health care provider in Dallas. Charity Eleda operated Charry HHA. Dr.
   Jacques Roy operated a medical company called Medistat and was the
   certifying physician for various home health providers. All of these entities
   provided services to Medicare beneficiaries.
          Medicare is a federal health care program for people who are over the
   age of 65 or disabled. Medicare has multiple parts and is administered by the
   United States Department of Health and Human Services (HHS) through
   the Center for Medicare & Medicaid Services. 1 Part A covers hospital
   insurance and includes home health services.                  Part B covers medical
   insurance. A health care provider must apply to Medicare and be assigned a
   National Provider Identifier (NPI) to be able to provide services to a
   Medicare beneficiary and bill Medicare. This requires the provider to follow
   certain laws, rules and regulations.
          There are additional requirements for home health services under
   Medicare. To qualify for home health, a beneficiary must: essentially be
   confined to the home; under the care of a physician who certifies that the
   beneficiary is homebound; be receiving services under a plan of care
   established by and reviewed periodically by the physician; and need skilled
   nursing services, physical therapy or speech therapy on an intermittent basis,

          1
              Medicaid is a state-run program for low-income individuals and children.

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   i.e., fewer than eight hours a day and seven days a week. 2 The standard form
   for a certification of need and plan of care (POC) is numbered 485. The
   physician who prescribes home health must sign the 485 POC before
   Medicare will pay the home health agency (HHA) in full. The POC must
   include various information including diagnoses, types of services, frequency
   of visits, prognosis, rehabilitation potential, functional limitations, activities
   permitted, medications, treatments, nutritional requirements, safety
   measures, discharge plans and goals. Physicians cannot prescribe services to
   an entity in which they have a financial interest.
           Between 2004 and 2011, the number of HHAs in Dallas tripled.
   Federal authorities 3 began investigating Roy based on the large number of
   patients he certified for home health. At the time, Roy was first in the nation
   in certifying patients and more than double the next highest certifying
   physician. Roy was also receiving a large amount of payments from HHAs.
   The HHAs included those operated by Veasey, Stiger and Eleda.
           Chelsie Drews, a special agent with the FBI and member of the strike
   force, testified that, pursuant to the investigation, officials conducted
   surveillance and interviewed beneficiaries.             Through those interviews,
   authorities began to discover evidence of beneficiaries who did not appear to
   meet the requisite criteria for home health services. Investigators executed
   search warrants at various locations associated with the appellants and the
   relevant HHAs.         As a result, authorities indicted several individuals,

           2
            Skilled nursing is a service that must be provided by a registered nurse or a
   licensed vocational nurse under the supervision of a registered nurse and cannot be
   something that can safely be self-administered or performed by a non-medical person.
           3
             Various agencies, including the FBI, HHS, Office of the Inspector General, Texas
   Attorney General’s Medicaid Fraud Control Unit, and the U.S. Attorney’s Office, created
   a health care fraud strike force.

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   including Roy, Stiger, Veasey, and Eleda, who are the individuals relevant to
   this appeal, for conspiracy to commit health care fraud and substantive
   counts of health care fraud.
          In the multicount superseding indictment: Count 1 charged Roy,
   Veasey, Stiger and Eleda with conspiracy to commit health care fraud in
   violation of 18 U.S.C. § 1349; Counts 2, 3 and 4 charged Roy and Veasey with
   health care fraud in violation of 18 U.S.C. § 1347; Counts 5, 6, 7 charged Roy
   with health care fraud; Counts 8, 9, 10, 11 charged Roy and Eleda with health
   care fraud; Counts 12-14 charged Eleda with false statements to Medicare in
   violation of 42 U.S.C. § 1320a-7b(a)(2); Counts 15 and 16 charged Roy with
   false statements relating to health care matters in violation of 18 U.S.C. §
   1035; and Count 17 charged Roy with obstruction of justice in violation of 18
   U.S.C. § 1505. Before trial, the court dismissed Count 5 on the government’s
   motion.
          Roy, Veasey, Stiger and Eleda were tried together. Roy was acquitted
   on Count 6, but the defendants were convicted on all remaining counts. Roy
   was sentenced to 120 months as to each of Counts 1-3, consecutively to each
   other; 120 months as to each of Counts 4 and 7-11, to run concurrently with
   each other and concurrently with Counts 1-3; and sixty months as to each of
   Counts 15-17, to run concurrently with each other, concurrently with Counts
   4 and 7-11, and consecutively to Counts 1-3. Roy’s total aggregate sentence
   was 420 months, along with six years of supervised release and various
   forfeitures. Pursuant to the Mandatory Victims Restitution Act of 1996
   (MVRA), Roy was also ordered to pay restitution in the amount of
   $268,147,699.15, jointly and severally with Stiger, Veasey, Eleda and three
   other defendants who are not parties to this appeal. The restitution would be
   disbursed to the Centers for Medicare and Medicaid Services.

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          Stiger was sentenced to 120 months as to Count 1, three years of
   supervised release, and ordered to pay restitution in the amount of
   $23,630,777.26, jointly and severally with Roy and Veasey, to be disbursed to
   Medicare and Medicaid.
          Veasey was sentenced to 120 months as to Count 1 and 90 months as
   to Counts 2, 3 and 4, to run concurrently to each other and consecutively to
   the term in Count 1. Veasey’s total aggregate sentence was 210 months,
   along with two years of supervised release, and he was ordered to pay
   $23,630,777.26 in restitution, jointly and severally with Roy, Stiger, Eleda,
   and three other defendants not parties to this appeal.
          Eleda was sentenced to 48 months each as to Counts 1, 8-11 and 12-
   14, to run concurrently, three years of supervised release and ordered to pay
   restitution in the amount of $397,294.51, jointly and severally with Roy.
          Thereafter, the appellants filed this appeal.
                                  DISCUSSION
   I. Whether the district court abused its discretion when it refused to
   strike a juror based on perceived bias against the defense.

          Roy, Veasey, Stiger and Eleda all assert that the district court abused
   its discretion when it refused to remove a juror that they argue demonstrated
   bias toward the defense.
          A district court may dismiss a juror for “good cause” after trial has
   begun. Fed. R. Crim. P. 23(b)(2)(B). We review a district court’s decision
   to dismiss a juror for abuse of discretion. United States v. Pruett, 681 F.3d
   232, 247 (5th Cir. 2012) (per curiam). “A district court abuses its discretion
   only when its ruling is based on an erroneous view of the law or on a clearly
   erroneous assessment of the evidence.” United States v. Ebron, 683 F.3d 105,
   126 (5th Cir. 2012). “A factual finding is not clearly erroneous as long as it

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   is plausible in light of the record as a whole.” Id. at 126-27. “A district
   court’s decision to remove a juror is discretionary whenever the judge
   becomes convinced that the juror’s abilities to perform his duties become
   impaired.” United States v. Virgen-Moreno, 265 F.3d 276, 288 (5th Cir. 2001)
   (internal marks and citations omitted).
          This court has also said that an inability to follow instructions or a lack
   of candor may be a valid basis for dismissing a juror. Ebron, 683 F.3d at 127
   (internal citations omitted). Stiger’s counsel concedes that her trial counsel
   did not join the request to remove the juror. Thus, Stiger would have to meet
   the more stringent plain error standard and show an error, that is clear or
   obvious and which affects her substantial rights. Fed. R. Civ. P. 52(b); see
   also Molina-Martinez v. United States, 136 S.Ct. 1338, 1343 (2016); and United
   States v. Olano, 507 U.S. 725, 732-34 (1993)
          During the trial when Roy’s defense counsel was cross-examining
   Drews, a juror interrupted the proceedings to give the judge a note. The note
   stated: “We need to take a break for the judge. The judge is not alert.
   Lawyer is badgering witness. Thank you.” The district court called a bench
   conference to discuss the note and ways of handling the situation. Defense
   counsel wanted to dismiss the juror as being prejudicial. The government
   wanted to ignore the note and move on. The court decided to conduct an in
   camera examination of the juror on the record. During this examination, the
   court said:
                  Let me explain a couple things. The lawyer is asking
          questions, and they are tough questions. That does not mean
          she is being badgered. Nobody has made any objection.
                  Now, as for you saying I am not alert, I am alert. You
          may have heard me say yesterday I had a doctor’s appointment.
          The reason I had a doctor’s appointment is I had surgery on my
          right eye. You may notice it is much redder than the other, and
          I was a little concerned because I thought it should be healing

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             faster, but the doctor said it is doing fine. The vision is okay,
             and what it does at times is it becomes irritated, and I will close
             it at times because of that. It is healing.
   The juror said, “okay.” The court then continued:
                     But just so you know, the witness—when tough
             questions are being asked or—or the lawyers are asking
             questions, all the lawyers are doing is trying to test the witness’
             recall, test how she investigated the case and so forth, okay.
                     Now, if it gets out of line, if he is mistreating her, the
             lawyers are going to object or else I am going to step in. It has
             not gotten to that point, but I appreciate you being concerned
             about me.
   The juror replied, “That’s all my intentions [sic]. That was my only
   intention.” The court said: “No, that’s fine. But anyway I am aware of what
   is going on and the questions have been tough, and I have shifted positions a
   couple of times.” The court also added, “[m]y eye is irritated, but it is not
   to the point that I need a break, but I appreciate your concern.” The juror
   again indicated that was her intention, and when asked if she had any
   questions, she said: “No, no. I just wanted to make sure everything was fair
   on both sides.” The court then stated:
                     Okay. All right [sic], I will remind you once again your
             job is to be fair and impartial to both sides and listen to the
             evidence and keep an open mind, and at the conclusion of the
             case along with your fellow jurors make a decision as to
             whether the defendants are guilty or not guilty based upon what
             you have heard in the trial and in conjunction with my
             instructions; all right?
   The juror replied, “Okay.” The examination concluded and the juror was
   instructed not to discuss anything that took place in chambers with the other
   jurors.

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          Defense counsel objected and asked that the juror be struck from the
   jury on the belief that she had formed an opinion and, thus, became
   disqualified. Defense counsel also argued that, during the original voir dire,
   the court had made clear to the jurors that the court would control the
   proceedings and they were not to concern themselves with questions of law
   or proceedings. Counsel also moved for a mistrial. The court made a finding
   that it did not believe the juror had formed any bias at that point and denied
   the motions.
          The appellants now assert that the district court abused its discretion
   by not removing the juror and seating an alternate. Appellants particularly
   take issue with the fact that the juror became the presiding juror. However,
   the mere fact that she became the presiding juror and signed the verdict form
   in no way established bias or that she somehow poisoned the proceedings.
   The appellants also take issue with the juror being a health care administrator
   at a large hospital who had acknowledged that she had heard patients
   complain about home health care and that she was aware that physicians
   knew which HHAs they preferred and which they did not. However, those
   facts were openly discussed during voir dire and not something discovered
   during trial evidencing any kind of bias or suddenly establishing good cause
   for dismissal.
          The juror indicated to the court that she could be fair and impartial
   and follow the court’s instructions. There was nothing to indicate good cause
   for removal, a lack of candor, or that the note or discussion in camera
   established any specific bias. The note appeared to be an isolated incident.
   Thus, under the applicable standard set out above, the appellants are unable
   to establish an abuse of discretion, much less plain error in the case of Stiger.

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   II. Whether the evidence was sufficient to convict Dr. Roy and Cynthia
   Stiger.

          Roy and Stiger argue that there was insufficient evidence introduced
   at trial to support their respective convictions. We review a properly
   preserved challenge to the sufficiency of the evidence de novo, but we afford
   considerable deference to the jury’s verdict. United States v. Curtis, 635 F.3d
   704, 717-18 (5th Cir. 2011). We view the evidence in the light most favorable
   to the verdict, and we will affirm if any reasonable trier of fact could have
   found every element of the offense beyond a reasonable doubt. Id.; see also
   United States v. Ford, 558 F.3d 371, 375 (5th Cir.2009). “The jury retains the
   sole authority to weigh any conflicting evidence and to evaluate the
   credibility of the witnesses.” United States v. Grant, 683 F.3d 639, 642 (5th
   Cir. 2012) (internal marks and citation omitted). “However, the government
   must do more than pile inference upon inference upon which to base a
   conspiracy charge.” Id. (internal marks and citation omitted). Under this
   standard, the district court’s denials of the motions for judgment of acquittal
   do not appear to be in error.
          Roy – Counts 1, 2-11, 15-16, 17
          Roy asserts that the district court abused its discretion by denying the
   motion of acquittal because the defense established that there was no intent
   to defraud Medicare. Thus, Roy argues that he could not be convicted of
   conspiracy or Medicare fraud since the intent was the missing element for
   both charges. Specifically, Roy asserts that the factual determination of
   “homebound” is a medical opinion and a difference in opinion cannot
   establish an intent to commit fraud. Roy also asserts that none of the three
   agreements exposed by the prosecution were about defrauding Medicare.
   We disagree.

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            To establish a conspiracy to commit health care fraud, the government
   must prove beyond a reasonable doubt that (1) two or more individuals made
   an agreement to pursue the unlawful offense of fraud; (2) the defendant knew
   of the agreement; and (3) the defendant voluntarily participated. 18 U.S.C.
   §§ 1347, 1349; United States v. Imo, 739 F.3d 226, 235 (5th Cir. 2014). The
   agreement may be silent and informal. Id. Further, “voluntary participation
   may be inferred from a collection of circumstances, and knowledge may be
   inferred from surrounding circumstances.” Id. (internal citation omitted).
            For these purposes, “health care benefit program” is defined as “any
   public or private plan or contract, affecting commerce, under which any
   medical benefit, item, or service is provided to any individual, and includes
   any individual or entity who is providing a medical benefit, item, or service
   for which payment may be made under the plan or contract.” 18 U.S.C. §
   24(b).
            The health care fraud statute states, in relevant part, that “[w]hoever
   knowingly and willfully executes, or attempts to execute, a scheme or
   artifice—(1) to defraud any health care benefit program; or (2) to obtain, by
   means of false or fraudulent pretenses, representations, or promises, any of
   the money or property” of any health care benefit program “in connection
   with the delivery of or payment for health care benefits, items, or services”
   commits health care fraud. 18 U.S.C. § 1347(a). Further, subsection (b)
   states that “[w]ith respect to violations of this section, a person need not have
   actual knowledge of this section or specific intent to commit a violation of
   this section.” 18 U.S.C. § 1347(b).
            Both conspiracy and health care fraud “require proof of knowledge
   and specific intent to defraud.” United States v. Willett, 751 F.3d 335, 339
   (5th Cir. 2014). “However, this proof may be inferred from circumstantial
   evidence. … Furthermore, a defendant need not have actually submitted the

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   fraudulent documentation … in order to be guilty of health care fraud or
   conspiracy to commit health care fraud.” Id. (internal marks and citations
   omitted). The government does not have to prove that a defendant knew that
   the purpose of the agreement was an actual violation of a statute. The
   government must prove that the defendant knew the purpose of the
   agreement and must prove that the purpose was unlawful. United States v.
   Brooks, 681 F.3d 678, 699 (5th Cir. 2012). “Conspiracy actually has two
   intent elements—intent to further the unlawful purpose and the level of
   intent required for proving the underlying substantive offense.”             Id.
   However, these two intents “often functionally collapse into a single intent.”
   Id. at n.16 (citing United States v. Chagra, 807 F.2d 398, 401 (5th Cir. 1986)).
          The evidence introduced at trial established that Roy provided money
   for the operation of Apple in exchange for 50 percent of the profits. Roy’s
   principal duty was to certify POCs. Stiger and Veasey retained 50 percent of
   Apple’s profits because they were responsible for finding patients. Veasey
   recruited patients throughout the community, at times pretending to be a
   preacher. Stiger was Apple’s administrator and would recruit patients
   throughout the community via word-of-mouth. Roy’s employees testified
   that Roy did not always review the POCs before they signed his name to
   them, up to 100 a day, as he authorized them to do. This evidence was
   sufficient to establish the elements of conspiracy to commit health care fraud.
          With regard to the substantive counts, the patient from Count 2
   testified that she met Veasey while walking home from a dollar store. The
   patient for Count 3 testified he signed up for home health simply because his
   wife did. That patient’s wife, from Count 4, testified that she signed up after
   Veasey came to the door dressed like a preacher and told her about home
   health. Despite the patient believing she would not qualify and the fact that
   she got around without any sign of immobility, Roy signed her POC. The
   patient from Count 7 was signed up by a co-conspirator not a party to this

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   appeal and her own physician testified she did not qualify for home health.
   The patient from Count 8 testified that he was spending days at The Bridge,
   a homeless shelter, when he was recruited by Eleda and certified for home
   health by Roy. The administrator from the shelter testified that individuals
   staying there had to be able to take care of themselves. That patient’s POC
   falsely stated he had an amputation. The patient from Count 9 also stayed at
   The Bridge when he was recruited, and his POC falsely stated he was
   incontinent. The patient from Count 10 also stayed at The Bridge but would
   often take the train in the morning from Dallas to Fort Worth to go to the
   mall and go sightseeing. The doctor from the shelter’s clinic testified that
   she would not qualify as homebound. The patient from Count 11 said Eleda
   recruited him and paid him for signing up. Roy certified him and his POC
   included false information about bowel and bladder complications.
          Under 18 U.S.C. § 1035, an individual is guilty of making false
   statements related to health care matters when he “knowingly and
   willingly—(1) falsifies, conceals, or covers up by any trick, scheme, or device
   a material fact; or (2) makes any materially false, fictitious, or fraudulent
   statements or representations, or makes or uses any materially false writing
   or document” containing such matters involving a health care benefit
   program. 18 U.S.C. § 1035(a).
          Roy argues that there was no false statement because he “kept billing
   with his PIN number suspended and the other providers provided the
   medical care to the patients under their numbers with the new group.” Also,
   Roy argues, “No false address or false information provided to Medicare.
   There was no evidence anywhere in the records that [he] was involved with
   the medical care for Count 15 and 16.” Roy further asserts that he did not
   attempt to circumvent the suspension because he did not receive any money
   from Medicare.

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          After Medistat was suspended by Medicare, Roy created a new entity,
   Medcare HouseCalls, obtained a new billing identification number and
   continued billing Medicare for Medistat patients. Those patients pertain to
   Counts 15 and 16.
          The offense of obstruction, in this context, provides that an individual
   “with intent to avoid, evade, prevent, or obstruct compliance, in whole or in
   part,” with an investigation who “willfully withholds, misrepresents,
   removes from any place, conceals, covers up, destroys, mutilates, alters, or
   by other means falsifies any documentary material, answers to written
   interrogatories, or oral testimony, which is the subject of such demand; or
   attempts to do so or solicits another to do so,” commits the offense of
   obstruction. 18 U.S.C. § 1505. Obstruction may also be committed by threats
   or force. Id.
          Roy asserts that there was no obstruction, as charged in Count 17.
   Further, Roy argues the government’s witness, Scott Ward, testified that he
   stopped the audit because the OIG told him to, not because Roy obstructed
   the investigation. Actually, Ward also said that they were unable to complete
   the audit in part because they were unable to access the records at Medcare
   HouseCalls.
          The government charged Roy with obstruction based on the creation
   and use of Medcare HouseCalls to circumvent Medistat’s suspension for
   fraud. Special Agent Miranda Bennett provided testimony to support this
   offense.
          A review of the record in this matter indicates that there was sufficient
   evidence to support Roy’s convictions for conspiracy to commit health care
   fraud, health care fraud, false statements and obstruction.

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          Stiger – Count 1
          Stiger asserts that the district court erred in failing to grant her motion
   for judgment of acquittal under Rule 29 because the evidence was insufficient
   to support a finding beyond a reasonable doubt on all three elements of
   conspiracy to commit health care fraud. See Fed. R. Crim. P. 29. Stiger
   asserts that, because she was indicted only for conspiracy and not for any
   substantive counts of fraud, the government’s evidence did not sufficiently
   prove the element that she agreed to commit health care fraud. Stiger cites
   United States v. Ganji, 880 F.3d 760, 767-773 (5th Cir. 2018), for support.
          In Ganji, this court reversed a doctor’s conviction of conspiracy to
   commit health care fraud because the circumstantial evidence was
   insufficient to establish a concert of action to prove an agreement. Id. at 768-
   69. The court said, “when proving an agreement exists by using the concert
   of action theory, the Government must present evidence of the conspirators’
   individual actions that, taken together, evidence an agreement to commit an
   unlawful objective beyond a reasonable doubt.” Id. This court concluded
   that witnesses admitted their own fraud but did not implicate Ganji. Id. at
   770. Unlike Ganji, Stiger was indeed implicated.
          Stiger asserts that the testimony from nurses who worked at Apple
   that Stiger overruled their decisions on whether to admit patients to home
   health care or discharge them, at most, shows a simple disagreement.
   However, this is essentially Stiger arguing that the jury should have believed
   her theory over the government’s theory.             That does not establish
   insufficiency of the evidence. Also, those nurses testified that Stiger was
   undermining their professional judgment and overriding their nursing
   decisions. Stiger also asserts that the testimony she reimbursed an employee
   who provided groceries, pest control services, or payment of utility bills to
   patients who needed those services indicated she just wanted patients to have

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   those services, which she claims would be medically necessary, and not that
   she sought reimbursement of those amounts from Medicare. Further, Stiger
   asserts that the agreement between Roy, Veasey and herself to provide funds
   for the operation of Apple was a legitimate loan.
            Stiger also argues that, regardless of whether there was a discussion
   about “ping-ponging,” James Aston admitted that no patients were ping-
   ponged between his agency and Stiger’s agency. Aston was a former
   employee of Roy who eventually opened his own HHA, Provider Texas
   Home Health, with a loan from Roy. Aston testified about attending a
   conference with Roy and Stiger and a discussion about bouncing patients
   back and forth between Provider Texas and Apple so that patients could
   continue receiving services. While Aston did admit that there was no “ping-
   ponging” between Provider Texas, which only operated for six months
   serving Roy’s patients and never became certified, and Apple, he did not
   state that there was no “ping-ponging” between Apple and any other HHAs.
   Moreover, the fact that it did not happen with Provider Texas in no way
   establishes that the agreement or discussion did not exist.
            The record in this matter likewise establishes that the evidence was
   sufficient to support Stiger’s conviction for conspiracy to commit health care
   fraud.
   III. Whether Roy can establish prosecutorial misconduct.
            We review unpreserved claims of prosecutorial misconduct for plain
   error, i.e., Roy must show an error that is plain and that affects his substantial
   rights. United States v. Bennett, 874 F.3d 236, 247-48. If Roy is able to do so,
   then “we may exercise our discretion to correct the error if it seriously affects
   the fairness, integrity, or public reputation of judicial proceedings.” Id.
   (internal marks omitted).

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          Roy asserts multiple claims of prosecutorial misconduct, including
   whether: (A) the prosecution knew or should have known that the testimony
   of co-conspirator Cyprian Akamnonu, who is not part of this appeal, was
   perjured and was material; (B) the failure to produce in evidence the content
   of the Lytec program constituted a due process violation and legal prejudice;
   (C) the prosecution violated Roy’s right to due process by creating
   deceptions to mislead the jury; and (D) the prosecution improperly argued
   burden shifting at closing.
          Specifically, Roy argues that Akamnonu lied when he testified that he
   never forged Roy’s signature. However, Roy argued this claim at trial and
   unsuccessfully tried to convince the jury that Roy did not sign the POCs with
   regard to Ultimate, the HHA with which Akamnonu was affiliated. The mere
   fact that this strategy did not work does not establish perjury, reversible error
   or prosecutorial misconduct. Roy also asserts that the government knew or
   should have known that HHAs could bill and get paid by Medicare without a
   signed POC. Roy is referencing Akamnonu’s statement that “[i]f he doesn’t
   sign the 485, then [Ultimate] can’t bill” Medicare. Roy argues that the
   defense proved Ultimate did get paid without a signed 485. However, the
   testimony Roy references established that Ultimate was able to see a patient
   and bill Medicare without a signed 485, not that Ultimate received payment
   in full from Medicare for that patient. Roy fails to establish that the
   prosecution “brainwashed” the jury into believing any knowingly false
   statements or perjury.
          Roy next asserts that the government failed to introduce into evidence
   the content of the Lytec program, the medical practice management software
   and database used by Roy’s practice. Miranda Bennett, a special agent with
   HHS-OIG, and Drews testified that they imaged Medistat’s computers
   containing the Lytec program and data. Roy argues the seized evidence was
   not opened and not analyzed because the government did not have a license

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   to use the software. Actually, the testimony was that the government imaged
   the data, but could not utilize it in the same way as Medistat because the
   government did not have a license for the software. Moreover, Roy fails to
   cite any authority establishing that the government had a duty to introduce
   the Lytec data. Additionally, Roy had the Lytec data and could have
   introduced it himself. Thus, again Roy fails to establish error.
          Roy next argues that the government “created deceptions, conviction
   traps, cunning play on words to incite the convictions by depicting the jury’s
   decision toward a seeming obvious choice in favor of the prosecution by
   corrupting the facts and subverting the proceedings.” He then points to
   various statements that he takes issue with and claims are deceptions. But
   the record does not support his claims and he fails to establish error.
          Finally, Roy argues that prosecutorial misconduct is established
   through the burden shifting during closing argument when the government
   referenced the fact that all of its medical professionals testified that the
   patients at issue were not homebound. Roy claims that statement improperly
   shifted the burden onto him to present a witness to establish the patients were
   homebound. He is mistaken. The government was summing up the evidence
   it had presented. Again, he fails to establish error.
          For these reasons, Roy is unable to establish plain error on his claims
   of prosecutorial misconduct.
   IV. Whether Roy can show plain error of constructive amendment to the
   indictment.
          Roy failed to preserve this claim, so we review for plain error. United
   States v. McGilberry, 480 F.3d 326, 331 (5th Cir. 2007). Roy asserts that the
   government was allowed to constructively amend the indictment by inciting
   and compelling the jury to convict him for Medicare fraud because he was

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   not reviewing the POCs, which was not included as an element of fraud in
   the indictment.
          A broadening of the indictment can be explicit, implicit or
   constructive. United States v. Doucet, 994 F.2d 169, 172 (5th Cir. 1993). “To
   be a constructive amendment, a jury charge must permit the jury ‘to convict
   on an alternative basis permitted by the statute but not charged in the
   indictment.’” United States v. Griffin, 800 F.3d 198, 202 (5th Cir. 2015). “A
   constructive amendment occurs when it permits the defendant to be
   convicted upon a factual basis that effectively modifies an essential element
   of the offense charged or permits the government to convict the defendant
   on a materially different theory or set of facts than that with which [he] was
   charged.” United States v. McMillan, 600 F.3d 434, 451 (5th Cir. 2010)
   (internal quotations and citations omitted).
          The indictment charged Roy with billing for services he did not
   perform, and that was established by the evidence. Roy fails to even allege
   anything that would constitute an amendment of the indictment or that
   modified any element of the offense charged. He, again, merely takes issue
   with some of the evidence introduced at trial. Roy was not convicted “on a
   materially different theory or set of facts than that with which [he] was
   charged.” Id. Because we find no plain error, this issue is without merit.
   V. Whether the district court erred or abused its discretion with regard
   to jury instructions.
          Roy asserts that the trial court erred by including civil regulations in
   the jury instructions and abused its discretion by failing to give his requested
   limiting instruction. Specifically, Roy argues that the inclusion of the
   definition of “homebound” from the Medicare regulation “poisoned the
   proceedings” by causing the jury to focus on the civil regulations rather than
   the criminal statute. Further, he argues that the court abused its discretion

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   by denying his requested instruction referencing United States v. Christo, 614
   F.2d 486, 490-92 (5th Cir. 1980).
          We review a court’s failure to give a limiting instruction for an abuse
   of discretion. Imo, 609 F.3d at 233. Further:
          Reversal is proper only if the requested instruction (1) was a
          substantially correct statement of the law, (2) was not
          substantially covered in the charge as a whole, and (3)
          concerned an important point in the trial such that the failure
          to instruct the jury on the issue seriously impaired the
          defendant’s ability to present a given defense.
   Id. (internal citation and marks omitted).
          Roy sought the following jury instruction: “Any violations of a civil
   Medicare or Medicaid regulation, if such violations indeed occurred, are not
   considered criminal offenses.        You are only to decide whether the
   government has proved beyond a reasonable doubt that the Defendant
   committed a criminal offense charged in the indictment.”
          Roy argues that, like in Christo, the civil standards were equated with
   the criminal standards by the inclusion of the definition from the Medicare
   regulations. However, Roy admits that the holding in Christo was “that the
   government may not prove a criminal case violation of federal banking law
   solely by proving a violation of a civil banking regulation.” (Roy Br. at 31).
   In Christo, the government’s case centered on violations of a regulatory
   banking statute. 614 F.2d at 489. Here, unlike Christo, the government did
   not attempt to prove a criminal violation solely by proving a violation of a civil
   regulation.
          Additionally, a review of the instruction regarding “homebound”
   indicates that it provided clarity and in no way indicates that it would have
   caused the jurors to focus on the civil regulations rather than the crimes
   alleged. In fact, portions of the “homebound” discussion clearly aided Roy

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   by explaining that patients can still be considered homebound even if they are
   able to and do leave home periodically for various reasons. Further, the
   instructions as a whole clearly instructed jurors to consider only the crimes
   charged and fully explained the elements the government must prove beyond
   a reasonable doubt. This court found no abuse of discretion in Imo, 739 F.3d
   at 233-34, for these same reasons.
          Thus, this claim is without merit.
   VI. Whether the district court plainly erred when it allowed lay
   testimony from witnesses regarding the Medicare program.

          This court typically reviews rulings on the admission of lay person and
   expert testimony for an abuse of discretion. However, as this claim is
   unpreserved, we review for plain error. See United States v. Caldwell, 586
   F.3d 338, 341 (5th Cir. 2009).
          Roy asserts that the district court committed plain error by allowing
   lay witnesses to offer testimony expressing a flawed interpretation of
   “homebound” in contradiction to the Medicare regulation which required
   the requisite knowledge and in violation of Rules 701 and 702 of the Federal
   Rules of Evidence. Rule 701 states:
                 If a witness is not testifying as an expert, testimony in
          the form of an opinion is limited to one that is:
                 (a) rationally based on the witness’s perception;
                 (b) helpful to clearly understanding the witness’s
                 testimony or to determining a fact in issue; and
                 (c) not based on scientific, technical, or other
                 specialized knowledge within the scope of Rule 702.

   Fed. R. Evid. 701.
          This court has said that “[t]he distinction between lay and expert
   witness testimony is that lay testimony results from a process of reasoning

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   familiar in everyday life, while expert testimony results from a process of
   reasoning which can be mastered only by specialists in the field.” Ebron, 683
   F.3d at 136-37 (internal marks and citations omitted).
           Roy first cites the “false narrative scripted by the prosecution” in the
   government’s opening statement. That, of course, is not testimony. Then
   Roy cites to the testimony of various doctors of specific patients whom Roy
   had certified for home health, including: (1) Dr. Muhammad Nasir, who
   described his understanding of homebound as “[b]asically, the patient is
   homebound status where they cannot come to visit their primary care
   physician in the clinic . . .”; (2) Dr. Michael Muncy, who did not recall
   specifics of a particular patient without referring to the medical record and
   said he was not particularly familiar with the details of the requirements for
   someone to be certified for home health care; (3) Dr. Minaj Kahn, who said
   he did not prescribe home health to a specific patient in 2011 because he did
   not believe the patient qualified for it; and (4) Dr. Cornelia Tan, who said
   that she did not consider a specific patient to be homebound. 4
           However, in each instance, defense counsel was able to do extensive
   cross-examination to clarify any definitions, to point out that witness’
   unfamiliarity with the regulation, have the witness read the actual regulation
   and recite what it says, specify time periods, and correct any possible
   confusion that Roy believes may have resulted from any testimony.
   Moreover, Roy fails to point to any testimony from any of these witnesses
   claiming to be an expert on Medicare regulations. Additionally, as previously
   discussed, the relevant Medicare regulations were provided to the jury.

           4
            The government’s briefed response to this discusses two other witnesses, Mark
   Porter and Lisa Garcia, who testified generally regarding the Medicare program guidelines
   and processes. The government provided pretrial notice of its intent to call these two
   witnesses. However, it does not appear that Roy is taking issue with these witnesses.

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          For these reasons, Roy is unable to establish plain error.

   VII. Whether the district court erred in determining the loss amount;
   whether the district court erred in applying the four-point enhancement
   under U.S.S.G. § 2B1.1(b)(7)(iii) to Veasey; and whether the sentences
   were procedurally and substantively unreasonable.
          Veasey asserts that his sentence is based upon an erroneous loss
   calculation of $23,630,377.26. Roy asserts that his sentence was based upon
   an erroneous loss calculation of $268,147,699.15.
           We review the district court’s finding regarding the amount of loss
   for clear error, but we review the district court’s method for determining that
   amount de novo. United States v. Harris, 821 F.3d 589, 601 (5th Cir. 2016).
   The district court need only make “a reasonable estimate of the loss,” based
   on its assessment of the evidence and its “loss determination is entitled to
   appropriate deference.” United States v. Hebron, 684 F.3d 554, 560 (5th Cir.
   2012); U.S.S.G. § 2B1.1, cmt. 3(C). We will not overturn these factual
   findings as long as they are “plausible in light of the record as a whole.”
   United States v. Sanders, 343 F.3d 511, 520 (5th Cir. 2003).
          For purposes of the guidelines, “loss is the greater of actual loss or
   intended loss.” U.S.S.G. § 2B1.1 cmt. n.3(A). Actual loss “means the
   reasonably foreseeable pecuniary harm that resulted from the offense.” Id.
   cmt. n.3(A)(i). Intended loss, on the other hand, “means the pecuniary harm
   that the defendant purposely sought to inflict.” Id. cmt. n.3(A)(ii).
          We review the district court’s interpretation and application of the
   Guidelines de novo and its factual findings for clear error. United States v.
   Trujillo, 502 F.3d 353, 356 (5th Cir. 2007). We review an appellant’s claim
   that a sentence is substantively unreasonable for an abuse of discretion.
   United States v. Scott, 654 F.3d 552, 555 (5th Cir. 2011); see also Gall v. United

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   States, 552 U.S. 38, 51 (2007). This review is “highly deferential, because
   the sentencing court is in a better position to find facts and judge their import
   under the § 3553(a) factors with respect to a particular defendant.” Scott 654
   F.3d at 555.
          A sentence within the Guidelines range is presumptively reasonable,
   and this presumption is rebutted only if the appellant demonstrates that the
   sentence does not account for a factor that should receive significant weight,
   gives significant weight to an irrelevant or improper factor, or represents a
   clear error of judgment in balancing sentencing factors. United States v.
   Cooks, 589 F.3d 173, 186 (5th Cir. 2009).
          With Veasey, the district court adopted the loss calculation in ¶ 30 of
   the PSR of $23,630,377.26.           This put Veasey under U.S.S.G. §
   2B1.1(b)(1)(K) and required an increase of 20 because the loss was over
   $9,500,000 and less than $25,000,000.
          Veasey asserts that, according to the PSR, there were only three
   specific claims that Apple billed fraudulently for $2,996.74, $1,815.27 and
   $1,196.74, totaling $6,009.22 for those three patients. Thus, because the loss
   is under $6,500, Veasey argues that there should be no increase under
   U.S.S.G. § 2B1.1(b)(1)(A).
          Veasey then makes an alternative argument based on his admission
   that ¶ 30 of his PSR states that Apple billed Medicare $9,282,690.07 and
   Medistat billed Medicare $1,088,495.74 on behalf of Apple’s patients.
   Veasey argues that Apple was paid only $8,753,055.84 in fraudulent claims,
   and Roy was paid $631,064.78 in fraudulent claims by Apple. Veasey asserts
   the court should combine those two amounts for a loss calculation of
   $9,384,120.62, which would fall under U.S.S.G. § 2B1.1(b)(1)(J) and require
   an 18-level increase if the loss is more than $2,500,000 but less than
   $9,500,000. U.S.S.G. § 2B1.1(b)(1)(J).

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          Veasey’s assertions fail to take into account the additional
   $14,246,656.64 Medistat received pursuant to this conspiracy. Veasey relies
   on Bennett’s testimony that he was not present during the “ping-pong”
   discussion. However, that was only a minor part of the entire conspiracy with
   which Veasey was involved. Further, other evidence indicates that Veasey
   was aware of the “ping-pong” plan.
           Veasey is unable to establish that the district court’s estimate of the
   loss was unreasonable. Hebron, 684 F.3d at 560. Further, the district court’s
   findings are plausible in light of the record as a whole. Sanders, 343 F.3d 520.
   For these reasons, the district court did not err.
          Veasey also asserts that the district court erred by applying the four-
   point enhancement under U.S.S.G. § 2B1.1(b)(7)(iii), which states: “If (A)
   the defendant was convicted of a Federal health care offense involving a
   Government health care program; and (B) the loss under subsection (b)(1) to
   the Government health care program was . . . (iii) more than $20,000,000,
   increase by 4 levels.” U.S.S.G. § 2B1.1(b)(7)(iii). Because the district court
   did not err in its calculation of loss, Veasey is likewise unable to establish
   error on this issue.
          Veasey’s argument that his sentence was procedurally or
   substantively unreasonable is based solely on his argument that the loss
   calculation was erroneous. He is unable to establish any error or abuse of
   discretion.
          Roy asserts that his “sentence was procedurally unreasonable due to
   error in calculation of actual and intended loss based on false and unreliable
   information in the PSR relating the amount of Medicare billings reported by
   the HHAs relevant to Dr. Roy’s certifications which was false, large amount
   was not relevant to Dr. Roy.” Roy appears to be arguing that he was not

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                                     No. 17-10665

   aware of what the HHAs were doing. However, the record does not support
   that claim.
          Further, Roy asserts that “[i]t was clear error in calculation of the
   actual loss and the intended loss amount based on all the certifications from
   Dr. Roy were fraudulent due to the creation of the 485 department and the
   POCs were not reviewed and signed by Dr. Roy.” Roy then basically argues
   that the evidence presented at trial was false, that the services and tests he
   provided were medically necessary, that not all of the patients were not
   homebound, that the fact that the government dismissed Count 5 and he was
   acquitted of Count 6 indicate a finding that across-the-board fraud cannot be
   sustained in this case, and takes particular issue with the Ultimate
   certifications being considered relevant to him. However, again, the record
   does not support this.
          Accordingly, these issues are without merit.
   VIII. Whether Roy, Stiger and Veasey can show error in the
   district court’s restitution awards.
          We review preserved error as to the quantum of an award of
   restitution for abuse of discretion. United States v. Sharma, 703 F.3d 318, 322
   (5th Cir. 2012). Absent an objection, we review for plain error. United States
   v. De Leon, 728 F.3d 500, 507 (5th Cir. 2013). A district court’s factual
   findings are reviewed for clear error. Sharma 703 F.3d at 322. “A factual
   finding is clearly erroneous only if based on the record as a whole, we are left
   with the definite and firm conviction that a mistake has been committed.”
   Id. (internal marks and citation omitted). “We may affirm in the absence of
   express findings if the record provides an adequate basis to support the
   restitution order.” Id. (internal marks and citation omitted).
          Under the MVRA, the district court is required to award restitution
   to victims “directly and proximately harmed” by a defendant’s offense, as

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   long as the court does not award a windfall greater than the victim’s actual
   loss. De Leon, 728 F.3d at 506. “The government has the burden of proving
   a victim's actual losses.” Id.
           Roy asserts that the district court abused its discretion by assessing
   restitution in the amount of $268,147,699.15 “[f]or the same reason the
   court’s loss calculation was erroneous, its restitution order also was
   erroneous including amounts not relevant to Dr. Roy for the actual loss.”
   Roy was unable to establish error in loss calculation and is unable to establish
   an abuse of discretion here.
           Veasey also asserts the same arguments here as he did for the loss
   calculation. For the same reasons those arguments failed there, Veasey is
   unable to establish an abuse of discretion or clear error here.
           Stiger asserts that the district court clearly erred by not reducing her
   restitution by 50 percent based on Dupon’s testimony that 50 percent of
   Apple patients during her tenure were qualified for home health care. 5
   Accordingly, Stiger asserts that her restitution amount should have been
   reduced from $23,630,777.26 to $11,815,388.63.
           During trial, Dupon was asked: “Looking back at your time at Apple,
   can you give a reasonable approximation of the number of patients that
   qualified for Medicare home health care?” Dupon replied: “About 50. 50
   percent.” That brief mention of her belief as to an approximate number is
   hardly sufficient to rebut the evidence of loss presented at trial, or to establish
   clear error or an abuse of discretion.

           5
              Stiger mentions that counsel’s objection to the PSR may have been based on the
   fact that she was co-owner of Apple with Veasey. While Stiger does not argue that now, it
   would likewise fail to establish clear error or an abuse of discretion.

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           Stiger also asserts that she should not be held jointly and severally
   liable for restitution incurred by other defendants unrelated to Apple based
   upon Honeycutt v. United States, 137 S.Ct. 1626 (2017). Stiger concedes that
   Honeycutt applied only to forfeiture. But Stiger states that she is raising the
   issue in the event Honeycutt is applied to restitution during the pendency of
   this appeal, for such a ruling by this court, or to preserve it for possible
   Supreme Court review. We decline to apply Honeycutt here. Not only did
   Honeycutt have to do with forfeiture, it had to do with forfeiture of substitute
   property when the tainted property itself was not available. Id. at 1634-35.
   That is nothing like restitution, which has to do with actual loss. Further,
   Honeycutt did not alter or overrule liability under Pinkerton v. United States,
   328 U.S. 640 (1946). In fact, in response to the government’s argument that
   Congress must be presumed to have legislated against the background
   principles of conspiracy liability, the Supreme Court said that the “plain text
   and structure” of the statute in question “leave no doubt that Congress did
   not incorporate those background principles.” Honeycutt, 137 S.Ct. at 1634.
           For these reasons, we find no error.
   IX. Whether Stiger and Eleda can establish that Standard Condition of
   Supervised Release No. 6 is unreasonably broad.
           Stiger and Eleda both assert that one of the conditions of their
   supervised release is unreasonably broad. The condition at issue here,
   Standard Condition of Supervised Release No. 6, states: “You must allow
   the probation officer to visit you at any time at your home or elsewhere, and
   you must permit the probation officer to take any items prohibited by the
   conditions of your supervision that he or she observes in plain view.”
           In United States v. Duke, 788 F.3d 392, 398 (5th Cir. 2015), this court
   said:

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                                     No. 17-10665

                  A district court has wide, but not unfettered, discretion
          in imposing terms and conditions of supervised release. A
          district court’s discretion is curtailed by statute in two ways.
          First, the condition of supervised release must be reasonably
          related to one of four statutory factors: (1) the nature and
          characteristics of the offense and the history and
          characteristics of the defendant; (2) the need for deterrence of
          criminal conduct; (3) the need to protect the public from
          further crimes of the defendant; and (4) the need to provide the
          defendant with vocational training, medical care, or other
          correctional treatment. Second, the condition must be
          narrowly tailored such that it does not involve a greater
          deprivation of liberty than is reasonably necessary to fulfill the
          purposes set forth in [18 U.S.C.] 3553(a). Moreover, the
          sentence should consider the policy statements issued by the
          Sentencing Commission.

   Id. at 398 (internal marks and citations omitted); see also 18 U.S.C. § 3583.
   Neither Eleda nor Stiger objected, thus review is for plain error.
          This court recently concluded that a district court did not abuse its
   discretion by imposing that very condition. See United States v. Payton, 959
   F.3d 654, 656, 658 (5th Cir. 2020). Thus, Eleda and Stiger are unable to
   establish error, plain or otherwise.
   X. Whether Roy can establish cumulative error.
          Roy asserts that if the court does not find that reversal is warranted on
   other grounds, then the cumulative effect of all of the errors at trial warrant
   a new trial. Roy cites United States v. Eghobor, 812 F.3d 352 (5th Cir. 2015),
   as support. In Eghobor, we said: “The cumulative error doctrine provides
   that an aggregation of non-reversible errors (i.e., plain errors failing to
   necessitate reversal and harmless errors) can yield a denial of the
   constitutional right to a fair trial, which calls for reversal.” Id. at 361. As
   there are no plain or harmless errors here, there can be no cumulative error.

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                               CONCLUSION
          For these reasons, we AFFIRM the judgments in the district court as
   to all appellants.

                                       29