Court Opinion

ID: 9556512
Source: CourtListenerOpinion
Date Created: 2023-08-17 16:01:28.566427+00
Date Added: 2024-06-11T08:05:16.822610
License: Public Domain

USCA11 Case: 21-11621   Document: 110-1      Date Filed: 08/17/2023   Page: 1 of 34

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

                          ____________________
                               No. 21-11621
                          ____________________

        UNITED STATES OF AMERICA,
                                                       Plaintiﬀ-Appellee,
        versus
        JOHN GLADDEN,
        JESSICA LINTON,

                                                  Defendants-Appellants.

                          ____________________

                 Appeals from the United States District Court
                    for the Northern District of Alabama
                  D.C. Docket No. 6:19-cr-00219-LSC-SGC-7
                           ____________________
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        21-11621                   Opinion of the Court                           2

        Before WILSON, JILL PRYOR, Circuit Judges, and COVINGTON,∗
        District Judge.
        COVINGTON, District Judge:
               Jessica Linton and John Gladden were convicted of
        conspiracy to commit health care fraud and mail fraud, and the
        substantive offenses of health care fraud, mail fraud, and
        aggravated identity theft, for their roles in a multi-year scheme to
        defraud insurance companies. Linton, Gladden, and several others
        at Global Compounding Pharmacy received inflated
        reimbursement payments by billing for medically unnecessary and
        fraudulent prescriptions. Linton and Gladden now appeal their
        convictions. In addition, Gladden appeals the district court’s
        restitution and forfeiture orders. For the following reasons, we
        affirm as to Linton and affirm in part, vacate in part, and remand as
        to Gladden.
                                                    I
                Global Compounding Pharmacy began operations in 2014.
        In its ﬁrst two years of existence, Global billed approximately $193
        million to pharmacy beneﬁt managers (PBMs) and received over
        $49 million in reimbursement payments from PBMs and insurance
        companies.
             As it turns out, Global’s success was attributable to a
        company-wide scheme to defraud pharmacy networks by secretly

        ∗ Honorable Virginia M. Covington, United States District Judge for the

        Middle District of Florida, sitting by designation.
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        21-11621              Opinion of the Court                       3

        billing PBMs for medically unnecessary and fraudulent
        prescriptions.
               When it began operations, Global focused on ﬁlling
        prescriptions for compounded drugs, which are supposed to be
        personalized medications for patients with individual needs. The
        reimbursement rates for these drugs are very high: Global could be
        reimbursed as much as $20,000 for a single tube of a compounded
        cream. Global employees thus saw an opportunity to generate
        signiﬁcant revenue by dispensing more compounded drugs.
        Whether the patients actually had a medical need for these drugs
        was of little concern.
               The underlying conspiracy at Global, which is not in
        dispute, relied on the following methods: adding non-prescribed
        items to prescription forms; incentivizing or paying prescribers to
        write medically unnecessary prescriptions; directing employees to
        obtain high-reimbursement, medically unnecessary prescriptions;
        billing for unauthorized or forged prescriptions; altering
        prescriptions to increase revenue; automatically reﬁlling
        medications; inﬂating the average wholesale price of ingredients
        for compounded drugs; hiring sales representatives who were close
        to prescribers; adding or removing ingredients from compounded
        drugs to increase proﬁts; reducing co-pays to induce beneﬁciaries
        to obtain medically unnecessary prescriptions; and providing false
        information to PBMs during audits.
             A PBM is a company that acts as an intermediary between
        pharmacies and insurance companies. Typically, an insurance
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        21-11621              Opinion of the Court                        4

        company beneﬁciary visits his or her doctor, the doctor prescribes
        the beneﬁciary a prescription drug, and then the beneﬁciary visits
        a pharmacy to ﬁll the prescription. Once the patient brings the
        prescription to a pharmacy, the pharmacy inputs the information
        into the pharmacy processing system, which communicates with
        the PBM. The PBM checks whether the drug is covered and
        determines the beneﬁciary’s co-pay. The PBM shares this
        information with the pharmacy, so that the pharmacy can collect
        the co-pay and dispense the drug.
              A.            Jessica Linton’s Role
              As the manager of the billing department at the Clearwater
        Call Center, Jessica Linton played an integral role in the scheme at
        Global.
               First, Linton and other billers at the Clearwater Call Center
        would run “dummy claims” to identify products covered by
        insurance. The billing department would submit test claims for
        prescriptions to an insurance company to see whether the
        company would reimburse the product, and then claw back the
        claim. Linton would proceed to solicit Global employees to obtain
        prescriptions for the most lucrative products.
               Second, Linton used Global’s preprinted prescription forms
        to add and change prescriptions without the approval of the
        prescribing doctors. For example, on January 6, 2015, Global sales
        representative Joshlyn Bowen emailed Linton about a prescription
        for her husband, Robert Cody Bowen. Dr. John Almirol, who
        treated Robert Bowen as a patient, issued the prescription. In
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        21-11621               Opinion of the Court                        5

        response to Joshlyn Bowen’s email, Linton stated that she received
        the prescription, and confirmed, “[j]ust pain and migraine cream is
        all he needs?” Joshlyn Bowen then asked Linton to add additional
        medication to the prescriptions—without consulting Dr. Almirol.
        Linton did just that.
               Third, Linton directed employees to obtain prescriptions for
        products that the patients would not—or should not—use. For
        example, Jamey Mays, Global’s lead pharmacist, testified that he
        and Linton emailed about a scar patch for which he had received a
        prescription. In an email to Linton regarding whether to reverse
        the prescription, Mays wrote “you can leave it. It is working really
        well,” followed by a winking smiley face. In fact, Mays had never
        received the product. Nor could he have, because as Linton was
        well aware, the product had been discontinued.
                This was not the only time Linton authorized the filling of
        prescriptions for products that would never be used. In June 2015,
        Linton sent a text message to Angie Nelson, a Global district
        manager, about a skin treatment medication called SilaPak that had
        been prescribed to Nelson’s child. Linton’s text message read “hey
        girl, Jamey [Mays] is not comfortable with [patients] under 6 using
        SilaPak. He said he’d let [Nelson’s daughter’s] order ship as long as
        you don’t actually use it on her.”
              As mentioned before, automatic refills were part of Global’s
        scheme. But eventually, some patients began to take issue with the
        surplus of products they were receiving through automatic refills.
        Linton had a solution: reroute the medications of dissatisfied
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        21-11621               Opinion of the Court                        6

        customers to the address of Jeremy Adams, Global’s owner. That
        way, Global could continue to bill insurance for the refilled
        prescriptions that were no longer wanted by the actual patients.
               Donald Edenfield, the former husband of Lori Dawn
        Edenfield, a nurse practitioner relied upon by Global, testified that
        he had received several refills of compounded creams from Global,
        even though he did not need them, had not requested the refills,
        and did not submit co-pays for the refills. Donald Edenfield
        contacted Lori Dawn Edenfield to request that Global stop sending
        him the creams. This seemed to work: Donald Edenfield no longer
        received the creams at his address. However, Global subsequently
        issued a prescription in Donald Edenfield’s name for the
        compounded creams, but with the shipping address on the
        prescription labels listed as Jeremy Adams’ address. Of course,
        Donald Edenfield did not live with Jeremy Adams.
                The same practice was applied to Donald Edenfield’s
        mother, Doris Edenfield. The edit log for Doris Edenfield’s patient
        file reflected that her address on file had been changed to that of
        Jeremy Adams and that prescriptions in her name had been shipped
        to that address.
                 Derrick Wester, who was also formerly married to Lori
        Dawn Edenfield, testified that he too received unwanted refills of
        medication. Wester called Global to ask that it stop sending him
        refills. Global complied, but it continued to issue prescriptions in
        Wester’s name, sending the refills to Adams’s address.
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        21-11621                Opinion of the Court                            7

              The government’s evidence reflects that Linton changed the
        addresses on file for the Edenfields and Wester, permitting Global
        to continue billing insurance for prescriptions that the Edenfields
        and Wester neither wanted nor knew about.
               B.             John Gladden’s Role
                John Gladden was not employed at Global for long before
        he began to notice certain oddities. Shortly after he joined Global
        in 2015 as the district manager for Georgia, Gladden saw “some red
        flags.” Those red flags involved his subordinates’ obtaining a
        significant number of prescriptions for themselves. Specifically,
        after viewing a subordinate’s commission report in February 2015,
        Gladden sent a series of emails to his supervisor, Phillip Marks. In
        one email, Gladden wrote “AMAZING . . . of the 27 scripts, only 2
        are for [] real patients . . . the other 25 appear to be for [the
        employee].” He then sent another email: “I’m sorry, I had to go
        back and take a third look in disbelief at his report . . . it was three
        actual patients not two . . . clearly still an amazing feet [sic]! lol[.]”
               Gladden did not resign in response to these red flags. Nor
        did he report the false prescriptions to his superiors. Instead, he
        decided that he wanted in on the action. So, Gladden directed his
        sales representatives to obtain prescriptions for themselves for
        products with high reimbursement rates, like SilaPak. On July 9,
        2015, Gladden sent his sales team an email with the subject line
        “Get your personal scripts,” proclaiming that “everyone should
        have a personal script for yourself, spouse, and family members.”
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        21-11621               Opinion of the Court                         8

               As it turns out, Gladden was not deeply concerned with the
        health and wellbeing of his employees and their family members.
        One of Gladden’s sales representatives, Dawn Whitten, responded
        to Gladden’s email, stating that she did not “want to draw a red flag
        to the MD or to me and my family.” She noted that none of her
        family members “have any documentation in our medical chart
        that would require a Rx for pain.” This was not an issue for
        Gladden: he responded to Whitten, writing that she should “[a]t
        least get the SilaPak . . . I would just have ur buddy wright [sic] it
        for you[.]” The “buddy” was Dr. Steven Leichter, an
        endocrinologist. Gladden had visited Dr. Leichter’s office with
        Whitten before, so he knew that Dr. Leichter was a diabetes
        specialist with no reason to prescribe dermatology products.
               Whitten ultimately obtained prescriptions for herself and
        her family members, including her twelve-year-old daughter. Dr.
        Leichter was listed as the prescribing physician for those
        prescriptions; however, Whitten testified that Dr. Leichter did not
        authorize the prescriptions.
               Megan Rumble, another sales representative who worked
        for Gladden, also obtained medically unnecessary prescriptions at
        his direction. Rumble testified that she did not have any “medical
        need” for the prescriptions she obtained, but she got them “because
        [she] was instructed to.”
              C.            District Court Proceedings
              A grand jury sitting in the Northern District of Alabama
        returned a 103-count indictment charging Linton, Gladden, and
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        21-11621               Opinion of the Court                        9

        eight co-defendants for their roles in this scheme. Linton was
        charged with conspiracy to commit health care fraud and mail
        fraud, in violation of 18 U.S.C. § 1349 (Count 1), thirteen counts of
        health care fraud, in violation of 18 U.S.C. § 1347 (Counts 10–11,
        16–19, 23–25, 30–33), three counts of mail fraud, in violation of 18
        U.S.C. § 1341 (Counts 60, 64–65), and seven counts of aggravated
        identity theft, in violation of 18 U.S.C. § 1028A (Counts 70–75, 79).
               Gladden was charged with conspiracy to commit health care
        fraud and mail fraud (Count 1), six counts of health care fraud
        (Counts 34–39), one count of mail fraud (Count 66), and one count
        of aggravated identity theft (Count 84).
               Following a six-day jury trial, Gladden and Linton were
        convicted on all counts. Linton was sentenced to 132 months’
        imprisonment, followed by three years of supervised release.
        Gladden was sentenced to 64 months’ imprisonment, followed by
        one year of supervised release. Linton was ordered to pay
        restitution in the amount of $39,370,481.41 and forfeiture in the
        amount of $335,775.93. Gladden was ordered to pay restitution in
        the amount of $134,772.86 and forfeiture in the amount of
        $157,587.33.
               Specifically, the presentence investigation report (PSR) for
        Gladden reported the amount of loss attributable to Gladden for
        his role in the scheme as between $1,500,000 and $3,500,000. To
        calculate the Guidelines range, the probation officer grouped
        together the conspiracy and fraud claims, resulting in a base offense
        level of seven. The probation officer applied a two-level
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         21-11621              Opinion of the Court                      10

         enhancement for Gladden’s role as a manager in the scheme, and
         another two-level obstruction of justice enhancement. After an
         additional sixteen-level enhancement to account for Gladden’s
         attributable loss ranging from $1,500,000 to $3,500,000, Gladden’s
         total offense level was 27.
                The PSR indicated that restitution would be ordered at
         sentencing, but that the court could apportion restitution
         payments based on the victims’ losses and Gladden’s economic
         circumstances. The PSR also noted that the government intended
         to seek an order of forfeiture against Gladden.
                Gladden objected to the PSR. He contended that the
         government failed to provide sufficient documentation or evidence
         for the loss amount. According to Gladden, the attributable loss
         amount should not exceed $31,104.
                Before sentencing, the government moved for a final order
         of forfeiture for $167,587.33 against Gladden, which was the
         amount of his salary during his time at Global. The government
         sought forfeiture only as to property derived from gross proceeds
         traceable to the commission of the health care fraud conspiracy
         charged in count one of the indictment. The government argued
         that Gladden’s salary constituted the proceeds from his role in the
         fraud conspiracy. According to the government, fraud permeated
         so many aspects of Global’s operations that Global would not have
         operated in the way that it did or paid Gladden his salary but for
         the fraudulent conduct.
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         21-11621              Opinion of the Court                     11

               In response, Gladden argued that the proposed forfeiture
         order was overly punitive because he was found responsible for
         only six fraudulent prescriptions at a total cost of $31,104.
         According to Gladden, the forfeiture amount should be $210.21,
         which was the total compensation he received for those six
         fraudulent prescriptions. Gladden also asserted that it was
         improper to attribute all of his income to his offenses because he
         was not involved in the overall conspiracy beyond forwarding
         emails.
                At sentencing, the government called investigator Katherine
         Gerhardt to explain the total loss and restitution calculations.
         Gerhardt calculated that the entire fraudulent scheme at Global
         generated $2,118,271.54 in insurance payments, which Gerhardt
         considered the loss amount. To calculate the loss amount,
         Gerhardt first isolated the prescriptions for which no co-pay had
         been collected. Next, for each of those prescriptions, Gerhardt
         subtracted the co-pay amount from the retail price, the sum of
         which reflected the amount that insurance paid to Global. To
         calculate the loss amount attributable to Gladden, Gerhardt
         applied this methodology to the commission reports of Gladden’s
         subordinates. Based on Gerhardt’s methodology, the government
         proposed $134,772.86 in restitution, which represented the amount
         insurance paid Global for the fraudulent prescriptions that two of
         Gladden’s subordinates, Whitten and Rumble, obtained for
         themselves and their family members.
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                Gladden contended that the restitution calculation should
         exclude prescriptions that were medically necessary, which, in his
         view, could be established if a patient ultimately used the
         prescribed drugs for a medical purpose. According to Gladden,
         because Whitten and her family used the drugs they received, they
         should be omitted from the restitution amount. The district court
         rejected Gladden’s argument, disagreeing with the premise that an
         overprescribed product was medically necessary simply because
         some of it was used. The district court also found unavailing
         Gladden’s argument that the restitution amount should not
         include refills, reasoning that Gladden knew his subordinates were
         ordering the refills.
                As for Gladden’s forfeiture order, the district court accepted
         the government’s argument that Gladden’s full salary should be the
         forfeiture amount because his salary constituted the gross proceeds
         traceable to the commission of the health care fraud conspiracy
         charged in count one of the indictment.
                On appeal, Linton challenges only her convictions. Gladden
         challenges his convictions, as well as the restitution order and
         forfeiture judgment against him.
                                              II
                When analyzing the sufficiency of the evidence, this Court’s
         review is de novo, “viewing the evidence in the light most favorable
         to the government, with all reasonable inferences and credibility
         choices made in the government’s favor.” United States v. Sosa, 777
         F.3d 1279, 1289 (11th Cir. 2015) (quotations omitted). We “will not
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         21-11621                Opinion of the Court                         13

         overturn a conviction on the grounds of insufficient evidence
         unless no rational trier of fact could have found the essential
         elements of the crime beyond a reasonable doubt.” United States v.
         Wright, 392 F.3d 1269, 1273 (11th Cir. 2004) (internal quotations
         omitted).
                This Court reviews the legal bases for a restitution order de
         novo and factual findings concerning a restitution order for clear
         error. United States v. Foley, 508 F.3d 627, 632 (11th Cir. 2007).
         Likewise, “[i]n reviewing forfeiture orders, we review findings of
         fact for clear error and legal conclusions de novo.” United States v.
         Goldstein, 989 F.3d 1178, 1202 (11th Cir. 2021). The Court will find
         clear error if, “after reviewing all the evidence, [it is] left with the
         definite and firm conviction that a mistake has been committed.”
         United States v. Alicea, 875 F.3d 606, 608 (11th Cir. 2017) (per
         curiam) (internal quotations omitted).
                                               III
                A.            Jessica Linton’s Convictions
                Linton argues that, as to all her convictions, the government
         failed to present sufficient evidence to demonstrate that she
         possessed the requisite mens rea. We disagree.
                Beginning with Linton’s conspiracy conviction, the jury
         reasonably found that Linton knowingly and voluntarily joined the
         conspiracy at Global based on her conversations with Jamey Mays
         and Angie Nelson about prescriptions for medically unnecessary
         products. See United States v. Moran, 778 F.3d 942, 960 (11th Cir.
         2015) (stating that to establish conspiracy under 18 U.S.C. § 1349,
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         21-11621               Opinion of the Court                        14

         “the government must prove that (1) a conspiracy existed; (2) the
         defendant knew of it; and (3) the defendant knowingly and
         voluntarily joined it.”). While Linton contends she was unaware of
         the conspiracy at Global, her argument is belied by the evidence
         reflecting her willingness to bill for prescriptions that were never
         filled or intended to be used. See id. (noting that the government
         may prove the elements of conspiracy by circumstantial evidence).
         Indeed, Mays told Linton not to reverse a prescription for a
         discontinued product, even going so far as to joke about how it was
         working really well—punctuated by a winking smiley face. Linton
         also told Nelson that Mays would permit her to fill a prescription
         for Nelson’s minor daughter, on the express condition that
         Nelson’s daughter not use the product.
                 Linton’s efforts to conceal aspects of the conspiracy further
         support her conviction. See United States v. Reeves, 742 F.3d 487, 500
         (11th Cir. 2014) (“[E]fforts to conceal a conspiracy may support the
         inference that a defendant knew of the conspiracy and joined it
         while it was in operation.”). On at least one occasion, Linton
         disciplined an employee who provided truthful information to a
         pharmacist about Global’s billing practices. Specifically, Fermin
         Alfonso—a biller who reported to Linton at the Clearwater Call
         Center—testified that he told Global pharmacist Judith Reynolds
         that several sales representatives were automatically adding certain
         ingredients to prescriptions in order to receive higher
         reimbursements. Linton subsequently issued a written warning to
         Alfonso for “[p]utting in writing a false statement that could result
         in legal action[.]” In reality, however, Linton displayed little
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         21-11621               Opinion of the Court                         15

         concern with the substance of Alfonso’s allegations. Linton told
         Alfonso “not to worry about” the reprimand and “not to take it too
         seriously.” Nor did Linton find it necessary to instruct Alfonso to
         change anything about his billing practices. The written warning,
         juxtaposed with Linton’s verbal indication not to worry about it,
         supports an inference that the warning was an effort to obscure the
         nature of the billing practices that Linton condoned.
                 Linton also instructed her subordinates in an August 12,
         2015, email to avoid putting notes in patients’ prescription
         management systems that would reveal that the patient “is paying
         a certain amount less than what their copay is.” Such a discrepancy,
         as it turns out, could raise red flags in an audit. The jury could thus
         reasonably infer from Linton’s email that she participated in the
         practice of reducing co-pays and took steps to conceal it.
                 As to Linton’s substantive fraud convictions, she contends
         that she lacked the specific intent to defraud necessary to support
         the convictions for health care and mail fraud. We disagree.
         Linton’s conversations with Mays and Nelson are more than
         sufficient to demonstrate her knowledge that Mays and Nelson
         were submitting false claims. See United States v. Medina, 485 F.3d
         1291, 1297 (11th Cir. 2007) (stating that to sustain a conviction for
         health care fraud, the government must prove that the defendant
         knew that the claims submitted to the health care benefit program
         were false); United States v. Wheeler, 16 F.4th 805, 819 (11th Cir.
         2021) (per curiam) (“To prove that a defendant had the intent to
         defraud, the [g]overnment has to prove that the defendants either
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         21-11621               Opinion of the Court                       16

         knew they were making false representations or acted with
         ‘reckless indifference to the truth.’”). Indeed, it is difficult to
         conceive that Linton was unaware of the falsity of the prescriptions
         in light of her knowledge that Mays was issuing prescriptions with
         an explicit directive that the patient not use the product.
                Linton nevertheless contends that she did not intend to
         defraud because she lacked experience in the compounding
         industry. This argument is unpersuasive. Linton’s conversations
         with Mays and Nelson would give pause to even a novice in the
         industry. Furthermore, Linton was made aware of the fraudulent
         practices at Global at various points throughout the scheme.
                Specifically, Judith Reynolds testified that she expressed her
         concerns about certain practices at Global at a meeting where
         Linton was present. Those practices involved unpaid co-pays and
         the receipt of duplicate therapies by patients—including sales
         representatives. Reynolds also highlighted that patients were
         receiving significantly more of a product than necessary and that
         Global employees were underbilling certain insurance companies
         to avoid reaching a cap.
                 Likewise, Stapp Harrison, another pharmacist at Global,
         testified that he took issue with some of the practices at the
         Clearwater Billing Center. Harrison testified that he noticed issues
         such as erroneous billing, which he relayed to Jamey Mays.
         Specifically, in a June 22, 2015, email to Mays, Harrison stated “I
         would like to reiterate that the billing center appears to be billing
         erroneously,” noting that “we should not bill for something and
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         21-11621               Opinion of the Court                        17

         when not covered mark through it, and choose a different drug.”
         Harrison then wrote “Jamey its [sic.] time for this to stop. I want
         better business practices.” Thereafter, Mays forwarded the email
         to Jeremy Adams and Linton.
               Despite learning of fraudulent conduct at Global, Linton
         made no effort to change any of her practices. Linton’s inaction
         undermines her argument that lack of experience was to blame for
         her improper conduct. For all of these reasons, the evidence
         presented at trial is more than sufficient to sustain Linton’s
         convictions for conspiracy, health care fraud, and mail fraud.
                As for Linton’s substantive aggravated identity theft
         convictions, Linton contends that the Supreme Court’s recent
         decision in Dubin v. United States, 143 S.Ct. 1557 (2023), requires
         vacatur. We disagree.
                In Dubin, the Supreme Court held that the words “use” and
         “in relation to” in 18 U.S.C. § 1028A should not be read so broadly
         that the statute would “apply automatically any time a name or
         other means of identification happens to be part of the payment or
         billing method used in the commission of a long list of predicate
         offenses.” Id. at 1564–65. Instead, the Court explained that a
         “defendant ‘uses’ another person’s means of identification ‘in
         relation to’ a predicate offense when this use is at the crux of what
         makes the conduct criminal.” Id. at 1573. Section 1028A’s reach is
         thus limited to situations where “a genuine nexus” exists between
         the use of a means of identification and the predicate offense. Id. at
         1565.
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                The Court clarified, however, that the statute still proscribes
         “use[s] [of a means of identification] involving fraud or deceit about
         identity[.]” Id. at 1570. Dubin thus redirects the statute’s focus to
         “offenses built around what the defendant does with the means of
         identification in particular.” Id. at 1568. “In other words, the means
         of identification specifically [must be] a key mover in the
         criminality.” Id.
                Again, Linton contends that, pursuant to Dubin, her
         aggravated identity theft convictions should be vacated. According
         to Linton, the jury instructions presented at trial were erroneous,
         and further, Section 1028A is an unconstitutionally vague statute.
                 As an initial matter, we review Linton’s Dubin-related
         arguments under a plain-error standard. Linton did not object to
         the indictment or the jury instructions on the basis of the elements
         of the statute at issue in Dubin. “The plain-error standard applies
         even if, as is the case here, there were no legal grounds for
         challenging the instructions at the time they were given, but such
         legal grounds have since arisen due to a new rule of law arising
         between the time of conviction and the time of appeal.” United
         States v. Pelisamen, 641 F.3d 399, 404 (9th Cir. 2011); see United States
         v. Reed, 941 F.3d 1018, 1020 (11th Cir. 2019) (reviewing a conviction
         for plain error where an intervening change in law altered the
         elements the government was required to prove under the charged
         statute). Plain error exists only if the defendant “demonstrates that
         (1) there is an ‘error’; (2) the error is ‘clear or obvious, rather than
         subject to reasonable dispute’; (3) the error ‘affected the
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         21-11621               Opinion of the Court                       19

         [defendant’s] substantial rights, which in the ordinary case means’
         it ‘affected the outcome of the district court proceedings’; and (4)
         ‘the error seriously affect[s] the fairness, integrity or public
         reputation of judicial proceedings.’” United States v. Marcus, 560
         U.S. 258, 262 (2010) (citations omitted).
                Linton cannot establish plain error because, even if the first
         two requirements are met, she has not established “a reasonable
         probability that the error affected the outcome of the trial.” Id.
         Even under the circumscribed reading of Section 1048A set forth in
         Dubin, Linton’s conduct falls within the statute’s purview. Linton
         deliberately changed the addresses on file for Donald Edenfield,
         Doris Edenfield, and Derrick Wester to that of Jeremy Adams so
         that Global could continue billing for the products. In other words,
         Linton represented to the PBMs and insurance companies that
         Global was filling prescriptions for the Edenfields and Wester
         when, in reality, the products were being sent to Adams.
                Linton’s forgery of the Edenfields’ and Wester’s identities is
         at the heart of the deception: Linton used the identities of the
         Edenfields and Wester to continue refilling prescriptions in their
         names, even though they were neither aware of nor received any
         products. Because the deception centered on the identity of the
         individual receiving the product, Linton committed identity theft.
         See Dubin, 143 S.Ct. at 1568 (“This central role played by the means
         of identification, which serves to designate a specific person’s
         identity, explains why we say that the ‘identity’ itself has been
         stolen.”). The use of the fraudulent identities was central to the
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         21-11621               Opinion of the Court                       20

         scheme at Global; Linton’s fraudulent representation that
         individuals such as the Edenfields and Wester were the recipients
         of the prescriptions issued in their names directly enabled Global
         to continue billing for medically unnecessary prescriptions.
                Further, as to Robert Bowen, Linton obtained a prescription
         for additional medications on his behalf through the fraudulent use
         of Dr. John Almirol’s means of identification. Dr. Almirol had
         signed and authorized a prescription for Robert Bowen. After
         emailing with Joshlyn Bowen, Linton fraudulently altered the
         already-signed prescription to permit Global to bill for additional
         medically unnecessary drugs without Dr. Almirol’s knowledge. In
         other words, Linton affirmatively represented to the insurance
         companies and PBMs that Dr. Almirol had authorized the
         additional prescriptions when, in fact, he had not.
                 Linton’s use of Dr. Almirol’s means of identification is
         distinct from the conduct at issue in Dubin, where the defendant
         misrepresented only the qualifications of the professional who
         performed psychological testing on a patient to increase the
         reimbursement from Medicaid. Dubin, 143 S. Ct. at 1563–64.
         Linton’s use of Dr. Almirol’s identity was central to the deception:
         she used his “means of identification itself to defraud or deceive.”
         Id. at 1568. The insurance companies and PBMs would not have
         provided reimbursement had they known that Dr. Almirol had not
         actually authorized the prescriptions. That Dr. Almirol had
         originally authorized at least one prescription for Robert Bowen is
         of no moment. See id. at 1568 n.6 (noting that the act of stealing an
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         21-11621               Opinion of the Court                        21

         identity can “include situations where [it] was initially lawfully
         acquired”). By explicitly using Dr. Almirol’s identity to falsely
         represent to insurance and PBMs that the prescriptions were
         authorized, Linton appropriated Dr. Almirol’s personal
         information to deceive others. See id. at 1570 (“As the definitions
         reveal, identity theft covers both when ‘someone steals personal
         information about and belonging to another . . . and uses the
         information to deceive others[.]’” (quoting Black’s Law Dictionary
         894 (11th ed. 2019)). Thus, because Dr. Almirol’s signature on the
         prescription form directly enabled Linton to bill for the medically
         unnecessary products, “the means of identification specifically
         [was] a key mover in the criminality.” Id. at 1568.
                 In short, unlike in Dubin, Linton did not provide a service to
         a client while merely misrepresenting how the service was
         performed to inflate the bill. Rather, Linton used the means of
         identification of former patients and prescribing doctors to overbill
         for certain products. Linton’s conduct thus falls squarely within the
         classic variety of identity theft left untouched by Dubin. Her use of
         the Edenfields’ and Wester’s identifying information was itself
         fraudulent or deceptive because Linton represented those patients
         were receiving the refills, despite shipping the product to Jeremy
         Adams. And her use of Dr. Almirol’s means of identification was
         fraudulent because she falsely represented he had authorized the
         additional prescriptions for Robert Bowen.
               Linton’s mens rea argument similarly fails. Linton contends
         that because Section 1028A contains the word “knowingly,” the
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         21-11621               Opinion of the Court                       22

         government must prove that Linton knew that the means of
         identification was at the crux of the health care fraud.
                We need not opine on the correctness of Linton’s reading of
         the mens rea requirement because even under her interpretation
         of the statute, the evidence at trial is more than sufficient to
         establish that she knew the means of identification of Donald and
         Doris Edenfield, Derrick Wester, and Dr. Almirol were “used . . .
         during and in relation to” the health care fraud conspiracy. First,
         the evidence that Linton rerouted prescriptions for Donald and
         Doris Edenfield and Derrick Wester to the address of Jeremy
         Adams demonstrates her knowledge that the means of
         identification were critical to the conspiracy. Linton knew that the
         Edenfields and Wester had asked to no longer receive refills of their
         prescriptions, yet she deliberately chose to continue billing
         insurance for prescriptions obtained in their names. Linton thus
         knew that the Edenfields’ and Wester’s means of identification
         were being used to further the conspiracy—indeed, she was the
         one who was using them.
                Second, there is ample evidence that Linton knew that Dr.
         Almirol’s means of identification were misappropriated. In her
         email to Linton, Joshlyn Bowen offered to return to Dr. Almirol to
         have him write an additional prescription for her husband. Linton
         declined this invitation, instead choosing to alter the prescription
         herself. Linton was thus aware that Dr. Almirol’s means of
         identification would be used to permit her to bill for additional
         medications on Robert Bowen’s behalf.
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         21-11621               Opinion of the Court                       23

                 Finally, Linton’s vagueness argument is unavailing. As the
         government correctly points out, Linton failed to preserve this
         argument: she neither argued it to the district court, nor did she
         raise it on appeal in her opening or reply briefs. While the question
         of vagueness was not directly before the Court in Dubin, the Court
         nevertheless made clear that “[t]he concurrence’s bewilderment is
         not, fortunately, the standard for striking down an Act of Congress
         as unconstitutionally vague.” Dubin, 143 S. Ct. at 1573 n.10. Under
         that guidance, we decline to find that Section 1028A is
         unconstitutionally vague.
               B.            John Gladden’s Convictions
                Gladden raises several challenges to his convictions for
         conspiracy, health care and mail fraud, and aggravated identity
         theft. We address his arguments in turn, and ultimately uphold his
         convictions for conspiracy, health care fraud, and mail fraud. But
         we vacate his conviction for aggravated identity theft.
               While Gladden acknowledges that “there is no doubt that a
         conspiracy existed within Global to defraud various insurance
         companies,” he contends there is insufficient evidence to find that
         he was aware of and willfully joined the conspiracy. We disagree.
                The jury reasonably found that Gladden was aware of and
         joined the conspiracy at Global based on the email Gladden sent to
         Phillip Marks regarding Boyd’s medically unnecessary
         prescriptions and the emails Gladden sent to his subordinates
         urging them to obtain prescriptions. Gladden’s email to Marks, in
         which he wrote “AMAZING . . . of the 27 scripts, only 2 are for []
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         21-11621               Opinion of the Court                        24

         real patients . . . the other 25 appear to be for [Boyd],” undermines
         any claim that he was unaware of the scheme at Global. See United
         States v. Gonzalez, 834 F.3d 1206, 1216 (11th Cir. 2016) (finding a
         jury could infer knowledge based on evidence that the defendant
         knew she was providing services that were not medically
         necessary). The email exchange between Gladden and Megan
         Rumble, where Rumble stated “I run into issues every month
         getting my RXs filled along with the appropriate ones,” further
         supports the jury’s finding that Gladden was privy to the scheme at
         Global.
                Not only was Gladden aware of the scheme at Global; he
         capitalized on it. In one email to his subordinates, Gladden wrote
         “everyone should have a personal script for yourself, spouse, and
         family members” and that he “[would] be monitoring this to make
         sure that ALL OF TEAM GEORGIA has [their prescriptions].”
         When Dawn Whitten responded to Gladden that she was worried
         that obtaining prescriptions she did not need would raise “red
         flags,” he did not share her concern. Instead, he said she should
         have her endocrinologist “buddy” write her a prescription for a
         topical cream. Thus, the jury could reasonably have interpreted
         Gladden’s emails as a directive to his subordinates to obtain
         medically unnecessary prescriptions.
                 As for Gladden’s health care and mail fraud convictions, he
         argues that (1) there was insufficient evidence that the prescriptions
         were medically unnecessary, given that it is not per se illegal for
         sales representatives to obtain prescriptions for themselves or their
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         21-11621              Opinion of the Court                       25

         family members; and (2) there was insufficient evidence of a
         specific intent to defraud. We are unpersuaded.
                 With respect to Gladden’s convictions for health care fraud,
         the evidence presented at trial overwhelmingly demonstrates
         Gladden’s knowledge that the prescriptions obtained by Whitten
         for herself and her family members were medically unnecessary.
         See Medina, 485 F.3d at 1297 (stating that, to sustain a conviction
         for health care fraud under Section 1347, the government must
         prove that the defendant knew that the submitted claims were
         false). Gladden’s argument that it is not per se illegal for sales
         representatives to obtain prescriptions for themselves or their
         family members is unavailing. The emails from Gladden to his
         subordinates—in which he directed them to obtain prescriptions
         before any of them had visited a doctor—supports the jury’s
         inference that Gladden knew the prescriptions were medically
         unnecessary. See United States v. Grow, 977 F.3d 1310, 1322 (11th
         Cir. 2020) (per curiam) (finding sufficient evidence of Defendant’s
         knowledge of healthcare fraud where “there was evidence that
         [Defendant] and his representatives told the telemedicine doctors
         what to prescribe before the doctors consulted with recruits”);
         United States v. Melgen, 967 F.3d 1250, 1255–57 (11th Cir. 2020)
         (upholding a conviction for healthcare fraud where the scheme
         involved a doctor “pre-filling” patient forms so that the eye
         condition was a default diagnosis before the doctor even met with
         a patient).
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                 These emails also support Gladden’s mail fraud conviction.
         Despite Whitten’s email explaining that neither she nor her family
         members had any medical need for the prescriptions Gladden was
         encouraging her to obtain, Gladden nevertheless told her to get a
         “buddy” to write the prescriptions. This email exchange
         sufficiently evinces the intent to defraud necessary to sustain
         Gladden’s mail fraud conviction. See Wheeler, 16 F.4th at 819 (“To
         prove that a defendant had the intent to defraud, the Government
         has to prove that the defendants either knew they were making
         false representations or acted with ‘reckless indifference to the
         truth.’”).
                However, Dubin requires that we vacate Gladden’s
         conviction for aggravated identity theft. Because Gladden did not
         raise a Dubin claim in the district court proceedings or on appeal,
         we review for plain error.
                 As an initial matter, we disagree with the government’s
         contention that “there is no error or defect in the indictment or
         jury instruction.” Rather, Dubin makes clear that the jury
         instruction for aggravated identity theft is erroneous at least in part
         because one sentence in the jury instruction—“[t]he means of
         identification at least must facilitate, or have the potential of
         facilitating, the crime alleged in the indictment”—suggests that
         mere facilitation of the predicate offense is sufficient to support a
         conviction. The Court in Dubin rejected such a broad reading of
         Section 1028A. Dubin, 143 S.Ct. at 1573. Because Dubin made clear
         that “being at the crux of the criminality requires more than . . .
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         21-11621               Opinion of the Court                       27

         facilitation of the offense,” the jury instruction was erroneous. Id.
         (internal quotation marks omitted).
                 Further, we find that this error “affected the outcome of the
         district court proceedings” as to Gladden. Marcus, 560 U.S. at 262.
         Gladden’s conviction for aggravated identity theft was based on the
         prescription that Whitten obtained for her minor daughter.
         Whitten testified that the prescription in question was not
         medically necessary, and that it was obtained using a pre-filled
         prescription. The deception at the heart of Whitten and Gladden’s
         conduct, then, was obtaining the medically unnecessary
         prescriptions. The use of Whitten’s daughter’s identifying
         information was merely ancillary to the deception; indeed, at no
         point did Whitten and Gladden misrepresent who received the
         prescriptions. See Dubin, 143 S.Ct. at 1565 (“When a means of
         identification is used deceptively, this deception goes to ‘who’ is
         involved, rather than just ‘how’ or ‘when’ services were
         provided.”).
                The conduct underlying Gladden’s identity theft conviction
         is thus distinct from Linton’s. While Linton misrepresented who
         was receiving the prescriptions, Gladden’s misrepresentation to the
         insurance companies and PBMs involved only whether the
         prescriptions were medically necessary. This conduct was illegal—
         as we discuss above—but it was not aggravated identity theft.
               The government’s reliance on United States v. Michael, 882
         F.3d 624 (6th Cir. 2018), is misplaced. There, the Sixth Circuit
         found identity theft where the defendant used both the doctor and
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         21-11621               Opinion of the Court                       28

         the patient’s identifying information to “fashion a fraudulent
         submission out of whole cloth.” Id. at 629. Here, in contrast,
         Gladden did not forge the name of the prescribing doctor on the
         prescription. Nor did he misrepresent who would be receiving the
         filled prescription. Rather, Whitten had her “doctor buddy” write
         a prescription for her minor daughter, which she was lawfully
         entitled to do. The only misrepresentation that occurred was
         whether the prescription was medically necessary. Because a
         reasonable jury could not convict Gladden of identity theft under
         the standard articulated in Dubin, fairness dictates we vacate his
         conviction. See Marcus, 560 U.S. at 262.
                C.           Forfeiture and Restitution
                Only Gladden challenges the district court’s forfeiture and
         restitution orders. Gladden argues that the restitution and
         forfeiture orders exceed the amount of loss that his actions caused.
         Pursuant to Medina, he insists that his restitution and forfeiture
         amounts should be limited to “the amount of loss the government
         proved the victim PBMs suﬀered when they paid for these
         prescriptions,” rather than all of the income and prescriptions
         Gladden’s sales representatives generated.
                 The government argues that the district court did not clearly
         err in imposing Gladden’s restitution amount, as it is supported by
         the total amount of loss attributable to him. Given the
         reimbursements for medically unnecessary prescriptions that
         Gladden directed others to obtain for themselves and their family
         members, the government contends that $134,772.86 is a
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         21-11621               Opinion of the Court                         29

         reasonable estimate of loss. As for forfeiture, the government
         argues that the district court did not clearly err in ordering
         forfeiture in the amount of $157,587.33. The calculated forfeiture
         amount represents the net proceeds Gladden received during his
         time at Global minus a $10,000 payment from Global that predated
         his employment. Thus, the government contends that “the district
         court reasonably estimated that Gladden’s salary represented gross
         proceeds traceable to” the fraud because he would not have
         received the money but for “his active participation in the
         fraudulent conspiracy at Global.”
               We ﬁrst address Gladden’s arguments as to restitution,
         before moving on to forfeiture.
                1.     Restitution
                The Mandatory Victim Restitution Act of 1996 (“MVRA”),
         18 U.S.C. § 3663A, requires a defendant convicted of fraud to pay
         restitution to the victims of his offense. 18 U.S.C. § 3663A(a)(1),
         (c)(1)(A)(ii). The government bears the burden of proving the
         amount of loss by a preponderance of the evidence. Id. § 3664(e).
         However, “the government need not calculate the victim’s actual
         loss with laser-like precision, but may instead provide a ‘reasonable
         estimate’ of that amount.” United States v. Martin, 803 F.3d 581, 595
         (11th Cir. 2015).
                Under the MVRA, an entity is a “victim” if it suffered “harm
         that directly and proximately result[ed] from the commission of”
         the offense. United States v. Robertson, 493 F.3d 1322, 1334 (11th Cir.
         2007) (internal quotations omitted). “[T]he government must
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         21-11621               Opinion of the Court                       30

         show not only that a particular loss would not have occurred but
         for the conduct underlying the offense of conviction, but also that
         the causal connection between the conduct and the loss is not too
         attenuated (either factually or temporally).” Id. (quotations
         omitted). In healthcare fraud cases, restitution amounts must be
         offset by the value of medically necessary goods and services that
         were provided. United States v. Bane, 720 F.3d 818, 828 (11th Cir.
         2013). “The defendant bears the burden to prove the value of any
         medically necessary goods or services he provided that he claims
         should not be included in the restitution amount.” Id. at 829 n.10.
                We find no reason to disturb the district court’s restitution
         order. The evidence presented at trial demonstrates that Gladden
         was an active participant in the conspiracy at Global and directed
         his subordinates to take out medically unnecessary prescriptions.
         See United States v. Whitman, 887 F.3d 1240, 1248 (11th Cir. 2018)
         (explaining that the district court may hold all participants in a
         conspiracy responsible for the losses resulting from the reasonably
         foreseeable acts of co-conspirators that are “within the scope of the
         jointly undertaken criminal activity [and] in furtherance of” the
         activity (internal quotations omitted)). The district court thus did
         not clearly err in basing restitution on the medically unnecessary
         prescriptions that Gladden directed his subordinates to obtain.
                Further, Gladden does not dispute Gerhardt’s calculations of
         the loss amount caused by the medically unnecessary prescriptions.
         However, Gladden argues that, under Medina, a prescription is
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         21-11621               Opinion of the Court                        31

         medically necessary and should not be used to calculate restitution
         so long as some of the medicine was used.
                 Gladden’s reliance on Medina is misplaced. First, nowhere in
         Medina did this Court hold that a prescription is medically
         necessary so long as the intended recipient used some of the drug.
         See generally Medina, 485 F.3d at 1304–05 (holding that the district
         court clearly erred when it did not make specific factual findings on
         which to base the loss amounts attributable to each defendant).
         Second, in Medina, this Court found the district court committed
         clear error where there was “no evidence presented” that the
         claims at issue were not medically necessary. Id. at 1304. Here, in
         contrast, the district court did not clearly err in finding that the
         claims were not medically necessary. The evidence at trial was
         sufficient to establish that Whitten and Rumble did not have a
         medical need for the prescriptions they were obtaining. The district
         court’s restitution order stands.
               2.     Forfeiture
                A defendant convicted of health care fraud must forfeit
         property “that constitutes or is derived, directly or indirectly, from
         gross proceeds traceable to the commission of the offense.” 18
         U.S.C. § 982(a)(7). To evaluate whether “gross proceeds” are
         “traceable to the commission of the offense,” this Court applies a
         but-for standard. United States v. Hoffman-Vaile, 568 F.3d 1335, 1344
         (11th Cir. 2009). A defendant’s salary may be the proper measure
         of forfeiture where “the fraud was pervasive and the [company’s]
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         21-11621                Opinion of the Court                          32

         operations could not have continued at all without [the fraud].”
         United States v. Moss, 34 F.4th 1176, 1195 (11th Cir. 2022).
                Relevant here, the D.C. Circuit has applied a but-for test to
         determine whether a forfeiture ordered under Section 982(a)(7)
         excludes legitimate services from proceeds. See United States v.
         Bikundi, 926 F.3d 761 (D.C. Cir. 2019) (per curiam); see also Moss, 34
         F.4th at 1195 (citing Bikundi favorably in discussing but-for
         reasoning in forfeiture cases). The Bikundi court held that forfeiture
         ordered under Section 982(a)(7) did not exclude legitimate services
         from proceeds where the money obtained from the fraud had
         propped up the defendants’ legitimate services. Bikundi, 926 F.3d at
         793. On appeal, defendants challenged the forfeiture of the entirety
         of the Medicaid proceeds received by defendants’ company, despite
         the district court’s acknowledgement that the company provided
         and was reimbursed for some legitimate services unconnected to
         the health care fraud offenses. Id. at 792–93.
                 In upholding the forfeiture order, the D.C. Circuit first
         emphasized the breadth of the statute that authorizes forfeiture in
         health care fraud cases, noting that “‘[g]ross proceeds traceable to’
         the fraud include ‘the total amount of money brought in through
         the fraudulent activity, with no costs deducted or set-offs applied.’”
         Id. at 792 (citing United States v. Poulin, 461 F. App’x 272, 288 (4th
         Cir. 2012)). Thus, the court noted that “whereas other forfeiture
         statutes allow credit for ‘lawful services,’ . . . the statute for health
         care fraud does not.” Id. at 793.
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         21-11621               Opinion of the Court                       33

                The Bikundi court found no error in the district court’s
         determination that the total payments received constituted or were
         derived from gross proceeds traceable to the health care fraud
         offenses because “the pervasive fraud was integral to each and
         every Medicaid payment” to the company. Id. The district court
         based this determination on the finding that the company “would
         not have operated but for [each] defendant’s fraud” and that the
         total Medicaid proceeds received were “only paid due to the
         defendants’ persistent and rampant fraudulent conduct.” Id.
         (quotations omitted).
                Here, the district court’s forfeiture amount—$157,587.33—
         represents a subset of the $167,587.33 in salary that Gladden was
         paid by Global in 2015. The district court based this amount on the
         determination that, at the time of the scheme, Global was
         permeated with fraud and that “but for the long-running health-
         care-fraud conspiracy perpetrated by Defendant Gladden and
         others, it would not have existed in the form in which it did,
         generated anywhere near the revenue that it did, or paid Defendant
         his $167,587.33 salary in 2015.”
                Like in Bikundi, the evidence demonstrates that Global’s
         legitimate operations were facilitated by the illegitimate
         operations. Gladden has presented no evidence calling the factual
         accuracy of the district court’s statement into question; there is
         nothing to suggest that this was clear error by the district court.
         Gladden’s salary is thus the proper subject of forfeiture because, in
         the absence of the conspiracy in which Gladden participated,
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         21-11621               Opinion of the Court                        34

         Global would not have employed and compensated Gladden the
         way that it did. In the language of the statute, Gladden’s salary
         constitutes the gross proceeds traceable to the commission of the
         offense, because in the absence of Gladden’s—and the other
         conspirators’—conduct, it is unlikely that Global would have been
         able to continue operations in the manner that it did. Even if
         Gladden did participate in some legitimate transactions during his
         time at Global, these transactions were propped up by the
         illegitimate transactions.
                The district court thus did not clearly err in determining that
         Global’s operations were so pervaded by fraud that Gladden would
         not have received his salary but for the scheme. The district court’s
         forfeiture order stands.
                                              IV
                For the reasons stated above, we conclude that the evidence
         presented at trial was suﬃcient to support the jury’s verdict as to
         all of Jessica Linton’s convictions and as to John Gladden’s
         convictions for conspiracy, health care fraud, and mail fraud. In
         addition, the district court did not clearly err in calculating John
         Gladden’s restitution and forfeiture amounts. However, because
         John Gladden’s use of the means of identiﬁcation of Dawn
         Whitten’s minor daughter was merely ancillary to the health care
         fraud, we vacate his conviction for aggravated identity theft and
         remand for further proceedings consistent with this opinion.
             AFFIRMED as to Jessica Linton and AFFIRMED IN PART,
         VACATED IN PART, AND REMANDED as to John Gladden.