Court Opinion

ID: 9881441
Source: CourtListenerOpinion
Date Created: 2023-10-02 18:00:31.101705+00
Date Added: 2024-06-11T14:08:51.506301
License: Public Domain

Case: 21-10292    Document: 00516915625        Page: 1   Date Filed: 10/02/2023

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

                                                                        FILED
                                                                  October 2, 2023
                                No. 21-10292
                                                                   Lyle W. Cayce
                                                                        Clerk

   United States of America,

                                                         Plaintiff—Appellee,

                                    versus

   Mrugeshkumar Kumar Shah; Iris Kathleen Forrest;
   Douglas Sung Won; Shawn Mark Henry; Michael
   Bassem Rimlawi; Wilton McPherson Burt; Jackson
   Jacob,

                                                    Defendants—Appellants.

                 Appeal from the United States District Court
                     for the Northern District of Texas
                          USDC No. 3:16-CR-516-14

   Before Richman, Chief Judge, and Wiener and Willett, Circuit
   Judges.
   Priscilla Richman, Chief Judge:
         Seven codefendants appeal their various convictions stemming from
   a multi-million-dollar healthcare conspiracy involving surgery-referral
   kickbacks at Forest Park Medical Center in Dallas, Texas. They challenge
   convictions under the Anti-Kickback Statute (which will sometimes be
Case: 21-10292           Document: 00516915625           Page: 2   Date Filed: 10/02/2023

                                          No. 21-10292

   referred to as AKS), 1 the Travel Act,2 and for money laundering. 3 Finding
   no reversible error, we affirm the district court’s judgment.
                                               I
          The seven codefendants on appeal were all convicted of engaging in a
   $40 million healthcare conspiracy in Dallas, Texas. Our initial discussion of
   the facts is limited to the general outline of the conspiracy: its origins, its
   major players, and its operation. We reserve a more detailed discussion of
   the evidence against the defendants for the sections of this opinion that deal
   with those facts more directly. 4
          There are three main sets of actors in this case: the staff at Forest Park
   Medical Center (Forest Park or the hospital), surgeons Forest Park paid to
   perform surgeries at its hospital, and pass-through entities affiliated with
   both Forest Park and the surgeons. The defendants in this case are, with
   three exceptions, the surgeons whom Forest Park paid to direct surgeries to
   the hospital—Won, Rimlawi, Shah, and Henry. One exception is Forrest—
   she is a nurse. Another is Jacob—he ran Adelaide Business Solutions
   (Adelaide), a pass-through entity. The other is Burt—he was part of the
   hospital’s staff.
          But this case begins with three men who are not parties to the current
   appeal—Alan Beauchamp, Wade Barker, and Richard Toussaint. They
   decided to open a hospital together—Forest Park. Forest Park was to be an
   “out-of-network” hospital, meaning that it was not affiliated with any

          1
              42 U.S.C. § 1320a-7b.
          2
              18 U.S.C. § 1952.
          3
              18 U.S.C. § 1956(a)(1)(B)(1).
          4
              See infra Part II.

                                               2
Case: 21-10292        Document: 00516915625             Page: 3      Date Filed: 10/02/2023

                                         No. 21-10292

   insurance carrier and any surgeries performed there would be considered
   out-of-network for the patients. They planned for their hospital to be out-of-
   network because insurers were reimbursing out-of-network facilities at very
   high rates. But they faced a difficulty: how to convince patients to pay out-
   of-network costs when they could have the surgery performed at an in-
   network facility? Their answer: pay surgeons to refer patients to Forest Park
   and then waive the patient’s financial responsibility beyond what the surgery
   would cost in-network.
           In creating such a structure, the Government asserts that Forest Park
   engaged in illegal conduct. First, the hospital was “buying surgeries,” i.e., it
   paid surgeons to perform a surgery at the hospital. It is well established that
   buying surgeries is illegal, as many witnesses testified. 5               Second, the
   hospital’s formal internal policy was not to waive patient financial
   responsibility. So, the Government argues, Forest Park’s upper management
   had to cover its tracks. It did this by creating or partnering with a number of
   pass-through entities to create sham marketing or consulting contracts with
   the surgeons. One such entity was Adelaide, overseen by defendant Jacob.
   Another was Unique, which was operated by Beauchamp, Andrea Smith (a
   longtime aid to Beauchamp), and defendant Burt.
           The Government argued that the conspiracy was as follows: The
   hospital and surgeons reached an agreement whereby the hospital would pay
   the surgeons to refer patients to Forest Park; the hospital would then contract
   with a pass-through entity for sham marketing or consulting services; the

           5
             See Tex. Occ. Code § 102.001(a) (criminalizing accepting money for patient
   referrals); Tex. Penal Code § 32.43 (same); see also, e.g., Calif. Bus. & Prof.
   Code § 650(a) (California statute holding unlawful receiving money for patient referrals);
   Fla. Stat. § 455.227(n) (similar Florida statute); N.Y. Educ. Law § 6530 (similar
   New York statute).

                                               3
Case: 21-10292     Document: 00516915625           Page: 4   Date Filed: 10/02/2023

                                    No. 21-10292

   surgeons would contract with the same pass-through entity for sham
   marketing or consulting services as well; the surgeons would then direct their
   patients to Forest Park for surgery; Forest Park would obtain
   reimbursements from insurers at the out-of-network rate; the hospital would
   pay the pass-through entities some of those profits; and then the pass-
   through entities would pass along those profits to the surgeons for marketing
   and consulting services the surgeons never rendered.
          Although Forest Park employed legitimate hospital staff, it also
   employed a number of individuals in roles relating directly to the conspiracy.
   Andrea Smith’s role was to keep track of all the surgeries that the hospital
   “bought” and make sure that the surgeons were reimbursed according to the
   rates they had agreed to. She created detailed spreadsheets to keep track of
   this, and those spreadsheets became a major part of the Government’s case.
   Burt’s job was to assist Beauchamp in recruiting surgeons and patients.
   Along with Beauchamp and Smith, Burt formed an organization called
   Unique that was a pass-through entity. Eventually the controller for Forest
   Park began to resist doing business with Unique. The hospital’s leadership
   team decided to create an outside group.
          Jacob owned a radiology company near the hospital.            He and
   Beauchamp were friends.        Beauchamp approached Jacob to join the
   enterprise, and Jacob agreed. Jacob formed Adelaide, which assumed the role
   of the pass-through entity formerly occupied by Unique. Forest Park paid
   Adelaide monthly for services that Adelaide never rendered to the hospital.
   Instead, Beauchamp sent a monthly check to Adelaide with specific
   instructions as to how Jacob was to pay the surgeons he “contracted” with
   for marketing or consulting services. Often, the surgeons would complain
   they had not been reimbursed at their agreed-upon rate.

                                         4
Case: 21-10292         Document: 00516915625         Page: 5   Date Filed: 10/02/2023

                                      No. 21-10292

          Won, Rimlawi, Shah, and Henry are surgeons who contracted with a
   pass-through entity for marketing or consulting services and who directed
   some of their patients to Forest Park. Most of these patients had private
   insurance, but some of them were covered by a federal healthcare program
   including Medicare, TRICARE, or DOL/FECA. Forest Park then paid the
   surgeons with checks issued through the pass-through entity. Forrest is a
   nurse who was involved in the scheme, who at the time persuaded patients
   to have their surgery performed at Forest Park.
          The district court’s description is apt: “[O]nce you separate all the
   ‘noise,’ the trial involved a single pyramid conspiracy with a number of
   participants. . . . Attempts were made to paper their dishonest conduct—to
   hide behind sham contracts—which ultimately proved unsuccessful.”
          The defendants who are parties to this appeal were tried together.
   The jury convicted all but Burt for engaging in a conspiracy that violated the
   Anti-Kickback Statute. 6 The jury convicted Jacob, Shah, Burt, Rimlawi, and
   Forrest of substantive violations of that statute. It convicted Henry and Burt
   on substantive violations of the Travel Act 7 as well as conspiring to commit
   money laundering. The jury acquitted a surgeon who is not a party to this
   appeal and failed to reach a verdict as to another. Shah was sentenced to 42
   months of imprisonment; Rimlawi was sentenced to 90 months; Jacob to 96
   months; Burt to 150 months; Henry to 90 months; Won to 60 months; and
   Forrest to 36 months. The defendants timely appealed.
          The defendants raise many of the same issues on appeal, often
   adopting each other’s arguments. We have organized this opinion into
   eighteen Parts following this one. This reflects the lowest combined count of

          6
              42 U.S.C. § 1320a-7b.
          7
              18 U.S.C. § 1952.

                                           5
Case: 21-10292          Document: 00516915625         Page: 6    Date Filed: 10/02/2023

                                       No. 21-10292

   the defendants’ various issues.        In each part, we address the various
   arguments each defendant makes regarding a particular issue, including
   closely related sub-issues where appropriate. We begin with the defendants’
   sufficiency of the evidence challenges. Then we address the remaining
   issues: whether the Texas Commercial Bribery Statute 8 is a proper predicate
   offense to a violation of the Travel Act; potential Speedy Trial Act 9 and
   Court Reporter Act 10 violations; purported violations of Burt’s proffer
   agreement and any Bruton 11 error stemming therefrom; various challenges to
   district court evidentiary rulings, jury instructions, and prosecutor
   arguments; and finally, challenges to sentencing and restitution.
                                            II
          Six defendants (all but Burt) challenge the sufficiency of the evidence
   supporting their respective convictions of conspiring to violate the AKS.
   The AKS provides, in relevant part, that:
          (1) [w]hoever 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 . . . in return
          for referring an individual to a person for 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 . . .

          8
               Tex. Penal Code § 32.43.
          9
               18 U.S.C. §§ 3161-74.
          10
               28 U.S.C. § 753.
          11
               391 U.S. 123 (1968).

                                            6
Case: 21-10292               Document: 00516915625           Page: 7       Date Filed: 10/02/2023

                                             No. 21-10292

           (2) [w]hoever knowingly and willfully offers or pays any [such]
           remuneration . . . to induce [such a referral] . . . shall be guilty
           of a felony. 12
           These six defendants were convicted of engaging in a conspiracy to
   violate the AKS. To prove a conspiracy, the prosecutors had to show: (1) an
   agreement between two or more persons to pursue an unlawful objective;
   (2) that the defendant knew of the unlawful objective and voluntarily joined
   the conspiracy; and (3) an overt act done by one or more members of the
   conspiracy in furtherance of the conspiracy’s objective. 13 The degree of
   criminal intent necessary to sustain a conviction of conspiracy is the same as
   to sustain a conviction of the underlying offense. 14 To prove a violation of
   the AKS, the Government must prove that the defendant acted willfully, that
   is, “with the specific intent to do something the law forbids” 15 or “with bad
   purpose either to disobey or disregard the law.” 16
           We review sufficiency of the evidence challenges de novo, but we
   remain “highly deferential to the verdict.” 17 “[T]he relevant question is
   whether, after viewing the evidence in the light most favorable to the
   prosecution, any rational trier of fact could have found the essential elements

           12
                42 U.S.C. § 1320a-7b(b)(1), (2).
           13
            See United States v. Njoku, 737 F.3d 55, 63-64 (5th Cir. 2013) (citing United States
   v. Mauskar, 557 F.3d 219, 229 (5th Cir. 2009)).
           14
                Id. at 64 (quoting United States v. Peterson, 244 F.3d 385, 389 (5th Cir. 2001)).
           15
                Id. (quoting United States v. Garcia, 762 F.2d 1222, 1224 (5th Cir. 1985)).
           16
                Id. at 72.
           17
             United States v. Moreno-Gonzalez, 662 F.3d 369, 372 (5th Cir. 2011) (quoting
   United States v. Harris, 293 F.3d 863, 869 (5th Cir. 2002)).

                                                   7
Case: 21-10292          Document: 00516915625               Page: 8      Date Filed: 10/02/2023

                                            No. 21-10292

   of the crime beyond a reasonable doubt.” 18 “We will not second guess the
   jury in its choice of which witnesses to believe.” 19
                                             A. Won
          Won argues that there was insufficient evidence to prove that he
   agreed to violate the AKS and that he willfully sent federal patients to Forest
   Park—arguing that the government had to prove that he knew the patients
   he sent were federally insured.              The Government contends that Won
   misconstrues the AKS and that the Government did not need to prove that
   Won knew his patients were federally insured.
                                                  1
          First, and as an apparent matter of first impression, this court must
   decide whether a conviction under the AKS requires the defendant to have
   knowledge that payment for the surgeries he referred “may be made in whole
   or in part under a Federal healthcare program.” 20 The Government argues
   that the “Federal healthcare reference” in the statute is simply the hook

          18
               Id. (quoting Jackson v. Virginia, 443 U.S. 307, 319 (1979)).
          19
               United States v. Zuniga, 18 F.3d 1254, 1260 (5th Cir. 1994).
          20
               42 U.S.C. § 1320a-7b(b)(1). The AKS provides, in pertinent part:
          (b) Illegal remunerations
          (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 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 $100,000 or imprisoned for not more than 10 years, or both.

                                                  8
Case: 21-10292             Document: 00516915625               Page: 9    Date Filed: 10/02/2023

                                              No. 21-10292

   upon which jurisdiction is based and that, under well-settled precedent, it
   need not prove scienter as to the jurisdictional element. Jurisdictional
   elements “simply ensure that the Federal Government has the constitutional
   authority to regulate the defendant’s conduct.” 21 The Government is not
   required to prove mens rea for those elements. 22
            Won argues that the federal healthcare program provision is not a
   jurisdictional hook, but a substantive element of the crime for which the
   Government had to prove intent. A Maryland district court has addressed
   this question and decided that the federal healthcare program requirement is
   a jurisdictional hook. 23 The Eleventh Circuit has addressed the question as
   well, and that court also appeared to consider the requirement of a federal
   healthcare program to be jurisdictional. 24 In Ruan v. United States, 25 the
   Supreme Court vacated the Eleventh Circuit’s decision on other grounds.
   The Supreme Court did, however, discuss the scienter requirement in a
   statute. The Court concluded that “knowingly” “modifies not only the
   words directly following it, but also those other statutory terms that ‘separate
   wrongful from innocent acts.’” 26 We note that as a general proposition,

            21
                 Rehaif v. United States, 139 S. Ct. 2191, 2196 (2019).
            22
                 See id.
            23
                 United States v. Malik, No. 16-0324, 2018 WL 3036479, at *3 (D. Md. June 18,
   2018).
            24
              United States v. Ruan, 966 F.3d 1101, 1144-45 (11th Cir. 2020), vacated on other
   grounds, Ruan v. United States, 142 S. Ct. 2370 (2022) (explaining that “[i]n determining
   whether federal jurisdiction exists, the court examines the sufficiency of the evidence
   offered by the government” and that “[t]he relevant inquiry in making this determination
   is whether a reasonable jury could have found the jurisdictional element to have been
   satisfied beyond a reasonable doubt”).
            25
                 142 S. Ct. 2370 (2022).
            26
                 Id. at 2377 (quoting Rehaif, 139 S. Ct. at 2197).

                                                     9
Case: 21-10292          Document: 00516915625                Page: 10     Date Filed: 10/02/2023

                                              No. 21-10292

   “buying” surgeries is not “innocent” conduct. That conduct is illegal under
   a number of states’ laws, and no party disputes that. 27
           Nevertheless, in Ruan the Court said that “knowingly” also
   “modifies . . . the words directly following it.” 28 Here, “Federal healthcare
   programs” follows “knowingly.” At the very least, the federal healthcare
   reference in this statute clarifies to which “item[s] or service[s]” the statute
   applies. The question remains, does “knowingly” apply to “item[s] or
   service[s].”
           We think that Won overlooks a key clause in the AKS. The AKS
   requires only that payment “may” be made by a federal healthcare
   program. 29 In United States v. Miles 30 we characterized that as meaning only
   that “an item or service . . . could be paid for by a federal health care
   program.” 31 Further support for this proposition is found in the AKS itself,
   which provides that “a person need not have actual knowledge of this section
   or specific intent to commit a violation of this section.” 32 So, contrary to
   Won’s argument, the Government did not have to show he knowingly

           27
               See, e.g., Tex. Occ. Code § 102.001(a) (criminalizing the acceptance of
   money for patient referrals); Tex. Penal Code § 32.43 (same); see also, e.g., Cal. Bus.
   & Prof. Code § 650(a) (California statute holding unlawful receiving money for patient
   referrals); Fla. Stat. § 455.227(n) (listing as grounds for discipline, among other things,
   “[e]xercising influence on the patient or client for the purpose of financial gain of the
   licensee or a third party”); N.Y. Educ. Law § 6530 (defining professional misconduct
   as, among other things, “[d]irectly or indirectly offering, giving, soliciting, or receiving or
   agreeing to receive, any fee or other consideration to or from a third party for the referral
   of a patient or in connection with the performance of professional services”).
           28
                Ruan, 142 S. Ct. at 2377.
           29
                42 U.S.C. § 1320a-7b(b)(1).
           30
                360 F.3d 472 (5th Cir. 2004).
           31
                Id. at 480 (emphasis added).
           32
                42 U.S.C. § 1320a-7b(h).

                                                  10
Case: 21-10292          Document: 00516915625              Page: 11       Date Filed: 10/02/2023

                                            No. 21-10292

   referred federally insured patients for remuneration. All it had to show was
   that he knowingly agreed to accept remuneration for referring patients that
   could be federally insured. The Government met that burden. To the extent
   defendants argue they cannot be guilty because they intentionally avoided
   federally insured patients, they admit that they had agreed to accept
   remuneration for referring patients for services that could be paid for through
   a federal healthcare program. The Government did not need to prove Won
   knew he was referring federally insured patients.
                                                  2
           The Government did need to prove that at least some patients were
   federally insured or that payment “may” have been made by a federal
   healthcare program—to establish federal jurisdiction. 33 The Government
   points to evidence that Won sent a TRICARE patient to Forest Park as well
   as tracking sheets showing Won received credit for Medicare patients. Won
   disputes both pieces of evidence. He argues that the TRICARE patient had
   TRICARE only as a backup and that Aetna actually paid for her surgery. He
   also argues that the tracking sheets showing Medicare patients were never
   referenced at trial.
           Even assuming that no TRICARE money changed hands, Won cannot
   nullify the Medicare evidence by claiming that it was never discussed at trial.
   The inquiry is whether a rational trier of fact could have found for the
   prosecution; we review the evidence, not the prosecution’s argument. 34 The
   evidence shows that Won referred some federally insured patients to Forest

           33
             See United States v. Ruan, 966 F.3d 1101, 1144-46 (11th Cir. 2020) (vacating AKS
   conspiracy conviction because there was no federal health care program associated with the
   medical facility), vacated on other grounds, Ruan v. United States, 142 S. Ct. 2370 (2022).
           34
                See United States v. Moreno-Gonzalez, 662 F.3d 369, 372 (5th Cir. 2011).

                                                  11
Case: 21-10292          Document: 00516915625              Page: 12        Date Filed: 10/02/2023

                                            No. 21-10292

   Park. Further, it shows that Won “want[ed] to discuss [with Beauchamp]
   the amount [his] surgeries [we]re going to be billed for and [the]
   expect[ed] . . . reimburse[ment].”             The evidence also establishes that
   kickbacks were widely known to be illegal. A reasonable juror could have
   found an agreement between Won and Beauchamp to refer patients to Forest
   Park for remuneration, knowing that services to some of those patients might
   be paid, in whole or in part, under a federally funded healthcare program.
   This would satisfy the first two prongs of a conspiracy conviction. 35 Finally,
   the tracking sheets provide evidence that the referrals actually happened,
   satisfying the overt act element of a conspiracy conviction. 36
                                           B. Rimlawi
           Rimlawi challenges the sufficiency of the evidence to support his
   conspiracy conviction for violations of the AKS on the grounds that there was
   no evidence that he received kickbacks for his four federal patients. Rimlawi
   argues that the evidence submitted to the jury established that the marketing
   agreements paid money only for “out-of-network” surgeries. He attempts
   to define “out-of-network” as excluding federal-pay surgeries. Under that
   theory, he argues, the jury could not infer that he received money for
   federally insured patients.
           At least on paper, the agreements sought to avoid federal-pay patients,
   but, regardless of what the paper agreement said, the question is whether the
   jury had enough evidence in front of it to infer that Rimlawi knowingly
   referred patients who may have been federal-pay patients. The Government

           35
             See United States v. Njoku, 737 F.3d 55, 63-64 (5th Cir. 2013); see also United States
   v. Hamilton, 37 F.4th 246, 256-57 (5th Cir. 2022) (finding willfulness to conspire when the
   defendant testified that she knew kickbacks were illegal and had discussed them with her
   coconspirators).
           36
                See Njoku, 737 F.3d at 64-65; 42 U.S.C. § 1320a-7b(b)(1), (2).

                                                  12
Case: 21-10292       Document: 00516915625             Page: 13      Date Filed: 10/02/2023

                                        No. 21-10292

   argues that the tracking sheets, emails, and testimony of Beauchamp provide
   sufficient evidence to find that Rimlawi knowingly accepted payments “in
   return for referring an individual to a person for furnishing . . . of any item or
   service for which payment may be made in whole or in part under a Federal
   healthcare program.” Viewed in the light most favorable to the verdict, they
   do. 37 Beauchamp, for example, testified that Forest Park paid for federally
   insured patients.      Rimlawi admits to having federally insured patients.
   Smith’s kickback tracking sheets show that Rimlawi was credited with
   DOL/FECA insured patients who are federal pay, and Rimlawi does not
   contest that DOL/FECA patients are federal pay. A jury could reasonably
   infer that Rimlawi received kickbacks for those patients and knew that
   payments might be made for at least some patients he referred by a federal
   healthcare program.
                                         C. Henry
           Henry essentially repeats Won’s and Rimlawi’s arguments. He
   claims that the jury did not have sufficient evidence to find that he accepted
   kickbacks for federal patients and that there was insufficient evidence to
   prove that he knew his DOL patients were federally insured. As to the
   former, Henry’s argument fails for the same reason as Rimlawi’s. There is
   evidence in the record that Henry sent DOL/FECA patients to Forest Park
   and received remuneration. Henry admits this.
           Henry’s second argument is stronger. He claims that in order for his
   conspiracy conviction to stand, the Government needed to prove that he
   knew his DOL patients were federally insured for purposes of the AKS. But
   this argument fails for the same reason that Won’s argument fails. The

           37
             See Moreno-Gonzalez, 662 F.3d at 372 (holding that conflicting evidence must be
   resolved in favor of the verdict).

                                              13
Case: 21-10292           Document: 00516915625             Page: 14   Date Filed: 10/02/2023

                                            No. 21-10292

   Government did not need to prove that the defendants knew their conduct
   targeted federal healthcare programs. It needed to prove that the defendants
   knew services to some patients they referred might be paid, in whole or in
   part, by a federal healthcare program. Additionally, as already noted, the
   AKS itself provides that “a person need not have actual knowledge of this
   section or specific intent to commit a violation of this section.” 38
           Henry’s reliance on this court’s holding in United States v. Anderson 39
   is misplaced.         Henry cites that case for the proposition that to prove
   conspiracy to violate the AKS, the Government needed to prove that he
   entered the conspiracy with “the specific intent that the underlying crime be
   committed by some member of the conspiracy” and that the specific intent
   included the intent to send patients he knew to be federally insured to Forest
   Park. Anderson is inapposite. It is not an AKS case. 40
           Finally, Henry admits to sending DOL/FECA patients to Forest Park.
   His only argument is that he did not know they were federally insured for
   purposes of the AKS. But there is sufficient evidence in the record that,
   because he was a licensed DOL/FECA provider, Henry knew that FECA was
   a federal program. Even if the Government were required to prove that
   Henry knew he was sending federal patients to Forest Park and that
   DOL/FECA was a federal program, there is sufficient evidence supporting
   both.

           38
                42 U.S.C. § 1320a-7b(h).
           39
                932 F.3d 344 (5th Cir. 2019).
           40
                See id. at 352.

                                                 14
Case: 21-10292       Document: 00516915625              Page: 15       Date Filed: 10/02/2023

                                         No. 21-10292

                                          D. Jacob
           Jacob argues that his conspiracy conviction cannot stand because he
   did not knowingly join the conspiracy. He claims that he had no knowledge
   that the payments Forest Park made to Adelaide were for referrals.
           Jacob’s argument fails under the weight of evidence in the record from
   which the jury could conclude that he knew exactly what was transpiring.
   Beauchamp testified that Jacob formed Adelaide specifically to be a pass-
   through entity for his referral program. Jacob acknowledges that paid patient
   referrals are illegal. Smith testified that she believed Jacob knew that the
   payments were for referrals. There are numerous emails corroborating this
   testimony.
           Jacob has no response to this evidence other than a claim that it is
   “speculative and inferential,” but that does not mean that there is not
   sufficient evidence for the jury to find him guilty. Further, he relies on Forest
   Park’s representation to him that the money was simply for marketing, as
   well as its representation to him that such marketing agreements were legal.
   This reliance ignores the evidence that Jacob was in on the conspiracy from
   the beginning. Forest Park certainly laid a paper trail to cover its tracks, but
   “it was within the sole province of the jury as the fact finder to . . . choose
   among reasonable constructions of evidence.” 41
                                           E. Shah
           Shah’s argument fails for the same reason as the other surgeons’
   (Won, Rimlawi, and Henry). Shah admits that his payments from Adelaide
   were for patient referrals. His only argument is that (1) there is no evidence

           41
             United States v. Zuniga, 18 F.3d 1254, 1260 (5th Cir. 1994) (citing United States
   v. Garza, 990 F.2d 171 (5th Cir. 1993)).

                                               15
Case: 21-10292     Document: 00516915625           Page: 16    Date Filed: 10/02/2023

                                    No. 21-10292

   that he knew accepting those payments was unlawful, and that (2) even if he
   did, there is no evidence that he knew DOL was subject to the AKS.
          As to his first argument, there is sufficient of evidence in the record
   from which a juror could infer that Shah, as a medical professional, knew
   taking money for patient referrals was unlawful. During cross-examination,
   Shah’s codefendant Rimlawi agreed that “taking money for patients is
   wrong” and testified, “I know I can’t take money for patients.” Several
   other witnesses testified likewise. As to his second argument, it fails for the
   same reasons Won’s and Henry’s argument fails. As noted in Part II(C)
   (Henry), even if the government had to prove that Shah knew his patients
   were federally insured and that DOL/FECA fell under the AKS umbrella,
   there is sufficient evidence in the record from which the jury could infer both.
                                     F. Forrest
          Forrest claims that there was insufficient evidence to sustain her
   conviction because nothing proved that she knew her involvement was
   unlawful. She claims that she thought the money was for preauthorization
   services. But the evidence supports the opposite inference. For one, in an
   email exchange between Forrest and Smith, Forrest asks, “How do the
   commissions work? I am on commission for a percentage of the surgeries
   that I send over. (just mine).” Smith replied that that was correct and
   requested that Forrest send over “an invoice for $10k.” At trial, Smith
   testified that Forrest was being paid for the referrals. Smith was asked,
   “[W]as it a service [Forrest] was paid for?” She responded, “To me it was
   the — the surgeries that were done.” Beauchamp’s testimony further
   cements that Forrest knew she was being paid for patient referrals, not
   preauthorization services. Beauchamp was asked, “Were you paying Ms.
   Forrest for preauthorization services, or were you paying her for surgical

                                          16
Case: 21-10292          Document: 00516915625               Page: 17     Date Filed: 10/02/2023

                                             No. 21-10292

   referrals?” He responded, “I was paying her for the surgical referrals, her
   surgical referrals.”
          Forrest further argues that the AKS does not apply to her because she
   is not a physician and she lacked “control over . . . physicians,” but the text
   of the statute is not so limited. It applies to “[w]hoever . . . solicits or
   receives any remuneration . . . in return for referring an individual.” 42
   Forrest has no answer to this. And our caselaw makes clear that the AKS is
   not limited to those with “formal authority to effect the desired referral.” 43
   It is enough that “remuneration [be] paid with certain illegal ends in mind.” 44
   There is sufficient evidence in the record that Forrest was experienced in the
   healthcare field and that it was well-known in the healthcare industry that
   taking money in exchange for patient referrals was wrong.
                                                 III
          Next, we turn to the substantive convictions. Jacob, Shah, and Forrest
   were convicted of violating the AKS. They challenge the sufficiency of the
   evidence supporting their convictions.
                                             A. Jacob
          Jacob argues that under the Government’s theory of the case, he was
   to be paid 10% of the kickback and that there is insufficient evidence to sustain
   his conviction because the checks the Government produced do not
   represent the theorized 10% kickback, nor can they be tied to individual
   patients. He also argues that he never induced Shah to steer patients to
   Forest Park because Shah gave the patients a choice of hospital.

          42
               42 U.S.C. § 1320a-7b(b)(1).
          43
               United States v. Shoemaker, 746 F.3d 614, 627-30 (5th Cir. 2014).
          44
               Id. at 629.

                                                  17
Case: 21-10292       Document: 00516915625              Page: 18      Date Filed: 10/02/2023

                                         No. 21-10292

           The Government counters that just because the checks do not equal
   10% of the federal reimbursement does not mean they were not bribes. The
   Government also points to numerous emails detailing Shah’s complaints that
   he was indeed shorted his 10% and that Jacob questioned how accurate the
   tracking and payments were. Shah emailed Jacob: “10% was the number told
   to me by you and alan [Beauchamp].” Just because the math did not quite
   compute does not mean that the checks were not bribes. Based on these
   emails, the tracking sheets, and witness testimony from Beauchamp, the jury
   could have reasonably inferred that the checks were inducements or
   payments for referred patients in violation of the AKS.
           Jacob’s argument that the Government produced no evidence that the
   checks could be tied to the individual patients fares no better. At a minimum,
   the jury could have reasonably concluded that the checks Jacob and Shah
   received were for the patients Shah brought in on a monthly basis. There are
   numerous emails between the two men that demonstrate this knowledge—
   Shah complained to Jacob about being shorted month-to-month. Smith’s
   tracking sheets also track referrals and surgeries by month. Beauchamp’s
   testimony also established that payment was made on a monthly basis. There
   was sufficient evidence from which the jury could conclude that the checks
   supporting conviction were for patient referrals.
           Finally, Jacob’s contention that Shah never induced patients to go to
   Forest Park fails. Several witnesses said that Shah “gave [them] a choice”
   of clinic, but they all ended up at Forest Park. The jury chose to believe the
   Government over Shah, Jacob, and their witnesses. “We will not second
   guess the jury in its choice of which witnesses to believe.” 45

           45
             Zuniga, 18 F.3d at 1260 (citing United States v. Jones, 839 F.2d 1041, 1047 (5th
   Cir. 1988)).

                                              18
Case: 21-10292         Document: 00516915625               Page: 19        Date Filed: 10/02/2023

                                           No. 21-10292

                                             B. Shah
          In challenging the sufficiency of the evidence for the substantive AKS
   counts, Shah reiterates his arguments as to the lack of criminal intent for the
   conspiracy count. He also adopts by reference Jacob’s arguments as to the
   sufficiency of the evidence for the substantive AKS counts.                           Shah’s
   arguments fail for the same reasons as those discussed supra Part II(E) and
   Part III(A).
                                           C. Forrest
          Forrest’s arguments also fail. She reiterates her argument discussed
   above in Part II(F), contending that the fact she was not the patient’s doctor
   somehow excuses any inducement, but that argument fails for the reasons
   stated above. She also argues, like Jacob, that the Government could not tie
   the checks to her conduct. But the tracking sheets of Smith clearly tie Forrest
   to the patient, month of surgery, and check. The jury had sufficient evidence
   on which to convict.
                                                 IV
          Burt and Henry challenge their Travel Act convictions, but there is
   enough evidence to convict each of them.
          The        Travel      Act     prohibits     the    use     of    a      “facility   in
   interstate . . . commerce with [the] intent to . . . distribute the proceeds of
   an[] unlawful activity; or . . . otherwise . . . facilitate . . . an[] unlawful
   activity.” 46 To convict, the Government must prove that the defendant used
   facilities of interstate commerce with the specific intent to engage in or
   facilitate an unlawful activity in furtherance of a criminal enterprise. 47 The

          46
               18 U.S.C. § 1952(a).
          47
               See United States v. Roberson, 6 F.3d 1088, 1094 (5th Cir. 1993).

                                                 19
Case: 21-10292         Document: 00516915625               Page: 20          Date Filed: 10/02/2023

                                            No. 21-10292

   Supreme Court long ago recognized that the unlawful activity that predicates
   a Travel Act conviction may be commercial bribery in violation of a state
   statute, and it even cited the Texas statute at issue here as an example. 48
   Further, this court has long held that a state statute serves merely to define
   the “unlawful conduct” required in the Travel Act and that there “is no need
   to prove a violation of the state law as an essential element of the federal
   crime.” 49
          The state law at issue here is the Texas Commercial Bribery Statute
   (TCBS). The statute provides that it is a state felony for a physician to
   “intentionally or knowingly solicit[], accept[], or agree[] to accept any
   benefit from another person on agreement or understanding that the benefit
   will influence the conduct of the [physician] in relation to the affairs of his
   beneficiary.” 50
                                              A. Burt
          Burt challenges his conviction on the ground that he was convicted on
   an aiding-and-abetting theory but that the physician he aided was acquitted.
   He argues that the TCBS would not support his conviction. He asserts there
   was no “unlawful conduct” for purposes of the Travel Act.                              The
   Government contends that the ultimate acquittal of the principal does not
   matter under Texas law and that federal law does not draw a distinction
   between principals and aiders and abettors.

          48
               Perrin v. United States, 444 U.S. 37, 44 n.10, 50 (1979).
          49
               United States v. Prince, 515 F.2d 564, 566 (5th Cir. 1975).
          50
               Tex. Penal Code § 32.43.

                                                  20
Case: 21-10292           Document: 00516915625            Page: 21    Date Filed: 10/02/2023

                                           No. 21-10292

           The Government is correct that federal law draws no distinction
   between principals and aiders or abettors. 51 But, more importantly, the
   Government is correct about the TCBS. Burt could still be found guilty of a
   violation of the TCBS even if his fiduciary physician was acquitted. This is
   because the TCBS criminalizes not only the fiduciary’s taking of the bribe,
   but also “offer[ing], confer[ring], or agree[ing] to confer any benefit the
   acceptance of which is an offense under [the statute].” 52 The Government
   produced evidence that Burt handled bribe money and at least offered it to if
   not conferred it on the physicians in question. 53 Because of this unlawful
   conduct, the fact that a physician was acquitted means nothing for purposes
   of Burt’s Travel Act conviction.
           Burt relies on United States v. Armstrong 54 for the proposition that he
   cannot be held liable when the principal was acquitted. But Armstrong is
   inapposite because the court there held that there was insufficient evidence
   to support the conviction, not that the defendant could not be convicted if
   the principal was acquitted. 55 Here, it does not matter if the physician was
   acquitted because there could still be sufficient evidence in the record that
   Burt “offer[ed]” a benefit in violation of the TCBS regardless of whether any
   physician accepted it. 56

           51
              18 U.S.C. § 2 (“Whoever commits an offense against the United States or aids
   [or] abets . . . its commission, is punishable as a principal.”).
           52
                Tex. Penal Code § 32.43(c).
           53
             See generally infra Part IX (Burt proffer issue detailing his knowledge from the
   beginning of the conspiracy of doctor kickback payments).
           54
                550 F.3d 382 (5th Cir. 2008).
           55
                See id. at 394.
           56
                See Tex. Penal Code § 32.43(c).

                                                21
Case: 21-10292        Document: 00516915625               Page: 22        Date Filed: 10/02/2023

                                           No. 21-10292

                                            B. Henry
           Henry was convicted of a violation of the Travel Act because
   commercial-bribery proceeds were moved via the internet from Forest Park
   into a bank account controlled by a pass-through entity and from there to
   Henry. He argues that he cannot be convicted because the Government
   failed to prove that a facility of interstate commerce was used or that Henry
   used such a facility. Specifically, he argues that the interstate passage of a
   check is too tangential to confer federal jurisdiction. He also argues that the
   Government could not prove any subsequent overt act on his part.57
           The Government responds that Henry relies far too heavily on
   inapposite, pre-internet caselaw and that it is now well established that the
   passage of a check via the internet is a use of the facilities of interstate
   commerce.        This is true even for wholly intrastate transfers. 58                   The
   Government has the better of the two arguments here. This court’s caselaw
   is clear that the use of the internet provides the interstate hook necessary for
   jurisdiction. 59 Henry’s out-of-circuit cases, predating this court’s more

           57
              See 18 U.S.C. § 1952(a) (prohibiting the conduct itself and “thereafter
   perform[ing] or attempt[ing] to perform” the conduct); United States v. Bams, 858 F.3d
   937, 946 (5th Cir. 2017) (explaining that a Travel Act violation is not complete until the
   defendant “commit[s] a knowing and willful act in furtherance of th[e] intent [to promote
   bribery]” after using the facility of interstate commerce).
           58
               See, e.g., United States v. Marek, 238 F.3d 310, 318-20 (5th Cir. 2001); cf. United
   States v. Lopez, 514 U.S. 549, 558 (1995) (“Congress is empowered to regulate and protect
   the instrumentalities of interstate commerce, or persons or things in interstate commerce,
   even though the threat may come only from intrastate activities.”); United States v.
   Heacock, 31 F.3d 249, 255 (5th Cir. 1994) (“[A]ny use of the United States mails in this case
   is sufficient to invoke jurisdiction under 18 U.S.C. § 1952.”).
           59
              See Marek, 238 F.3d at 318-20; United States v. Barlow, 568 F.3d 215, 220 (5th
   Cir. 2009) (“In 2009, it is beyond debate that the Internet and email are facilities or means
   of interstate commerce.”); United States v. Phea, 755 F.3d 255, 266 (5th Cir. 2014)
   (explaining that “telephones, the Internet, and hotels that service interstate travelers are

                                                 22
Case: 21-10292          Document: 00516915625               Page: 23      Date Filed: 10/02/2023

                                             No. 21-10292

   recent published decisions, are distinguishable and do not control the
   outcome here.
           Henry argues there is no evidence that the check traveled via the
   internet or that he personally used a facility of interstate commerce. It is
   undisputed that $30,000 was credited to Henry’s bank account, but he says
   that the bank employee who testified as to the interstate workings of the bank
   put forward hearsay when she said the check traveled through Illinois. He
   also argues that the Government put on no evidence that Henry had actually
   used a facility of interstate commerce.
           To the extent that the bank witness’s testimony that the check was
   cleared in Illinois was hearsay, it is irrelevant because all that is required
   under the Act is the use of an interstate facility—even if the entire transaction
   remained within the state. 60 Here, the check was indisputably routed over
   computer networks before clearing Henry’s bank account. As to Henry’s
   second point, that the Government cannot point to his actual use of interstate
   commerce facilities, the Government responds that he “caused the use of
   such facilities,” and that specific knowledge about the use of interstate
   facilities is “legally irrelevant” because the “words of § 1952 do not require
   specific knowledge of the use of interstate facilities.” 61 We have held that
   “[t]here is no requirement that the defendant either have knowledge of the
   use of interstate facilities or specifically intend to use” them. 62 The jury

   all means or facilities of interstate commerce sufficient to establish the requisite interstate
   nexus”).
           60
                See, e.g., Marek, 238 F.3d at 318-20.
           61
              See United States v. Doolittle, 507 F.2d 1368, 1372 (5th Cir.), aff’d, 518 F.2d 500
   (5th Cir. 1975) (en banc) (per curiam).
           62
               United States v. Edelman, 873 F.2d 791, 794 (5th Cir. 1989) (quoting United States
   v. Perrin, 580 F.2d 730, 737 (5th Cir. 1978), aff’d on other grounds, 444 U.S. 37 (1979)).

                                                  23
Case: 21-10292        Document: 00516915625               Page: 24        Date Filed: 10/02/2023

                                           No. 21-10292

   could have inferred use of interstate facilities by the fact that the funds Henry
   received were transferred via electronic routing over computer networks.
           Finally, Henry challenges the evidence of a subsequent act. He
   contends that the government put forward no proof that he actually cashed
   the check. It is undisputed, however, that Henry received a $30,000 check
   from the pass-through entity and that the money subsequently was credited
   to Henry’s bank account. Henry’s only response is that there was no direct
   evidence that he deposited that money. But there is nothing in this court’s
   caselaw that requires such strict evidence of a subsequent act, and other
   circuits have held that “mere acceptance of the [bribe] money” is a sufficient
   overt act. 63 Further, there appears to have been no argument that someone
   other than Henry deposited the money. “[T]he relevant question is whether,
   after viewing the evidence in the light most favorable to the prosecution, any
   rational trier of fact could have found the essential elements of the crime
   beyond a reasonable doubt.” 64 In the light most favorable to the prosecution,
   the jury could have found that Henry deposited the check. At the very least,
   the jury could have found that he accepted the bribe.
                                                 V
           Next, Henry and Burt challenge their money laundering convictions.
   Henry and Burt were charged with conspiracy to commit concealment money
   laundering under 18 U.S.C. § 1956(a)(1)(B)(i), and there is sufficient

           63
             United States v. Arruda, 715 F.2d 671, 682 (1st Cir. 1983); see also United States v.
   McNair, 605 F.3d 1152, 1214 (11th Cir. 2010) (explaining that a “conspirator’s receipt of a
   benefit can be considered an overt act” and discussing United States v. Anderson, 326 F.3d
   1319 (11th Cir. 2003) for further support of that proposition).
           64
              United States v. Moreno-Gonzalez, 662 F.3d 369, 372 (5th Cir. 2011) (quoting
   Jackson v. Virginia, 443 U.S. 307, 319 (1979)).

                                                 24
Case: 21-10292          Document: 00516915625              Page: 25        Date Filed: 10/02/2023

                                            No. 21-10292

   evidence to show that they agreed to commit money laundering and that they
   joined the agreement knowing its purpose and with the intent to further it. 65
          To prove the charge, the Government had to establish that the men
   conspired to “conduct a financial transaction with proceeds of a specified
   illegal activity . . . with the knowledge that the transaction’s design was to
   conceal or disguise the source of the proceeds.” 66 The predicate unlawful
   activity that produced illegal proceeds was the Travel Act violation discussed
   above. “Conspiracy to commit money laundering does not require that the
   defendant know exactly what ‘unlawful activity’ generated the proceeds.” 67
   The defendant merely must know “that the transaction involve[d] profits of
   unlawful activity.” 68
          The Government argues that it produced sufficient evidence that
   Henry and Jacob joined with Burt in a conspiracy to commit money
   laundering primarily through the testimony of Beauchamp.                             The
   Government points to the testimony of Beauchamp to argue that Burt was a
   mastermind of the operation alongside Beauchamp and that he worked with
   Jacob and Jacob’s company, Adelaide, to disburse illegal proceeds. The
   Government argues that Burt did the same with Henry, also based on
   Beauchamp’s testimony.                The proceeds came from the Travel Act
   convictions, discussed above, which were predicated on bribery under the
   TCBS. The men concealed the illegal nature of the proceeds that Forest Park
   made on the bought surgeries by passing it through Adelaide and another

          65
               See United States v. Cessa, 785 F.3d 165, 173 (5th Cir. 2015).
          66
               Id. at 173-74.
          67
             United States v. Rivas-Estrada, 761 F. App’x 318, 326 (5th Cir. 2019)
   (unpublished) (per curiam).
          68
               Cessa, 785 F.3d at 174.

                                                  25
Case: 21-10292         Document: 00516915625               Page: 26       Date Filed: 10/02/2023

                                           No. 21-10292

   entity, NRG, under consulting and marketing contracts.                       Beauchamp
   testified that the contracts were a sham and that both Burt and Henry knew
   it. Henry was instrumental in conceiving the idea of using NRG to funnel the
   proceeds to him.
          Henry counters that the Government produced insufficient evidence
   to prove a Travel Act violation and therefore could not prove a conspiracy to
   conceal the proceeds of that unproven Travel Act violation. Similarly, Burt
   argues that the evidence was insufficient to prove that the proceeds resulted
   from Travel Act violations. The Government responds, citing this court’s
   caselaw, that it “[is] not required to prove that [the defendants] actually
   committed the substantive offense[] of . . . money laundering” because this
   is a conspiracy charge. 69
          The Government needed to prove only that the two men entered into
   an agreement to commit money laundering, that is, to conceal the illegal
   origin of ill-gotten proceeds, 70 and that they intended to carry it out. 71 The
   Government has met this burden through the testimony of Beauchamp who
   testified as to his relationship with Burt and the dealings between them and
   Jacob in creating Adelaide to funnel money to the surgeons under the guise
   of sham consulting contracts. Beauchamp testified as to the same with regard
   to Henry and NRG. A reasonable juror could have found conspiracy to
   commit money laundering on these facts.

          69
               See United States v. Reed, 908 F.3d 102, 124 (5th Cir. 2018).
          70
               See Cessa, 785 F.3d at 173-74; 18 U.S.C. § 1956(a)(1)(B)(i).
          71
               See Cessa, 785 F.3d at 173-74.

                                                 26
Case: 21-10292          Document: 00516915625               Page: 27        Date Filed: 10/02/2023

                                             No. 21-10292

                                                  VI
           Won and Shah argue that the evidence proved several conspiracies, at
   odds with the indictment which alleged only one. Henry also raises this
   argument. 72 Forrest adopts this argument by reference. 73 Their argument
   fails. This court will affirm a “jury’s finding that the government proved a
   single conspiracy unless the evidence and all reasonable inferences, examined
   in the light most favorable to the government, would preclude reasonable
   jurors from finding a single conspiracy beyond a reasonable doubt.” 74 Even
   then, this court will only reverse if it finds prejudice. 75
           The surgeons rely on several out-of-circuit cases to establish that the
   trial strayed from the indictment. Those cases lean heavily on wheel and
   chain models of conspiracies that have been firmly rejected by this circuit. 76
   Their argument is that, at most, the Government attempted to establish
   several separate conspiracies rather than the one in the indictment. But this
   court does not use wheel and chain analogies to determine whether there is a
   single conspiracy. Rather, we look to “(1) the existence of a common goal;
   (2) the nature of the scheme; and (3) the overlapping of the participants in

           72
              Henry did not raise the issue below, and although he attempted to adopt his
   codefendants’ arguments for acquittal, sufficiency of the evidence challenges are fact
   specific and cannot be adopted by reference. See United States v. Solis, 299 F.3d 420, 441
   n.46, 444 n.70 (5th Cir. 2002).
           73
             As with Henry, Forrest failed to raise this issue below, and sufficiency of the
   evidence challenges cannot be adopted by reference. See Solis, 299 F.3d at 444 n.70.
           74
            United States v. Beacham, 774 F.3d 267, 273 (5th Cir. 2014) (internal quotation
   marks omitted) (quoting United States v. Simpson, 741 F.3d 539, 548 (5th Cir. 2014)).
           75
                See United States v. Richerson, 833 F.2d 1147, 1154-55 (5th Cir. 1987).
           76
                See, e.g., United States v. Elam, 678 F.2d 1234, 1246 (5th Cir. 1982).

                                                   27
Case: 21-10292            Document: 00516915625             Page: 28        Date Filed: 10/02/2023

                                             No. 21-10292

   the various dealings.” 77 The surgeons fail to engage in this analysis, and even
   if they had, they would be unsuccessful.
           As to the first prong, this court interprets the “existence of a common
   goal” broadly. 78 A common pursuit of personal gain is sufficient, and that
   was unquestionably the goal of the conspiracy. 79
           Second, as to the nature of the scheme, if the “activities of one aspect
   of the scheme are necessary or advantageous to the success of another
   aspect” then that supports a finding of a single conspiracy. 80 Here, although
   each surgeon was responsible for referring his own patients, his individual
   activities were advantageous to the success of the whole enterprise because
   Forest Park used that revenue to pay the pass-through entities as well as the
   surgeon. Moreover, the surgeons were necessary to “another aspect” of the
   conspiracy—unindicted non-surgeon bribe recipients. These non-surgeon
   bribe recipients referred patients to the surgeons who then passed them on
   to Forest Park. These non-surgeon recipients needed the surgeons to send
   those patients to Forest Park in order for the non-surgeons to receive
   payment from the conspiracy.
           Finally, regarding the overlapping of participants, this court finds that
   “[a] single conspiracy exists where a ‘key man’ is involved in and directs
   illegal activities, while various combinations of other participants exert
   individual efforts toward a common goal.” 81                     That is the case here.

           77
              Beacham, 774 F.3d at 273 (quoting United States v. Mitchell, 484 F.3d 762, 770
   (5th Cir. 2007)).
           78
                See id.
           79
                Id.
           80
                Id. at 274 (quoting United States v. Morris, 46 F.3d 410, 415 (5th Cir. 1995)).
           81
                United States v. Richerson, 833 F.2d 1147, 1154 (5th Cir. 1987).

                                                  28
Case: 21-10292          Document: 00516915625               Page: 29       Date Filed: 10/02/2023

                                            No. 21-10292

   Beauchamp, Toussaint, and Barker were the “key men.” They used Burt
   and Jacob to run the day-to-day operations, and they used the surgeons and
   Forrest to recruit patients all for the common goal of making money.
           In arguing otherwise, the surgeons cite Kotteakos v. United States,82
   which involved several separate conspiracies, but Kotteakos is easily
   distinguishable. In that case, “[t]here was no drawing of all together in a
   single, over-all, comprehensive plan.” 83
           Even assuming no rational jury could have found a single conspiracy,
   the surgeons fail to show that this error “prejudiced [their] substantial
   rights.” 84 Henry and Forrest do not raise this point at all. Won and Shah
   address it only briefly and fail to provide any record citations to support the
   proposition that “clear, specific, and compelling prejudice” resulted in an
   unfair trial. 85 They argue that there was a great disparity in the quantity of
   evidence specific to them, but this court has held that quantitative disparities
   alone do not prove prejudice. 86
                                                 VII
           Henry argues that the TCBS is not a valid predicate offense to support
   a Travel Act conviction because it has been preempted by the Texas
   Solicitation of Patients Act (TSPA). 87 He first raised this argument in his
   motion to dismiss the indictment and repeats it on appeal. Henry’s argument

           82
                328 U.S. 750 (1946).
           83
                 Blumenthal v. United States, 332 U.S. 539, 558-59 (1947) (distinguishing
   Kotteakos).
           84
                See Richerson, 833 F.2d at 1154-55.
           85
                See United States v. Reed, 908 F.3d 102, 116 (5th Cir. 2018).
           86
                See United States v. Merida, 765 F.2d 1205, 1219 (5th Cir. 1985).
           87
                Tex. Occ. Code § 102.001(a).

                                                  29
Case: 21-10292          Document: 00516915625               Page: 30        Date Filed: 10/02/2023

                                             No. 21-10292

   is that these two statutes are in pari materia, meaning they “deal with the
   same general subject, have the same general purpose, or relate to the same
   person or thing or class of persons and things.” 88 According to Henry, the
   TSPA, as the more recent of the two, supplants the TCBS. We review this
   question of law de novo. 89
           The Travel Act “aims to deny those engaged in a criminal business
   enterprise access to channels of interstate commerce.” 90 It provides, inter
   alia, that “[w]hoever . . . uses . . . any facility in interstate or foreign
   commerce, with intent to . . . distribute the proceeds of any unlawful
   activity[] or . . . otherwise promote, manage, establish, carry on, or facilitate
   the promotion, management, establishment, or carrying on, of any unlawful
   activity” may be fined or imprisoned. 91 The Supreme Court, citing the Texas
   statute as an example, has recognized that the unlawful activity that
   predicates a Travel Act conviction may be commercial bribery in violation of
   a state statute. 92 Henry does not contest this; rather, he argues that the
   TCBS has been supplanted by the TSPA by way of in pari materia. When
   two statutes are in pari materia, Texas law dictates that they should be
   harmonized. 93 The laws “should be construed together, and both given

           88
              Jones v. State, 396 S.W.3d 558, 561 (Tex. Crim. App. 2013) (quoting Azeez v.
   State, 248 S.W.3d 182, 191 (Tex. Crim. App. 2008)).
           89
               See United States v. Clark, 582 F.3d 607, 612 (5th Cir. 2009) (explaining that
   facial challenges to the validity of statutes are pure questions of law reviewed de novo).
           90
                United States v. Roberson, 6 F.3d 1088, 1094 (5th Cir. 1993).
           91
                18 U.S.C. § 1952(a).
           92
                Perrin v. United States, 444 U.S. 37, 44 n.10, 50 (1979).
           93
               See Aldine Indep. Sch. Dist. v. Ogg, 122 S.W.3d 257, 270 (Tex. App.—Houston
   [1st Dist.] 2003, no pet.).

                                                   30
Case: 21-10292          Document: 00516915625                Page: 31    Date Filed: 10/02/2023

                                              No. 21-10292

   effect, if possible.” 94 It is only when the statutes “irreconcilabl[y] conflict[]”
   that “the more specific statute controls.” 95
           Henry argues that the two statutes conflict in that the TSPA
   incorporates the AKS safe harbor provisions whereas the TCBS does not. 96
   In order for the TCBS and TSPA to conflict, conduct unlawful under the
   TCBS must fall within a defense provided for in the TSPA. Because the two
   statutes criminalize nearly identical conduct, the only way for this to be the
   case is if something in the safe harbor provisions incorporated into the TSPA
   would prevent conviction that otherwise would be proper under the TCBS. 97
   There are twelve exceptions to the AKS found in the safe harbor provision. 98
   Henry addresses none of them. Henry has forfeited this argument by failing
   to brief it adequately. 99
           Even assuming the statutes are in pari materia, Henry cites no
   authority for why the latter would supplant the former. As discussed above,

           94
              Id. (citing Font v. Carr, 867 S.W.2d 873, 881 (Tex. App.—Houston [1st Dist.]
   1993, writ dism’d w.o.j.)).
           95
              See Rodriguez v. State, 879 S.W.2d 283, 285 (Tex. App.—Houston [14th Dist.]
   1994, pet. ref’d.).
           96
                See Tex. Occ. Code § 102.003 (citing 42 U.S.C. § 1320a-7b(b)).
           97
             Compare Tex. Penal Code § 32.43 (providing that fiduciaries are prohibited
   from soliciting or accepting a benefit to influence the affairs of the beneficiary), with Tex.
   Occ. Code § 102.001 (prohibiting accepting remuneration for soliciting a patient).
           98
                42 U.S.C. § 1320a-7b(b)(3).
           99
                See Rollins v. Home Depot USA, 8 F.4th 393, 397 & n.1 (5th Cir. 2021).

                                                   31
Case: 21-10292          Document: 00516915625                Page: 32         Date Filed: 10/02/2023

                                              No. 21-10292

   Texas law requires that the statutes be harmonized if possible. 100 If both
   cannot be given effect, then the more specific statute would control. 101
          Moreover, the Supreme Court has long recognized that violation of
   state commercial bribery statutes is a valid predicate for Travel Act
   convictions, 102 and this court has long held that a state statute serves merely
   to define the “unlawful conduct” required in the Travel Act. 103 There “is
   no need to prove a violation of the state law as an essential element of the
   federal crime.” 104 We decline to depart from this long-settled precedent.
                                                 VIII
          Won argues that the district court erred in denying his motion to
   dismiss the indictment for a violation of the Speedy Trial Act (STA). 105 The
   district court did not err in denying Won’s motion because Won consented
   to a continuance encompassing most of the delay he now challenges.
          In May 2017, the parties requested and the court granted an “ends-of-
   justice” continuance through January 2018. 106 In November 2017, Judge
   Fitzwater (the original judge assigned to this case) announced he was taking
   senior status and his intention to transfer this case to another judge. Because
   that process would take at least several months to complete, he vacated the

          100
                See Aldine Indep. Sch. Dist. v. Ogg, 122 S.W.3d 257, 270 (Tex. App.—Houston
   [1st Dist.] 2003, no pet.).
          101
               See Rodriguez v. State, 879 S.W.2d 283, 285 (Tex. App.—Houston [14th Dist.]
   1994, pet. ref’d.).
          102
                Perrin v. United States, 444 U.S. 37, 50 (1979).
          103
                United States v. Prince, 515 F.2d 564, 566 (5th Cir. 1975).
          104
                Id.
          105
                18 U.S.C. §§ 3161(c)(1), 3162(a)(2).
          106
                See 18 U.S.C. § 3161(h)(7).

                                                  32
Case: 21-10292          Document: 00516915625               Page: 33      Date Filed: 10/02/2023

                                             No. 21-10292

   late January 2018 trial date. Won did not object at that time. In late January,
   Chief Justice Roberts assigned Judge Zouhary to the case, and again without
   any objection from the defendants, Judge Zouhary set trial for early 2019. It
   was not until October 2018 that Won objected to any delay.
          The STA “‘generally requires a criminal defendant’s trial to start
   within 70 days of his indictment or his appearance before a judicial officer,’
   whichever date last occurs.” 107 But the STA includes a “long and detailed
   list of periods of delay that are excluded” from the 70-day window. 108
   Relevant to this appeal, the STA excludes delay resulting from a continuance
   on the basis that the ends of justice outweigh the interest of the public and
   the defendant in a speedy trial. 109
          Won does not appear to dispute that the May 2017 continuance
   through January 2018 was an ends-of-justice continuance. Nor is it disputed
   that motion filings in early February 2018 tolled the 70-day clock. His only
   argument for an STA violation is that the November 2017 order vacating the
   January trial date reset the STA clock and that there are more than 70 non-
   excludable days between November 17, 2017, and February 2018 when the
   filing of motions stopped the clock. We review the district court’s factual
   findings for clear error and its legal conclusions de novo. 110
          This court has held that defendants are precluded from challenging
   any delay to which they have consented. 111 Won consented to the May 2017

          107
              United States v. Dignam, 716 F.3d 915, 920-21 (5th Cir. 2013) (alteration
   omitted) (quoting United States v. McNealy, 625 F.3d 858, 862 (5th Cir. 2010)).
          108
                Zedner v. United States, 547 U.S. 489, 497 (2006) (citing § 3161(h)).
          109
                18 U.S.C. § 3161(h)(7)(A).
          110
                Dignam, 716 F.3d at 920.
          111
                United States v. Whitfield, 590 F.3d 325, 358 (5th Cir. 2009).

                                                  33
Case: 21-10292            Document: 00516915625           Page: 34   Date Filed: 10/02/2023

                                           No. 21-10292

   ends-of-justice continuance setting the trial date for no earlier than January
   2018. He cannot now object to any delay between November 2017 and
   January 2018 to which he has already consented. 112 He cites no authority to
   support his argument that Judge Fitzwater’s November order vacating the
   January trial date has any effect on his ability to challenge a delay to which he
   had already consented. Nor does he support his argument that the November
   order restarted the 70-day clock, and there is caselaw to support the
   proposition that the November order did not restart the clock.
          In United States v. Bieganowski, 113 for example, this court suggested
   that an ends-of-justice continuance excluded all the days of the continuance
   from STA calculations even though a later act arguably restarted the clock.114
   In Bieganowski, the court granted an ends-of-justice continuance until August
   23. 115 On August 12, the court granted another continuance, this one until
   November. 116 The court also granted a third continuance in September. 117
   The first and third continuances satisfied the requirements of the STA. 118
   The second continuance arguably did not, but this court declined to answer
   the question of whether it did because the third continuance met the
   requirements of the STA. 119 Key to the court’s analysis was the fact that only
   10 days passed between the end of the first continuance and the beginning of

          112
                See id.
          113
                313 F.3d 264 (5th Cir. 2002).
          114
                Id. at 282.
          115
                Id. at 281.
          116
                Id.
          117
                Id.
          118
                Id. at 282.
          119
                Id.

                                                34
Case: 21-10292         Document: 00516915625         Page: 35   Date Filed: 10/02/2023

                                      No. 21-10292

   the third. 120 The questionable second continuance was granted prior to the
   end of the first one, yet this court used the end of that first continuance as the
   point at which the STA would restart assuming the second continuance was
   contrary to the STA. In other words, the court’s actions prior to the end of
   the first continuance had no effect on the STA calculations because the
   parties had consented to the entirety of that first continuance.
          So too here. It is undisputed that Won consented to the May 2017
   continuance through January 2018. It is also undisputed that the 70-day clock
   was tolled on February 3, 2018. Won cannot point to more than 70 non-
   excluded days.
                                          IX
          Won next argues that the district court violated the Court Reporter’s
   Act 121 (CRA) when it went off the record 46 times during the 29-day trial.
   Jacob adopts this argument specifically as to the court’s failure to record the
   charge conference. But whatever gaps exist in the record of this case do not
   amount to a violation of the CRA.
          The CRA provides that “[e]ach session of the court” in a criminal
   proceeding “shall be recorded verbatim by shorthand, mechanical means,
   electronic sound recording, or any other method.” 122 In cases, as here, where
   appellate counsel was not trial counsel, a CRA violation occurs when “a
   substantial and significant portion of the record” is missing such that “even
   the most careful consideration of the available transcript will not permit [this

          120
                Id.
          121
                28 U.S.C. § 753(b).
          122
                Id.

                                           35
Case: 21-10292           Document: 00516915625                 Page: 36      Date Filed: 10/02/2023

                                                No. 21-10292

   court] to discern whether reversible error occurred.” 123 But this court has
   long held that “a gapless transcription of a trial is not required.” 124 “We
   have not found reversible error even when a transcript was missing seventy-
   two bench conferences.” 125 “[A] merely technically incomplete record” is
   not error. 126
           Won argues that the 46 missing bench conferences robbed his
   appellate counsel of the rationale for various district court rulings, especially
   the exclusion of some of Ford’s testimony and several exhibits. Without that
   rationale, Won argues, he faces substantial prejudice because he cannot
   mount an appeal.
           The first question presented to this court is the standard of review.
   Won claims that he raised his CRA argument to the district court in a table
   of evidentiary rulings he filed mid-trial and that he presents a question of law
   reviewed de novo. This table memorialized Won’s objections to various
   rulings, but it did not raise the CRA directly. The closest it came to the CRA
   was mentioning in a footnote that “many of the evidentiary rulings regarding
   trial exhibits in this case occur[red] off of the record.” Won then explains
   that he filed the list to “reflect[] the current status of the trial exhibits
   admitted and excluded” including “Dr. Won’s objections.” Won neither
   raised the CRA nor objected to the court’s procedure. Accordingly, we agree
   with the Government and review the potential violation for plain error. 127

           123
                 United States v. Selva, 559 F.2d 1303, 1306 (5th Cir. 1977).
           124
                 United States v. Delgado, 672 F.3d 320, 343 (5th Cir. 2012).
           125
                 Id. (citing United States v. Gieger, 190 F.3d 661, 667 (5th Cir. 1999)).
           126
                 Selva, 559 F.2d at 1306 n.5.
           127
              See United States v. Whitelaw, 580 F.3d 256, 259 (5th Cir. 2009) (holding that
   claims not raised before the district court are reviewed for plain error).

                                                    36
Case: 21-10292          Document: 00516915625              Page: 37       Date Filed: 10/02/2023

                                            No. 21-10292

   Won must show that the error was “plain,” “affected [his] substantial
   rights,” and “seriously affected the fairness” of his trial.128
           Won cannot show plain error. This court has only recognized CRA
   violations for truly egregious omissions like an absence from the record of
   voir dire, opening statements, closing arguments, or even an entire
   transcript. 129 Won does not point this court to any case in which the court
   found reversible error for off-the-record bench conferences, especially when
   objections were later memorialized. The Government, on the other hand,
   points this court to a litany of cases in which the court has not found
   reversible error even in the face of several dozen more missing conferences
   than at issue here. 130 The district court did not plainly err.
                                                  X
           Burt argues that the district court erred by finding that he had
   breached his pre-trial proffer agreement with the Government. We hold that
   the district court did not commit clear error in determining that Burt offered
   evidence inconsistent with his proffer and that this constituted a breach of
   his agreement.
           Well before trial, Burt engaged in a proffer agreement with the Office
   of the Inspector General. He agreed to tell the truth about Forest Park in
   exchange for the Government not using his statements against him. The
   agreement, which is interpreted according to the general principles of

           128
                 See United States v. Conn, 657 F.3d 280, 284 (5th Cir. 2011) (per curiam).
           129
              United States v. Gregory, 472 F.2d 484 (5th Cir. 1973) (absence of voir dire and
   opening and closing statements); Stephens v. United States, 289 F.2d 308 (5th Cir. 1961)
   (absence of voir dire and closing arguments); United States v. Rosa, 434 F.2d 964 (5th Cir.
   1970) (per curiam) (absence of entire transcript).
           130
             See, e.g., Gieger, 190 F.3d at 667 (finding no error despite missing 72 bench
   conferences).

                                                  37
Case: 21-10292            Document: 00516915625              Page: 38       Date Filed: 10/02/2023

                                              No. 21-10292

   contract law, 131 stated that the Government would not use Burt’s statements
   against him in the Government’s case-in-chief “except . . . for statements
   outside the proffer that are inconsistent” with the proffer. In a later
   paragraph, the agreement makes clear that if Burt or his attorney elicited
   “arguments that are inconsistent with [the proffer,] . . . [then the
   Government] may use proffer information to rebut or refute the
   inconsistencies.” In his proffer interview, Burt stated that “[y]ou don’t
   entice doctors because that would be against the law” and that he realized
   from the beginning that the $600,000 check Beauchamp paid to Adelaide was
   for kickbacks.
            In pre-trial filings, Burt argued that he did not know that the checks
   were for kickbacks and that he was generally unaware of impropriety. The
   Government objected, claiming that he had breached his proffer agreement.
   The court held an evidentiary hearing and agreed that Burt had breached the
   proffer and that the remedy, according to the agreement, was for the
   Government to be able to rebut any breach statements that Burt elicited at
   trial.    At trial, Burt’s attorney cross-examined Forest Park’s former
   controller, David Wheeler who had testified to various improprieties at
   Forest Park. To impeach Wheeler, Burt used a representation letter that not
   only Wheeler but also Burt had signed. The letter generally attested that
   none of the signatories had knowledge of fraud within the hospital. Burt’s
   attorney made use of a projector for this part of his cross examination,
   blowing up the representation letter on the screen for the jury. The attorney
   made repeated references to the signatures depicted on the screen, blew up
   the signature page until it was quite large, and told the jury to “look at the

            131
                  See United States v. Castaneda, 162 F.3d 832, 835-36 (5th Cir. 1998).

                                                   38
Case: 21-10292     Document: 00516915625           Page: 39   Date Filed: 10/02/2023

                                    No. 21-10292

   signatures” while eliciting testimony from Wheeler that those signatures,
   including Burt’s, attested to the fact that there was no fraud or impropriety.
          The Government renewed its objection that Burt had breached the
   proffer agreement. It argued, as it does on appeal, that the testimony Burt’s
   attorney elicited from Wheeler that the signatures meant that no one knew of
   any fraud directly contradicted Burt’s earlier statement that he knew about
   the kickbacks all along. The court agreed, concluding that Burt had breached
   the agreement and that the Government was entitled to rebut Burt’s
   assertion that he had no knowledge of fraud. The parties disagreed as to how.
   After a lengthy discussion with the parties, the court settled on a remedy
   whereby the judge would read an agreed-to statement to the jury. That
   statement reads as follows:
          Defendant Mac Burt made statements in June 2016 to Casey
          England, an agent with the Office of Inspector General. You
          may have heard those initials OIG during the trial. Those
          statements were during a voluntary interview where he was
          represented by legal counsel. The interview, consistent with
          Department of Justice policy, was not taped. The agent took
          notes. Those notes include a statement by Defendant Burt that
          he realized from the very beginning that the $600,000 check
          Beauchamp requested from Forest Park to be paid to Adelaide
          was for doctor kickbacks. You may consider this evidence as to
          Defendant Burt.
          Burt first claims that he did not breach the agreement because the
   testimony was merely used to impeach Wheeler. Second, Burt claims that
   the district court misinterpreted the proffer agreement by allowing the
   Government to rebut any inconsistency during its case-in-chief. Third, Burt
   argues that the court’s remedy was error. Finally, Burt argues that any error
   was not harmless.

                                         39
Case: 21-10292           Document: 00516915625              Page: 40       Date Filed: 10/02/2023

                                             No. 21-10292

                                                   A
           The district court’s finding of breach is reviewed for clear error. 132
   We review de novo whether, under those facts, the agreement was in fact
   breached. 133 A factual finding is clearly erroneous only if it is implausible “in
   light of the record as a whole.” 134 The court referenced the testimony of
   Wheeler as well as the proffer agreement and found them to be inconsistent.
   We agree.
           Burt bargained with the Government to tell the truth in his proffer and
   to not make inconsistent statements at trial. The agreement was explicit that
   statements Burt elicited would count as inconsistent. Burt was on notice for
   several months that he was violating the proffer every time he tried to argue
   that he had no knowledge of any fraud or impropriety, yet at trial he elicited
   testimony contrary to his proffer.                    Wheeler’s testimony that the
   representation letter was an attestation of no impropriety, when combined
   with Burt’s attorney’s focus on the signature page containing Burt’s
   signature, leads to a not clearly erroneous conclusion that Burt was acting
   inconsistently with his earlier statement that he had knowledge of
   wrongdoing.
           Burt’s argument to the contrary is not persuasive. He argues that he
   was merely impeaching Wheeler, and he relies heavily on a Seventh Circuit
   case for the proposition that defendants ought to be given broad leeway to
   impeach government witnesses even while under the stricture of a proffer

           132
               Castaneda, 162 F.3d at 836 n.24 (citing United States v. Gibson, 48 F.3d 876, 878
   (5th Cir. 1995) (per curiam)).
           133
                 United States v. Chavful, 781 F.3d 758, 761 (5th Cir. 2015).
           134
                 See United States v. Rodriguez, 630 F.3d 377, 380 (5th Cir. 2011) (per curiam).

                                                   40
Case: 21-10292           Document: 00516915625               Page: 41       Date Filed: 10/02/2023

                                             No. 21-10292

   agreement. 135 But United States v. Krilich 136 does more to hurt Burt’s
   argument than help it. There, the Seventh Circuit affirmed the district
   court’s determination that the defendant breached the proffer because he
   was not merely impeaching the witness; rather, his counsel was eliciting
   statements “inconsistent with the proffer.” 137 So too here.
                                                   B
           Burt also argues that the district court erred by not harmonizing the
   agreement’s provision protecting him from the Government’s use of any
   statement in its case-in-chief with the provision allowing rebuttal evidence.
   This argument fails on its face. The court expressly explained the two
   provisions’ interaction, concluding that the latter provided the Government
   with a rebuttal remedy should Burt breach the agreement not to make
   inconsistent statements. There is no clear error in this construction.
           Nor is Burt correct to argue that the rebuttal was precluded from
   taking place in the Government’s case-in-chief. It is true that paragraph 3 of
   the agreement explains that the Government would not use Burt’s proffer
   against him in its case-in-chief, but the agreement included an express
   exception for inconsistent statements. Paragraph 7 clearly provides that the
   remedy is rebuttal. Moreover, this court has recognized that “rebuttal
   waiver[s] might be worded so broadly as to allow admission of plea
   statements in the government’s case-in-chief.” 138 If rebuttal could not take

           135
                 See United States v. Krilich, 159 F.3d 1020, 1025 (7th Cir. 1998).
           136
                 159 F.3d 1020 (7th Cir. 1998).
           137
              Id. at 1026 (holding that the testimony elicited by defense counsel went “well
   beyond casting doubt on the prosecutor’s evidence” because it “advance[d] a position
   inconsistent with the proffer”).
           138
                 United States v. Sylvester, 583 F.3d 285, 292 (5th Cir. 2009).

                                                   41
Case: 21-10292             Document: 00516915625         Page: 42       Date Filed: 10/02/2023

                                          No. 21-10292

   place during the case-in-chief, the Government might never get an
   opportunity to hold defendants accountable for breaching the agreement
   because defendants can choose not to present a case at all. 139
                                                C
           Burt argues that the district court’s remedy of reading a statement to
   the jury prejudiced him, and he urges this court to review that decision for
   abuse of discretion. This court does not appear to have addressed a standard
   of review for the remedy chosen by the district court, nor does the
   Government in its brief. We have suggested, however, that we would review
   the admission of plea negotiation evidence for abuse of discretion. 140 We
   reasoned that an objection to the admission of such evidence would be no
   different than an objection to any other evidence and that the same abuse of
   discretion standard should apply. 141 Other circuits have approached breaches
   of plea agreements in accordance with contract principles, reasoning that
   “[i]t is for the district court to decide what remedy is appropriate.” 142 We
   adopt the abuse of discretion standard here.
           Burt argues that the proper remedy should have been either: (1) an
   instruction that Wheeler’s testimony could only be considered as to
   Wheeler’s knowledge and beliefs and not Burt’s; or (2) an opportunity to
   cross-examine the agent who interviewed Burt. But in doing so, Burt

           139
                 See id.
           140
                 Id. at 288 n.4.
           141
                 Id.
           142
              United States v. Anderson, 970 F.2d 602, 608 (9th Cir. 1992); see United States v.
   Chiu, 109 F.3d 624, 626 (9th Cir. 1997) (“A district court has broad discretion in fashioning
   a remedy for the government’s breach of a plea agreement.”); United States v. Bowe, 257
   F.3d 336, 346 (4th Cir. 2001) (holding that the defendant breached his plea agreement and
   remanding to the district court to “fashion[] an appropriate remedy”).

                                                42
Case: 21-10292             Document: 00516915625           Page: 43       Date Filed: 10/02/2023

                                            No. 21-10292

   essentially asks this court to strike a different balance than that of the district
   court. That is not our role in reviewing for abuse of discretion. “A trial court
   abuses its discretion when its ruling is based on an erroneous view of the law
   or a clearly erroneous assessment of the evidence.” 143 As explained above,
   the district court was correct in determining that Burt elicited inconsistent
   statements and in concluding that they amounted to a breach of his proffer
   agreement. It is hard to see how reading the statement was an abuse of
   discretion.
           Burt falls back on the argument that the district court’s decision to
   read the statement as opposed to allow Burt to cross-examine the agent who
   interviewed him violated his due process rights. 144 He cites little in the way
   of elaboration, and it does not appear that he raised this argument in the
   district court. What little analysis he provides is simply a rehash of his earlier
   arguments that he did not breach the agreement and an objection that the
   prosecutor characterized the statement as a “confession” during closing
   arguments. This argument is forfeited for lack of adequate briefing. 145 Nor
   does the (limited) argument Burt makes with regard to a violation of the
   Confrontation Clause affect this analysis. Burt waived any Confrontation
   Clause challenge at trial. Even if he had not, he has not adequately briefed it
   here and we would deem it forfeited. 146
           Further, even assuming the court erred, any error was harmless given
   the other, substantial evidence against Burt, including testimony from

           143
               United States v. Yanez Sosa, 513 F.3d 194, 200 (5th Cir. 2008) (quoting United
   States v. Ragsdale, 426 F.3d 765, 774 (5th Cir. 2005)).
           144
                 He does not raise a Confrontation Clause challenge.
           145
                 See Rollins v. Home Depot USA, 8 F.4th 393, 397 & n.1 (5th Cir. 2021).
           146
                 See id.

                                                  43
Case: 21-10292          Document: 00516915625               Page: 44       Date Filed: 10/02/2023

                                            No. 21-10292

   numerous witnesses that he did in fact know what was going on from the
   beginning and that the money was for bribes and illegal kickbacks.
                                                 XI
          Jacob, Rimlawi, Won, and Henry all argue that the court erred by
   reading a portion 147 of Burt’s proffer into the record. The defendants argue
   that this was Bruton error. Shah and Forrest adopt the arguments of their
   codefendants. Rimlawi further argues that the court erred in allowing the
   prosecution to cross-examine him with the proffer. 148 Because the proffer
   “could only be linked [to the defendants] through additional evidentiary
   material,” there was no Bruton error. 149 Rimlawi’s argument, however, fares
   better. Assuming the district court erred by cross-examining Rimlawi with
   the proffer, that error was harmless. We will address the threshold challenge
   to the admission of the proffer raised by Jacob and the physicians below. We
   will then address Rimlawi’s challenge to the proffer’s use during his cross-
   examination.
          But first, the defendants challenge the exact wording of the court’s
   limiting instruction. They urge this court to reverse because the court limited
   the use of the proffer “as to Defendant Burt” and not as to Burt only. The
   omission of “only” in the limiting instruction, they argue, is reversible error.
   The parties have not provided any caselaw on point to support their
   assertion, nor have we found any. We are not convinced that the omission of
   “only” is reversible error. We may safely assume “the almost invariable

          147
                Reproduced above, supra Section X.
          148
                Assuming without deciding that Won may adopt this argument by reference, it
   fails as to him for the same reasons discussed below.
          149
                See United States v. Powell, 732 F.3d 361, 376-77 (5th Cir. 2013).

                                                  44
Case: 21-10292           Document: 00516915625             Page: 45    Date Filed: 10/02/2023

                                            No. 21-10292

   assumption . . . that jurors follow their instructions.” 150 The instruction
   given was that the jury may consider the proffer “as to Defendant Burt.”
   The “only” is implied. Additionally, any error in the instruction was
   harmless given the weight of evidence against all of the defendants.
                                                 A
           In Bruton, the Supreme Court held that the admission of a non-
   testifying codefendant’s statements may violate a testifying codefendant’s
   Sixth Amendment right to confront his accusers. 151 But “[o]rdinarily, a
   witness whose testimony is introduced at a joint trial is not considered to be
   a witness ‘against’ a defendant if the jury is instructed to consider that
   testimony only against a codefendant.” 152 There is “a narrow exception to
   this principle.” 153 If the admitted testimony “facially incriminate[s]” the
   defendant, then the admission may violate the defendant’s Confrontation
   Clause rights even if the court gives a limiting instruction. 154 Further,
   although it is assumed that “jurors follow their instructions,” 155 the
   “prosecution [can] upend[] this assumption” by “clearly, directly, and
   repeatedly” using the non-testifying codefendants’ statements against a

           150
              Richardson v. Marsh, 481 U.S. 200, 206 (1987) (citing Francis v. Franklin, 471
   U.S. 307, 325 n.9 (1985)).
           151
                 See Bruton v. United States, 391 U.S. 123, 136-37 (1968); U.S. Const. amend.
   VI.
           152
                 Richardson, 481 U.S. at 206.
           153
                 Id. at 207.
           154
                 Id.
           155
                 Id. at 206.

                                                45
Case: 21-10292             Document: 00516915625               Page: 46       Date Filed: 10/02/2023

                                                No. 21-10292

   testifying codefendant. 156             Such use of a non-testifying codefendant’s
   statements is “a clear and obvious violation of a constitutional right that
   substantially affects the fairness of judicial proceedings” and is plainly
   erroneous. 157
             The “key analytic factor” in deciding whether there is Bruton error is
   whether the admitted proffer “clearly refer[s]” to the other codefendants or
   whether it “could only be linked through additional evidentiary material.” 158
   If further linkage is required, then the proffer does not “facially implicate[]”
   the other physicians and it does not violate their Sixth Amendment rights. 159
   We review constitutional challenges de novo, but we review the trial court’s
   “evidentiary decisions on a Bruton issue . . . for abuse of discretion.” 160
   Bruton errors are subject to harmless error analysis. 161
             The only objectionable part of the court’s statement to the jury was
   that “[Burt] realized from the very beginning that the $600,000 check
   Beauchamp requested from Forest Park to be paid to Adelaide was for doctor
   kickbacks.” The physicians (Won, Rimlawi, and Henry) argue that the
   court’s use of “doctor” facially implicated them. Jacob argues that the
   reference to his company, Adelaide, is enough to facially implicate him.

             156
               See United States v. Powell, 732 F.3d 361, 379 (5th Cir. 2013) (“[T]he prosecution
   itself upended this assumption. The prosecution’s cross-examination of Powell clearly,
   directly, and repeatedly used Akin’s statements against him.”).
             157
                   Id. Rimlawi never raised his objection at trial, so it is reviewed for plain error.
   See id.
             158
                   Id. at 376-77.
             159
                   See id.; see also Richardson, 481 U.S. at 206-07.
             160
              Powell, 732 F.3d at 376 (quoting United States v. Jimenez, 509 F.3d 682, 691 (5th
   Cir. 2007)).
             161
                   Id.

                                                     46
Case: 21-10292          Document: 00516915625             Page: 47   Date Filed: 10/02/2023

                                           No. 21-10292

          In United States v. Powell, 162 on which the defendants rely, this court
   held that the admission of a non-testifying codefendant’s statement to an
   investigator did not violate Bruton. 163 A husband (Powell) and his wife (Akin)
   transported cocaine together in their car. They were stopped by police and
   interviewed separately.           Akin made several inculpating statements to
   investigators that the prosecution used at trial against Powell.               The
   statements related to Akin’s knowledge that the car she was a passenger in
   was transporting crack cocaine. 164 Akin did not testify at trial. This court
   held that the admission of the statements “did not directly implicate” Powell
   despite the fact that it was well established that the two were in the car
   together. 165 The testimony concerned only Akin’s knowledge and actions—
   any relation to Powell had to be inferred.
          So too here.           Although the proffer statement directly mentions
   “doctors” and Adelaide, further evidence is required to link Won, Rimlawi,
   and Henry to “doctors” and Jacob to “Adelaide.” Burt’s use of “doctors”
   could have referred to any number of physicians. The fact that the three
   defendants were on trial and also doctors does not mean that the use of
   “doctors” facially implicated them. The jury had to examine other evidence
   to determine whether those three doctors were indeed the doctors who had
   received kickbacks. All the proffer stands for directly is that Burt knew
   Beauchamp was paying physician kickbacks. The jury had to decide which
   physicians were receiving kickbacks. Likewise, although the statement
   directly refers to Adelaide, more is required to link Jacob to Adelaide. First,

          162
                732 F.3d 361, 379 (5th Cir. 2013)
          163
                Id. at 377.
          164
                Id.
          165
                Id. at 377-78.

                                                    47
Case: 21-10292          Document: 00516915625       Page: 48    Date Filed: 10/02/2023

                                     No. 21-10292

   of course, would be evidence that Jacob operates Adelaide. Second, the jury
   would have to find that any illegal actions of Adelaide could be imputed to
   Jacob. More evidence was required to link Jacob to the illegal conduct for
   which he was eventually convicted.
                                           B
          Even if the admission of the proffer statement was not error, and we
   hold that it was not, that does not end the Bruton analysis. This court has
   recognized that while admission of a non-testifying defendant’s statement
   may not be erroneous if properly limited, that statement’s use against other
   defendants outside the limiting instruction may violate the Confrontation
   Clause. 166 Here, the district court limited the proffer’s use by instructing that
   the jury may consider the statement “as to Defendant Burt.” Nonetheless,
   the prosecution’s subsequent use of the proffer against Rimlawi may have
   been in error. 167
          When Rimlawi took the stand in his own defense, the Government
   used the proffer against him directly. Rimlawi claimed that he “didn’t have
   any deal or side deal that was illegal or involved kickbacks.”               The
   Government cross-examined him with the statements of several individuals
   who had testified that Rimlawi had in fact been “paid for patients.” The
   prosecutor listed 10 individuals who had testified that Rimlawi was involved
   in the kickback scheme. At the end of this list and as the eleventh individual
   to testify against Rimlawi, the Government briefly mentioned Burt’s proffer
   statement. Rimlawi claims that this admission violated the Confrontation
   Clause.

          166
                Id. at 378-79.
          167
                See id. at 379.

                                          48
Case: 21-10292          Document: 00516915625              Page: 49        Date Filed: 10/02/2023

                                            No. 21-10292

          In Powell, discussed above, this court determined that the admission
   of Akin’s statement was not Bruton error, but it held that the prosecution’s
   use of that statement to cross-examine Powell was erroneous. 168                          The
   Government attempts to distinguish Powell, contrasting the extent of the
   cross-examination in that case versus here.                   It is true that the cross-
   examination in Powell focused more on the potentially violative statement
   than here—the prosecutor brought up Akin’s statement five times in a
   row. 169 But the rationale in Powell was that the prosecution “upended” the
   court’s limiting instruction when it used the statement “clearly, directly, and
   repeatedly” against Powell. 170 While the extent of the use of the proffer at
   issue here is less than in Powell (used once versus five times), it was “clearly”
   and “directly” used against Rimlawi. That use may violate Rimlawi’s
   constitutional right to confront his accusers.
          But even assuming without deciding that the admission of the
   statement in cross-examination was error, that error was harmless. “It is well
   established that a Bruton error may be considered harmless when,
   disregarding the co-defendant’s confession, there is otherwise ample
   evidence against the defendant.” 171 To find an error harmless, we must be
   convinced beyond a reasonable doubt that the error was in fact harmless in
   light of the other evidence presented at trial. 172 We will not find a Bruton

          168
                Id. at 378-79.
          169
                Id. at 378.
          170
                Id. at 379.
          171
                Id. (quoting United States v. Vejar-Urias, 165 F.3d 337, 340 (5th Cir. 1999)).
          172
                Vejar-Urias, 165 F.3d at 340.

                                                  49
Case: 21-10292            Document: 00516915625            Page: 50       Date Filed: 10/02/2023

                                            No. 21-10292

   error harmless if there is “a reasonable probability that the defendants would
   be acquitted.” 173
          In Powell, the court held that even though the admission during cross-
   examination was plain error, the error was harmless and the conviction could
   stand because of the weight of the other evidence against Powell. 174 So too
   here. As evident in the exchange at issue for Rimlawi, no fewer than 10 other
   individuals implicated him in the kickback scheme. Just as Powell was caught
   driving “a car loaded with crack cocaine packaged for sale,” a mountain of
   other evidence inculpates Rimlawi. 175 As discussed above in Part II(B),
   Beauchamp testified that Forest Park paid for federally insured patients.
   Rimlawi admits to having federally insured patients. Smith’s kickback
   tracking sheets show that Rimlawi was credited with DOL/FECA insured
   patients, and Rimlawi does not contest that DOL/FECA patients are federal
   pay.
                                                XII
          Won, Rimlawi, and Shah argue that the district court abused its
   discretion in excluding various portions of two witnesses’ testimony:
   Theresa Ford and Bill Meier. The court did not abuse its discretion.
          The surgeons argue that the district court erred in excluding portions
   of Ford and Meier’s testimony along with a related email from Ford and
   certain billing invoices from Meier. The surgeons attempted to introduce
   this evidence to bolster their advice-of-counsel defense. The surgeons
   suggest now that neither attorney was able to testify at trial meaningfully, but

          173
                Powell, 732 F.3d at 379 (quoting Vejar-Urias, 165 F.3d at 340).
          174
                Id. at 380.
          175
                See id.

                                                 50
Case: 21-10292         Document: 00516915625               Page: 51        Date Filed: 10/02/2023

                                            No. 21-10292

   that is not the case. Both attorneys testified at trial. The surgeons’ appeal
   focuses on three sets of excluded evidence: (1) an email Won wrote to Ford
   as well as testimony that Won told Ford that Forest Park did not accept
   federally insured patients; (2) Ford’s testimony regarding how common
   marketing schemes for physicians are and her opinion that Forest Park’s was
   legal; and (3) Meier’s testimony concerning the same.
          The court ruled that the attorneys could testify “as relevant to the
   state of mind of a defendant,” but they were not allowed to “be a mouthpiece
   for the defendant” or to “offer legal opinions.” The court did not allow the
   lawyer-witnesses “to make legal conclusions or opinions” with regard to
   central issues in the case. It excluded the evidence at issue on a variety of
   grounds. The district court found testimony about the legality of the
   marketing scheme to be irrelevant given that the marketing agreement was,
   on its face, legal and not at issue. It also excluded the testimony regarding
   the ultimate legality of the programs as legal conclusions by a lay witness. It
   concluded that conversations between the surgeons and attorneys about
   whether the surgeons’ actions were legal were hearsay.
          Evidentiary rulings are reviewed for abuse of discretion. 176 The
   harmless error doctrine applies. 177 Irrelevant evidence is inadmissible. 178 So
   too is hearsay evidence that does not fall within an exception. 179 A lay
   witness’s opinion testimony is limited to opinions that are “based on the

          176
                United States v. Liu, 960 F.2d 449, 452 (5th Cir. 1992).
          177
                Id.
          178
                See Fed. R. Evid. 402.
          179
                Fed. R. Evid. 801, 802.

                                                 51
Case: 21-10292        Document: 00516915625            Page: 52   Date Filed: 10/02/2023

                                        No. 21-10292

   witness’s perception[,] helpful[,] . . . and not based on . . . specialized
   knowledge.” 180
                                             A
          The district court did not abuse its discretion in excluding the Ford
   email because the only statements the surgeons object to are hearsay.
          The surgeons object to the exclusion of three statements: (1) a
   statement that the hospital “only accepts private commercial insurance,”
   and “do[es] not accept any federally funded programs and [has] no plans to
   do it in the future”; (2) a statement that Forest Park told Won it was not
   “participating in any federally funded program” or “affected by stark or anti-
   kickback issues”; and (3) a statement that Won “want[ed] to make sure we
   are compliant.”
          Federal Rule of Evidence 803(3) creates an exception to hearsay for
   statements concerning a declarant’s “then-existing state of mind” but not
   for “a statement of memory or belief to prove the fact remembered or
   believed.” 181 The Government argues that the first two statements listed
   above fall outside Rule 803(3) because they are statements of memory or
   belief offered to prove the fact remembered or believed. In each case, the
   surgeons seek admission of testimony that Forest Park was not connected to
   federally funded programs to prove the same. This court held, in nearly
   identical circumstances, that this is “the kind of statement of historical fact

          180
                Fed. R. Evid. 701.
          181
                Fed. R. Evid. 803(3).

                                            52
Case: 21-10292          Document: 00516915625               Page: 53       Date Filed: 10/02/2023

                                             No. 21-10292

   or belief that Rule 803(3) precludes.” 182 We see no reason for a different
   result here. 183
           As for the third statement, Won’s only argument is that the statement
   was a verbal act and not hearsay. He does not raise Rule 803(3) with regard
   to that statement and has forfeited that argument. 184 The statement itself is
   not a verbal act within the meaning of the term because he sought to admit it
   for the truth of the matter asserted, i.e., that he sought compliance. 185
           Rimlawi challenges the exclusion of his own testimony related to this
   same topic, i.e., his state of mind and advice-of-counsel defense. For the
   same reasons as above, the court did not abuse its discretion in excluding
   them.
           Shah raises a distinct challenge to the exclusion of this evidence. He
   asserts that its exclusion violated his Sixth Amendment right to present a
   complete advice-of-counsel defense. Even under de novo review, which
   would apply here, 186 Shah’s argument lacks merit. The right protected is to

           182
                 United States v. Gibson, 875 F.3d 179, 194 n.10 (5th Cir. 2017).
           183
              These statements are not, as Won argues, verbal acts that are excluded from
   hearsay restrictions. See United States v. Gauthier, 248 F.3d 1138 (5th Cir. 2001)
   (unpublished) (per curiam) (offering a bribe); Tompkins v. Cyr, 202 F.3d 770, 779 n.3 (5th
   Cir. 2000) (making a threat).
           184
                 See Rollins v. Home Depot USA, 8 F.4th 393, 397 & n.1 (5th Cir. 2021).
           185
               Cf. United States v. Hansbrough, 450 F.2d 328, 329 (5th Cir. 1971) (per curiam)
   (“[T]he statement was not offered to prove the truth of the matter asserted therein (i.e.
   the identity of the caller) but rather was offered merely to establish that the call was made.
   As such, the statement was offered to prove a ‘verbal act.’”) (citing Overton v. United
   States, 403 F.2d 444, 447 (5th Cir. 1968)). In addition, even if Rule 803(3) applies to this
   statement, the district court may have been within its discretion in excluding the testimony
   because it was irrelevant: it went to Won’s state of mind several years prior to the
   conspiracy.
           186
                 See United States v. Skelton, 514 F.3d 433, 438 (5th Cir. 2008).

                                                   53
Case: 21-10292           Document: 00516915625             Page: 54   Date Filed: 10/02/2023

                                            No. 21-10292

   “present a defense” in part by “present[ing] his own witnesses to establish
   a defense.” 187 Shah fails to address the fact that Ford did in fact testify about
   her relationship with Won and Rimlawi (she does not appear to have ever
   worked with Shah). Rimlawi’s attorney managed to ask about whether the
   surgeons sought compliance with all applicable laws during her allotted time
   to examine Ford. It is hard to see how Shah was not afforded the opportunity
   to present a defense.
           United States v. Garber 188 is not to the contrary.                There, the
   defendant’s witness was prevented from testifying to the existence of a legal
   theory supporting the defense. 189 This court found error. 190 Here, on the
   other hand, the statements the district court excluded are simple, run-of-the-
   mill hearsay statements from Won. Ford was allowed to testify as to what
   she looked for in making sure marketing agreements were legal. Garber is
   inapposite.
                                                  B
           Next, the surgeons argue that the district court erred by not allowing
   Ford to testify as to the categorization of healthcare programs and the legality
   of the marketing agreement she reviewed. The court did not err.
           First, Ford was not allowed to testify to the jury as to whether
   DOL/FECA is a federal healthcare program. But she was not qualified as an
   expert witness, and the surgeons did not establish that she had personal
   knowledge of the source of DOL funding. There is no abuse of discretion in

           187
              Taylor v. Illinois, 484 U.S. 400, 409 (1986) (quoting Washington v. Texas, 388
   U.S. 14, 19 (1967)).
           188
                 607 F.2d 92 (5th Cir. 1979) (en banc).
           189
                 Id. at 99.
           190
                 Id.

                                                  54
Case: 21-10292            Document: 00516915625         Page: 55   Date Filed: 10/02/2023

                                         No. 21-10292

   precluding a lay witness from testifying as to something of which they lack
   personal knowledge. 191
          Second, Ford was also not allowed to testify that comarketing
   agreements are common and that Forest Park’s actual arrangement was legal.
   But Ford was allowed to testify about comarketing in general and the
   marketing agreement Won had sent her in 2009 (which was not the one that
   ended up being the operative agreement between Won and Forest Park pass-
   through entities). The Government does not contest that the marketing
   agreement was facially legal. What mattered, the Government urges, is what
   the agreement did not say—that the physicians were accepting illegal
   kickbacks as part of this agreement. Ford did not have personal knowledge
   of these facts. She could not opine that the agreement Won and the pass-
   through entity reached and operated under was legal. 192
                                              C
          Attorney Meier was also not allowed to testify as to the legality of the
   surgeons’ marketing agreements. For the same reasons as above, the district
   court did not err.
                                            XIII
          Next, Won, Rimlawi, and Shah argue that the district court erred by
   denying their request for specific jury instructions on advice-of-counsel and
   good-faith defenses. Jacob argues that the district court erred by denying the
   good-faith instruction. Forrest adopts by reference arguments as to the
   denial of the good-faith instruction. The district court did not abuse its
   discretion in declining the defendants’ request for the two jury instructions

          191
                See Fed. R. Evid. 701.
          192
                See id.

                                              55
Case: 21-10292           Document: 00516915625               Page: 56       Date Filed: 10/02/2023

                                             No. 21-10292

   because the instructions were covered by the jury instructions given.
   Alternatively, and as an independent basis for affirming, Won and Rimlawi
   were not entitled to an advice-of-counsel instruction because there was not a
   proper foundation for it in evidence.
           Won, Rimlawi, and Shah appeal the district court’s denial of their
   request for specific jury instructions as to advice-of-counsel and good-faith
   defenses. Jacob appeals the denial of the good-faith instruction as well as the
   district court’s ultimate instruction on willfulness because it “exceeded the
   circuit pattern.” We review the denial of a jury instruction under an
   “exceedingly deferential” abuse of discretion standard. 193 We afford district
   courts “substantial latitude in tailoring” their jury instructions so long as the
   instructions “fairly and adequately cover the issues presented.” 194 The
   district court abuses its discretion only if “(1) the requested instruction is
   substantively correct; (2) the requested instruction is not substantially
   covered in the charge given to the jury; and (3) it concerns an important point
   in the trial so that the failure to give it seriously impairs the defendant’s
   ability to effectively present a particular defense.” 195
                                                   A
           The defendants’ argument fails because the jury instructions the court
   gave covered the instructions it denied. This court has held that “the
   omission of a good faith jury instruction is not an abuse of discretion if the
   defendant is able to present his good faith defense to the jury through, inter

           193
              Tompkins v. Cyr, 202 F.3d 770, 784 (5th Cir. 2000); see also United States v.
   Daniels, 247 F.3d 598, 601 (5th Cir. 2001).
           194
              United States v. Hunt, 794 F.2d 1095, 1097 (5th Cir. 1986) (quoting United States
   v. Kimmel, 777 F.2d 290, 293 (5th Cir. 1985)).
           195
                 United States v. St. Gelais, 952 F.2d 90, 93 (5th Cir. 1992) (citing Hunt, 794 F.2d
   at 1097).

                                                   56
Case: 21-10292          Document: 00516915625                Page: 57   Date Filed: 10/02/2023

                                              No. 21-10292

   alia, witnesses, closing arguments, and the other jury instructions.” 196 Key
   among these other jury instructions are those related to “knowing” and
   “willful” conduct because good-faith reliance defenses depend on
   disproving knowing or willful elements of the crime. 197 In other words, so
   long as the defendants are able to present their good-faith defense within the
   existing jury instructions regarding “knowing” and “willful” conduct, there
   is no error.
           Here, the district court’s instructions concerning “knowing” and
   “willful” conduct are similar to those in United States v. Frame 198 and United
   States v. Davis. 199          Although unpublished, the analysis in Frame is
   informative. There, this court affirmed the denial of the jury instruction as
   to a good-faith defense because it was captured within the jury instructions
   actually given; the court held that the instructions made plain that the jury
   was required to acquit Frame if, “because of his good faith, he lacked specific
   intent.” 200 Likewise, in Davis this court affirmed the denial of a requested
   jury instruction as to good faith because “those concepts were adequately
   explained through the district court’s definitions of the terms ‘knowingly’
   and ‘willfully.’” 201
           The same result holds here. The district court instructed the jurors
   that the Government had to prove that the defendants acted knowingly,

           196
             United States v. Frame, 236 F. App’x 15, 18 (5th Cir. 2007) (unpublished) (citing
   Hunt, 794 F.2d at 1098); see also Hunt, 794 F.2d at 1098 (distinguishing prior caselaw).
           197
                 See Frame, 236 F. App’x at 18.
           198
                 236 F. App’x 15 (5th Cir. 2007) (unpublished).
           199
                 132 F.3d 1092 (5th Cir. 1998).
           200
                 Frame, 236 F. App’x at 18.
           201
                 Davis, 132 F.3d at 1094.

                                                   57
Case: 21-10292          Document: 00516915625              Page: 58          Date Filed: 10/02/2023

                                            No. 21-10292

   which it defined as “done voluntarily and intentionally and not because of
   mistake or accident.” It then defined “willfully” as an “act [that] was
   committed voluntarily and purposely with the specific intent to do something
   that the law forbids, that is to say, with the bad purpose either to disobey or
   disregard the law.” 202 These instructions make clear that the jury could not
   convict the surgeons if they found that they had acted without the specific
   intent to do something the law forbids, i.e., if they were acting in good faith. 203
   In addition, Jacob’s argument that the district court’s willfulness instruction
   here “exceeded circuit pattern” is unsupported by caselaw and fails.
           This same instruction also substantially covers the surgeons’ advice-
   of-counsel defense for the same reason. Like a good-faith reliance defense,
   an advice-of-counsel defense is effective only insofar as it negates
   willfulness. 204 Willfulness, under the AKS, means acting with specific intent
   to do something the law forbids. 205 It does not require, as it does in a narrow
   set of “complex statutes,” knowledge of the exact terms of the statute the
   defendants were willfully violating. 206 In arguing that it does, the surgeons
   miss the mark. In those “complex” cases, namely tax cases, we have held
   that failure to instruct on an advice-of-counsel defense is reversible error

           202
               See United States v Ricard, 922 F.3d 639, 648 (5th Cir. 2019) (defining
   “willfulness” in a nearly identical fashion).
           203
              See Frame, 236 F. App’x at 16 n.1, 18 (affirming conviction under nearly identical
   willfulness definition despite omitting good-faith instruction); Davis, 132 F.3d at 1094
   (affirming nearly identical definitions in AKS case jury instructions).
           204
               See United States v. Mathes, 151 F.3d 251, 255 (5th Cir. 1998) (explaining that
   “[r]eliance on counsel’s advice excuses a criminal act only to the extent it negates
   willfulness” (quoting United States v. Benson, 941 F.2d 598, 614 (7th Cir. 1991), mandate
   recalled and amended in other respects by 957 F.2d 301 (7th Cir. 1992))).
           205
                 United States v. Nora, 988 F.3d 823, 830 (5th Cir. 2021).
           206
                 See United States v. Kay, 513 F.3d 432, 448 (5th Cir. 2007).

                                                  58
Case: 21-10292          Document: 00516915625               Page: 59          Date Filed: 10/02/2023

                                             No. 21-10292

   because of the complexity of the statute at issue and the heightened scienter
   required to violate it. 207 But that is not the case here.
                                                   B
           As an alternative, and independent, ground for affirming the denial of
   the advice-of-counsel instruction, the Government argues that the
   defendants failed to establish the requisite evidentiary foundation. We agree.
           A court “may . . . refuse to give a requested instruct[ion] that lacks
   sufficient foundation in the evidence.” 208 An advice-of-counsel defense has
   four elements: (1) before taking action, the defendant in good faith sought the
   advice of an attorney; (2) for the purpose of securing advice on the lawfulness
   of potential future conduct; (3) gave a full and accurate report of all material
   facts; and (4) the defendant acted strictly in accordance with the attorney’s
   advice. 209 A successful advice-of-counsel defense negates willfulness by
   “creat[ing] (or perpetuat[ing]) an honest misunderstanding of one’s legal
   duties.” 210
           Even assuming without deciding that the defendants can meet the first
   and second prongs of the test, they fail to meet the third and fourth. It is
   undisputed that Ford only billed 1.3 hours and did so preparing an agreement
   that ended up not being used. Further, neither Ford nor Meier was aware of
   the surgeons’ full dealings with the principals of Forest Park. They explicitly

           207
                 See Bursten v. United States, 395 F.2d 976, 982 (5th Cir. 1968).
           208
                 United States v. Branch, 91 F.3d 699, 712 (5th Cir. 1996).
           209
            See United States v. Bush, 599 F.2d 72, 77 n.12 (5th Cir. 1979); United States v.
   West, 22 F.3d 586, 598 n.36 (5th Cir. 1994) (reproducing the district court’s
   “comprehensive[]” explanation of the advice-of-counsel defense to the jury).
           210
              United States v. Mathes, 151 F.3d 251, 255 (5th Cir. 1988) (quoting United States
   v. Benson, 941 F.2d 598, 614 (7th Cir. 1991), mandate recalled and amended in other respects
   by 957 F.2d 301 (7th Cir. 1992)).

                                                  59
Case: 21-10292           Document: 00516915625              Page: 60       Date Filed: 10/02/2023

                                             No. 21-10292

   informed the surgeons that they should not accept kickbacks for patient
   referrals, yet that is exactly what the surgeons did. The surgeons do not
   satisfy the fourth prong of the defense as well.
                                                 XIV
           Shah argues that the district court erred by not instructing the jury on
   multiple conspiracies and instead instructing it only as to a single conspiracy,
   as alleged in the indictment. Shah’s argument is counter to well-settled
   precedent.
           Shah failed to make his objection during trial, so plain error review
   applies. 211 Shah argues that he preserved the objection in a document of
   proposed instructions he filed before trial even began. But nowhere in his
   145-page document does he note his “specific objection and the grounds for
   the objection” as required by Federal Rule of Criminal Procedure 30. 212 Plain
   error review applies.
           “[A] failure to instruct on multiple conspiracies generally does not
   constitute plain error.” 213 Shah cannot show error here because a lack of a
   multiple-conspiracies instruction did not prejudice his defense that he never
   conspired in the first place. 214
           Won, Forrest, and Jacob attempt to adopt Shah’s argument here by
   reference. The Government argues that this argument cannot be adopted by

           211
                 See United States v. Dupre, 117 F.3d 810, 816-17 (5th Cir. 1997).
           212
                 Fed. R. Crim. P. 30.
           213
               United States v. Devine, 934 F.2d 1325, 1341-42 (5th Cir. 1991) (citing United
   States v. Richerson, 833 F.2d 1147, 1155-56 (5th Cir. 1987)).
           214
               See United States v. Hunt, 794 F.2d 1095, 1099 (5th Cir. 1986) (finding no error
   when the lack of an instruction “cannot be said to have seriously impaired [the defendant’s]
   ability to present his defense”).

                                                   60
Case: 21-10292           Document: 00516915625              Page: 61        Date Filed: 10/02/2023

                                             No. 21-10292

   reference because the analysis is too fact specific. Even assuming without
   deciding that Shah’s argument could be adopted by reference, any adoption
   would fail for the same reasons discussed above.
                                                  XV
           Shah and Jacob raise myriad complaints about the prosecutors’
   actions during closing argument.                 Forrest adopts these arguments by
   reference. Even assuming the prosecutors engaged in some misconduct
   during closing argument, the defendants have failed to establish that the
   misconduct affected their substantial rights.
           We review allegations of prosecutorial misconduct with a two-step
   analysis: first, we look to whether the prosecutor “made an improper
   remark”; if so, we analyze whether that remark affected the defendant’s
   “substantial rights.” 215 The defendants did not raise their objections at trial,
   so we review them for plain error. 216 Reversing a conviction “on the basis of
   a prosecutor’s remarks alone” is not a decision this court makes “lightly.” 217
   “[T]he determinative question is whether the prosecutor’s remarks cast
   serious doubt on the correctness of the jury’s verdict.” 218 This is a “high
   bar.” 219 This court considers “the magnitude of the prejudicial effect,” “the

           215
              United States v. McCann, 613 F.3d 486, 494-95 (5th Cir. 2010) (quoting United
   States v. Gallardo-Trapero, 185 F.3d 307, 320 (5th Cir. 1999)).
           216
                 United States v. Aguilar, 645 F.3d 319, 323 (5th Cir. 2011).
           217
                United States v. Virgen-Moreno, 265 F.3d 276, 290 (5th Cir. 2001) (citing United
   States v. Iredia, 866 F.2d 114, 117 (5th Cir. 1989)).
           218
               Aguilar, 645 F.3d at 325 (internal quotation marks omitted) (quoting United
   States v. Gracia, 522 F.3d 597, 603 (5th Cir. 2008)).
           219
                 Id.

                                                   61
Case: 21-10292          Document: 00516915625              Page: 62       Date Filed: 10/02/2023

                                            No. 21-10292

   efficacy” of any instructions, and “the strength of the evidence.” 220 Even if
   the surgeons can meet this high burden, this court retains discretion whether
   to reverse, “which we generally will not do unless the plain error seriously
   affected the fairness, integrity, or public reputation of the judicial
   proceeding.” 221
           The alleged misconduct can be summarized as follows: improper
   vouching; personal attacks; misstatement of the evidence; telling jurors they
   are victims; faulting the defense’s choice to remain silent; and shifting the
   burden of proof. But most of the objected-to conduct is not objectionable
   when viewed in context. For example, Shah and Jacob argue that the
   prosecutor faulted the defense’s choice to remain silent, but when viewed in
   context, all of the statements relate to the paucity of the evidence the defense
   did put on to support their various defenses. 222 Similarly, the defendants’
   objections as to burden-shifting fail for the same reason—the prosecutor’s
   statements referred to their lack of evidence for affirmative defenses. 223

           220
              Virgen-Moreno, 265 F.3d at 290-91 (quoting United States v. Palmer, 37 F.3d
   1080, 1085 (5th Cir. 1994)).
           221
                 Aguilar, 645 F.3d at 323 (quoting Gracia, 522 F.3d at 600).
           222
               See United States v. Johnston, 127 F.3d 380, 396 (5th Cir. 1997) (holding that
   prosecutor comments on a defendant’s silence are only prohibited if the intent to comment
   on the silence was “manifest” or if the jury would “naturally and necessarily construe [the
   prosecutor’s remark] as a comment on the defendant’s silence”); id. (explaining that a
   prosecutor’s intent to comment on the defendant’s silence is not manifest if “there is an
   equally plausible [alternative] explanation of the prosecutor’s remark”); see also United
   States v. Ramirez, 963 F.2d 693, 700 (5th Cir. 1992) (allowing prosecutorial comment as to
   paucity of defendant’s evidence).
           223
              See United States v. Mackay, 33 F.3d 489, 496 (5th Cir. 1994) (holding that the
   government may “comment on the defendant’s failure to produce evidence on a phase of
   the defense” (quoting United States v. Dula, 989 F.2d 772, 777 (5th Cir. 1993))).

                                                  62
Case: 21-10292           Document: 00516915625               Page: 63       Date Filed: 10/02/2023

                                             No. 21-10292

           Shah also argues that the prosecutors committed misconduct by
   telling the jurors that the jurors were victims and by making personal attacks
   against the defendants.              These arguments carry more weight.                    The
   prosecutors referred to the effect the fraud had on the medical system in the
   United States, explaining to the jurors that “[t]here are a lot of victims in this
   case” and that “[t]he greed of the defendant[s] impacted us as a
   community.” Shah complains that this amounted to a “so-called ‘golden
   rule’ argument” because it urged the jury to put itself into the shoes of the
   victim. 224         Citing out-of-circuit precedent, Shah contends that such
   arguments are “universally condemned.” 225 He also argues that “invoking
   the individual pecuniary interests of jurors as taxpayers” is improper.
           In response, the Government points this court to United States v.
   Robichaux 226 for the proposition that the prosecutors were allowably
   “impress[ing] upon the jury the seriousness of the charges.” 227 There, this
   court found no error in the statement that “Louisiana citizens and all those
   who seek to purchase insurance suffer[ed] from Robichaux’s fraud.” 228 The
   court reasoned that the prosecutors remained “within the bounds of
   reasonableness” because they were simply “impressing upon the jury the
   seriousness of the charges” which involved “complicated financial
   transaction[s].” 229 We agree with the Government that if the statements in

           224
                 See United States v. Gaspard, 744 F.2d 438, 441 n.5 (5th Cir. 1984).
           225
               United States v. Palma, 473 F.3d 899, 902 (8th Cir. 2007) (quoting Lovett ex rel.
   Lovett v. Union Pac. R.R. Co., 201 F.3d 1074, 1083 (8th Cir. 2000)); see also Gov’t of V.I. v.
   Mills, 821 F.3d 448, 458 (3rd Cir. 2016); Hodge v. Hurley, 426 F.3d 368, 384 (6th Cir. 2005).
           226
                 995 F.2d 565 (5th Cir. 1993).
           227
                 Id. at 570 (quoting United States v. Lowenberg, 853 F.2d 295, 304 (5th Cir. 1988)).
           228
                 Id.
           229
                 Id.

                                                   63
Case: 21-10292     Document: 00516915625           Page: 64   Date Filed: 10/02/2023

                                    No. 21-10292

   Robichaux were not prejudicial, then neither are the ones here.          The
   statements are similar and so is the complicated nature of the transactions
   and fraud.
          Jacob and Shah argue that the prosecution personally attacked the
   defendants. Jacob argues that the prosecution “compar[ed] him to a drug
   dealer.” The prosecution had stated during closing argument that “[m]ost
   criminals pay their taxes. Drug dealers pay their taxes.” Even if this
   juxtaposition did constitute an improper remark, Jacob has not shown how it
   substantially prejudiced him such that reversal is warranted. Shah argues
   that the Government’s alleged personal attacks launched against Rimlawi
   were improper and prejudicial. A prosecutor described Rimlawi and his
   attorney as “cut from the same sleeve. Dirty, nasty.” The Government
   “regrets” this statement, but it argues that it is not clear Shah has standing
   to object to a statement made about Rimlawi. Also, even if Shah does have
   standing, the Government argues that he cannot prove that he received an
   unfair trial as a result. Rimlawi does not object to the statements made
   concerning him. Even assuming those remarks were improper and that Shah
   has standing to object, we agree with the Government that Shah cannot clear
   the high burden of plain error review and reverse his conviction.
          Relatedly, even assuming some of the other objected-to statements
   amounted to misconduct, the defendants have not carried their burden of
   showing substantial prejudice. The evidence against these defendants was
   strong, these allegations of misconduct occurred solely during closing
   argument, and the court offered several limiting instructions throughout the

                                        64
Case: 21-10292            Document: 00516915625               Page: 65       Date Filed: 10/02/2023

                                              No. 21-10292

   trial. Defendants have not shown that, taken together, the “remarks cast
   serious doubt on the correctness of the jury’s verdict.” 230
                                                   XVI
            Shah next argues that the district court erred in applying the abuse-of-
   trust sentencing enhancement to his sentence, but the court did not clearly
   err.
            The district court imposed a two-level enhancement under U.S.S.G.
   § 3B1.3. The enhancement applies “[i]f the defendant abused a position of
   public or private trust . . . in a manner that significantly facilitated the
   commission or concealment of the offense.” 231 Shah does not dispute that
   he occupied a position of trust. His only argument is that he did not use it to
   facilitate significantly any crime he may have committed. We review for clear
   error, upholding the enhancement “so long as it is plausible in light of the
   record as a whole.” 232
            We see no clear error in the district court’s finding that Shah used his
   position of trust to facilitate his crime. He does not dispute that he occupied
   a position of trust as his patients’ surgeon, and offered Forest Park as a
   facility where those patients could have their surgeries performed. He was
   then paid for that referral contrary to law.
            Shah points to the fact that the sentencing memorandum discusses
   how Shah was different because he treated DOL patients. Shah argues that

            230
               See United States v. Aguilar, 645 F.3d 319, 325 (5th Cir. 2011) (quoting United
   States v. Gracia, 522 F.3d 597, 603 (5th Cir. 2008)).
            231
                  U.S.S.G. § 3B1.3; see also United States v. Ollison, 555 F.3d 152, 165-66 (5th Cir.
   2009).
            232
             United States v. Miller, 607 F.3d 144, 148 (5th Cir. 2010) (quoting United States
   v. Ekanem, 555 F.3d 172, 175 (5th Cir. 2009)).

                                                    65
Case: 21-10292          Document: 00516915625              Page: 66       Date Filed: 10/02/2023

                                           No. 21-10292

   the memorandum then ignored that difference by saying he “still took a
   kickback.” Shah calls the district court’s alleged failure to account for this
   difference nonsensical because the district court’s omnibus order applied the
   enhancement to the other surgeons because they were lying to private
   patients and private insurers.             But Shah provides no reason why his
   enhancement should be any different just because he lied to federal as
   opposed to private patients.
          We may affirm “on any basis supported by the record.” 233 The record
   is clear that Shah used his position as a referring surgeon to facilitate the
   kickback scheme for which he was convicted.
                                               XVII
          The defendants argue that the district court erred by including
   proceeds from private-pay surgeries in its calculation of the improper benefit
   conferred by the kickback scheme. But the district court did not err because
   the bribes for private insurance patients occurred in the same course of
   criminal conduct as the bribes for federal-pay patients. The calculation was
   also otherwise reasonable.
          At sentencing, the Government requested and the court applied, the
   sentencing enhancement found at USSG § 2B4.1. That enhancement applies
   to bribery and kickback cases and enhances the sentence based on the “value
   of the improper benefit . . . conferred.” 234             That value is measured by
   “deducting direct costs from the gross value received.” 235 Direct costs are
   “all variable costs that can be specifically identified as costs of performing”

          233
                United States v. Chacon, 742 F.3d 219, 220 (5th Cir. 2014).
          234
                See United States v. Landers, 68 F.3d 882, 884 (5th Cir. 1995).
          235
                Id. at 886.

                                                 66
Case: 21-10292           Document: 00516915625             Page: 67        Date Filed: 10/02/2023

                                            No. 21-10292

   the bought surgeries. 236 Variable overhead costs generally are not direct costs
   because they usually “cannot readily be apportioned[,] . . . [and] sentencing
   courts are not required to make precise calculations.” 237 The difference in
   cost is also usually de minimis. 238 Indirect (fixed) costs, such as rent and debt
   obligations, are not deducted from the value of the improper benefit. 239
          Henry, Shah, Jacob, and Forrest argue that the court erred in
   determining the improper benefit amount for purposes of the sentence
   enhancement found at USSG § 2B4.1. They make two primary arguments:
   (1) that the district court improperly included the proceeds from Forest
   Park’s private-insurance patients in its calculation; and (2) that the court
   calculated the direct-cost reduction incorrectly. Henry and Shah preserved
   all their arguments below. Forrest did not preserve any, and her claim is
   reviewed for plain error. Jacob preserved at least some of his argument, but
   he raises an additional argument on appeal that he did not raise below. That
   additional argument is reviewed only for plain error. For preserved claims,
   we review the district court’s interpretation of the guidelines de novo and its
   factual findings for clear error. 240 There is no clear error if the court’s
   calculation is plausible; we give district courts wide latitude to calculate the
   correct amount; and the amount “need only [be] a reasonable
   estimate . . . based on available information.” 241 We begin with whether the

           236
                 See id. at 884 n.2.
           237
                 Id.
           238
                 Id. at 885 n.3.
           239
                 See id. at 885 & n.3.
           240
                 United States v. Harris, 597 F.3d 242, 250 (5th Cir. 2010).
           241
              See United States v. De Nieto, 922 F.3d 669, 674-75 (5th Cir. 2019) (internal
   quotation marks omitted) (quoting U.S.S.G. § 2B1.1 cmt. 3(C)).

                                                  67
Case: 21-10292            Document: 00516915625              Page: 68   Date Filed: 10/02/2023

                                              No. 21-10292

   private-pay patient proceeds are properly within the calculation and then
   turn to whether that calculation was otherwise reasonable.
                                                   A
             The improper-benefit sentence enhancement scales according to the
   amount of the improper benefit received. 242 The greater the improper
   benefit received, the greater the sentence enhancement. Here, the district
   court’s calculation of the improper benefit included not only the benefit
   received from federal-pay surgeries but also from private-pay surgeries.
   Shah, Forrest, and Jacob contend that the AKS conspiracy involved only
   federal patients, so the improper-benefit calculation cannot include private-
   pay patients. Won also attempts to raise this argument but he does so in a
   single sentence unsupported by caselaw or record citations and has forfeited
   it. 243
             The Government raises two counterarguments. First, it says that the
   conspiracy was broad enough to encompass private-pay patients. The
   Government argues that the federal patients served merely to satisfy the
   jurisdictional hook of the AKS, and that the defendants conspired more
   broadly to receive remuneration in exchange for referring patients to Forest
   Park. This conduct, the Government argues, is a conspiracy to violate the
   AKS because the defendants need not have knowledge of the federal status
   of their patients, see supra Part II(A). Second, the Government argues that
   even if the private-pay surgeries were not themselves part of the conspiracy,
   they were still relevant conduct under the sentencing guidelines and could be

             242
                   See Landers, 68 F.3d at 886.
             243
              Even if not forfeited, it would fail for the same reasons as those who properly
   presented this argument.

                                                  68
Case: 21-10292          Document: 00516915625             Page: 69       Date Filed: 10/02/2023

                                           No. 21-10292

   factored into the calculation. 244 The Government argues that U.S.S.G.
   § 1B1.3 requires the court to determine the enhancement based on “all acts
   and omissions, committed, aided, abetted, counseled, commanded, induced,
   procured, or willfully caused by the defendant” that either “occurred during
   the commission of the offense” or “were part of the same course of conduct
   or common scheme or plan as the offense of conviction.” 245                            The
   Government argues that the private-pay patient kickbacks occurred during
   the commission of the offense and were part of the same scheme. Shah and
   Forrest respond that the private-pay patients were not part of the same
   common scheme because they involved different victims.
           As in Part II(A), we disagree with the Government’s argument that
   the federal healthcare program reference in the AKS is only a jurisdictional
   hook, knowledge of which is not necessary for conviction. The defendants
   needed to have knowledge that services provided to referred patients may be
   paid in whole or part by federal healthcare programs.
           The private-pay surgeries were relevant conduct under U.S.S.G.
   § 1B1.3 and properly included within the calculation.                    The sentencing
   guideline is broad, defining relevant conduct to include “all acts and
   omissions” that occurred “during the commission of the offense” or as
   “part of the same course of conduct or common scheme.” 246                             “An
   unadjudicated offense may be part of a ‘common scheme or plan’ if it is
   ‘substantially connected to the offense of conviction by at least one common

           244
            United States v. Thomas, 973 F.2d 1152, 1159 (5th Cir. 1992) (noting that a district
   court “must consider a defendant’s relevant conduct” in calculating the guideline range).
           245
                 U.S.S.G. § 1B1.3.
           246
                 Id. § 1B1.3(a) (emphasis added).

                                                    69
Case: 21-10292             Document: 00516915625         Page: 70       Date Filed: 10/02/2023

                                          No. 21-10292

   factor, such as common victims, common accomplices, common purpose, or
   similar modus operandi.’” 247
           While it may be a close call whether the private-pay surgeries
   “occurred during the commission of the offense,” they certainly involved the
   same accomplices (Smith, Burt, and Beauchamp), were completed for the
   same purpose (bilk insurance providers, whether private or federal, for a high
   reimbursement rate), and operated with the same modus operandi (pay
   surgeons to refer surgeries to Forest Park and then use Jacob’s pass-through
   entity to launder the money). 248 The district court did not err in finding that
   the private-pay surgeries were part of the same common scheme as the
   federal-pay surgeries.
           Shah and Forrest have no answer for this other than an argument that
   the private-pay surgeries involved different victims, but that does not matter
   given the substantial overlap of the crimes in all other ways. 249                     The
   defendants also argue that the private-pay surgeries were not relevant
   conduct because relevant conduct must be criminal, and Jacob argues that
   the Government never requested a relevant conduct finding in the PSR. 250
   Both arguments fail. First, the Government identified several statutes that
   the private-pay surgeries may have violated. The district court recognized
   that the Government “ha[d] proven by a preponderance of the evidence” the

           247
             United States v. Ortiz, 613 F.3d 550, 557 (5th Cir. 2010) (alteration omitted)
   (quoting United States v. Rhine, 583 F.3d 878, 885 (5th Cir. 2009)).
           248
                 See id.
           249
                 See id.
           250
              Jacob also argues, unpreserved, that the prosecution never requested that the
   PSR analyze relevant conduct and that the PSR did no such thing. But the Government
   did request it, the PSR did analyze it, and the district court did as well. This is not plain
   error.

                                                70
Case: 21-10292             Document: 00516915625              Page: 71       Date Filed: 10/02/2023

                                               No. 21-10292

   relevant conduct with which it sought to enhance the sentence. Second,
   Jacob’s argument is unpreserved, so we review only for plain error, and he is
   incorrect that the Government did not bring up relevant conduct—it did. So
   did the PSR. The district court did as well.
             Finally, Jacob raises a challenge that his enhancements were based on
   acquitted conduct in violation of the Sixth Amendment right to trial by
   jury. 251 He argues that sentences that consider acquitted conduct necessarily
   diminish the jury trial right. In rebuttal, the Government maintains first that
   Jacob was not acquitted of conspiracy to violate the Travel Act despite being
   acquitted of the substantive Travel Act counts. It further argues that under
   this court’s precedent, even acquitted conduct can be the basis of an
   enhancement so long as the district court finds that the defendant engaged in
   the conduct by a preponderance of the evidence. 252
             While distinguished jurists have questioned the constitutionality of
   using acquitted conduct for sentencing enhancements, 253 this court has
   previously recognized that the Supreme Court’s holding in United States v.

             251
                   As above, Won raises a similar argument in passing. He has forfeited it by failing
   to brief it.
             252
             See United States v. Watts, 519 U.S. 148 (1997) (holding that sentencing courts
   may consider conduct of which the defendant has been acquitted).
             253
               See, e.g., McClinton v. United States, 143 S. Ct. 2400, 2401 (2023) (Sotomayor,
   J., respecting the denial of certiorari); Jones v. United States, 574 U.S. 948, 948-50 (2014)
   (Scalia, J., joined by Thomas & Ginsberg, JJ., dissenting from denial of certiorari)
   (encouraging the Court to decide whether the Sixth Amendment’s jury trial right permits
   judges to sentence defendants based on uncharged or acquitted conduct); United States v.
   Sabillon-Umana, 772 F.3d 1328, 1331 (10th Cir. 2014) (Gorsuch, J., majority) (citing Justice
   Scalia’s dissent in Jones); United States v. Bell, 808 F.3d 926, 928 (D.C. Cir. 2015)
   (Kavanaugh, J., concurring in denial of rehearing en banc) (per curiam) (“Allowing judges
   to rely on acquitted or uncharged conduct to impose higher sentences than they otherwise
   would impose seems a dubious infringement of the rights to due process and to a jury
   trial.”).

                                                     71
Case: 21-10292           Document: 00516915625             Page: 72      Date Filed: 10/02/2023

                                            No. 21-10292

   Watts 254 forecloses Sixth Amendment challenges to the use of acquitted
   conduct at sentencing. 255 In United States v. Hernandez, 256 we specifically
   noted that “[Sixth Amendment] challenges are foreclosed under our
   precedent” and that “the sentencing court is entitled to find by a
   preponderance of the evidence all the facts relevant to the determination of
   a sentence below the statutory maximum.” 257 For this reason, Jacob’s
   argument is unavailing. The record reflects that the district court considered
   Jacob’s arguments against the use of acquitted conduct, as well as the
   applicable guidelines range. Jacob thus has not shown that the district court
   erred when it enhanced his sentence based on acquitted conduct.
                                                 B
           Shah, Forrest, and Henry object to the district court’s calculation of
   the direct-cost reduction. The district court analyzed the hospital’s direct
   costs as defined by this court’s Landers 258 formula. It looked to costs tied
   directly to the surgeries performed, i.e., supplies used in the surgery that
   could not be reused at a later surgery. It determined that the direct costs
   averaged out to about 21.48% of the total amount Forest Park received in
   reimbursements. The total amount received in reimbursements, the court
   reasoned, was the starting place in determining the improper benefit
   received, and no party challenges this.

           254
                 519 U.S. 148 (1997).
           255
               See United States v. Hernandez, 633 F.3d 370, 374 (5th Cir. 2011); see also United
   States v. Preston, 544 F. App'x 527, 528 (5th Cir. 2013) (unpublished) (per curiam); United
   States v. Cabrera-Rangel, 730 F. App'x 227, 228 (5th Cir. 2018) (unpublished) (per curiam).
           256
                 633 F.3d 370 (5th Cir. 2011).
           257
                 Id. at 374.
           258
                 68 F.3d 882 (5th Cir. 1995).

                                                 72
Case: 21-10292           Document: 00516915625            Page: 73       Date Filed: 10/02/2023

                                          No. 21-10292

           Shah and Forrest challenge only the 21.48% reduction, arguing that it
   should be a reduction of 94.2% instead. They arrive at their figure based on
   the hospital’s net profit margin on the theory that the court had to deduct all
   costs attributable to the surgery such that the only amount left is the
   hospital’s net profit. We rejected this exact argument in Landers and do so
   again. 259
           Henry brings a narrower argument, contending that the district court
   erred because it did not account for the salaries of hospital staff. But again,
   his argument runs against this court’s holding in Landers that “variable
   overhead costs that cannot easily be identified” are not direct costs. 260
   Although we did not explicitly include staff salaries in the definition of
   variable overhead costs, they will usually fall within that category of costs.
   Like rent, debt obligations, and other general overhead costs, staff salaries are
   not likely to change much because of a specific surgery. Regardless of how
   many surgeries are performed, those salaries are still paid. In this way, the
   salaries are costs “incurred independently of output” and not deductible
   under Landers. 261          Henry has not established that the salaries are not
   independent of output.
           Henry’s other arguments to the contrary are unavailing. He cites a
   study that included salaries as a measure of direct costs, but the study is
   inapposite. “Direct costs” has a very broad meaning when used in an
   accounting sense, sufficient even to include staff salaries, but we rejected that

           259
                See id. at 885 & n.3 (defining indirect costs and rejecting the argument that net
   profits is the correct measure of net value).
           260
                 Id. at 884 n.2.
           261
                 See id. at 885 n.3.

                                                73
Case: 21-10292          Document: 00516915625               Page: 74       Date Filed: 10/02/2023

                                            No. 21-10292

   definition in Landers. 262 Henry’s citation to United States v. Ricard 263 is
   similarly inapplicable. There, we reversed because the district court failed to
   account for any direct costs at all. 264 We never reached the question of
   whether salaries should be included in direct costs.
                                                  C
          Finally, Shah and Forrest briefly argue that the district court erred by
   “shift[ing] between bribery and fraud theories whenever doing so would
   increase the sentence.” It is not entirely clear what either defendant is
   arguing. They do not identify any violation, statutory or constitutional. They
   do not cite any caselaw. They do not provide record citations. Moreover,
   the district court only ever applied the bribery guidelines. Any argument that
   the court misapplied the guidelines has been dealt with above. Any further
   argument Shah and Forrest may have is forfeited. 265
                                                XVIII
          Won, Rimlawi, Henry, Jacob, Shah, and Forrest all challenge their
   restitution amounts. Burt also challenges a part of his restitution judgment.
   We find no error.
          Shah, Jacob, Rimlawi, and Won preserved error. Their claims are
   reviewed de novo as to the legality of the award 266 and method of calculating
   loss. 267 We review the final restitution amount for abuse of discretion and

          262
                See id. at 884 n.2.
          263
                922 F.3d 639 (5th Cir. 2019).
          264
                See id. at 657-58.
          265
                See Rollins v. Home Depot USA, 8 F.4th 393, 397 (5th Cir. 2021).
          266
                United States v. Mann, 493 F.3d 484, 498 (5th Cir. 2007).
          267
                United States v. Isiwele, 635 F.3d 196, 202 (5th Cir. 2011).

                                                  74
Case: 21-10292           Document: 00516915625              Page: 75          Date Filed: 10/02/2023

                                             No. 21-10292

   any factual findings for clear error. 268 We “may affirm in the absence of
   express findings ‘if the record provides an adequate basis to support the
   restitution order.’” 269 Forrest did not preserve error, so her claim is
   reviewed for plain error. 270
           Henry and Jacob argue that the Mandatory Victims Restitution Act
   (MVRA) does not apply to their count-one conviction because it was not “an
   offense against property,” but they did not preserve this argument. The
   defendants argue that their claim is reviewed de novo. They base their
   argument primarily on United States v. Nolen 271 in which a panel of this court
   reviewed such a claim de novo. 272 United States v. Inman, 273 however,
   predates Nolen and applied plain error review to such a claim. 274 The
   Government argues that Inman controls under the rule of orderliness. 275 The
   Government further argues that Nolen was wrongly decided because it relied
   on authority that reviewed only for plain error. Relying on the rule of
   orderliness, we review Henry and Jacob’s unpreserved argument for plain
   error under Inman. 276 We express no opinion as to whether Nolen was

           268
              Mann, 493 F.3d at 498 (final amount); United States v. Sharma, 703 F.3d 318,
   322 (5th Cir. 2012) (factual findings).
           269
              Sharma, 703 F.3d at 322 (quoting United States v. Blocker, 104 F.3d 720, 737 (5th
   Cir. 1997)).
           270
                 United States v. Inman, 411 F.3d 591, 595 (5th Cir. 2005).
           271
                 472 F.3d 362 (5th Cir. 2006).
           272
                 Id. at 382.
           273
                 411 F.3d 591 (5th Cir. 2005).
           274
                 Id. at 595.
           275
                See United States v. Hernandez, 525 F. App’x 274, 275 (5th Cir. 2013)
   (unpublished) (per curiam) (acknowledging this court’s cases “applying plain-error review
   to restitution orders”).
           276
                 See Jacobs v. Nat’l Drug Intelligence Ctr., 548 F.3d 375, 378 (5th Cir. 2008).

                                                   75
Case: 21-10292        Document: 00516915625               Page: 76        Date Filed: 10/02/2023

                                           No. 21-10292

   correctly decided, only that it misapplied the rule of orderliness. We turn to
   the merits of the argument now.
                                                 A
           Henry and Jacob argue that the MVRA does not apply to their count-
   one convictions of conspiracy to violate the AKS because the conspiracy
   charge did not have fraud or deceit as an element of the crime. They argue
   that this court should apply the categorical approach to determine whether
   an offense is an offense against property for purposes of the MVRA. This is
   a matter of first impression in this circuit, but every other circuit to have
   addressed this question has determined that the categorical approach does
   not apply to the MVRA. 277
           Neither defendant disputes that, at least as alleged in the indictment,
   their conduct deprived private insurance companies of property by means of
   fraud or deceit. But they claim that this is irrelevant because the court must
   employ the categorical approach and look to the elements of the statute of
   conviction (18 U.S.C. § 371) to determine whether the MVRA applies. They
   conclude that no element of conspiracy involves fraud or deceit, so the
   MVRA does not apply. They further argue that the language of the MVRA

           277
               See United States v. Razzouk, 984 F.3d 181, 186 (2d Cir. 2020) (“[C]ourts may
   consider the facts and circumstances of the crime that was committed to determine if it is
   an ‘offense against property’ within the meaning of the MVRA.”); United States v. Ritchie,
   858 F.3d 201, 211 (4th Cir. 2017) (“[T]he categorical approach has no role to play in
   determining whether a Title 18 offense is ‘an offense against property’ that triggers
   mandatory restitution under the MVRA.”); United States v. Collins, 854 F.3d 1324, 1334
   (11th Cir. 2017) (holding that the categorical approach does not apply); see also United States
   v. Sawyer, 825 F.3d 287, 292-93 (6th Cir. 2016) (looking to the facts and circumstances of
   the crime rather than the elements); United States v. Luis, 765 F.3d 1061, 1066 (9th Cir.
   2014) (same).

                                                 76
Case: 21-10292           Document: 00516915625                Page: 77      Date Filed: 10/02/2023

                                              No. 21-10292

   mirrors that of other statutes the Supreme Court has held require categorical
   interpretation.
            But we find the reasoning of our sister circuits more persuasive on this
   point.     The MVRA provides that restitution must be paid “for[] any
   offense . . . that       is . . . an   offense        against   property      under   [Title
   18] . . . including any offense committed by fraud or deceit . . . in which an
   identifiable victim or victims has suffered a . . . pecuniary loss.” 278 As the
   Second Circuit explained, the “committed by fraud or deceit” prong of the
   MVRA “refers to the way in which some offenses ‘against property’ are
   ‘committed.’” 279 This “suggests that the way the crime is carried out is
   relevant to its application.” 280 Further, the statute makes no reference to any
   elements of a crime against property. This stands in stark contrast to statutes
   like 18 U.S.C. § 16, which takes an explicit elements-based approach to
   defining crimes of violence. 281 The categorical approach is inappropriate for
   this statute and “the [district] court may look to the facts and circumstances
   of the offense of conviction to determine if the MVRA authorizes a
   restitution order.” 282
            The MVRA is applicable here.                     The defendants’ “facilitation
   of . . . payments . . . for phantom work” and general pattern of making and
   accepting bribes is textbook fraud or deceit. 283 Further, neither defendant

            278
                  18 U.S.C. § 3663A(c)(1).
            279
                  Razzouk, 984 F.3d at 187.
            280
                  Id. (citing Taylor v. United States, 495 U.S. 575, 599-600 (1990)).
            281
             See 18 U.S.C. § 16(a) (defining a “crime of violence” as one that has as “an
   element the use, attempted use, or threatened use of physical force”).
            282
                  Razzouk, 984 F.3d at 188 (collecting cases).
            283
              See id. at 189 (holding that Razzouk’s bribery was a property offense involving
   fraud or deceit).

                                                    77
Case: 21-10292         Document: 00516915625              Page: 78   Date Filed: 10/02/2023

                                           No. 21-10292

   objects that at least on its face the indictment alleges that insurance
   companies suffered pecuniary harm. For further discussion of the private
   insurers, see below.
                                                B
          Shah, Jacob, Rimlawi, Won, Forrest, and Henry argue that private
   insurers were not proper victims under the MVRA and that their restitution
   amounts must be reduced accordingly. Under the MVRA, “victim” means:
          a person directly and proximately harmed as a result of the
          commission of an offense for which restitution may be ordered
          including, in the case of an offense that involves as an element
          a scheme, conspiracy, or pattern of criminal activity, any
          person directly harmed by the defendant’s criminal conduct in
          the course of the scheme, conspiracy, or pattern. 284
          The district court found that the private insurers were victims under
   the Act because they paid inflated claims to Forest Park as a result of the
   defendants’ surgery-buying scheme. The defendants do not dispute that the
   private insurers suffered direct and proximate harm. Their only argument,
   mirroring that found in Part XVII, is that the private insurers were outside
   the conspiracy’s scope.
          For the same reasons as outlined above in Part XVII, the private
   insurers were within the scope of the conspiracy. While true that it was the
   presence of federal insureds that granted federal jurisdiction in this case and
   was necessary for conviction, the conspiracy was one to steer patients to
   Forest Park by way of buying surgeries. It covered both private and federal
   patients. In fact, as the defendants themselves argue, they were expressly
   trying to avoid federal patients. They targeted private patients directly.

          284
                18 U.S.C. § 3663A(a)(2).

                                               78
Case: 21-10292           Document: 00516915625            Page: 79      Date Filed: 10/02/2023

                                           No. 21-10292

           Further, the MVRA’s definition of “victim” is quite broad such that
   even assuming the private-pay patients were not part of the conspiracy, we
   would still affirm. As above, the MVRA defines victims as those harmed “in
   the course of the . . . conspiracy.” 285 The private insurers were harmed at
   the same time and in the same manner as the federal insurers because the
   bribe payment that was the basis for the inflated claims was the same no
   matter whether the patient was insured federally or privately. This overlap,
   similar to the analysis in Part XVII, brings the private insurers into the role of
   victim. 286 We have held, in United States v. Gutierrez-Avascal, 287 that the
   driver of a car hit by a fleeing member of a marijuana conspiracy was a victim
   of the marijuana conspiracy. 288 There is very little daylight between the
   rationale there and here. As the defendants conspired to buy surgeries,
   private insurers suffered direct losses just as the driver in Gutierrez-Avascal
   did.
           The defendants’ arguments to the contrary are unavailing. They
   largely reiterate their arguments that private patients and insurers were not
   part of the conspiracy. We have already rejected this argument. They also
   argue that the various Travel Act acquittals somehow bring the private
   insurers out of the role of victim, but for the reasons explained above, the
   private insurers are victims of the count one, AKS conspiracy, so the Travel
   Act acquittals mean nothing in this context.

           285
                 18 U.S.C. § 3663A(a)(2); see United States v. Maturin, 488 F.3d 657, 661 (5th
   Cir. 2007).
           286
               See United States v. Gutierrez-Avascal, 542 F.3d 495, 498 (5th Cir. 2008)
   (holding that the driver of a vehicle hit by defendant while defendant fled law enforcement
   was a victim of defendant’s marijuana conspiracy for purposes of the MVRA).
           287
                 542 F.3d 495 (5th Cir. 2008).
           288
                 Id. at 498.

                                                 79
Case: 21-10292           Document: 00516915625               Page: 80       Date Filed: 10/02/2023

                                             No. 21-10292

                                                   C
           Only Rimlawi challenges the final amount of restitution ordered
   against him. His main argument is that the district court did not properly
   address his restitution arguments. He did not raise this argument below
   when the district court at sentencing asked if there were “any unaddressed
   issues.” Accordingly, we review it for plain error. 289 The PSR and the
   Government put forward a detailed explanation as to the restitution amount
   for each defendant. The record has “an adequate basis” for the restitution
   amount. 290 We may affirm on that basis.291 Further, the district court is
   granted “wide latitude” in calculating the final amount which need only be
   “a reasonable estimate.” 292 Rimlawi has done nothing to show how a
   different treatment of his restitution arguments would result in a different
   amount, nor how a different amount would substantially affect his rights.
                                                   D
           Finally, seizing upon a recent dissent from a denial of certiorari,
   Rimlawi, Shah, Henry, and Forrest argue that a jury must find the restitution
   amount beyond a reasonable doubt.                    They concede that this issue is
   foreclosed—they seek only to preserve it for further review. 293 We will not
   address it further.

           289
                 See United States v. Mondragon-Santiago, 564 F.3d 357, 361 (5th Cir. 2009).
           290
                 See United States v. Sharma, 703 F.3d 318, 322 (5th Cir. 2012).
           291
                 See United States v. Mitchell, 876 F.2d 1178, 1183 (5th Cir. 1989).
           292
             United States v. Bolton, 908 F.3d 75, 97 (5th Cir. 2018) (quoting United States v.
   Westbrooks, 858 F.3d 317, 329 (5th Cir. 2017), vacated on other grounds, 138 S. Ct. 1323
   (2018)).
           293
                 See United States v. Rosbottom, 763 F.3d 408, 420 (5th Cir. 2014).

                                                   80
Case: 21-10292            Document: 00516915625            Page: 81       Date Filed: 10/02/2023

                                            No. 21-10292

                                                XIX
          Finally, Won and Rimlawi argue that the district court erred in
   calculating the forfeiture amount. We find no error.
          We review the legality of forfeiture de novo. 294                        The criminal
   forfeiture statute, 18 U.S.C. § 982, requires the court, “in imposing sentence
   on a person convicted of a Federal health care offense, . . . [to] order the
   person to forfeit property, real or personal, that constitutes or is derived,
   directly or indirectly, from gross proceeds traceable to the commission of the
   offense.” 295 The analytical inquiry is whether the defendant would have
   received the property “but for” his criminal conduct. 296
          The basis of Won and Rimlawi’s argument is essentially the same as
   their argument as to restitution. They claim that the private insurers were
   not part of the conspiracy and therefore any proceeds derived therefrom do
   not fall within the forfeiture statute. As explained above, receiving kickbacks
   for the privately insured patients was part of the conspiracy.
          Won and Rimlawi would not have received their bribe money “but
   for” their referrals to Forest Park. 297 These referrals included not only
   private but also federal patients. The agreement, however, was the same for
   both sets of patients—the surgeons referred patients and the hospital paid
   them per patient. But for that illegal conduct of conspiring to send the
   patients to Forest Park under a handshake deal for a kickback, the surgeons
   would not have received their proceeds. As above, the bribe money did not

          294
                United States v. Ayika, 837 F.3d 460, 468 (5th Cir. 2016).
          295
                18 U.S.C. § 982(a)(1)(7).
          296
                See United States v. Faulkner, 17 F.3d 745, 774 (5th Cir. 1994).
          297
                See id.

                                                  81
Case: 21-10292          Document: 00516915625                Page: 82      Date Filed: 10/02/2023

                                              No. 21-10292

   differentiate between federal patients or private patients—the agreement and
   reimbursement were the same for both. The surgeons’ conduct falls squarely
   within the realm of forfeiture. 298
           Won and Rimlawi’s arguments to the contrary are unavailing.
   Largely, they repeat arguments already dealt with above. They hang their hat
   on the Travel Act acquittals, but again, any acquittal there is meaningless
   here because the private insurers were part of the count-one AKS conspiracy
   conviction. Thus, forfeiture of proceeds derived from their loss is still “tied
   to the specific criminal acts of which the defendant was convicted.” 299
                                          *        *         *
           For the foregoing reasons, we AFFIRM.

           298
               See United States v. Hoffman-Vaile, 568 F.3d 1335, 1344-45 (11th Cir. 2009)
   (holding, in a Medicare fraud case, that a doctor must forfeit proceeds she received from
   private insurers when the private insurers reimbursed her for procedures not covered by
   Medicare even though she was never convicted of defrauding the private insurers).
           299
                 United States v. Juluke, 426 F.3d 323, 327 (5th Cir. 2005).

                                                  82