Court Opinion

ID: 4218334
Source: CourtListenerOpinion
Date Created: 2017-11-07 19:01:32.724828+00
Date Added: 2024-06-11T07:47:45.975259
License: Public Domain

Case: 15-20323        Document: 00514227799        Page: 1    Date Filed: 11/07/2017

          IN THE UNITED STATES COURT OF APPEALS
                   FOR THE FIFTH CIRCUIT
                                                                         United States Court of Appeals

                                       No. 15-20323
                                                                                  Fif h Circuit

                                                                                FILED
                                                                         November 7, 2017

UNITED STATES OF AMERICA,                                                  Lyle W. Cayce
                                                                                Clerk
                Plaintiff - Appellee

v.

EARNEST GIBSON, III; EARNEST GIBSON, IV,

                Defendants - Appellants

                    Appeals from the United States District Court
                         for the Southern District of Texas

Before WIENER, HIGGINSON, and COSTA, Circuit Judges.
STEPHEN A. HIGGINSON, Circuit Judge:
      “The trouble with conspiracies is that they rot internally.” 1 According to
the government’s cooperating witnesses, the appellants—Earnest Gibson, III
(Gibson III) and his son, Earnest Gibson, IV (Gibson IV)—participated in three:
one to defraud Medicare, another to pay unlawful kickbacks, and a third to
launder money. A jury convicted the Gibsons for each, plus several substantive
kickback counts. On appeal, the Gibsons advance sufficiency challenges and
assert that the health care fraud and money laundering conspiracies merged.

      1   Robert A. Heinlein, The Moon is a Harsh Mistress 76 (1966).
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For his part, Gibson III argues that the district court infringed his constitu-
tional rights by limiting one of his cross-examinations and by admitting a co-
conspirator’s confession, in violation of the Bruton doctrine. He also faults the
trial court for giving the jury “deliberate ignorance” instructions on charges
requiring specific intent. In turn, Gibson IV posits that the district court im-
posed too much restitution. Both appellants also invoke the cumulative error
doctrine, claiming that the trial court’s alleged mistakes infected the verdict.
We find no reversible error and thus affirm.
                                         I.
      This case presents another instance of Medicare fraud involving Partial
Hospitalization Programs (PHPs). PHPs are outpatient programs designed to
provide daily, intensive treatment for patients suffering from an “acute exac-
erbation” of a chronic mental disorder. Houston’s Riverside General Hospital
(Riverside) ran PHPs, both onsite and at satellite locations. Riverside’s Chief
Executive Officer, president, and administrator was Gibson III. His son, Gib-
son IV, operated an affiliated, offsite PHP, Devotions Care Solutions (Devo-
tions).
      In 2006, Medicare approved Riverside and its PHPs to submit reimburse-
ment claims. Not surprisingly, a PHP costs more to operate than does a stand-
ard outpatient service. So it is also unsurprising that Medicare attached sev-
eral strings to its PHP coverage.
      One condition was patient eligibility. To bill Medicare for PHP services,
a physician needed to certify that the Medicare beneficiary required treatment
comparable with inpatient care. Naturally, a patient must have had “the ca-

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pacity for active participation in all phases of the multidisciplinary and multi-
modal program.” Patients diagnosed with Alzheimer’s or dementia, for exam-
ple, would raise “red flag[s]” for Medicare.
      The type of treatment mattered, too. A doctor must have certified that
the PHP services would be “furnished while the individual [wa]s under the care
of a physician” according to “an individualized written plan of care.” Expressly
excluded from Medicare coverage were, to name a few: “services to hospital
inpatients and meals, self-administered medications and transportation”; “cus-
todial or respite care”; “programs attempting to maintain psychiatric well-
ness”; “daycare programs for the chronically mentally ill”; and “services to a
nursing facility resident that should be expected to be provided by the nursing
facility staff.” And if a hospital operated an offsite PHP—like Gibson IV’s De-
votions—treatment must have occurred under a licensed physician’s “direct
supervision.” That meant the physician had to be “physically present” in the
office suite housing the offsite PHP and “immediately available to provide as-
sistance and direction throughout the time the employee is performing ser-
vices.”
      Medicare also imposed timing requirements. A PHP patient needed to
receive “active treatment” at least four days and twenty hours a week. And if
a patient’s condition “improve[d] or stabilize[d],” or if she could not benefit from
“the intensive multimodal treatment available in the PHP,” the PHP had to
discharge her.
      In 2006—and again in 2008, 2009, and 2011—Gibson III certified that
Riverside’s PHPs complied with “the laws, regulations and program instruc-
tions of the Medicare program.” That, according to the government, turned out
to be false. As the prosecutors put it, Riverside submitted on behalf of its PHPs

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$160,336,451.90 in Medicare bills, and Medicare paid $46,753,180.04 before
realizing it had been swindled.
       On October 1, 2012, a grand jury in the Southern District of Texas in-
dicted Gibson III, Gibson IV, and five others on thirteen counts, alleging vari-
ous illegal schemes relating to Riverside PHPs. Facing the prospect of a jury
trial, three defendants pleaded guilty. Two of them turned government’s wit-
nesses to testify against the Gibsons. By contrast, the Gibsons put the govern-
ment to its burden.
       Thus ensued a month-long trial. On October 20, 2014, a jury convicted
Gibson III of conspiracy to commit healthcare fraud (Count 1), conspiracy to
defraud the government and violate the Anti-Kickback Statute (AKS) (Count
2), seven substantive kickback offenses (Counts 3, 4, 5, 7, 9, 11 & 12), and con-
spiracy to commit money laundering promotion (Count 13). 2 The jury found
Gibson IV guilty on each conspiracy charge (Counts 1, 2 & 13) and two sub-
stantive kickback offenses (Counts 11 & 12). Soon after, the district court sen-
tenced Gibson III to 540 months’ imprisonment and $46,753,180.04 in restitu-
tion. On Gibson IV the court imposed a 240-month prison term and
$7,518,480.11 in restitution.
       The Gibsons now assert nearly a dozen grounds for reversal. 3 None is
persuasive.
                                            II.
       We first consider whether the government submitted enough evidence to
support the convictions. It did.

       2  The jury acquitted Gibson III on two substantive kickback charges, Counts 6 and 8.
Count 10 was not at issue because it pertained only to one of the defendants who pleaded
guilty.
        3 Both Gibsons have court-appointed attorneys. Before they obtained counsel, how-

ever, the Gibsons filed identical pro se motions to vacate their convictions. Assuming those
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      We take a de novo look at preserved sufficiency-of-the-evidence chal-
lenges. United States v. Davis, 735 F.3d 194, 198 (5th Cir. 2013). In doing so,
we “review[] the record to determine whether, considering the evidence and all
reasonable inferences in the light most favorable to the prosecution, any ra-
tional trier of fact could have found the essential elements of the crime beyond
a reasonable doubt.” United States v. Vargas-Ocampo, 747 F.3d 299, 303 (5th
Cir. 2014) (en banc). To suffice, “[t]he evidence need not exclude every reason-
able hypothesis of innocence or be wholly inconsistent with every conclusion
except that of guilt[.]” United States v. Grant, 683 F.3d 639, 642 (5th Cir. 2012)
(quotation marks omitted). “The jury retains the sole authority to weigh any
conflicting evidence and to evaluate the credibility of the witnesses.” Id. (quo-
tation marks omitted). Even “the ‘uncorroborated testimony of an accomplice
or of someone making a plea bargain with the government’ can support a con-
viction.” United States v. Chapman, 851 F.3d 363, 378 (5th Cir. 2017) (quoting
United States v. Shoemaker, 746 F.3d 614, 623 (5th Cir. 2014)).
                                            A.
      A rational juror could find beyond a reasonable doubt that the Gibsons
joined a health care fraud conspiracy (Count 1).
      That crime comprises three elements: that (1) two or more persons made
an agreement to commit health care fraud; 4 (2) the defendant knew the unlaw-
ful purpose of the agreement; and (3) the defendant joined in the agreement

pro se motions are properly before us, they must be denied for the same reasons stated in
this opinion.
       4 A person commits health care fraud in violation of 18 U.S.C. § 1347 by

      knowingly and willfully execut[ing], or attempt[ing] 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 owned by, or under the custody or control of, any health care
      benefit program, in connection with the delivery of or payment for health care
      benefits, items, or services.
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willfully, that is, with the intent to further the unlawful purpose. United States
v. Willett, 751 F.3d 335, 339 (5th Cir. 2014) (quotation marks omitted). The
jury need not find that the defendants “actually submitted the fraudulent doc-
umentation” to convict. United States v. Umawa Oke Imo, 739 F.3d 226, 235
(5th Cir. 2014). In fact, the government need not show an overt act at all.
United States v. Njoku, 737 F.3d 55, 67–68 (5th Cir. 2013). Nor must the pros-
ecution show direct evidence of the conspiracy; “each element may be inferred
from circumstantial evidence.” Willett, 751 F.3d at 339 (quotation marks omit-
ted). The illegal agreement may even be “silent and informal.” Id. (quotation
marks omitted). Still, a conviction must rest on sturdier legs than mere infer-
ence or supposition. United States v. Grant, 683 F.3d 639, 642 (5th Cir. 2012)
(“[T]he government must do more than pile inference upon inference upon
which to base a conspiracy charge.” (quotation marks omitted)).
       The government equipped the jury with enough evidence to conclude
that the Gibsons unlawfully agreed to bill Medicare for unnecessary or unper-
formed services. For starters, the evidence against Gibson IV was as robust as
it was simple. Take, for instance, the testimony of a behavioral technician who
said Gibson IV instructed her to bill Medicare for unperformed services. Or the
FBI agent who reviewed with the jury Riverside’s internal compliance memo-
randa—incriminating documents showing that Gibson IV’s PHP billed Medi-
care for never-performed treatment.
       The evidence against Gibson III was similarly powerful. One PHP super-
visor explained that he and Gibson III entered two contracts; one to pay the
supervisor a percentage of Riverside’s Medicare returns, and another to pay
him $16,000 each month he referred 26 to 30 Medicare patients to a Riverside

United States v. Willett, 751 F.3d 335, 339 (5th Cir. 2014) (quotation marks omitted).
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PHP. The supervisor further admitted to paying marketers to meet his patient
quota. What is more, he testified that Gibson III tracked those marketers’ lo-
cations with a spreadsheet. According to the supervisor, Gibson III also talked
about the “census”—the number of billable patients in a PHP—“all the time.”
The instructions were to “keep [the] census up,” else Gibson III would termi-
nate their contract. And this was no rare threat. The boss sent several letters
warning the supervisor to bring in more patients to increase Riverside’s “mar-
ket share.”
       That supervisor was one of many informants who implicated Gibson III.
A patient recruiter explained how Gibson III skirted Medicare rules by direct-
ing PHPs to keep beneficiaries for 90 days, put them in onsite “aftercare” pro-
grams to watch television for a few weeks, and then readmit those patients to
avoid losing them to competitor-PHPs. A behavioral-health technician testified
that the PHPs often admitted ineligible patients and rendered bogus treat-
ment. The jury also learned that Gibson III heard complaints that the only on-
duty psychiatrist was often absent and failed to fill out necessary patient
forms. But those complaints fell on deaf ears and into obstructive hands. When
an exasperated PHP supervisor finally replaced that psychiatrist with some-
one willing to do the work, Gibson III pulled rank and reinstated the absentee
doctor. 5
       The testimony unveiled similar shenanigans at other Riverside PHPs.
One worker revealed that his PHP’s assigned psychiatrist showed up only once
a week. Another testified that some patients waited a fortnight in a cafeteria
before seeing a doctor. And the patients themselves grew impatient; they con-
sistently complained that they couldn’t see a doctor. Still more evidence

       5 A jury in a separate trial convicted that doctor of Medicare and Medicaid fraud. We
later upheld her convictions and sentence. See United States v. Iglehart, 687 F. App’x 333
(5th Cir. 2017) (per curiam).
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showed that Devotions violated Medicare rules by permitting nurse practition-
ers to admit and discharge patients.
      Even Gibson III’s own testimony supported the verdict. He admitted he
knew that Medicare required a psychiatrist to be present full-time at every
PHP, and that one psychiatrist was assigned to be at two places at once. He
conceded he also knew Medicare had reimbursed Riverside for “false claims,”
but failed to alert Medicare or fire the people responsible. He further acknowl-
edged he reviewed compliance memoranda and internal audits exposing fraud,
but the conduct continued. Faced with so much evidence, a rational juror could
have found that Gibson III declined to act because he was part of the conspir-
acy. See, e.g., Imo, 739 F.3d at 236–37 (inferring a defendant’s (1) knowledge
of a health care fraud conspiracy from his proximity to unlawful acts and (2)
complicity from the continued unlawful activities); Willett, 751 F.3d at 340 (in-
ferring knowledge of a health care fraud conspiracy from the defendant’s “prox-
imity to the fraudulent activities” and frequent meetings with his alleged co-
conspirator).
      To be sure, throughout trial Gibson III professed ignorance and stressed
his steps to stem misconduct. He also shifted blame to supposedly rogue sub-
ordinates. A rational juror, however, could have disbelieved his account and
credited instead the cooperating co-conspirators’. And a successful sufficiency
challenge cannot hinge on such credibility calls. United States v. Sanjar, 853
F.3d 190, 212 (5th Cir. 2017) (“To the extent [appellants] identify inconsisten-
cies in the . . . testimony, that credibility determination is for the jury to
make.”), cert. denied, No. 17-5340, 2017 WL 3184826 (U.S. Oct. 2, 2017); see
also United States v. Burns, 526 F.3d 852, 860 (5th Cir. 2008) (“[I]t is up to the

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jury to judge the credibility of witnesses who receive favorable treatment from
the Government to testify.”).
      Put succinctly, a juror could rationally draw from the evidence a simple
conclusion: that the Gibsons knew of and willfully joined a conspiracy to submit
false PHP claims and pilfer Medicare money.
                                       B.
      A reasonable juror could also find that the Gibsons conspired to violate—
and actually violated—the AKS.
      The statute provides that
      whoever knowingly and willfully offers or pays any remuneration
      (including any kickback, bribe, or rebate) directly or indirectly,
      overtly or covertly, in cash or in kind to any person to induce such
      person . . . to refer an individual to a person for the furnishing or
      arranging for the furnishing of any item or service for which pay-
      ment may be made in whole or in part under a Federal health care
      program, . . . shall be guilty of a felony . . . .
42 U.S.C. § 1320a-7b(b)(2)(A). In other words, the AKS “criminalizes the pay-
ment of any funds or benefits designed to encourage an individual to refer an-
other party to a Medicare provider for services to be paid for by the Medicare
program.” United States v. Miles, 360 F.3d 472, 479 (5th Cir. 2004). To prove
an AKS conspiracy, the government must show “(1) an agreement between two
or more persons to pursue an unlawful objective; (2) the defendant’s knowledge
of the unlawful objective and voluntary agreement to join the conspiracy; and
(3) an overt act by one or more of the members of the conspiracy in furtherance
of the objective of the conspiracy.” Njoku, 737 F.3d at 64 (quotation marks
omitted); see also 18 U.S.C. § 371. The defendant must have “acted willfully,
that is, with the specific intent to do something the law forbids.” Miles, 360
F.3d at 479 (quotation marks omitted).

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      Here, too, multiple witnesses exposed Gibson IV at trial, testifying that
through February 2012 he agreed to pay them for referrals. One recruiter de-
scribed it as an “illegal deal” involving cash paid “under the table.”
      Some evidence was indeed devastating. A recruiter described how Gib-
son IV twice paid $1,000 in cash, in a restaurant bathroom, after circling the
block to ensure no one had followed them. That first bathroom handoff, accord-
ing to the recruiter, was for “partial payment of the patients that was [sic]
going to Devotions.” As for the second payment, Gibson IV said that “he had to
get it approved from his pops” and “was going to the bank to get it,” and that
“he didn’t know how much his pops was going to approve, but he was going to
do something.” Gibson IV later agreed to pay $50 per week if that recruiter
kept bringing patients to Devotions.
      Even Riverside’s security smelled something fishy. A guard testified that
a group-home owner once visited to complain that Gibson IV “wanted the
[owner’s] patients to come to the [Devotions] program, but he didn’t want to
pay.” So the guard paged Gibson IV, who appeared in the lobby and handed
the owner a white envelope. Given all this, a rational juror could conclude be-
yond a reasonable doubt that Gibson IV conspired to pay kickbacks.
      So, too, for Gibson III. Start with Gibson IV’s references to his “pops”;
that supports a finding that Gibson III was the scheme’s knowing and willful
guarantor. Consider also the familial link between Gibson III and other rele-
vant players—including his son, Gibson IV, and daughter-in-law, a hospital
representative who coordinated with a recruiter to hide illicit, per-patient pay-
ments—which is circumstantial evidence of Gibson III’s role in the conspiracy.
See Willett, 751 F.3d at 340 (“[W]hen inferences drawn from the existence of a
family relationship or mere knowing presence are combined with other circum-

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stantial evidence, there may be sufficient evidence to support a conspiracy con-
viction” (quotation marks and citation omitted)). Circumstantial evidence is
also shown by Gibson III’s position of authority at Riverside. See id. at 340–41.
      Circumstantial evidence aside, the jury heard several cooperating wit-
nesses identify Gibson III as a kickback conspirator. One testified that Gibson
III was part of the recruiting racket. That witness said that he thrice met Gib-
son III to discuss the kickback scheme. During an October 2010 meeting at a
Riverside office, for example, Gibson IV introduced the recruiter as Gibson IV’s
“business partner,” and Gibson III heard a proposal to recruit 350 to 500 pa-
tients to a Riverside PHP. Responded Gibson III: “I don’t want to know what
you-all are doing or how you-all doing [sic] it, but, you know, because it’s a lot
of patients, you-all be careful.” He later recommended that his son and the
recruiter create an artificial entity so that Riverside could cut them checks.
Gibson IV and the recruiter heeded that advice to avoid raising “flags” when
Riverside paid for patients.
      These were not isolated incidents. Another Riverside employee testified
that Gibson IV instructed her to go near Gibson III’s office to pick up “an en-
velope of cash” to pay recruiters. Other recruiters admitted to receiving pay-
ments per patient. The jury therefore had sufficient evidence rationally to find
Gibson III guilty of a kickback conspiracy. See Sanjar, 853 F.3d at 212 (infer-
ring knowledge and willfulness where defendants “meticulously monitored pa-
tient referrals, tracking patients, their referrers, and the billings on their
claims” and paid “patients in cash, delivered in envelopes”).
      But the government proved more than just a conspiracy. It matched the
recruiters’ testimony with specific checks bearing Gibson III’s signature. Thus,
under the Pinkerton doctrine, a juror could rationally convict the Gibsons on
the substantive AKS counts. See Pinkerton v. United States, 328 U.S. 640, 645–

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48 (1946). This doctrine holds the Gibsons responsible for foreseeable kick-
backs paid while the Gibsons were members of the kickback conspiracy. See id.
Here, the government proved specific kickbacks that were unquestionably fore-
seeable to the Gibsons. E.g., Sanjar, 853 F.3d at 209 (“[H]ow could the payment
of kickbacks not be foreseeable to a participant in a kickback conspiracy?”);
United States v. Barson, 845 F.3d 159, 165 (5th Cir. 2016) (upholding substan-
tive health care fraud convictions because “the jury was entitled to convict De-
fendants pursuant to the Pinkerton doctrine” and “the evidence was sufficient
to convict Defendants on [a health care fraud] conspiracy count”).
      Seeking to avoid this conclusion, the Gibsons protest that the govern-
ment failed to show either that (1) money flowed to a “relevant decision maker
for sending patients” to the PHPs, or (2) the payments “influenced the inde-
pendent medical judgment of a doctor concerning a patient’s care.” But the
AKS has no “relevant decision maker” or “medical judgment” requirement.
Shoemaker, 746 F.3d at 628–29. The statute criminalizes payments made to
“any person” with the requisite intent. Id.; 42 U.S.C. § 1320a-7b(b)(2)(A).
      Viewed in the light most favorable to the verdict, the trial evidence was
adequate to prove beyond a reasonable doubt that the Gibsons knowingly and
willfully entered in an expansive kickback conspiracy, intending to induce re-
cruiters to refer Medicare beneficiaries to Riverside’s PHPs. Numerous recruit-

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ers confirmed that is precisely what happened. Thus, under Pinkerton, the Gib-
sons were properly held accountable for substantive AKS violations. These con-
victions stand.
                                            C.
       Next, we consider the sufficiency challenge on the convictions for con-
spiracy to commit money laundering promotion. The Gibsons’ arguments fail
on this front too. 6
       It is unlawful to “conspire[] to commit any offense defined in [18 U.S.C.
§ 1956].” 18 U.S.C. § 1956(h). Count 13 alleges that the Gibsons conspired to
violate the money laundering promotion provision, which prohibits persons
“knowing that the property involved in a financial transaction represents the
proceeds of some form of unlawful activity” from “conduct[ing] or attempt[ing]
to conduct such a financial transaction which in fact involves the proceeds of
specified unlawful activity . . . with the intent to promote the carrying on of
specified unlawful activity[.]” § 1956(a)(1)(A)(i) (emphasis added); see also
United States v. Stanford, 823 F.3d 814, 849 (5th Cir. 2016). Like a health care
fraud conspiracy, this crime needs no overt act. Whitfield v. United States, 543
U.S. 209, 219 (2005).
       The Gibsons muster a three-pronged attack. First, they insist that the
government failed to identify any money actually derived from health care
fraud. Second, the Gibsons believe the government should have distinguished
whether, from September 2008 to May 20, 2009, the money laundering in-
volved “receipts” or “profits” of a predicate Medicare fraud. Last, the Gibsons
maintain that the government failed to establish their criminal intent because

       6 The government contends that the Gibsons failed to preserve their sufficiency argu-
ments on this count. We need not wrestle with that question because the evidence was suffi-
cient even under a de novo standard.
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perhaps the Gibsons used Medicare funds to cover legitimate business ex-
penses.
      These claims fail. To begin, the Gibsons’ arguments mistakenly seek
proof of an overt act in furtherance of the conspiracy. But a conspiracy to com-
mit money laundering promotion requires no such act. Id.
      Nevertheless, the first argument fails for an independent reason: a ra-
tional juror could have concluded beyond a reasonable doubt that the Gibsons
knowingly dealt in proceeds of unlawful activity. The government proved that
Medicare paid millions in Riverside’s claims for PHP services, and that River-
side’s claims were fraudulent. Recall that Gibson III himself admitted that he
knew some of the claims were false. And a forensic accountant testified that
once Medicare paid Riverside, Gibson III transferred some of those funds from
Riverside’s bank account to the Devotions bank account, titled “Earnest Gibson
IV DBA Devotions Care Solutions.” The government then traced how, from
2008 until June 2012, Gibson IV withdrew over $715,000 in cash from that
Devotions account and paid over $80,000 in checks to admitted recruiters. A
rational deduction from that evidence is that the Gibsons both (1) knew they
had fraudulently received Medicare funds, and (2) agreed to continue that
fraud by using some of those funds as kickbacks to harvest more patients and
generate new fraudulent claims.
      The Gibsons’ second argument—that the government should have dis-
tinguished between “receipts” and “profits” from September 2008 to May 20,
2009—also founders. Here, the Gibsons rely on a splintered Supreme Court
opinion that attempted to determine whether the term, “proceeds,” in a prior
version of the money laundering statute meant “receipts” or “profits.” See
United States v. Santos, 553 U.S. 507 (2008). But Congress effectively over-
ruled Santos by amending the statute to define “proceeds” more broadly, and
that law took effect on May 20, 2009. See Fraud Enforcement and Regulatory
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Act of 2009 (FERA), Pub. L. No. 111-21, § 2(f)(1), 123 Stat. 1617, 1618 (2009),
codified at 18 U.S.C. § 1956(c)(9) (“[T]he term ‘proceeds’ means any property
derived from or obtained or retained, directly or indirectly, through some form
of unlawful activity, including the gross receipts of such activity.”). No doubt
the jury saw enough evidence to find that the Gibsons participated in a money
laundering conspiracy after May 20, 2009. After all, Riverside’s PHPs in-
creased their Medicare bills and payments year over year until June 2012.
Santos, then, is of no moment. 7
         The Gibsons’ last point is similarly unpersuasive. Relying on our Miles
decision, the Gibsons urge us to overturn their convictions because the govern-
ment failed to disprove that they used Medicare funds for legitimate business
expenses. See 360 F.3d at 479 (“The crime of money laundering promotion is
aimed not at maintaining the legitimate aspects of a business nor at proscrib-
ing all expenditures of ill-gotten gains, but only at transactions which funnel
ill-gotten gains directly back into the criminal venture.”). Again, this argument
overlooks that the convictions are for conspiracy to commit money laundering
promotion—so the government bore no burden to identify any financial trans-
action, let alone distinguish between legitimate and unlawful ones. See Whit-
field, 543 U.S. at 219 (holding that money laundering conspiracy requires no
overt act). In any event, the convictions satisfy Miles because the indictment
alleged (and the evidence showed) that the Gibsons’ money laundering plan
contemplated transactions designed to foster further fraud. See, e.g., United
States v. Valdez, 726 F.3d 684, 691 (5th Cir. 2013) (upholding money launder-
ing promotion convictions and rejecting the defendants’ Miles arguments

         7   The Gibsons do not address whether (or how) Santos affects their restitution obliga-
tions.
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where the evidence showed a “clear nexus between the payments and [an un-
derlying] fraud” and suggested the transactions were “payments to secure loy-
alty or cooperation in [a] fraudulent scheme”). Viewing the evidence of kick-
backs outlined above and the year-over-year growth in Riverside’s Medicare
claims and reimbursements, a juror could rationally conclude that the Gibsons
agreed to “funnel ill-gotten gains directly back into the criminal venture.”
Miles, 360 F.3d at 479.
      The evidence supporting Count 13 was sufficient.
                                        III.
      The Gibsons also challenge the money laundering promotion conspiracy
count because, as they see it, that crime merged with the health care fraud
conspiracy. But there was no merger. The two counts are distinct conspiracies,
neither of which had as an element any overt act that could have overlapped
to create a merger problem. Rather, the convictions depend on different facts
and agreements.
      We turn first to the standard of review. The Gibsons concede their failure
to raise a merger argument below. They must therefore establish plain error—
no small task, as they must show a clear and obvious error affecting their sub-
stantial rights. United States v. Scott, 821 F.3d 562, 570 (5th Cir. 2016). And
even if they vault those hurdles, we fix the error only if it “seriously affects the
fairness, integrity or public reputation of judicial proceedings.” United

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                                        No. 15-20323
States v. Escalante-Reyes, 689 F.3d 415, 419 (5th Cir. 2012) (en banc) (altera-
tions and quotation marks omitted). 8
        In the money laundering context, the salient “merger” question is
“whether the money laundering crime is based upon the same or continuing
conduct of the underlying predicate crime, or whether the crimes are separate
and based upon separate conduct.” United States v. Kennedy, 707 F.3d 558, 565
(5th Cir. 2013). Merger, then,
        may be proved in two ways: (1) a defendant may demonstrate the
        underlying unlawful activity was not complete at the time the al-
        leged money laundering occurred; or (2) a defendant may show the
        transaction upon which the money laundering count is based was
        not a payment from profits of the underlying crime made in sup-
        port of new crimes, but, instead, was a payment from gross receipts
        of the previously committed crime made to cover the costs of that
        same crime.
Id.
        We see no plain error here because the jury convicted the Gibsons of con-
ceptually and temporally distinct agreements. The charged health care fraud
conspiracy was a pact to perpetrate Medicare fraud. To convict, the jury must
have found that the Gibsons joined that agreement knowing and intending to
further its purpose. See Willett, 751 F.3d at 339. By contrast, the alleged money
laundering promotion conspiracy was a compact to conduct a financial trans-
action involving the proceeds of health care fraud with the intent to promote or
further unlawful activity—an agreement the Gibsons must have joined know-
ingly and intending to further its purpose. See United States v. Alaniz, 726
F.3d 586, 601 (5th Cir. 2013). Put another way, Count 1 targeted a conspiracy

        8We do not address whether the Gibsons forfeited their merger argument by failing
to raise it pretrial. Cf. Njoku, 737 F.3d at 67 (holding that failure to raise a multiplicity ob-
jection pretrial forfeits that argument on appeal); United States v. Dixon, 273 F.3d 636, 642
(5th Cir. 2001) (same).
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                                       No. 15-20323
to submit false bills to Medicare, while Count 13 alleged a conspiracy to use
fraudulently obtained money with the goal of submitting subsequent false bills.
       Also important is that neither crime needed an overt act. Because the
Gibsons’ convictions do not rest on any actual money laundering, we see no
clear and obvious risk that “the underlying unlawful activity was not complete
at the time the alleged money laundering occurred” or that “the transaction
upon which the money laundering count is based . . . was a payment from gross
receipts of the previously committed crime made to cover the costs of that same
crime.” Kennedy, 707 F.3d at 565. By charging the Gibsons with these two in-
choate crimes, the government did not have to show that “money laundering
occurred” or that the Gibsons made any actual “transaction” or “payment.” Id.;
cf. Iannelli v. United States, 420 U.S. 770, 777–78 (1975) (noting that because
“a conspiracy poses distinct dangers quite apart from those of the substantive
offense,” a “conspiracy to commit an offense and the subsequent commission of
that crime normally do not merge into a single punishable act.” (citation omit-
ted)); Sanjar, 853 F.3d at 202 (finding no Double Jeopardy problem where an
indictment charged defendants with both a Medicare fraud conspiracy under
18 U.S.C. §§ 1347, 1349 and a conspiracy to violate the AKS under 18 U.S.C. §
371); United States v. Cloud, 680 F.3d 396, 408 (4th Cir. 2012) (finding no mer-
ger problem between money laundering conspiracy conviction and a mortgage
fraud conspiracy conviction because the former “was not tied to any specific
payment to a recruiter, buyer, or coconspirator”). 9 Because these distinct
agreements did not clearly and obviously merge, we find no plain error.

       9  Gibson IV argues for the first time in a reply brief that his money laundering con-
spiracy in Count 13 merged with his substantive AKS convictions on Counts 11 and 12. This
eleventh-hour argument is waived. United States v. Myers, 772 F.3d 213, 218 (5th Cir. 2014)
(“We generally do not consider arguments made for the first time in a reply brief . . . .”);
Stanford, 823 F.3d at 851 n.54 (“Stanford makes this argument for the first time in his reply
brief, so it is waived.”). Yet, were we to exercise our “discretion to decide legal issues that
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                                       No. 15-20323
                                              IV.
       Nor do we see reversible error in the district court’s minor limitation of
one cross-examination.
       While cross-examining a former Riverside employee, Gibson III sought
to establish that he had “made clear” to the employee that “it was against the
law to pay for a patient or to pay per patient.” The district court sustained the
government’s hearsay objection. See Fed. R. Evid. 801, 802. Gibson III coun-
tered, unsuccessfully, that the government opened the door by exploring on
direct other statements Gibson III made to the witness during the same con-
versation. Despite sustaining the objection, the district court still permitted
Gibson III to establish on cross that (1) Riverside had an official a policy to
comply with Medicare rules, (2) Gibson III implemented that policy, and (3)
Gibson III never orally contradicted the policy.
       We review for plain error because Gibson III switched tacks between
trial and appeal. See Fed. R. Evid. 103(a)(1)(B); United States v. Green, 324
F.3d 375, 381 (5th Cir. 2003). Whereas he previously insisted this evidence was
admissible because the government had “opened the door” to it, he now invokes
his constitutional right to present a defense and Rule 803’s state-of-mind ex-
ception to the hearsay bar. See U.S. Const. amends. V, VI; Fed. R. Evid. 803(3).
       The Constitution guarantees defendants the right “to present a complete
defense,” Njoku, 737 F.3d at 75, and the “opportunity” to conduct effective

[we]re not timely raised,” Myers, 772 F.3d at 218, we would find no plain error. Counts 11,
12, and 13 reflect different crimes. The alleged conspiracy count requires proof of an agree-
ment to use proceeds of fraud to promote further fraud; this crime is untethered to an actual
payment or kickback. See Njoku, 737 F.3d at 67. By contrast, the kickback offenses in Counts
11 and 12 require proof that the Gibsons knowingly and willfully gave or received a benefit
for referring a party to a health care provider for services paid for by a federal health care
program. Sanjar, 853 F.3d at 211. The jury must have found an actual payment, but not
necessarily fraud. See id. (“[A] kickback violation can occur without any fraudulent billing.”).
Thus, we do not find a clear and obvious merger here. See Scott, 821 F.3d at 570.
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                                   No. 15-20323
cross-examinations, Delaware v. Fensterer, 474 U.S. 15, 19–20 (1985) (per cu-
riam). Of course, the “right to present a complete defense may be violated by
‘evidence rules that infringe upon a weighty interest of the accused and are
arbitrary or disproportionate to the purposes they are designed to serve.’”
Njoku, 737 F.3d at 75 (quoting Holmes v. South Carolina, 547 U.S. 319, 324
(2006)). To establish a constitutionally infirm limitation on his cross-examina-
tion rights, Gibson III must show “that a reasonable jury might have received
a significantly different impression of the witness’s credibility had defense
counsel been permitted to pursue his proposed line of cross-examination.”
United States v. Skelton, 514 F.3d 433, 440 (5th Cir. 2008) (alterations and
quotation marks omitted).
      The district court committed no reversible error, constitutional or evi-
dentiary. Gibson III did not suffer a constitutional deprivation because the
court allowed him to ask whether the witness learned—during the same con-
versation at issue—that Gibson III set Riverside’s policies and that “the policy
was very clear . . . that Riverside General Hospital followed the law and the
regulations with Medicare.” Put differently, the district court permitted Gibson
III to elicit essentially the same (if not better) facts as those he originally prof-
fered. See Sanjar, 853 F.3d at 204–05 (supposed constitutional error in limiting
cross-examination was harmless where the district court permitted some ques-
tioning into the desired testimony). There was no constitutional error, let alone
a harmful one.
      Neither does the court’s evidentiary ruling require reversal. To be sure,
we wonder whether Gibson III’s out-of-court statement—that “it was against
the law to pay for a patient or to pay per patient”—is indeed hearsay. It is
unclear what truth value this statement could carry when everyone agreed
that the AKS indeed forbids such payments. See Fed. R. Evid. 801, 802; 42

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                                        No. 15-20323
U.S.C. § 1320a-7b(b). But as we explained above, any evidentiary error was
harmless. 10
                                               V.
       We also hold that the district court properly admitted a co-defendant’s
out-of-court confession over Gibson III’s Bruton objection. See Bruton v. United
States, 391 U.S. 123 (1968). 11
       The Bruton doctrine addresses the thorny Sixth Amendment problem
where one defendant confesses out of court and incriminates a co-defendant
without testifying at their joint trial. In its landmark opinion, the Bruton Court
reversed a defendant’s postal robbery conviction, see 18 U.S.C. § 2114, on Con-
frontation Clause grounds where his non-testifying co-defendant had made
“powerfully incriminating” statements against the defendant in a pretrial con-
fession, 391 U.S. at 135–36. At trial, a postal inspector testified that the de-
clarant twice confessed—once to say that both the declarant and the defendant
committed the robbery, and again to admit to having an “an accomplice he
would not name[.]” Id. at 124. Though the trial judge instructed the jury to
consider the confessions against only the declarant, the Supreme Court re-

       10  Gibson III argues in passing that the rule of completeness, Fed. R. Evid. 106, re-
quired the district court to admit Gibson III’s unrecorded, oral statement. Not so. Rule 106
applies only to written and recorded statements. Fed. R. Evid. 106; Sanjar, 853 F.3d at 204.
        Gibson III’s brief also asserts (incorrectly) that the proffered statement was “Riverside
did not pay for patients.” Were that truly his statement, his state-of-mind argument would
not establish plain error. Rule 803(3) permits a court to admit statements “of the declarant’s
then-existing state of mind (such as motive, intent, or plan) or emotional, sensory, or physical
condition (such as mental feeling, pain, or bodily health), but not including a statement of
memory or belief to prove the fact remembered or believed . . . .” Fed. R. Evid. 803(3) (empha-
sis added). The assertion, “Riverside did not pay,” is not clearly a statement of motive, intent,
or plan. Rather, it could just as easily be interpreted as the kind of statement of historical
fact or belief that Rule 803(3) precludes.
        11 We review a preserved Bruton argument de novo and for harmless error. United

States v. Ramos-Cardenas, 524 F.3d 600, 606 (5th Cir. 2008).
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                                 No. 15-20323
versed the conviction because there was a “substantial risk that the jury, de-
spite instructions to the contrary, looked to the incriminating extrajudicial
statements in determining petitioner’s guilt[.]” Id. at 126.
      Nearly twenty years later the Supreme Court clarified. Bruton, the Court
wrote, was a “narrow exception,” one that did not preclude a trial court from
admitting a confession that (1) had been redacted, (2) “was not incriminating
on its face,” and (3) “became [incriminating] only when linked with evidence
introduced later at trial (the defendant’s own testimony).” Richardson v.
Marsh, 481 U.S. 200, 207–08 (1987). Eleven years passed before the Supreme
Court again refined its Bruton rule. This time, in another redacted-confession
case, the Court noted that “Richardson must depend in significant part upon
the kind of, not the simple fact of, inference.” Gray v. Maryland, 523 U.S. 185,
196 (1998). Gray held that a redacted confession was “facially incriminat[ing]”
and offended Bruton if it included “statements that, despite redaction, obvi-
ously refer directly to someone, often obviously the defendant, and which in-
volve inferences that a jury ordinarily could make immediately, even were the
confession the very first item introduced at trial.” Id. In finding a Bruton vio-
lation in Gray’s trial, the Supreme Court also emphasized that the redacted
confession had a “blank prominent on its face[.]” Id.
      The Gibsons’ case is closer to Richardson than it is to Gray or Bruton. At
trial, the government called an FBI agent who testified that the Bureau twice
interviewed the Gibsons’ co-defendant, a patient recruiter and file auditor. Ac-
cording to the FBI agent, the co-defendant admitted that Riverside paid per-
sonal care homeowners to bring patients to Riverside, and that the co-defend-
ant herself received checks from Riverside for patients who attended the hos-
pital’s PHPs. Those statements do not include a facial or “obvious” reference to
Gibson III, Gray, 523 U.S. at 196, nor are they “powerfully incriminating,” Bru-

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                                    No. 15-20323
ton, 391 U.S. at 135. They do not mention Gibson III at all; the confession iden-
tifies instead the Riverside Hospital system as a whole. The jury would still
need to make several inferential leaps to conclude that Gibson III, as opposed
to a host of other hospital workers, was behind the kickbacks. The testimony
therefore did not run afoul of Bruton.
      Our recent opinion in United States v. Nanda, 867 F.3d 522 (5th Cir.
2017) confirms our conclusion. There, like here, multiple defendants faced
fraud conspiracy charges. 12 Id. at 526. There, like here, the defendants owned
and operated an entity that made false representations to federal programs.
Id. at 525–26. There, like here, one defendant confessed by accusing the entity
of wrongdoing, without identifying specific individuals. Id. at 526–27. And
there, like here, the non-confessing defendant argued that Bruton applied be-
cause “the reference to [the entity] was in effect a direct allusion to [the co-
defendant] personally.” Id. at 527. We rebuffed that argument in Nanda be-
cause the confessor’s reference to the entity—there, a company called
“Dibon”—did not “directly allude” to the objecting defendant, even if “the Gov-
ernment repeatedly stressed that [the co-defendants] were the central figures
in Dibon’s operation.” Id. Rather, we found that “there were a number of other
Dibon employees involved” in the unlawful scheme, so the confession “could
have referred to any of them.” Id. at 527–28. One need only substitute “Dibon”
with “Riverside” to see how Nanda’s logic and holding obtain here.
      Presented with nearly identical facts with those in Nanda, we follow that
case’s lead. There was no Bruton violation here.

      12 The crime at issue in Nanda was visa fraud in violation of 18 U.S.C. §§ 371 and
1546(a). See 867 F.3d at 526.
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                                   No. 15-20323
                                        VI.
        Gibson III further avers that the district court erred by giving the jury a
“deliberate ignorance” instruction. He raises three points: that the instruction
(1) lacked factual support, (2) impermissibly lowered the government’s burden
to prove his specific intent, and (3) constructively amended the indictment.
None prevails.
        We review preserved charges of instructional error for abuse of discretion
and harmlessness, and unpreserved ones for plain error. Alaniz, 726 F.3d at
611; United States v. St. Junius, 739 F.3d 193, 204 (5th Cir. 2013). Gibson III
preserved his first argument, but not the second and third. See Fed. R. Crim.
P. 30 (“A party who objects to any portion of the instructions . . . must inform
the court of the specific objection and the grounds for the objection before the
jury retires to deliberate.”); United States v. Daniels, 252 F.3d 411, 414 n.8 (5th
Cir. 2001) (“[T]his circuit applies plain error review to forfeited constructive
amendment arguments.”). But even viewing those latter arguments through
an abuse-of-discretion lens, we see no reversible error.
        “A deliberate ignorance instruction informs the jury that ‘it may consider
evidence of the defendant’s charade of ignorance as circumstantial proof of
guilty knowledge.’” United States v. Brown, 871 F.3d 352, 355 (5th Cir. 2017)
(quoting United States v. Nguyen, 493 F.3d 613, 618 (5th Cir. 2007)). Before
turning to the merits, we must reemphasize that deliberate ignorance instruc-
tions should “rarely be given.” Id. 356 (quoting United States v. Kuhrt, 788 F.3d
403, 417 (5th Cir. 2015)). But in some cases it is appropriate. This is one such
case.
        Gibson III’s first salvo is that the evidence did not justify the jury in-
struction. “[A] deliberate indifference instruction is warranted when a defend-
ant claims a lack of guilty knowledge and the proof at trial supports an infer-
ence of deliberate indifference.” United States v. Brooks, 681 F.3d 678, 701 (5th
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                                      No. 15-20323
Cir. 2012) (quotation marks omitted). Thus, “the evidence at trial must raise
two inferences: (1) the defendant was subjectively aware of high probability of
the existence of illegal conduct, and (2) the defendant purposely contrived to
avoid learning of the illegal conduct.” Id.; see also Brown, 871 F.3d at 355–56.
       This case meets both prongs. At trial, Gibson III maintained he lacked
guilty knowledge on all counts. See Brown, 871 F.3d at 356 (“A deliberate ig-
norance instruction is intended for this situation in which Brown knew it was
highly likely that something illegal was afoot, but tried looking the other way
while reaping the benefits of the likely criminal activity.”). And ample evidence
showed that Gibson III was subjectively aware of high probability of illegal
conduct and that he purposely contrived to avoid learning details of the illegal
conduct. Consider Gibson III’s PHP visits that would have revealed obvious
Medicare violations, or his statements that he did not “want to know” how his
son and recruiters were getting patients, or the compliance memos and audits
crossing his desk. Gibson III’s factual attack falters because there was plenty
of evidence from which to infer that Gibson III was deliberately ignorant. 13
       We are similarly unconvinced by Gibson III’s next two arguments—that
the instruction lowered the government’s burden and constructively amended
the indictment. The former is a nonstarter. United States v. Vasquez, 677 F.3d
685, 696 (5th Cir. 2012) (“The deliberate ignorance instruction does not lessen
the government’s burden to show, beyond a reasonable doubt, that the

       13But even assuming, arguendo, the district court erred, the error was harmless. The
same evidence of Gibson III’s subjective awareness of a high risk of illegal conduct supports
a reasonable inference that Gibson III actually knew of that conduct. See United States v.
Wofford, 560 F.3d 341, 354 (5th Cir. 2009) (“The evidence supporting the inference that Wof-
ford was subjectively aware that his conduct was unauthorized and illegal also supports the
inference that he had actual knowledge.”); United States v. Lara-Velasquez, 919 F.2d 946,
952 (5th Cir. 1990) (“[T]he same evidence that will raise an inference that the defendant had
actual knowledge of the illegal conduct ordinarily will also raise the inference that the de-
fendant was subjectively aware of a high probability of the existence of illegal conduct.”).
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                                        No. 15-20323
knowledge elements of the crimes have been satisfied.” (quotation marks omit-
ted)). 14 As is the latter. The jury charge did not tinker with the indictment
because the district court tracked almost verbatim the Fifth Circuit Pattern
Instruction, which we have affirmed time and again as a correct statement of
the law. Brooks, 681 F.3d at 702–03; see also Global-Tech Appliances v. SEB
S.A., 563 U.S. 754, 769–70 (2011); United States v. Hunter, 628 F. App’x 904,
906–07 (5th Cir. 2015) (per curiam). Equally telling is our repeated endorse-
ment of deliberate ignorance instructions in fraud and conspiracy cases just
like this one. See, e.g., Brown, 871 F.3d at 355–56; Sanjar, 853 F.3d at 207;
Hunter, 628 F. App’x at 906–07. This sensible approach squares with our con-
ception of deliberate ignorance instructions as informing a jury “that it may
consider evidence of the defendant’s charade of ignorance as circumstantial
proof of guilty knowledge.” Brown, 871 F.3d at 355 (quotation marks omit-
ted). 15 Thus, the trial court did not err.

       14   Gibson III also attacks the Pinkerton instruction, but offers no authority to explain
how that instruction lowered the government’s burden of proof. This argument is therefore
forfeited. See United States v. Scroggins, 599 F.3d 433, 446–47 (5th Cir. 2010).
        Nevertheless, the argument would also fail on the merits. Charitably construed, Gib-
son III’s brief can be read to argue that Pinkerton is inappropriate where the counts of con-
viction “incorporate[] a specific intent requirement far more stringent than mere foreseeabil-
ity.” United States v. Gonzales, 841 F.3d 339, 351 (5th Cir. 2016) (quotation marks omitted).
That argument ignores our caselaw. See id. at 352–53 (affirming a murder conviction based
on Pinkerton liability). We have consistently upheld convictions for conspiracy and specific-
intent crimes (like Gibson III’s) where the jury heard both Pinkerton and deliberate ignorance
instructions. See, e.g., Sanjar, 853 F.3d at 208–09; Barson, 845 F.3d at 165.
        15 In challenging the deliberate ignorance instruction, Gibson III relies primarily on

this circuit’s decision in United States v. Chen, 913 F.2d 183 (5th Cir. 1990). There, we found
a deliberate ignorance instruction improper for a charge of “knowingly maintaining a
place . . . for the purpose of distributing and using a controlled substance” in violation of 21
U.S.C. § 856(a)(1). Chen, 913 F.2d at 186 (quotation marks and alterations omitted). Alt-
hough at first blush Chen seems to lend Gibson III support, Chen itself eschewed a blanket
rule and apparently limited its holding to 21 U.S.C. § 856(a)(1). See 913 F.2d at 192 n.11
(rejecting the “argument that th[e deliberate ignorance] instruction should be limited to of-
fenses which only proscribe knowing conduct”). And we have since confirmed that Chen is
limited to § 856(a)(1). E.g., United States v. Scott, 159 F.3d 916, 923–24 & n.6 (5th Cir. 1998).
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                                        No. 15-20323
       And even if it did, the evidence of Gibson III’s actual knowledge rendered
any error harmless. Kuhrt, 788 F.3d at 417 (“[T]he giving of the [deliberate
ignorance] instruction is harmless where there is substantial evidence of ac-
tual knowledge.”). In short, although the deliberate ignorance instruction
should be infrequent, the district court spotted a proper case for it. 16
                                              VII.
       We also find no merit in Gibson IV’s restitution objection. The gist of this
argument is that the district court mistakenly based his $7,518,480.11 obliga-
tion on the Medicare payments that Devotions caused. In Gibson IV’s view, the
court should have used the amount of Medicare money Riverside transferred
to Devotions. He also states in passing that the district court should have offset
some amount because his PHP provided the occasional legitimate service to
patients.

        Gibson III also relies on United States v. Kuhrt, a 2015 wire fraud and conspiracy case
where this court quoted Chen in dicta. See 788 F.3d at 417 (“Undoubtedly, the deliberate
ignorance instruction is ‘inappropriate for an offense which requires a specific purpose by the
defendant.’” (quoting Chen, 913 F.2d at 190)). But Kuhrt’s holding did not offer Chen a strong
lifeline. The Kuhrt court found there was only “arguabl[e] error” in giving a deliberate igno-
rance instruction where “[t]he government constructed its case on the premise that Appel-
lants were criminally liable based upon their actual knowledge of the fraud and their efforts
to further the fraud.” Id. But then the opinion held that “[e]ven assuming arguendo that this
was error,” id., the “testimony that Appellants were actual participants in the illegal activity”
rendered the potential error “harmless,” id. at 418. Kuhrt, then, was far from a full-throated
endorsement of Chen and did not extend that case beyond the § 856(a)(1) context.
        16 Gibson III also notes as an aside that the district court erred by directing the delib-

erate ignorance exclusively to him, and not to his co-defendants. See United States v. Bie-
ganowski, 313 F.3d 264, 290 (5th Cir. 2002). But we have recognized that, in some cases,
“giving the [deliberate ignorance] instruction generally, without naming a specific defendant,
may prejudice those co-defendants who do not merit the instruction” and that “the better
approach” may be “to give the instruction and indicate that it may not apply to all of the
defendants.” Id. (quotation marks and citation omitted). In other words, whether to give the
instruction generally or to just one defendant is largely a matter within the trial court’s dis-
cretion. See id. Here, the facts supported the instruction against only Gibson III because his
defense theory differed from his co-defendants’: he argued that, as head of the hospital sys-
tem, he was too far removed to know of any illegal activity. We therefore find no error. See
St. Junius, 739 F.3d at 206 (finding no plain error in giving a deliberate ignorance instruction
for only one defendant).
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                                       No. 15-20323
       Gibson IV preserved his first argument, so we review the restitution or-
der’s legality de novo and its amount for abuse of discretion. United States v.
Benns, 810 F.3d 327, 329 (5th Cir. 2016). He waived the second contention,
however, by inadequately briefing it. United States v. Scroggins, 599 F.3d 433,
446–47 (5th Cir. 2010). True, Gibson IV’s offset claim appears in his statement
of issues, but he reprises it just once: a single sentence in a section devoted to
a different argument. That is insufficient. Id. 17
       We reverse a restitution order “only when” a defendant shows it “proba-
ble that the [trial] court failed to consider a mandatory factor and the failure
to consider the mandatory factor influenced the court.” United States v. Klein,
543 F.3d 206, 215 (5th Cir. 2008) (quoting United States v. Reese, 998 F.2d
1275, 1280–81 (5th Cir. 1993)). “We review the district court’s factual findings
for clear error,” and “[w]e may affirm in the absence of express findings ‘if the
record provides an adequate basis to support the restitution order.’” United
States v. Sharma, 703 F.3d 318, 322 (5th Cir. 2012) (quoting United States v.
Blocker, 104 F.3d 720, 737 (5th Cir. 1997)).
       Gibson IV’s argument—that he should pay restitution only for the Med-
icare funds Riverside transferred to his PHP—misapprehends governing law.
As its name suggests, the Mandatory Victims Restitution Act requires a de-
fendant convicted of “any offense committed by fraud or deceit” to pay restitu-
tion to the victim. 18 U.S.C. §§ 3663A(a)(1), (c)(1)(A)(ii). The statute defines a
“victim” as

       17 Had we reached this incipient argument on the merits, we would have found no
abuse of discretion. The trial court, having presided over weeks of testimony, appropriately
concluded that the fraud was so pervasive that Gibson IV should pay the full restitution
amount. See Sanjar, 853 F.3d at 213 (upholding a district court’s decision not to apply a
restitution credit where “[t]he government presented ample evidence . . . showing [the] entire
PHP practice was fraudulent” and the defendants “offered little to no concrete evidence to
rebut that showing”).
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                                 No. 15-20323
      a person directly and proximately harmed as a result of the com-
      mission of an offense for which restitution may be ordered includ-
      ing, in the case of an offense that involves as an element a scheme,
      conspiracy, or pattern of criminal activity, any person directly
      harmed by the defendant's criminal conduct in the course of the
      scheme, conspiracy, or pattern.
§ 3663A(a)(2). Thus, where, as here, “a fraudulent scheme is an element of the
conviction, the court may award restitution for actions pursuant to that
scheme.” United States v. Maturin, 488 F.3d 657, 661 (5th Cir. 2007) (quotation
marks omitted). Most important, the statute measures restitution by the vic-
tim’s losses, not the amount one guilty defendant transfers to another. 18
U.S.C. § 3664(f)(1)(A) (“The court shall order restitution to each victim in the
full amount of each victim’s losses as determined by the court . . . .” (emphasis
added)). Whether Riverside transferred to Gibson IV all—or just some—of the
Medicare losses he helped inflict is neither here nor there. The district court
did not abuse its discretion.
                                        VIII.
      The Gibsons’ closing charge is that the district court made so many mis-
takes that their trial was fundamentally unfair. Under the “cumulative error
doctrine,” we would reverse a conviction “when an aggregation of non-reversi-
ble errors, i.e., plain and harmless errors that do not individually warrant re-
versal, cumulatively deny a defendant’s constitutional right to a fair trial.”
United States v. Isgar, 739 F.3d 829, 841 (5th Cir. 2014) (quotation marks omit-
ted). At most, however, the Gibsons may have identified a harmless hearsay
mistake. The cumulative error doctrine thus does not apply; “there is nothing
to accumulate.” United States v. Delgado, 672 F.3d 320, 344 (5th Cir. 2012) (en
banc).
                                *   *    *      *   *

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   Case: 15-20323   Document: 00514227799     Page: 30   Date Filed: 11/07/2017

                               No. 15-20323
     For the reasons stated above, the Gibsons’ convictions and sentences are
AFFIRMED and the pro se motions to vacate are DENIED.

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