Court Opinion

ID: 4227933
Source: CourtListenerOpinion
Date Created: 2017-12-12 20:00:38.559935+00
Date Added: 2024-06-11T14:15:59.390089
License: Public Domain

Case: 16-13614   Date Filed: 12/12/2017   Page: 1 of 41

                                                                    [PUBLISH]

          IN THE UNITED STATES COURT OF APPEALS

                   FOR THE ELEVENTH CIRCUIT
                     ________________________

                           No. 16-13614
                     ________________________

                D.C. Docket No. 1:15-cr-20436-DPG-8

UNITED STATES OF AMERICA,

                                                             Plaintiff-Appellee,

                                versus

CARLOS RODRIGUEZ NEREY,

                                                        Defendant-Appellant.

                     ________________________

              Appeal from the United States District Court
                  for the Southern District of Florida
                    ________________________

                          (December 12, 2017)
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Before HULL, JORDAN, and BOGGS, * Circuit Judges.

HULL, Circuit Judge:

       In this direct criminal appeal, defendant Carlos Rodriguez Nerey appeals

both his convictions and total sentence related to his role as a patient recruiter and

his receipt of kickbacks in a complex health care fraud scheme. Following a five-

day trial, a jury found defendant Nerey guilty on the two charges against him in the

indictment. After thorough review of the briefs and extensive trial record, and with

the benefit of oral argument, we affirm.

                           I.     PROCEDURAL HISTORY

       On September 29, 2015, defendant Nerey and several other individuals—

including Milka Alvarez, Jesus Perez, Joel Alvarez, Sandra Jaramillo, Adolfo

Larrea, and Maria Teresa Pupo—were charged in a thirteen-count superseding

indictment. All of Nerey’s co-defendants eventually pled guilty while he

proceeded to trial. Nerey was charged on two counts: (1) conspiracy to defraud the

United States under 18 U.S.C. § 371 by paying and receiving health care

kickbacks, in violation of 42 U.S.C. § 1320a-7b(b)(1)(A), (b)(1)(B), and (b)(2)(A)

(Count 2) and (2) knowingly soliciting and receiving kickbacks in connection with

       *
        Honorable Danny J. Boggs, United States Circuit Judge for the Sixth Circuit, sitting by
designation.
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a federal health care program, in violation of 42 U.S.C. § 1320-7b(b)(1)(A)

(Count 9).

      On April 1, 2016, a jury found Nerey guilty on both counts. The district

court denied Nerey’s motion for judgment of acquittal before the verdict was

rendered and denied his renewed motion thereafter. On May 27, 2016, the district

court sentenced Nerey to sixty months’ imprisonment on each count to run

concurrently, three years of supervised release, and restitution in the amount of

$2,366,746.

                            II.     TRIAL EVIDENCE

      Because defendant Nerey challenges the sufficiency of the evidence

supporting his convictions, we outline the trial evidence about the Medicare

program, the various home health care agencies engaged in the fraud and

kickbacks, and Nerey’s involvement.

A. Medicare

      Medicare is a health insurance program overseen by the federal government

and is intended for people of age 65 or older or people with a qualifying disability.

Medicare is funded through taxpayer contributions and small recipient premiums.

Patients who qualify for Medicare benefits have services furnished by a Medicare

provider like a doctor, hospital, or home health agency. Once a service is

performed, that provider can bill Medicare and claim payment. Medicare
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contractors designated by the respective states will then review claims submitted

for payment. Some claims take two weeks to process, while others may take up to

a month.

      Claim reviewers look to the following five components for the legitimacy of

claims: (1) the patient’s entitlement to Medicare; (2) proper enrollment of the

provider; (3) the provision of services; (4) compliance with coverage rules; and

(5) proper reporting of records. Because Medicare receives such a high volume of

claims, however, rarely do all claims receive a complete and thorough review.

Categorically, Medicare does not pay for claims based on kickbacks or bribes. See

42 U.S.C. § 1320-7b(b).

B. Home Health Care

      Under Medicare, “home health care” refers to medical services for patients

who require special treatment because they are “homebound.” Homebound

patients suffer from a physical or mental limitation that prohibits them from

leaving home on a routine basis without the assistance of a wheelchair, walker, or

another individual.

      Homebound status must be determined and documented by a physician. For

home health care agencies to properly bill Medicare, their patients must have a

prescription for home health care. Patients must meet with a physician and

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establish a plan of care in order to legitimately receive a prescription. Thereafter,

the treating physician is required to provide progress notes once treatment begins.

      All treatment provided in home health care is by skilled professionals—

licensed doctors, nurses, and therapists. With respect to therapy, Medicare covers

physical therapy, occupational therapy, and speech language pathology. Massage

therapy is not covered under home health care. Likewise, therapy notes taken after

a session must be recorded by, and come from, a licensed physical therapist.

      Relevant to our review is the fact that home health care agencies engage in

fraud when they, inter alia, (1) submit claims for a patient who does not qualify for

treatment, (2) fail to perform the work billed to Medicare, or (3) pay a kickback to

a patient recruiter. As the name suggests, a patient recruiter procures eligible

Medicare beneficiaries and exchanges their information with providers for a

kickback on any claims paid by Medicare.

C. Jesus Perez and Mercy Home Care, Inc.

      The fraud perpetrated in this case, including Nerey’s involvement, centers

on Jesus Perez, one of Nerey’s co-defendants. Perez had a long history with home

health care agencies, starting with his work at Wong Home Health Care in 2006

and then La Caridad in 2013 or 2014. At trial, Perez admitted to engaging in

Medicare fraud and paying patient recruiters as far back as his work at La Caridad.

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      Eventually, in late 2014, Perez transitioned to working for Mercy Home

Care, Inc. (“Mercy HC”), where he continued these illegal practices. Before he

became the owner of Mercy HC, Perez complained to Nerey, one of his previous

acquaintances, about the salary Perez was receiving there as an employee. Nerey

responded by suggesting that Perez begin inflating invoices.

      Perez later became the owner of Mercy HC in October 2014 and enlisted the

assistance of close friends and family, including Jesus Garcia and Adolfo Larrea,

to help run his operation. At trial, Joel Alvarez described Adolfo Larrea as Perez’s

“right hand.” Several individuals, including Perez’s then-wife, Anelys Ayala, were

used to cash checks for the payment of illegal kickbacks to recruiters. Another

patient recruiter at Mercy HC was Yovani Suarez, who went by the nickname

“Tito.” As the group would later discover, Suarez was a confidential informant for

the Federal Bureau of Investigation (“FBI”).

      Perez’s testimony suggested that he obtained ownership of Mercy HC from

its actual owner, Contrado Pineida, through falsified documents. Perez insisted

that the transfer was nonetheless done at Pineida’s instruction. Under Perez’s

leadership, Mercy HC submitted fraudulent claims to Medicare and negotiated

extensive kickbacks for patient recruiters.

      Raciel Leon served as the manager at Mercy HC and kept a book of patient

recruiters and payoffs. Leon’s logbook was used to keep track of which recruiters
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held claim to recruiting which patients. It included patient information along with

a column coded by letters to mask kickback recipients. To keep track of his

patients, Nerey would cross-reference this logbook with his own records. While

each recruiter had his or her own letter or letters, entries containing the letter G

stood for “gordo,” or “fat guy” in Spanish, which was Nerey’s nickname. When

paying their recruiters, Perez and Leon utilized inflated invoices, which were later

submitted to Medicare, to mask payoffs and made special notations on the memo

lines in checks to recruiters—such as “SS” or “special service”—to identify

recruiting payments.

D. Nerey, Sweet Life Staffing, and Nerey Professional Services, Inc.

      Around November 2014, Nerey became associated with Mercy HC. Nerey

was active in Mercy HC’s operation by recruiting patients through an established

book of patients and purchasing prescriptions, both real and forged, for home

health care. Sandra Jaramillo and Karla Garcia, two other co-defendants, both

testified that defendant Nerey carried around a small notebook full of patient

names and information. At Mercy HC, Nerey was Perez’s top source of patients,

all of whom were eligible Medicare beneficiaries. Perez paid Nerey between

$1,800 and $2,200 per patient recruited.

      Nerey used several companies—the two most relevant being Sweet Life

Staffing (“Sweet Life”) and Nerey Professional Services, Inc. (“NPS”)—to funnel
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kickback money. Mercy HC would split payments to Nerey between cash to him,

which he requested, and checks to Sweet Life and NPS, which eventually became

necessary due to the amount of money involved in the conspiracy.

      Sweet Life was a therapy-staffing company used by Nerey to process his

recruiting kickbacks. While several witnesses testified that Nerey claimed

ownership of Sweet Life, the registered owner was actually Daylin Cabrera.

Nonetheless, Nerey required that all of the patients he recruited be assigned to

Sweet Life for “therapy.” Nerey processed kickbacks through Sweet Life using

inflated and falsified invoices for fraudulent therapy services. Invoices were

handled in several ways, but often broken into smaller $30 amounts per therapy

session to cover up larger kickback amounts.

      Nerey was not a licensed physical therapist or nurse, but nearly every fact

witness testified that he regularly wore medical scrubs when they encountered him.

Likewise, witnesses reported that patients received massages from Nerey and

others he employed in the place of prescribed physical therapy. Karla Garcia

described Nerey’s therapy office as a “very little” building with two small rooms

and a lobby located inside a shopping center.

      Defendant Nerey also owned and created NPS as a shell corporation to

deposit and process kickback payments. NPS observed no formalities of an

established business and paid no taxes, wages, or licensing fees during its
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existence. The company itself provided no services other than processing

payments related to Nerey’s patient-recruiting activities, and it enjoyed a 60%

profit margin. Nerey also used NPS to pay for fraudulent and forged home health

prescriptions, which he obtained mostly through Dr. Hugo Espinosa at Yava

Medical Office, Inc. (“Yava Medical”) and Karla Garcia at Larkin Community

Hospital (“Larkin Hospital”).

E. Recruiting Karla Garcia

      Karla Garcia worked as a medical assistant at Larkin Hospital. She was

introduced to defendant Nerey through another patient recruiter identified only as

“Alexis.” Around October or November 2014, Karla and Nerey met for the first

time in a Wendy’s parking lot to discuss patient recruiting. At this meeting, Nerey

told Karla that he received recruiting kickbacks from Mercy HC and a company

called Holistic Home Health. Nerey agreed to pay Karla $150 per prescription and

$600 per patient. He explained an approach for recruiting and instructed her on

exactly how to forge prescriptions. Nerey later told Karla that it was also

necessary to pay patients to keep them quiet.

      At some point, Karla’s husband also became involved in paying off patients

and processing funds through a shell company he created for Karla, Kb Health

Consultants, LLC. Karla testified that defendant Nerey offered her husband a job

as a “physical therapist” at Sweet Life even though he had no formal training.
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      After Karla and Nerey had a falling out over kickback payments, she began

recruiting patients independently for Perez. Karla was fired from Larkin Hospital

in April 2015, but she continued working as a patient recruiter. The operation at

Mercy HC was becoming so successful that, in an effort to slow the amount of

money funneled out, the agency had to lower patient admission rates to only those

patients who were truly homebound. Around the same time that Karla entered the

business, Perez decided that it was time to expand.

F. Joel Alvarez and D&D&D Home Health Care, Inc.

      Joel Alvarez became involved in the conspiracy through Jesus Garcia, an

above-mentioned associate whose son went to school with Alvarez’s daughter.

Garcia introduced Alvarez to Perez in a meeting at Mercy HC in November 2014.

Nerey was also present at that meeting. Perez explained aspects of home health

services and patient recruiting to Alvarez and asked him to enter the business.

      In December 2014, at the behest of Perez, Alvarez provided a capital

investment in the amount of $80,000 for the purchase of a new home health

agency, D&D&D Home Health Care, Inc. (“D&D&D”), to be owned jointly with

Perez and Garcia. Due to his relative experience and contacts in the field,

Perez established the operation and negotiated kickback rates for patient recruiting.

At the beginning, D&D&D did not have a sufficient patient volume to be

profitable.
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      To get the business off the ground, D&D&D immediately began providing

kickbacks to patient recruiters, specifically defendant Nerey. In fact, the initial

efforts to drum up business were facilitated entirely through Nerey. D&D&D paid

kickbacks to Nerey at the same rate negotiated at Mercy HC. Because of his

established book of patients, Nerey was able to negotiate favorable rates with

Perez. Like Mercy HC, all of D&D&D’s patients had to be eligible Medicare

beneficiaries because the agency was not approved by any other health

maintenance organization (“HMO”).

      In January 2015, Alvarez’s wife, Sandra Jaramillo, also became involved in

the scheme. Her role at D&D&D was to manage kickbacks. Raciel Leon, the

manager at Mercy HC, trained Jaramillo to track kickback payments in a logbook.

Jaramillo copied Leon’s system, and Alvarez later digitized the results in a chart.

Nerey described his recruiting efforts to Jaramillo as “filling the nest” for

D&D&D.

      At trial, Alvarez explained that recruiter kickbacks, a primary illegal aspect

of the operation, were often referred to among the group as the “parte negra,”

which translates from Spanish as the “black part.” Alvarez claims he later

discovered that not only were patient recruiters being paid in kickbacks but so were

the patients themselves. Patients involved in the scheme would regularly call

D&D&D asking for “flowers,” which referred to a promised kickback. Nerey and
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others would also use code language for patient kickbacks, as when Nerey told

Alvarez that he had “canes in his car” for the patients.

      Later still, Alvarez claims that he discovered that patients were not receiving

services that were billed by Sweet Life. After patients complained about not

receiving therapy services, Daylin Cabrera assured Alvarez and Jaramillo that

services were actually being provided. Nerey also claimed that he could handle the

problem. In some instances, the invoice for service included the signature of

therapists who no longer worked for the company. When challenged, Nerey and

Cabrera purportedly changed the signature to another therapist who had not

performed the service either. During the conspiracy, Nerey would bring therapist

notes into Mercy HC and D&D&D. Nerey later had Cabrera handle this task.

G. Medicare Investigation and Arrests

      At the end of February 2015, Medicare placed Dr. Hugo Espinosa under

review. Because Dr. Espinosa was a major source of prescriptions, Nerey was not

paid for many of his patients once this occurred. Soon thereafter, Medicare also

audited Mercy HC as a result of larger-than-normal patient growth. The

government investigation uncovered that many patients did not meet the

homebound requirement for home health care and that patients were going to

multiple home health care agencies under prescriptions from multiple doctors.

Once Medicare halted payments to Mercy HC, Perez continued to transfer Nerey’s
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patients from Mercy HC to D&D&D. The government investigation undoubtedly

created chaos within the operation. Sandra Jaramillo’s testimony suggests that, in

March or April 2015, Nerey sought to collect payment from D&D&D on the

patients that did not involve Dr. Espinosa.

      As the investigation progressed, Perez and Nerey had a phone conversation

about whether Yovani Suarez was a confidential informant for the FBI. The two

discussed “breaking [Suarez’s] head” because of his cooperation with the

government. Perez testified that Nerey said he went to find Suarez and had “strong

words” with him. Perez testified that Nerey also said he took apart all telephones

before speaking with Suarez to “make sure there were no microphones that could

have picked up their conversation.” In June 2015, the government began arresting

individuals involved in the fraud schemes at Mercy HC and D&D&D. Raciel

Leon purportedly burned his kickback logbook when these arrests began.

H. Transfer of Funds

      At trial, an FBI forensic accountant analyzed the business transactions of the

conspiracy through approximately fifteen bank accounts related to persons and

entities involved in this case. In a summary of her findings with respect to Nerey,

the accountant explained that “Medicare moneys that were deposited into the home

healthcare agencies [Mercy HC and D&D&D and could] then [be] trac[ed] . . . into

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other entities such as Sweet Life, [NPS] and Carlos Rodriguez Nerey or his d/b/a

known as Rodriguez Case Management.”

       In total, Medicare paid claims submitted by Mercy HC and D&D&D in the

amount of $2,366,746—$1,205,324 and $1,161,422, respectively. In turn, these

two home health care agencies paid, among others, Sweet Life, NPS, and Nerey.

Sweet Life would then also pay Nerey and NPS. Between the two home health

care agencies and Sweet Life, Nerey and NPS received at least $249,0981 in checks

traceable to claims submitted to and paid by Medicare. This amount does not

include cash payments to Nerey that he did not deposit.

       With this factual background, we now turn to the issues on appeal.

                     III.   SUFFICIENCY OF THE EVIDENCE

       Nerey first contends that the evidence at trial, which came mostly in the

form of co-conspirator testimony and corroborating documentation, was

insufficient to support his two convictions. Challenges to the sufficiency of

evidence to support a conviction are reviewed de novo. United States v. Baldwin,

774 F.3d 711, 721 (11th Cir. 2014). However, the court must view the evidence

and all reasonable inferences derived therefrom in the light most favorable to the

government. Id.; United States v. Doe, 661 F.3d 550, 560 (11th Cir. 2011); United

       1
         This figure does not represent an additional $10,800 transferred to Nerey from Sweet
Life that the FBI forensic accountant testified to discovering upon further review.
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States v. Diaz, 248 F.3d 1065, 1084 (11th Cir. 2001). Evidence will be deemed

sufficient to sustain a conviction unless “no rational trier of fact could have found

proof of guilt beyond a reasonable doubt.” Diaz, 248 F.3d at 1093 (citing Jackson

v. Virginia, 443 U.S. 307, 322–25, 99 S. Ct. 2781, 2790–92 (1979)).

      Here, Nerey was convicted of (1) conspiracy to defraud the United States, in

violation of 18 U.S.C. § 371, by paying and receiving health care kickbacks, in

violation of 42 U.S.C. § 1320a-7b(b)(1)(A), (b)(1)(B), and (b)(2)(A), and (2) the

receipt of kickbacks in connection with a federal health care program, in violation

of 42 U.S.C. § 1320a-7b(b)(1)(A). Underlying both the conspiracy and the

substantive violation is conduct prohibited by the Anti-Kickback statute. See

42 U.S.C. § 1320a-7b(b). Thus, we first address the Anti-Kickback statute and

then discuss its application to each offense.

      Section 1320a-7b(b), which is entitled “Illegal remunerations,” prohibits the

actual or attempted receipt or payment of kickbacks or other illicit funds in

connection with a federal health care program. See 42 U.S.C. § 1320a-7b(b).

Subsections (b)(1)(A) and (b)(1)(B) provide as follows:

      (1) whoever knowingly and willfully solicits or receives any
      remuneration (including any kickback, bribe, or rebate) directly or
      indirectly, overtly or covertly, in cash or in kind—

      (A) in return for referring an individual to a person for the furnishing
      or arranging for the furnishing of any item or service for which

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      payment may be made in whole or in part under a Federal health care
      program, or

      (B) in return for purchasing leasing, ordering, or arranging for or
      recommending purchasing, leasing, or ordering any good, facility,
      service, or item for which payment may be made in whole or in part
      under a Federal health care program,

      shall be guilty of a felony and upon conviction thereof, shall be fined
      not more than $25,000 or imprisoned for not more than five years, or
      both.

Id. § 1320a-7b(b)(1) (emphasis added).        Subsection (b)(2)(A) provides

similarly that

      (2) 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—

      (A) to refer an individual to a person for the furnishing or arranging
      for the furnishing of any item or service for which payment may be
      made in whole or in part under a Federal health care program, . . .

      shall be guilty of a felony and upon conviction thereof, shall be fined
      not more than $25,000 or imprisoned for not more than five years, or
      both.

Id. § 1320a-7b(b)(2) (emphasis added).

      “For a defendant to be found guilty of conspiracy, the government must

prove beyond a reasonable doubt (1) that the conspiracy existed; (2) that the

defendant knew of it; and (3) that the defendant, with knowledge, voluntarily

joined it.” United States v. Vernon, 723 F.3d 1234, 1273 (11th Cir. 2013)

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(quotation marks omitted); see United States v. Sosa, 777 F.3d 1279, 1290 (11th

Cir. 2015) (quoting same). The conduct charged in the conspiracy in Count 2

included violations of § 1320a-7b(b)(1)(A), (b)(1)(B), and (b)(2)(A). Thus, as to

the first element of this offense, the government had to show the existence of a

conspiracy involving the conduct described in these provisions.

      As to the substantive violation of the Anti-Kickback statute in Count 9,

which involved only (b)(1)(A), the government had to prove that Nerey

(1) knowingly and willfully (2) solicited or received money (3) for referring

individuals to a health care provider (4) for the furnishing of services to be paid by

Medicare. See Vernon, 723 F.3d at 1252.

      In this case, overwhelming evidence supports Nerey’s convictions. As

discussed above, Nerey solicited and paid for home health prescriptions from

Larkin Hospital through Karla Garcia and from Yava Medical through Dr. Hugo

Espinosa. In turn, Nerey would then refer patients with these home health

prescriptions to Mercy HC and D&D&D in exchange for kickbacks masked as

therapy and other professional services. Mercy HC and D&D&D would use these

patients and home health prescriptions to bill Medicare with inflated invoices for

services that were technically unnecessary or were never performed. Once claims

were processed by Medicare, Mercy HC and D&D&D would then remit funds to

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Nerey directly or through NPS, Sweet Life, or by checks made out to and cashed

by various co-conspirators.

      At trial, four of Nerey’s co-conspirators—Jesus Perez, Joel Alvarez, Sandra

Jaramillo, and Karla Garcia—testified that Nerey accepted and received kickbacks

for referring patients to Mercy HC and D&D&D. Perez, Alvarez, and Jaramillo

also each identified checks that they drafted to NPS and Sweet Life to compensate

Nerey for recruiting patients. Due to their lack of credibility with other HMOs,

Mercy HC and D&D&D only had patients who were eligible Medicare

beneficiaries, and so Nerey understood that his recruiting efforts and resulting

kickbacks would be tied to and for the purpose of inducing claims filed with

Medicare.

      Nerey contends that this evidence was insufficient to convict him because

the four co-conspirators were cooperating witnesses with the government. This

Court has held, however, that “[t]estimony of a co-conspirator, even if

uncorroborated, is sufficient to support a conviction.” United States v. Broadwell,

870 F.2d 594, 601 (11th Cir. 1989). In any event, the testimony in this case was

corroborated by a substantial paper trail and forensic analysis of bank accounts

accessible solely by Nerey.

      The government’s forensic accountant traced back to Nerey at least

$249,098 worth of checks linked to paid Medicare claims. Once Medicare paid the
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claims submitted by Mercy HC and D&D&D, these two agencies paid kickbacks

to Nerey and numerous other patient recruiters. Yet, Nerey’s prolific recruiting led

Mercy HC and D&D&D to furnish kickbacks in at least three ways. First, the two

agencies would pay Nerey directly, either with cash from another co-conspirator or

by checks written to Nerey for “special services.” Second, the agencies wrote

checks to Sweet Life, which would then funnel that money to Nerey under the

guise of therapy services. Third, the agencies would write checks to NPS or

another entity owned by Nerey. Nerey would then deposit all checks received into

various bank accounts associated with him and his companies.

      Nerey also challenges whether the government sufficiently proved willful

conduct under the substantive violation. See 42 U.S.C. § 1320a-7b(b)(1)(A).

Willful conduct under the Anti–Kickback statute means that the act was

“committed voluntarily and purposely, with the specific intent to do something the

law forbids, that is with a bad purpose, either to disobey or disregard the law.”

Vernon, 723 F.3d at 1256. In this case, the government showed Nerey’s

willfulness in a number of ways surrounding his attempts to hide the illegal

kickbacks.

      First, Nerey sought cash payments to avoid a paper trail. Second, Nerey

attempted to funnel his kickbacks through Sweet Life masked as therapy services.

Third, conspirators coded recruiter participation in a logbook and referred to
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kickbacks by code because of their illegal nature. Fourth, Nerey and Perez agreed

to a fallback story in the event of a Medicare audit. And fifth, Nerey showed

consciousness of his guilt through his reaction to the news that Suarez might be a

confidential informant by agreeing that he would like to “break his head.”

      For all of these reasons and after careful review of the trial record, we find

that the overwhelming evidence at trial sufficiently supported Nerey’s convictions.

                      IV.     PROSECUTOR’S CONDUCT

      Nerey also argues that the prosecution engaged in misconduct that shifted

the burden of proof. Determinations regarding prosecutorial misconduct involve

mixed questions of law and fact and, therefore, are subject to de novo review. See

United States v. Eckhardt, 466 F.3d 938, 947 (11th Cir. 2006); United States v.

Noriega, 117 F.3d 1206, 1218 (11th Cir. 1997).

      As discussed above, the government in a criminal proceeding has the burden

of proving every element of the charged offense beyond a reasonable doubt.

United States v. Simon, 964 F.2d 1082, 1086 (11th Cir. 1992). This being the

case, prosecutors must refrain from making arguments that improperly shift the

burden of proof to the defendant. Id. A defendant in a criminal case has no

obligation to produce any evidence or to prove his or her innocence. See id.

      Four factors influence a determination as to whether prosecutorial

misconduct occurred: “(1) the degree to which the challenged remarks have a
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tendency to mislead the jury and to prejudice the accused; (2) whether they are

isolated or extensive; (3) whether they were deliberately or accidentally placed

before the jury; and (4) the strength of the competent proof to establish the guilt of

the accused.” United States v. Feliciano, 761 F.3d 1202, 1211 (11th Cir. 2014)

(internal quotation marks omitted).

       Prosecutorial misconduct justifies a new trial only if the remarks in question

were both (a) improper and (b) prejudicial to the defendant’s substantial rights.

Eckhardt, 466 F.3d at 947; see also United States v. Frank, 599 F.3d 1221, 1237–

38 (11th Cir. 2010) (referring to rights as “substantive” rather than “substantial”).

Substantial rights are prejudiced when there is “a reasonable probability . . . that,

but for the remarks, the outcome of the trial would have been different.” Eckhardt,

466 F.3d at 947. Yet, substantial evidence establishing guilt may counteract claims

of prejudice. See United States v. McLean, 138 F.3d 1398, 1403 (11th Cir. 1998)

(“[Defendant] cannot show prejudice in the face of the overwhelming evidence of

his guilt.”).

       Likewise, the district court may negate prejudice from the improper

comments by issuing a curative instruction. Simon, 964 F.2d at 1087 (“This court

has held that the prejudice from the comments of a prosecutor which may result in

a shifting of the burden of proof can be cured by a court’s instruction regarding the

burden of proof.”); see also United States v. Gonzalez, 122 F.3d 1383, 1389 (11th
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Cir. 1997) (finding no substantial prejudice where district court sustained defense

counsel’s objections and gave a curative instruction). The jury is presumed to have

followed such a curative instruction by the district court. United States v. Wilson,

149 F.3d 1298, 1302 (11th Cir. 1998).

      In this case, defendant Nerey points to five instances of alleged misconduct

by the prosecution. Defense counsel objected on each occasion. First, during the

redirect examination of Jesus Perez, the prosecution inquired whether defense

counsel “ask[ed] anything at all about conversations that [Perez] had with [Nerey]

about kickbacks that [Perez] paid.” Nerey argues that this question was improper

because it implied that defense counsel should have asked such a question.

Whether proper or not, we cannot say that asking this question shifted the burden

of proof on redirect examination.

      The other four challenged instances were comments that occurred during

closing argument. The second and third instances both involved the prosecutor’s

reference back to what defense counsel had said in his opening statement. In the

second instance, the prosecution argued in closing the following:

      There is no dispute here that D&D&D and Mercy committed fraud
      from the day they opened their doors until the day their operation was
      cut short in June 2015 by a series of arrests. Defense counsel, he
      agreed with this in his opening statement but he said it was just a
      coincidence that the defendant happened to work there too. To accept
      his version of the facts[,] the defendant profited off the scheme.

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      In the third instance, the prosecution commented that “[t]his is a federal

crime and this is the crime charged in Count 9 of the indictment. [Defense

counsel] told you in his opening—.” Mid-sentence, defense counsel objected to

this characterization of his opening statement. On this ground, the district court

overruled the objection. The prosecution continued: “[Defense counsel] told you

in his opening statement that these two home healthcare companies were total

frauds and there was no doubt that this scheme hinged on an army of patient

recruiters.” Defense counsel never renewed the objection as to the complete

sentence.

      The second and third instances were not improper because they were in fact

consistent with defense counsel’s opening statement that “[n]ow, I’m not saying

that fraud did not occur [at Mercy HC and D&D&D] because it did. What I’m

saying is that Carlos Rodriguez Nerey was not involved in that fraud.” Defense

counsel also mentioned Nerey’s co-defendants, saying: “They’re going to tell you

that they committed fraud, and they are going to want you to believe that Carlos

committed fraud with them, these cooperating witnesses, as the prosecutor

mentioned earlier.” Defense counsel continued: “All of these individuals who

you’re going to hear from, the cooperating witnesses, the motivating witnesses,

they’re all friends. The only outsider is Carlos. The evidence will show this.”

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      We now review the fourth and fifth challenged comments. As to the fourth,

again in closing argument, the prosecution urged the jury to focus on the FBI

analyst’s chart and stated that defendant Nerey “can’t explain this. He can’t

explain why he got a quarter of a million dollars off this scheme.” The

prosecution’s fifth and final comment provided, “Now, you will hear from the

defendant’s attorney that you shouldn’t believe those witnesses because they are all

friends and they all got together.” While this final comment does not even

arguably shift the burden, the fourth comment was potentially burden shifting.

But, importantly, after comments four and five, the district court provided separate

curative instructions as to the burden of proof in a criminal case.

      After sustaining an objection to the fourth comment, the district court stated:

“Again, ladies and gentlemen, the burden is always on the Government to prove

the defendant guilty beyond a reasonable doubt. The defendant doesn’t have any

burden at all.” After the fifth comment, the district court sustained defense

counsel’s objection and reiterated the government’s burden:

      I do want to say, once again, ladies and gentlemen, as I said during
      jury selection and at different times throughout the trial, the
      Government, having brought the charges, has the burden of proving
      defendant guilty beyond a reasonable doubt. No defendant in a
      criminal case ever has the burden of proving his or her innocence.
      The defendant has no burden whatsoever in the trial, only the
      Government.

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      Here the challenged comments, some of which were perhaps improper, did

not amount to reversible misconduct by the prosecution. Four out of the five

comments pointed to by Nerey occurred relatively close to one another during

closing argument. The district court followed four of the challenged actions by

sustaining defense counsel’s objection and the last two by issuing a curative

instruction. See Gonzalez, 122 F.3d at 1389. Given the temporal proximity of the

comments to one another and the district court’s curative instructions, it is unlikely

that these comments, even taken together, served to “permeate[] the entire

atmosphere of the trial,” which began and ended with a discussion of the

government’s clear burden. Simon, 964 F.2d at 1086. The jury is presumed to

follow curative instructions by the district court. Wilson, 149 F.3d at 1302.

      Likewise, as discussed above, the government presented overwhelming

evidence of Nerey’s guilt in this case. Notwithstanding the prosecution’s

comments and the district court’s curative instructions, the jury had more than

sufficient evidence to find Nerey guilty of the charged crimes. McLean, 138 F.3d

at 1403 (“[Defendant] cannot show prejudice in the face of the overwhelming

evidence of his guilt.”). Thus, a substantial right of Nerey was not prejudiced

because it is improbable that the verdict in this case would have been different but

for the prosecution’s comments. Frank, 599 F.3d at 1237–38.

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                  V.    MOTION TO INTERVIEW A JUROR

      Nerey next argues that the district court improperly denied his motion for

leave to interview juror number four after the verdict. The denial of a motion to

interview a juror is reviewed for an abuse of discretion. United States v. Cuthel,

903 F.2d 1381, 1382 (11th Cir. 1990) (“The district court has discretion to

determine whether evidence of premature deliberation warrants an evidentiary

hearing.”); see United States v. Orisnord, 483 F.3d 1169, 1179 (11th Cir. 2007);

United States v. Hooshmand, 931 F.2d 725, 737 (11th Cir. 1991).

      In the context of an inquiry into the validity of a verdict or indictment, the

Federal Rules of Evidence prohibit a juror from testifying about (1) “any statement

made or incident that occurred during the jury’s deliberations;” (2) “the effect of

anything on that juror’s or another juror’s vote;” or (3) “any juror’s mental

processes concerning the verdict or indictment” Fed. R. Evid. 606(b)(1). A juror

may testify, however, about whether “(A) extraneous prejudicial information was

improperly brought to the jury’s attention; (B) an outside influence was improperly

brought to bear on any juror; or (C) a mistake was made entering the verdict on the

verdict form.” Fed. R. Evid. 606(b)(2).

      Under Southern District of Florida Local Rule 11.1(e), after the jury is

discharged and upon proper motion, the district court, “for good cause

shown[,] . . . . may allow counsel to interview jurors to determine whether their
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verdict is subject to legal challenge,” and may limit the time, place and

circumstances under which the interviews may be conducted. S.D. Fla. L.R.

11.1(e) (emphasis added). This Court has construed the “good cause” requirement

to mean satisfaction of one of the exceptions listed in Rule 606(b). United States

v. Griek, 920 F.2d 840, 842 (11th Cir. 1991). With respect to this same local rule,

we have upheld a district court’s denial of an interview where one juror called the

defendant to say “we were pressured into making our decision.” Cuthel, 903 F.2d

at 1382.

      A party’s ability to interview a juror exists on a spectrum, which is

dependent upon the nature of the alleged misconduct. See United States v.

Caldwell, 776 F.2d 989, 998 (11th Cir. 1985). On one end, serious accusations

usually require investigation. Id. On the other, speculative and unsubstantiated

allegations present little need to investigate. Id.; see United States v. Sun Myung

Moon, 718 F.2d 1210, 1234 (2d Cir. 1983) (“It hardly bears repeating that courts

are, and should be, hesitant to haul jurors in after they have reached a verdict in

order to probe for potential instances of bias, misconduct or extraneous

influences.”).

      To obtain a new trial based on juror non-disclosure, the challenging party

must demonstrate that (1) the juror failed to answer honestly a material question on

voir dire and that (2) a correct response would have provided a valid basis for a
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challenge for cause. United States v. Perkins, 748 F.2d 1519, 1531 (11th Cir.

1984). The party seeking a new trial in this context must also show actual bias of

the juror. Id. at 1532; see also Carter v. Jones, No. 08-civ-1119-C, 2010 WL

3023381, at *10 (W.D. Okla. May 28. 2010) (finding petitioner offered “nothing

but his own speculation” to support a claim that the juror was biased based on his

choice to wear a red shirt—the color of the Bloods, which was the victim’s gang—

during voir dire), adopted by, 2010 WL 3023374 (W.D. Okla. July 28, 2010).

      In this case, juror number four answered “no” to all questions of bias in his

juror questionnaire and, during voir dire, “no” as to whether he had “any reason

why [he] could not sit as a fair and impartial juror.” When the jury reached its

verdict on April 1, 2016, juror number four walked into the jury box wearing a

fluorescent green T-shirt with bold, black letters stating “American Greed.” This

also happens to be the name of a television program aired on CNBC relating to

white collar crimes.

      After the jury’s verdict and later that day, Nerey’s counsel filed a motion to

interview juror number four based on his wearing the T-shirt. In his motion, Nerey

explained that T-shirts for the program are sold over the internet and are promoted

with the idea that you can “show the world that you’re no sucker.” Nerey

contended that juror number four’s T-shirt demonstrated his intent to make a

statement to and exert potential influence on his fellow jurors and that this conduct
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adequately showed an “outside influence” to justify an interview of juror number

four. Fed. R. Evid. 606(b)(1)(B).

      In its response brief, the government pointed out that Nerey did not object to

or question juror number four’s attire when the verdict was rendered. While

Nerey’s counsel filed the motion later that day, the motion did not set forth the

questions to be asked of juror number four. For its part, the government also

included an undisputed factual proffer that this particular T-shirt (green with black

letters) was not one sold by the television program. On April 13, 2016, the district

court denied Nerey’s motion by docket order, stating that “defendant has not

shown good cause to delve into the jury’s deliberations.”

      On appeal, Nerey renews these arguments and contends that juror number

four’s shirt suggested that he lied about impartiality. Nerey urges that an interview

was justified. Yet, as established by filings in the district court, Nerey failed in his

motion to lay out the questions he intended to ask or to establish that the T-shirt in

question can even be linked with the television program. Even assuming arguendo

there was some connection, it is unlikely that juror number four is the only juror to

have seen, or enjoyed, primetime television depicting criminal activity in a

negative light.

      A juror’s wearing a T-shirt that refers to one of these television programs

does not prove his inability to serve as an impartial juror or to follow the
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instructions of the court. Additionally, it is worth noting that juror number four

wore this T-shirt in the presence of other jurors for at most only a few hours on the

second day of deliberations. His choice of clothing, while perhaps juvenile and

imprudent, does not bring into question the validity of the jury’s verdict, which

was unanimous. The district court did not abuse its discretion by denying Nerey’s

motion to interview the juror.

                         VI.     RULE 404(b) EVIDENCE

      Defendant Nerey argues that the district court erred by admitting various

types of Rule 404(b) evidence at trial. See Fed. R. Evid. 404(b). The district

court’s decision to admit or exclude evidence is reviewed for an abuse of

discretion. See, e.g., United States v. Eckhardt, 466 F.3d 938, 946 (11th Cir.

2006); United States v. Matthews, 431 F.3d 1296, 1310–11 (11th Cir 2005);

United States v. Henderson, 409 F.3d 1293, 1297 (11th Cir. 2005).

      Federal Rule of Evidence 404(b) provides generally that “[e]vidence of a

crime, wrong, or other act is not admissible to prove a person’s character in order

to show” action in conformity therewith. Fed. R. Evid. 404(b)(1). However, under

Rule 404(b)(2), such evidence “may be admissible for another purpose, such as

proving motive, opportunity, intent, preparation, plan, knowledge, identity,

absence of mistake, or lack of accident.” Fed. R. Evid. 404(b)(2). As to this

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second provision, Rule 404(b) is a rule of inclusion. See Eckhardt, 466 F.3d at

946.

       To be admissible under Rule 404(b)(2), a prior act (1) must be relevant to an

issue other than defendant’s character, (2) must be sufficiently proven to permit a

jury determination that the defendant committed the act, (3) must have probative

value that is not substantially outweighed by undue prejudice, and (4) must

otherwise satisfy Federal Rule of Evidence 403. Eckhardt, 466 F.3d at 946.

Extrinsic evidence of a crime, wrong, or other act is inherently prejudicial to the

defendant because it risks a jury’s convicting the defendant for the extrinsic

offense or conduct rather than the charged one. See United States v. Baker, 432

F.3d 1189, 1205 (11th Cir. 2005) (citing United States v. Beechum, 582 F.2d 898,

910 (5th Cir. 1978) (en banc)).

       Yet, Rule 404(b) does not apply where the evidence of other crimes, wrongs,

or acts constitutes res gestae. See United States v. Troya, 733 F.3d 1125, 1131–32

(11th Cir. 2013) (concluding that shooting into residence was inextricably

intertwined with evidence regarding charged drug conspiracy); United States v.

McLean, 138 F.3d 1398, 1403–04 (11th Cir. 1998) (holding that prior drug dealing

was inextricably intertwined where it explained the relationship between the

defendant and a witness and was needed to assess the witness’s credibility). In

other words, such evidence need not meet a category listed in 404(b)(2) to be
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admissible. Evidence meets this exception when it is (1) part of the same

transaction or series of transactions as the charged offense, (2) necessary to

complete the story of the crime, or (3) inextricably intertwined with the evidence

regarding the charged offense. Baker, 432 F.3d at 1205 n.9; see also McLean, 138

F.3d at 1403 (“Evidence, not part of the crime charged but pertaining to the chain

of events explaining the context, motive and set-up of the crime, is properly

admitted if linked in time and circumstances with the charged crime, or forms an

integral and natural part of an account of the crime, or is necessary to complete the

story of the crime for the jury.” (quoting United States v. Williford, 764 F.3d 1493,

1499 (11th Cir. 1985)).

      Lastly, Rule 403 allows a district court the discretion to exclude evidence if

“its probative value is substantially outweighed by [the] danger of . . . unfair

prejudice, confusing the issues, misleading the jury, undue delay, wasting time, or

needlessly presenting cumulative evidence.” Fed. R. Evid. 403. It is recognized,

however, that Rule 403 “is an extraordinary remedy which the district court should

invoke sparingly, and the balance should be struck in favor of admissibility.”

United States v. Lopez, 649 F.3d 1222, 1247 (11th Cir. 2011) (quoting United

States v. Alfaro-Moncada, 607 F.3d 720, 734 (11th Cir. 2010)); United States v.

Jernigan, 341 F.3d 1273, 1285 (11th Cir. 2003) (noting that “we are loathe to

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disturb the sound exercise of [the district court’s] discretion” in Rule 403

determinations).

      Before the trial in this case, the district court verbally denied defendant

Nerey’s motion in limine to exclude evidence of (1) his conduct with other home

health care agencies, (2) his knowledge of the fraud at Mercy HC and D&D&D,

and (3) his confronting Yovani Suarez as a cooperating witness. The district court

found all of this evidence was relevant, probative, and inextricably intertwined

with the charged counts. Alternatively, the district court found that the evidence

was admissible under Rule 404(b)(2) to show motive and lack of mistake.

      On appeal, Nerey argues that the district court improperly admitted each of

these three items of evidence. Nerey attacks each item separately as to whether it

satisfied Rule 404(b) or the “inextricably intertwined” exception. In either event,

Nerey argues the evidence should have been excluded under Rule 403.

      As to the first item, Nerey contends that evidence of his “alleged

involvement in other home health care agencies is not inextricably intertwined with

the receipt of kickbacks evidence as they are not part of the same series of

transactions.” This argument misses the mark. “Inextricably intertwined” and

“same transaction” are two separate exceptions to the same rule against

impermissible extrinsic evidence. See McLean, 138 F.3d at 1403 (listing three

exceptions separated by “or”).
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       Evidence of Nerey’s involvement with other home health care agencies, to

the extent it was admitted, was inextricably intertwined with, and probative of,

how Nerey became involved with the home health care agencies in this case and

why they trusted him as a patient recruiter. See McLean, 138 F.3d at 1404 (“[T]he

record makes clear . . . that [evidence of defendant’s involvement in a separate

criminal organization] was vital to an understanding of the context of the

government’s case against [defendant] and, therefore, can be said to be

‘inextricably intertwined’ with the government’s proof of the charged offenses.”).

Any testimony by Jesus Perez that he knew Nerey from other home health care

agencies goes directly to this point.2 Likewise, Karla Garcia’s testimony that she

worked with Nerey at an agency other than Mercy HC explained how they came to

know each other and was inextricably intertwined with the evidence regarding

Nerey’s involvement in patient recruiting. All of this evidence was also “necessary

to complete the story of the crime.” Id. at 1403; see Lopez, 649 F.3d at 1247–48

       2
          In its response brief, the government points out that some anticipated testimony by Jesus
Perez is missing from the trial transcripts and that attempts to obtain the missing testimony have
been unsuccessful. The government argues that Nerey did not mention Perez’s testimony in his
initial brief and thus he has waived the issue. We agree. See United States v. Levy, 379 F.3d
1241, 1242 (11th Cir. 2004) (“[W]e do not entertain this new issue because [appellant] did not
timely raise it in his initial brief on appeal.”). In addition, the appellant bears the burden to
complete the record on appeal, and Nerey has not proffered the missing testimony that he
contends was inadmissible.
        Alternatively, even if the issue is preserved and the missing testimony is, as Nerey
argues, the fact that Perez and Nerey met at another home health care agency engaged in similar
fraud, we conclude that such testimony was properly admitted under Rule 404(b) for the reasons
already explained above.
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(concluding that co-conspirator testimony regarding prior or similar criminal

involvement of the defendant provided context of the conduct charged and was not

unduly prejudicial).

      As to the second item, Nerey argues that evidence of his knowledge and

involvement in aspects of the fraud committed at Mercy HC and D&D&D does not

meet the standard for admissibility under Rule 404(b). Nerey was charged in this

case with a conspiracy to defraud the United States by paying and receiving health

care kickbacks and receiving kickbacks in connection with a federal health care

program. However, the full extent of the conspiracy in which he was involved was

much larger than that. Mercy HC and D&D&D were in the business of recruiting

patients who had forged or paid-for home health prescriptions and then billing

Medicare for services either not performed or not medically necessary. Showing

Nerey’s involvement as a patient recruiter who received kickbacks, many of which

were masked by his operations with Sweet Life, required an explanation of his

knowledge and involvement in these other aspects of the larger conspiracy to

defraud. Because Nerey insisted that all of his patients be assigned to Sweet Life

for therapy, it was also important to explain how Sweet Life was involved in order

to show Nerey’s willful conduct and explain the full extent of his relationship with

the other co-conspirators.

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      As to the third item, Nerey argues that evidence of his confronting Suarez is

“also not inextricably intertwined with any evidence related to receipt of kickbacks

since it does not arise out of the same transactions and it isn’t necessary to

complete the story for the jury.” However, one conclusion does not follow from

the other. These are separate and independent categories of res gestae evidence.

See McLean, 138 F.3d at 1403 (denoting “same transaction” and “necessary to

complete the story” as separate categories from “inextricably intertwined”). This

once again shows a fundamental misunderstanding about the application of this

exception to Rule 404(b).

      Nerey also contends that evidence that a “man fitting Nerey’s description”

approached and spoke to Suarez is not sufficient evidence under Rule 404(b) and is

not relevant to prove or disprove the receipt of kickbacks. While the government

included this evidence in its notice of intent to introduce 404(b) evidence, it never

came up at trial. Suarez did not testify, and the testimony about a “man fitting

Nerey’s description” was never introduced.

      At trial, Jesus Perez testified about a phone call with Nerey where they

discussed whether Suarez was a confidential informant. Angered at the thought,

the two discussed “breaking [Suarez’s] head.” This interaction does not go to prove

Nerey’s general character for violence. Rather, it was offered to show Nerey’s

specific intent to engage in the conspiracy to receive kickbacks at Mercy HC and
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D&D&D or to take steps to protect himself. See United States v. Vernon, 723 F.3d

1234, 1256 (11th Cir. 2013) (defining willfully as an act “committed voluntarily

and purposely, with the specific intent to do something the law forbids”).

      This testimony helped to establish Nerey’s willful involvement in the

scheme and an absence of mistake about the health-care-fraud conspiracy. An

individual who mistakenly accepted kickbacks would not feel anger or aggression

toward a purported government informant. Likewise, the testimony was probative

and not unduly prejudicial because it did not suggest actual violence but merely

that Nerey went to find Suarez and had “strong words” with him. See also Baker,

432 F.3d at 1220 (“Although prejudicial, ‘[c]ourts may consider evidence of

threats to witnesses as relevant in showing consciousness of guilt’ under Rule

404(b).” (alteration in original)).

      The district court did not err by admitting the challenged evidence. Even if

we were to find some error, the overwhelming evidence of Nerey’s guilt counsels

against reversing his convictions on this evidentiary ground. United States v.

House, 684 F.3d 1173, 1197 (11th Cir. 2012) (declining to reverse conviction on

evidentiary error “if the error had no substantial influence, and enough evidence

supports the result apart from the phase affected by error” (internal quotation

marks omitted)).

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                          VII. NEREY’S SENTENCE

      As to his sentence, Nerey argues that the district court incorrectly calculated

his advisory guidelines range based on an improper benefit to be conferred in the

amount of $2,366,756. In its guidelines calculations, the district court’s factual

findings are reviewed for clear error. United States v. Lebowitz, 676 F.3d 1000,

1015 (11th Cir. 2012). The district court’s interpretation and application of the

Guidelines is reviewed de novo. Id.; United States v. Massey, 443 F.3d 814, 818

(11th Cir. 2006).

      The presentence investigation report (“PSI”) calculated Nerey’s base offense

level as eight under U.S.S.G. § 2B4.1(a). The PSI determined that Nerey was

involved in the conspiracy at Mercy HC and D&D&D from October 2014 to

September 2015; that his acts contributed to the submission of fraudulent claims to

Medicare; and that he made more money from his role in the conspiracy than the

owner of Mercy HC, Jesus Perez. The PSI concluded that Nerey was responsible

for the entire amount of the improper benefit conferred on Mercy HC and

D&D&D.

      In addition to the base offense level of eight, the PSI recommended: (1) a

sixteen-level increase pursuant to U.S.S.G. § 2B4.1(b)(1)(B) and § 2B1.1(b)(1)(I)

because the benefit conferred by the conspiracy was between $1,500,000 and

$3,500,000; and (2) a three-level increase under U.S.S.G. § 3B1.1(b) because of
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Nerey’s significant role in the conspiracy. See U.S.S.G. § 3B1.1(b) (discussing

aggravating roles including “organizer, leader, manager, or supervisor in any

criminal activity”). Nerey objected to the PSI’s increases. Nerey argued that he

should be held responsible only for the $249,098 he received in kickbacks because

he did not agree to commit fraud in relation to the patients he did not recruit and

that he was not an organizer of the conspiracy but merely one patient recruiter.

      The district court found that Nerey was “pretty involved” in the conspiracy

and that he knew what the other co-conspirators were doing. It found that Nerey

recruited Karla Garcia into the conspiracy and that her involvement in the fraud

was foreseeable to him. Ultimately, the district court found that the trial evidence

supported the $2,366,746 figure and the sixteen-level increase. The district court

declined to impose a three-level increase for Nerey’s role in the conspiracy.

      On appeal, Nerey argues that the district court incorrectly determined that

the value of the benefit conferred was $2,366,746. See U.S.S.G. § 2B4.1(b)(1)(B).

Specifically, Nerey argues that he was only one of many patient recruiters at

Mercy HC and D&D&D and that he was not involved in their actual submission of

fraudulent claims to Medicare. Nerey also argues that he did not agree to commit

fraud with any patients he did not recruit and that the improper benefit conferred

should be based on his personal kickbacks rather than the amount fraudulently

billed for the entire conspiracy.
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      The application notes for § 2B4.1 provide that the “value of the improper

benefit to be conferred” means “the value of the action to be taken or effected in

return for the bribe.” U.S.S.G. § 2B4.1 cmt. n.2. In the case of jointly undertaken

criminal activity, the relevant conduct includes acts and omissions of others that

were (1) within the scope of the jointly undertaken criminal activity, (2) in

furtherance of that criminal activity, and (3) reasonably foreseeable in connection

with that criminal activity. U.S.S.G. § 1B1.3(a)(1)(B); see also United States v.

Valarezo-Orobio, 635 F.3d 1261, 1264 (11th Cir. 2011) (“Whether a co-

conspirator’s act was reasonably foreseeable to the defendant so that it qualifies as

relevant conduct is a question of fact reviewed for clear error.”).

      As to the scope of jointly undertaken criminal activity, Nerey was

significantly involved in the overall conspiracy. Nerey was the top source of

patients for both Mercy HC and D&D&D. Nerey also recruited Karla Garcia to

the conspiracy as an additional patient recruiter and attempted to recruit Karla’s

husband as a fraudulent physical therapist. Nerey cross-referenced his patient list

with the logbooks at D&D&D, negotiated payments for other recruiters, and paid

other conspirators through NPS.

      With respect to conduct in furtherance of the conspiracy, all of the kickbacks

to Nerey were made possible by the fraudulent Medicare claims filed by various

co-conspirators at Mercy HC and D&D&D. Nerey was aware that his receiving
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payment would require the filing of claims to Medicare. Mercy HC and D&D&D

were not approved by any other HMO and could submit claims only to Medicare.

Thus, Nerey recruited patients with these limitations in mind. Mercy HC and

D&D&D submitted patient claims using inflated invoices for home health care.

Once Medicare processed and paid these claims, Mercy HC and D&D&D would

pay kickbacks to Nerey based on the number of his patients that led to successful

claims. Mercy HC and D&D&D compensated recruiters only for their patients’

claims that Medicare accepted and paid. As such, the filing of these Medicare

claims was in furtherance of and necessary to Nerey’s receiving kickbacks.

U.S.S.G. § 1B1.3(a)(1)(B).

      It was also reasonably foreseeable that Nerey’s co-conspirators would take

the home health prescriptions, patients, and recruiters that Nerey procured and use

them in the scheme to file fraudulent Medicare claims. As such, Nerey’s conduct

encompasses the entire amount of $2,366,746 received from the conspiracy. The

district court’s determination as to the improper benefit conferred was not clearly

erroneous.

                              VIII. CONCLUSION

      For all of these reasons, we affirm Nerey’s convictions and sixty-month total

sentence.

      AFFIRMED.
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