Court Opinion

ID: 9407803
Source: CourtListenerOpinion
Date Created: 2023-07-10 13:00:36.738297+00
Date Added: 2024-06-11T17:20:40.277810
License: Public Domain

USCA11 Case: 20-11988    Document: 84-1      Date Filed: 07/10/2023   Page: 1 of 30

                                                   [DO NOT PUBLISH]
                                    In the
                 United States Court of Appeals
                         For the Eleventh Circuit

                           ____________________

                                 No. 20-11988
                           ____________________

        DAISY MILLER,
                                                     Petitioner-Appellant,
        versus
        UNITED STATES OF AMERICA,

                                                   Respondent-Appellee.

                           ____________________

                  Appeal from the United States District Court
                      for the Southern District of Florida
                     D.C. Docket Nos. 1:16-cv-21090-JEM,
                              1:12-cr-20757-JEM-2
                           ____________________
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        2                       Opinion of the Court                 20-11988

        Before WILSON, NEWSOM, and LAGOA, Circuit Judges.
        LAGOA, Circuit Judge:
                After a five-week trial, a jury found Daisy Miller guilty on
        various counts relating to Medicare fraud. During the trial, the jury
        heard from many witnesses and was presented with many docu-
        ments corroborating the government’s theory of the case and dis-
        crediting Miller’s testimony. Following our affirmance of her con-
        viction in United States v. Kallen-Zury (Kallen-Zury I), 629 F. App’x
        894 (11th Cir. 2015), Miller moved to vacate her conviction under
        28 U.S.C. § 2255. The district court denied the motion, and Miller
        now appeals that denial. On appeal, she argues that her trial coun-
        sel should have called several witnesses in her defense, that coun-
        sel’s failure to do so constituted ineffective assistance of counsel,
        and that we should vacate her conviction and grant her a new trial.
              For the reasons explained below, and with the benefit of oral
        argument, we conclude that trial counsel’s decision not to call
        these witnesses did not prejudice Miller or constitute deficient per-
        formance. Accordingly, we affirm.
            I.    FACTUAL AND PROCEDURAL BACKGROUND
                         A.     Underlying Criminal Case
               This is the second time Miller has come before this Court
        regarding her trial. We outlined the facts of this case in our previ-
        ous decision affirming Miller and her co-defendants’ convictions in
        their direct appeal, see Kallen-Zury I, 629 F. App’x 894, as well as in
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        23-10182               Opinion of the Court                         3

        our decision affirming the district court’s denial of Karen Kallen-
        Zury’s—Miller’s co-defendant—motion for a new trial, see United
        States v. Kallen-Zury (Kallen-Zury II), 710 F. App’x 365 (11th Cir.
        2017).
                On October 2, 2012, a federal grand jury in the Southern Dis-
        trict of Florida returned an indictment charging Miller with the fol-
        lowing offenses: conspiracy to commit health care fraud and wire
        fraud, in violation of 18 U.S.C. § 1349 (Count 1); wire fraud, in vio-
        lation of 18 U.S.C. §§ 1343 and 2 (Counts 2 to 6); health care fraud,
        in violation of 18 U.S.C. §§ 1347 and 2 (Counts 7 and 8); and con-
        spiracy to defraud the United States and to pay and receive health
        care kickbacks, in violation of 18 U.S.C. § 371 (Count 9). The in-
        dictment also charged her co-defendants Karen Kallen-Zury, Chris-
        tian Coloma, Michele Petrie, and Gloria Himmons with the same
        or related conspiracy, fraud, and kickback offenses. On November
        2, 2012, Omar Malone was appointed pursuant to the Criminal Jus-
        tice Act (the “CJA”) to represent Miller, who elected to proceed to
        trial.
                At trial, the government established that Hollywood Pavil-
        ion (“HP”) is “a mental health facility that included both inpatient
        and outpatient treatment programs.” Kallen-Zury I, 629 F. App’x at
        897. Miller was a licensed clinical social worker who began work-
        ing for HP in 2002. At all relevant times, she was the clinical direc-
        tor for HP’s inpatient facility and ran its day-to-day operations. Id.
        Miller worked closely with Chris Gabel, HP’s Chief Operating Of-
        ficer, and Dr. Alan Gumer, HP’s psychiatric medical director. Id.
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        4                      Opinion of the Court                  20-11988

               During Miller’s tenure at HP, the facility paid recruiters to
        recruit patients on its behalf and received Medicare reimburse-
        ments for those patients. Id. This practice, however, is illegal. The
        government’s theory of the case was that Miller and her co-defend-
        ants conspired to defraud the United States by creating a health
        care kickback scheme through Medicare reimbursements and that
        Miller participated in the scheme in order to keep her job, title, sal-
        ary, and status.
                “The backbone of the government’s case was the testimony
        of several patient recruiters”—Keith Humes, Jean Luc Veraguas,
        Mathis Moore, Curtis Gates, and Gloria Himmons—“who pleaded
        guilty to Medicare fraud related to HP and other facilities.” Id.
        “These recruiters would find patients from as far away as Maryland
        and would pay to have the patients ride buses down to HP in Hol-
        lywood, Florida.” Kallen-Zury II, 710 F. App’x at 367. “Most of
        the[se] patients were drug addicts who did not need the psychiatric
        services offered at HP.” Id. Therefore, “the conspirators often fal-
        sified the patients’ records to reflect serious psychiatric problems
        or told the patients to claim psychiatric issues upon admission” to
        HP. Id. HP would then pay the recruiter for each patient the re-
        cruiter sent to its facility. See id. at 367–68. Additionally, HP only
        admitted “patients who had enough days on their Medicare plans
        to have their treatment periods paid for by the government.”
        Kallen-Zury I, 629 F. App’x at 897. When the Medicare money ran
        out for a patient, the facility would stop treatment and discharge
        the patient. Id. “Some . . . recruiters also ran halfway houses and
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        23-10182               Opinion of the Court                        5

        made extra money when HP referred discharged patients to those
        facilities.” Id.
               “At trial, the recruiters explained that HP had them enter
        into contracts that stated they were providing either ‘case manage-
        ment’ or ‘marketing’ services.” Kallen-Zury II, 710 F. App’x at 367–
        68. “HP also asked the recruiters to submit reports documenting
        their purported performance of these services.” Id. at 368. “The
        recruiters’ reports, however, were false,” as the recruiters “were
        never asked to and never did provide these other services.” Id. In-
        stead, the recruiters “were paid solely to refer patients.” Id. The
        government also produced various documents at trial, including a
        “patient register” that tracked which patients were referred by
        which recruiters. Id. at 370.
               Several recruiters, each of whom testified under a grant of
        immunity, claimed to have discussed with Miller how HP would
        pay them to recruit patients and how HP would admit the re-
        cruited patients. For instance, Humes testified that when he had
        trouble admitting one of his recruited patients to HP, he called Mil-
        ler, and she arranged for his patient to be admitted to HP. Him-
        mons testified that, at first, she worked for Humes to recruit pa-
        tients for HP, and Miller later asked her to send patients to HP
        through Veraguas. Eventually, Miller and Kallen-Zury hired Him-
        mons to continue recruiting patients as a “marketer.” Miller also
        instructed Himmons to submit false monthly reports detailing her
        nonexistent marketing services. Moore testified that he met with
        Miller multiple times to get paid to recruit patients for HP and that
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        6                       Opinion of the Court                   20-11988

        she instructed him to have his patients falsely claim that they were
        suicidal and off their medication to be admitted to HP. Miller also
        agreed to pay Moore through his non-profit company to make his
        payments appear legitimate. Veraguas similarly testified that he
        called Miller to get paid to recruit patients for HP.
                The government also presented the testimony of Dr. Gumer
        to explain that most of the patients admitted to HP did not need
        psychiatric treatment, either because they only had substance
        abuse issues or because they were homeless. Kallen-Zury v. United
        States (Kallen-Zury IV), No. 20-12385, 2023 WL 164065, at *2 (11th
        Cir. Jan. 12, 2023). Dr. Marci Kagan and Marcia Starkman also tes-
        tified for the government. Dr. Kagan, a psychotherapist at HP, tes-
        tified that Miller told her to “stress the negative” in her patient files
        because, otherwise “the patient wouldn’t have criteria to be in the
        hospital.” Starkman, an HP employee, testified that she once
        learned patient files were being fabricated at HP and notified Miller
        about an incident where a doctor falsified a note and then tried to
        have the note shredded. Miller, however, never addressed the is-
        sue, and when Starkman tried to raise the issue in an administrative
        meeting, Miller jammed her elbow in Starkman’s side, signaling
        that Starkman should keep quiet.
                After the government rested its case, the defendants, includ-
        ing Miller, argued that “they acted in good faith and believed the
        recruiters were providing lawful ‘marketing’ services.” Kallen-Zury
        I, 629 F. App’x at 897. They also argued that “HP’s lawyers drafted
        the contracts with the recruiters and instructed HP’s management
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        23-10182               Opinion of the Court                          7

        [on] how to ensure that their agreements with the recruiters fell
        within statutory and regulatory ‘safe harbor’ provisions.” Id. at
        897–98.
                Miller’s trial counsel, Malone, called Miller to testify in her
        own defense. Miller denied all the charges in the indictment. She
        testified that she never asked anyone to increase the severity of
        their notes to justify the patients’ continued stays at HP. She knew
        that HP paid some halfway-house owners for marketing services
        but did not believe that HP was paying these owners to send pa-
        tients to HP. According to Miller, Veraguas and Humes “provided
        a lot of case management,” and Himmons “did business develop-
        ment” for HP. Miller also testified that she did not determine how
        long patients stayed in HP’s inpatient facility and that HP’s psychi-
        atrists decided when to admit and discharge patients. Miller dis-
        puted the testimony of all of the government’s witnesses regarding
        their interactions with her. Malone called no other witnesses.
               As an important side note, the government did not receive
        patient ﬁles for the two patients listed in Counts 7 and 8. See Kallen-
        Zury IV, 2023 WL 164065, at *6 n.4. The government raised a Fed-
        eral Rule of Criminal Procedure 16 objection to the use of the two
        patient ﬁles, which the defense expert, Dr. Jeﬀrey Danziger, had re-
        viewed. Id. The district court sustained the objection and preemp-
        tively excluded any testimony on the two patients, such that Dr.
        Danziger could not testify on those two patients if he were called
        as a witness. Id. That said, Dr. Danziger was not called as a witness
        by Malone.
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        8                       Opinion of the Court                  20-11988

               The jury found Miller guilty of all the charges. Kallen-Zury I,
        629 F. App’x at 898. The judge sentenced Miller to fifteen years in
        prison. After her conviction, Miller filed a direct appeal, and we
        affirmed her conviction. See id.
                              B.     Motion to Vacate
               On March 25, 2016, Miller moved to vacate her convictions
        under 28 U.S.C. § 2255, asserting that Malone provided ineffective
        assistance under Strickland v. Washington, 466 U.S. 668 (1984). Of
        relevance to this appeal, Miller claimed that Malone failed to con-
        duct an adequate investigation, consult and present an expert wit-
        ness, and subpoena potential witnesses for trial. In support of her
        motion, Miller attached the following: affidavits from herself and
        her husband, Dale Miller; a twenty-nine-page summary of HP em-
        ployees and their potential testimony; interview reports of prospec-
        tive witnesses from Malone’s investigator; and many emails from
        Malone, Miller, and other individuals. Miller’s motion referenced
        a separate list of prospective trial witnesses that she provided
        Malone after he was appointed to represent her. Miller also filed
        affidavits from potential trial witnesses who were not called at trial.
               The district court referred Miller’s motion to a magistrate
        judge. The magistrate judge then held an evidentiary hearing on
        Miller’s motion. The following testimony was elicited at the evi-
        dentiary hearing.
                First, Robin Smith, HP’s utilization review coordinator and
        psychotherapist, stated that, if called as a witness, she would have
        testified that in her role as a coordinator, she reviewed patient files,
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        23-10182               Opinion of the Court                        9

        and she did not notice any inconsistencies among entries by psy-
        chiatrists, therapists, and others. According to Smith, Miller super-
        vised the therapists but did not supervise HP’s psychiatrists, medi-
        cal doctors, or nurses. Smith stated that patients were not admitted
        to HP if they did not have the appropriate psychiatric criteria for
        admission. She was unaware of any policy to keep patients at HP
        for the duration of their Medicare coverage, regardless of their psy-
        chiatric needs, or to discharge them when their Medicare coverage
        ended. On cross-examination, Smith conceded that she was not
        responsible for billing or marketing decisions. She did not know if
        HP’s “marketers” were recruiters who were paid to bring patients
        to HP. She was also not present for any meetings that Miller had
        with Moore, Humes, or Himmons.
               Manuel Llano is a healthcare CEO who supervised Miller at
        Sunrise Regional Medical Center (“Sunrise”) from 1999 through
        2001, before she started working at HP. Llano testified that he of-
        fered Miller a job at least twice after she left Sunrise, but she de-
        clined those offers because she enjoyed working at HP. No one
        contacted Llano before the trial about testifying on Miller’s behalf.
        On cross-examination, Llano conceded that he was not present at
        the meetings between Miller and HP’s recruiters, never saw Miller
        interact with patients at HP, never reviewed any of HP’s patient
        charts, and was unaware of any instructions HP gave its employees
        about completing patient charts.
               Dr. Michael Piercey is the director of a medical facility that
        tests new medications and was the Chairman and CEO of Sunrise
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        10                     Opinion of the Court                20-11988

        when Miller worked there. Dr. Piercey testified that he was im-
        pressed by Miller’s intelligence, energy, and ethics, and would “be
        delighted to have [Miller] work with [him] again[,] . . . assuming
        she were available and interested.” Dr. Piercey was not contacted
        before the trial. On cross-examination, Piercey conceded that he
        was unfamiliar with HP’s admissions process, did not know
        whether HP paid recruiters to recruit patients, and did not know
        what Miller told Dr. Gumer and other HP employees.
                Rita Sordellini worked as a part-time psychotherapist for
        HP. Whenever Sordellini reviewed patient files at HP, she never
        noticed inconsistencies among the notes entered by different indi-
        viduals. She did not recall therapists raising concerns about incon-
        sistencies at the weekly treatment team meetings that Miller facili-
        tated. Sordellini never saw evidence of Miller instructing therapists
        to stress a patient’s negative symptoms to ensure that Medicare
        would reimburse HP. Miller never told her that particular patients
        needed to be discharged because they were out of Medicare days
        nor instructed her to keep patients longer because they had Medi-
        care days remaining. Sordellini only had a “very quick” conversa-
        tion with Malone or his investigator before trial and volunteered
        to testify for Miller, but she was not contacted afterward. On cross-
        examination, Sordellini conceded that Malone emailed her asking
        her to contact him about “anything or anyone that would be help-
        ful to [Miller’s] cause.” Sordellini acknowledged that she was not
        responsible for discharge, insurance, or marketing decisions at HP
        and would not be aware if HP hired “marketers” to recruit patients.
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        23-10182               Opinion of the Court                       11

        She also conceded that she was not present at any meetings be-
        tween Miller and the recruiters.
               Melvin Hunter oversaw the Admissions Department at HP,
        and he testified that patients who arrived at HP were usually “pre-
        cleared” through an interview process and that doctors at HP ulti-
        mately made the final admission decision. He also testified that HP
        admitted patients even though there was no chance HP would be
        paid on “quite a few” occasions. As for his willingness to testify in
        Miller’s case, Hunter explained that he had declined to testify be-
        fore the grand jury because his attorney was not permitted to ac-
        company him into the grand jury room. Hunter, however, stated
        that he would have testified at Miller’s trial, even if his attorney
        advised him not to testify, because he believed that the allegations
        against HP and its staff were false. Hunter did not know if anyone
        contacted his attorney about testifying at Miller’s trial or if his
        counsel invoked his Fifth Amendment rights. On cross-examina-
        tion, Hunter acknowledged that he did not know what happened
        to the patient files after the admissions process was completed or if
        they were falsified after he saw them. Hunter also conceded that
        he was not privy to all the conversations between Miller and Dr.
        Gumer, other staff members, or the recruiters.
               Michael Calabria provided an affidavit but did not testify at
        Miller’s hearing. According to his affidavit, he worked with Miller
        as a psychotherapist at Sunrise and HP and presently works at HP’s
        successor facility. Calabria stated that Miller was a “great supervi-
        sor” and a “great mental health professional.” Calabria also stated
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        12                       Opinion of the Court                        20-11988

        that the quality of care at HP was “very good” and that the doctors
        were responsible for admitting and discharging patients. Miller
        never told him to write anything specific in his patients’ charts. Fi-
        nally, he stated that no one contacted him about testifying at Mil-
        ler’s trial.
               Sandra Novak also provided an aﬃdavit but did not testify at
        Miller’s hearing. Novak worked with Miller as a therapist at Sun-
        rise and HP. In Novak’s opinion, Miller would not have jeopardized
        her career, family, and future to participate in the charged oﬀenses.
        No one contacted her about testifying at Miller’s trial.
                Additionally, Roy Rindom provided an affidavit but did not
        testify at Miller’s hearing. Rindom worked with Miller as a psycho-
        therapist at HP from 2004 to 2007. Rindom’s job was to conduct
        patient evaluations, including psychosocial interviews for admitted
        patients. Rindom stated that Miller never asked him to do anything
        unethical and that there were “no shenanigans” in connection with
        admissions, discharges, or treatment of patients. However, Rin-
        dom acknowledged that he was “engrossed in [his] daily duties and
        . . . was not aware of what Daisy Miller was doing at any given mo-
        ment of the work day.” Rindom was also not involved in insur-
        ance-based decisions at HP. Finally, according to Rindom, no one
        contacted him about testifying at Miller’s trial. 1

        1 Miller concedes, however, that contrary   to Rindom’s affidavit, Malone inter-
        viewed Rindom before the trial.
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        23-10182               Opinion of the Court                         13

                Karen Bryan provided an affidavit but did not testify at Mil-
        ler’s hearing. She monitored patients, took vital signs, and assisted
        with the intake process. Bryan acknowledged that she had little
        interaction with Miller but thought Miller was “amazing.” How-
        ever, she knew nothing about HP’s billing process. No one con-
        tacted her about testifying at Miller’s trial.
                Miller also testified at the evidentiary hearing. After she was
        indicted, she prepared a list of witnesses she believed would help
        her defense and provided it to Malone. Miller was aware that
        Malone agreed to a joint defense agreement with her co-defend-
        ants, and they attended the weekly joint defense meetings to-
        gether. But as the trial grew closer, Miller concluded that Malone’s
        loyalty was to the joint defense theme rather than to her individual
        defense. When Miller told Malone that she wanted a medical ex-
        pert to testify on her behalf and suggested several psychiatrists,
        Malone told her that Kallen-Zury’s attorney, Michael Pasano, had
        retained an expert, Dr. Danziger, who would testify about the clin-
        ical issues. Malone never discussed with Miller the reason why Dr.
        Danziger did not testify.
               On cross-examination, Miller conceded that she did not in-
        clude Calabria, Hunter, Llano, Piercey, Sordellini, and Bryan as po-
        tential witnesses in the twenty-nine-page memorandum she pre-
        pared for Malone before trial. Miller also acknowledged that, con-
        trary to Rindom’s affidavit, Malone had interviewed him before the
        trial. Miller also conceded that Malone contacted other witnesses
        on her behalf, sent her interview reports, and gave her periodic
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        14                     Opinion of the Court                 20-11988

        updates. Finally, she conceded that none of her witnesses at the
        evidentiary hearing interacted with HP’s recruiters, with the possi-
        ble exceptions of Humes and Veraguas.
                Malone testiﬁed on behalf of the government. Malone is an
        experienced criminal defense attorney who has tried between ﬁfty
        and sixty jury trials to verdict. Malone testiﬁed that, for this case,
        he conducted an extensive pretrial investigation, which entailed re-
        viewing discovery at the government’s warehouse, examining pa-
        tient ﬁles and other documents, hiring an investigator to obtain wit-
        ness statements, meeting and sharing information with attorneys
        for Miller’s co-defendants, and identifying and interviewing poten-
        tial witnesses. As for the joint defense agreement, Malone testiﬁed
        that he entered into the agreement in order to pool resources,
        jointly attack the government’s charges, identify who the govern-
        ment’s witnesses might be, and take advantage of the work that the
        other defense attorneys had already done. As to his strategy for
        Miller’s defense, Malone testiﬁed that he intended to present Miller
        to the jury as “an upstanding citizen of this community who took
        her work very seriously” and “looked out for the well-being of [HP]
        patients.” He believed that Miller would be an excellent witness in
        this regard, and he decided not to call other witnesses so that the
        government would be unable to repeat, through cross-examina-
        tion, the negative information it had presented in its case-in-chief.
        As to the allegations about Miller’s participation in recruiting pa-
        tients, Malone testiﬁed that he did not have any evidence to refute
        them other than Miller’s general denial.
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        23-10182               Opinion of the Court                        15

               Next, as to his investigation of potential witnesses, Malone
        remembered speaking with Llano, could not recall who Dr. Piercey
        was, could not recall if he spoke with Smith, and recalled interview-
        ing Sordellini but could not recall any details about their conversa-
        tion. With respect to Hunter, Malone testiﬁed that he could not
        contact him directly because he was represented by counsel and
        that Hunter’s counsel would not let him testify at Miller’s trial. As
        for Dr. Danziger, Malone determined that Dr. Danziger could not
        have explained why so many out-of-state patients were admitted
        when they could have gotten the same services much closer to
        home. Malone noted that Dr. Danziger admitted that the out-of-
        state patients were “a problem.” Malone was also concerned that
        Dr. Danziger would be cross-examined about how his opinion as-
        sumed that the patient ﬁles were not fabricated when Dr. Gumer
        had already testiﬁed that the patient ﬁles were fabricated.
                The magistrate judge also took judicial notice of Dr. Dan-
        ziger’s testimony from the hearing on Kallen-Zury’s § 2255 mo-
        tion. Kallen-Zury retained Dr. Danziger in May 2012 to review a
        sample of HP patient files. Over a one-year period, Dr. Danziger
        reviewed thirty-six charts of nineteen different patients to deter-
        mine whether there were reasonable grounds for the patients’ ad-
        missions. At Kallen-Zury’s § 2255 hearing, Dr. Danziger testified
        that all nineteen patients met Medicare’s standards for admission
        to HP. As for suspicions of document fabrication, Dr. Danziger
        testified that it was unlikely that the charts he reviewed were fabri-
        cated because the entries were made by multiple practitioners and
        internally consistent, and “it would stretch credibility that
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        16                     Opinion of the Court                 20-11988

        everyone was faking.” Still, Dr. Danziger conceded that he could
        not determine whether the notes he reviewed were truthful and
        could only determine that they were consistent across multiple
        medical practitioners. Finally, Dr. Danziger testified that he did
        not remember speaking with Malone. But contrary to his testi-
        mony at Kallen-Zury’s § 2255 hearing, Dr. Danziger’s declaration
        filed here states that on June 15, 2013, he spoke with Malone about
        his proposed trial testimony.
                Finally, the magistrate judge took judicial notice of Pasano’s
        testimony from Kallen-Zury’s § 2255 hearing. Pasano’s trial strat-
        egy was to build a case around Kallen-Zury’s good faith in operat-
        ing HP. Pasano testiﬁed that an important part of his defense strat-
        egy was to have Kallen-Zury testify and that he made a tactical de-
        cision not to call other witnesses once she completed her testi-
        mony. He had reservations about the limited nature of Dr. Dan-
        ziger’s testimony because Dr. Danziger only reviewed a few patient
        ﬁles. He also feared that, in cross-examining Dr. Danziger, the gov-
        ernment could highlight its contention that the patient records had
        been falsiﬁed, rendering Dr. Danziger’s opinion incorrect for hav-
        ing assumed the veracity of the patient ﬁles.
                On May 24, 2019, after the evidentiary hearing, the magis-
        trate judge issued a 110-page report and recommendation, recom-
        mending that the district court deny Miller’s motion because Miller
        had not satisfied the performance prong or the prejudice prong un-
        der Strickland and also recommending that the district court issue
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        23-10182              Opinion of the Court                       17

        a certificate of appealability (“COA”) regarding Malone’s failure to
        call additional witnesses.
               As for the performance prong of Strickland, the magistrate
        judge explained that Malone’s decision not to call additional wit-
        nesses, “made after balancing the potential risks against the possi-
        ble beneﬁts,” was “logical, rational, and understandable” and there-
        fore “reasonable.” The magistrate judge noted that Malone had
        spent about 1,200 hours defending Miller and that, in reviewing
        counsel’s performance, a court must avoid using “the distorting ef-
        fects of hindsight” and instead must evaluate the reasonableness of
        Malone’s performance from his perspective at the time. And the
        magistrate judge emphasized that Pasano had made exactly the
        same decision as Malone in not calling additional witnesses.
               As to the prejudice prong of Strickland, the magistrate judge
        concluded that “there is no reasonable probability that [Miller’s]
        prosecution would have had a diﬀerent outcome had Malone
        called” witnesses other than Miller at trial. Most of the witnesses
        could only oﬀer impermissible character evidence about Miller,
        which the trial court had already excluded. Other witnesses were
        not “smoking gun” type witnesses. Several witnesses never worked
        at HP in the ﬁrst place, so they could not testify about what Miller
        did or did not do at HP or what she did or did not know about the
        fraud at HP. Other witnesses did work at HP during the years at
        issue, but they did not know the inner workings of HP’s ﬁnance,
        marketing, insurance, and admissions departments. Still other wit-
        nesses were not at HP every day, were unaware of what Miller did
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        18                     Opinion of the Court                   20-11988

        every day, or were not privy to the conversations that Miller had
        with those involved in the fraud.
                On April 30, 2020, the district court adopted the “thorough,
        exhaustive, and persuasive” report and recommendation and de-
        nied Miller’s motion. The district court then issued a COA only as
        to Miller’s claim “that her former trial counsel was ineﬀective for
        failing to call any witnesses at trial other than [Miller] herself.”
               This appeal ensued.
                         II.    STANDARD OF REVIEW
                In a § 2255 proceeding, we review the district court’s legal
        conclusions de novo and the underlying factual findings for clear er-
        ror. Lynn v. United States, 365 F.3d 1225, 1232 (11th Cir. 2004). “We
        allot ‘substantial deference to the factfinder . . . in reaching credi-
        bility determinations with respect to witness testimony.’” Devine
        v. United States, 520 F.3d 1286, 1287 (11th Cir. 2008) (quoting United
        States v. McPhee, 336 F.3d 1269, 1275 (11th Cir. 2003)).
                                    III.     ANALYSIS
                               A.          Scope of Appeal
                Before reaching the merits of this case, we must address a
        procedural issue. The report and recommendation, which the dis-
        trict court adopted, states that “[t]rial counsel’s decisions, particu-
        larly about whether to call certain witnesses and introduce docu-
        ments, are entitled to great deference, and there is a presumption
        that trial counsel’s decisions are reasonable.” However, Miller ar-
        gues that Malone’s decisions should not be entitled to deference
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        23-10182                Opinion of the Court                         19

        because they were based on an inadequate investigation and were
        thus not informed, strategic decisions. Thus, according to Miller,
        our inquiry must include an analysis of whether Malone’s investi-
        gation “was itself reasonable.” That is, even though the COA spec-
        iﬁes that the only issue on appeal is whether Malone “was ineﬀec-
        tive for failing to call any witnesses at trial other than [Miller] her-
        self,” Miller argues that the Court should address a subsidiary claim
        that Malone failed to conduct an adequate investigation of poten-
        tial witnesses and documents. The government agrees that ad-
        dressing the issue on appeal necessarily encompasses the subsidiary
        claim of whether Malone conducted an adequate investigation of
        other potential witnesses. However, to the extent that Miller ar-
        gues that Malone failed to properly review the government’s dis-
        covery and investigate potential documents—rather than potential
        witnesses—the government contends that such arguments are be-
        yond the scope of the COA and that we should not address those
        issues.
               Although appellate review is limited to issues speciﬁed in the
        COA, Turner v. Sec’y, Dep’t of Corr., 991 F.3d 1208, 1211 n.1 (11th
        Cir. 2021) (quoting Murray v. United States, 145 F.3d 1249, 1250–51
        (11th Cir. 1998)), we conclude that Malone’s decision to call wit-
        nesses could have been elucidated by a reasonable investigation of
        the government’s discovery and documentary evidence. Thus, our
        inquiry will include an analysis of whether Malone’s investigation
        of the documentary evidence, as well the potential witnesses, was
        reasonable to determine whether Malone’s decisions at issue are
        entitled to deference.
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        20                     Opinion of the Court                 20-11988

              With this procedural matter resolved, we now turn to the
        merits of Miller’s ineffective assistance claim.
                                  B.     Prejudice
               To prevail on an ineffective assistance of counsel claim, a pe-
        titioner must “demonstrate both that (1) ‘counsel’s performance
        was deficient,’ and (2) ‘the deficient performance prejudiced the de-
        fense.’” United States v. Webb, 655 F.3d 1238, 1258 (11th Cir. 2011)
        (quoting Strickland, 466 U.S. at 687). “We may consider the prongs
        of the Strickland test in either order, and the defendant must show
        that both prongs are satisfied in order to demonstrate a Sixth
        Amendment violation.” Id. This standard is necessarily a fact-in-
        tensive one, requiring a court to “consider[] all the circumstances”
        when evaluating counsel’s performance. Strickland, 466 U.S. at
        688. If a defendant makes an insufficient showing on one of the
        requisite prongs, we need not address the other prong. Id. at 697.
        Determining whether there is prejudice under Strickland is a mixed
        question of law and fact, making our review plenary. See, e.g.,
        Brooks v. Comm’r, Ala. Dep’t of Corr., 719 F.3d 1292, 1300 (11th Cir.
        2013). Underlying factual determinations, however, are subject to
        clear error review. See Devine, 520 F.3d at 1287.
               To establish prejudice under the second prong of Strickland,
        a defendant must show “a reasonable probability that, but for coun-
        sel’s unprofessional errors, the result of the proceeding would have
        been different.” Id. at 694. “A reasonable probability is a probabil-
        ity sufficient to undermine confidence in the outcome.” Id. In
        other words, “[i]t is not enough for the defendant to show that the
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        23-10182               Opinion of the Court                       21

        errors had some conceivable effect on the outcome of the proceed-
        ing.” Id. at 693. The petitioner instead must show that counsel’s
        deficient representation rendered the result of the trial unfair. See
        id. at 697. The prejudice component of the Strickland standard thus
        reflects “[t]he purpose of the Sixth Amendment guarantee of coun-
        sel,” which is to “ensure that a defendant has the assistance neces-
        sary to justify reliance on the outcome of the proceeding.” Id. at
        691–92. We have recognized that, given the principles and pre-
        sumptions associated with ineffective assistance claims, “the cases
        in which habeas petitioners can properly prevail are few and far
        between.” Chandler v. United States, 218 F.3d 1305, 1313 (11th Cir.
        2000) (en banc) (omission adopted) (quoting Waters v. Thomas, 46
        F.3d 1506, 1511 (11th Cir. 1995) (en banc)).
                Here, we conclude that the district court did not err in de-
        termining Miller did not suffer prejudice by Malone’s decision not
        to call additional witnesses. The magistrate judge found that Mil-
        ler’s proposed witnesses were either not credible or credible but
        could not offer material testimony, meaning their testimony would
        not have changed the outcome of the trial. After a review of the
        record, we conclude that the magistrate judge’s factual findings
        about the potential witnesses are not clearly erroneous, especially
        given the substantial deference we afford to the factfinder as to
        credibility determinations. We discuss each proposed witness in
        turn.
               First, Dr. Danziger’s testimony would have been of little
        value to Miller’s defense. As we noted previously in Kallen-Zury IV,
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        22                     Opinion of the Court                  20-11988

        because Dr. Danziger analyzed only nineteen of the thousands of
        patients at HP during the period in question, his conclusions were
        not based on a significant sample to hold much weight at trial. See
        2023 WL 164065, at *9. “Additionally, his analysis assumed the ve-
        racity of the treatment forms, even though he had no corrobora-
        tion for such an assumption.” Id. Dr. Danziger conceded that,
        while the files were internally consistent, he could not determine
        whether the files were truthful, raising the possibility that the files
        were consistently falsified. Even if the jury believed Dr. Danziger’s
        claim that it was unlikely that everyone had falsified their part of
        the patient files in an internally consistent manner, he could not
        explain the out-of-state patients, which he described as a “prob-
        lem.” In addition, Dr. Danziger could not rebut the recruiters’ tes-
        timony and documentary evidence about Miller’s participation in
        hiring recruiters and preparing the recruiters’ false monthly re-
        ports. So even if he could convince the jury that the recruited pa-
        tients were properly admitted, he would not have been able to re-
        fute the evidence that HP was not permitted to pay recruiters to
        bring patients but did so anyway. Being unable to address that as-
        pect of the criminal scheme and Miller’s participation in that
        scheme, there is no reasonable probability that Dr. Danziger’s tes-
        timony would have led to a different outcome here.
               Next, Smith was not responsible for billing and marketing
        and did not know if the recruiters were paid to recruit patients. She
        testiﬁed that she did not attend any meetings that Miller had with
        Moore, Humes, or Himmons. Therefore, like Dr. Danziger, she
        would have not refuted Miller’s involvement in the recruiting
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        23-10182               Opinion of the Court                        23

        scheme. She would have merely testiﬁed that she did not know of
        any fraud at HP. Her lack of knowledge, however, would not have
        overturned the verdict. Indeed, it is unsurprising that those partic-
        ipating in a fraudulent scheme would not inform all of their em-
        ployees of the fraud. Thus, the jury could have reasonably con-
        cluded that Miller and her co-defendants took aﬃrmative steps to
        keep knowledge of the fraud from Smith and other non-participat-
        ing employees.
                Similarly, Sordellini’s potential testimony that the patients
        were properly admitted would not have overturned the verdict. As
        a part-time employee at HP, Sordellini conceded that she was not
        responsible for discharge, insurance, or marketing decisions at HP,
        and she was unaware if HP hired “marketers” to recruit patients.
        And Sordellini conceded that she was not present at any meetings
        with Miller and the recruiters. It is therefore unlikely that the jury
        would have rejected the government’s evidence of fraud and Mil-
        ler’s participation in the fraud based on a part-time employee’s tes-
        timony that she was unaware of the scheme. Instead, it is more
        likely that the jury would have concluded that, as a part-time em-
        ployee, Sordellini was simply not privy to the criminal scheme.
        Thus, like Dr. Danziger and Smith, she would not have refuted the
        government’s evidence of Miller’s involvement.
               As for Hunter, we already concluded in Kallen-Zury IV, that
        his testimony would not have impacted the outcome of the trial
        with respect to Kallen-Zury. See 2023 WL 164065, at *8. The same
        conclusion applies to the outcome of the trial with respect to
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        24                     Opinion of the Court                  20-11988

        Miller. Hunter conceded that he was unaware if Miller instructed
        Dr. Gumer to falsify records to ensure that patient ﬁles reﬂected
        severe symptoms. Similar to the previous witnesses, the fact that
        he was unaware does not mean that the jury would have rejected
        the government witnesses’ testimonies. Being unaware of the
        fraud does not establish that the alleged conduct did not happen; it
        merely suggests that Hunter did not know whether the conduct
        happened. Furthermore, similar to the magistrate judge in Kallen-
        Jury IV, 2023 WL 164065, at *8, the magistrate judge here did not
        ﬁnd Hunter’s testimony to be credible. We agree that Hunter’s
        claim that he would have testiﬁed at Miller’s trial is not credible be-
        cause he invoked his Fifth Amendment rights before the grand jury.
        In sum, Hunter lacked credibility and was not privy to the criminal
        scheme to have made a diﬀerence in Miller’s trial.
                As for Llano and Dr. Piercey, because they never worked at
        HP, they too could not credibly testify about the fraud at HP. To
        the extent that they could have undercut the government’s theory
        that Miller engaged in criminal conduct to keep her job by testify-
        ing that she had other job prospects, their testimony about her mo-
        tive, or the lack thereof, would not have overwhelmed other docu-
        mentary and testimonial evidence of her criminal conduct. The
        government presented signiﬁcant evidence over the ﬁve-week trial,
        and Llano and Dr. Piercey’s ancillary arguments related to motive
        would have been insigniﬁcant in comparison. Thus, even if their
        testimonies were admitted, it is unlikely that they would have made
        a diﬀerence.
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        23-10182               Opinion of the Court                        25

               The aﬃants, Calabria, Novak, Rindom, and Bryan, would
        not have made a diﬀerence either. Even if the aﬃants testiﬁed that
        they were unaware of the criminal scheme, that does not exclude
        the possibility that Miller asked other employees to participate in
        the scheme without the aﬃants’ knowledge. In addition, Novak
        and Bryan would have merely provided character evidence that
        Miller was honest, which would not have overturned the outcome
        of the trial.
                In sum, the testimony from these witnesses—taken together
        or separately—would not have created a reasonable probability
        that Miller’s trial would have resulted in a different outcome. See
        Devine, 520 F.3d at 1287. None of the potential witnesses could re-
        but the government’s evidence that Miller participated in a kick-
        back scheme with the recruiters because they were not privy to the
        pertinent conversations between Miller and the recruiters. Thus,
        and considering the weight of the evidence presented against Miller
        during the five-week trial, we conclude that Miller cannot show
        that she was prejudiced by Malone’s failure to call these witnesses
        at trial and cannot satisfy the second Strickland prong.
                          C.     Deficient Performance
                Because Miller has failed to show that she was prejudiced by
        counsel’s failure to call witnesses at trial, we need not consider the
        first prong of Strickland. However, even if we were to assume that
        Miller were prejudiced and met the second Strickland prong, Miller
        still cannot prevail because Malone’s decision not to call additional
        witnesses did not amount to deficient performance.
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        26                     Opinion of the Court                  20-11988

                “The standard for counsel’s performance is ‘reasonableness
        under prevailing professional norms.’” Chandler, 218 F.3d at 1313
        (quoting Strickland, 466 U.S. at 688). There is a strong presumption
        that counsel rendered reasonable professional assistance and thus
        Miller has the burden to overcome this presumption. See Dingle v.
        Sec’y for Dep’t of Corr., 480 F.3d 1092, 1099 (11th Cir. 2007). We
        generally afford great deference to counsel’s strategic decision not
        to call witnesses. Conklin v. Schofield, 366 F.3d 1191, 1204 (11th Cir.
        2004); Chandler, 218 F.3d at 1313. Further, “[o]ur strong reluctance
        to second guess strategic decisions is even greater where those de-
        cisions were made by experienced criminal defense counsel.”
        Provenzano v. Singletary, 148 F.3d 1327, 1332 (11th Cir. 1998). And
        “[e]ven if counsel’s decision appears to have been unwise in retro-
        spect, the decision will be held to have been ineffective assistance
        only if it was ‘so patently unreasonable that no competent attorney
        would have chosen it.’” Dingle, 480 F.3d at 1099 (quoting Adams v.
        Wainwright, 709 F.2d 1443, 1445 (11th Cir. 1983)).
               As noted above, we must first determine whether Malone’s
        investigation was adequate before giving great deference to his de-
        cision not to call witnesses. See Wiggins, 539 U.S. at 521–23. Turn-
        ing to Malone’s investigative efforts, the magistrate judge found
        that Malone, an experienced criminal defense attorney, spent about
        1,200 hours defending Miller.
               Although Malone did not speak to Dr. Danziger until after
        Miller’s trial began, Malone testiﬁed that he knew what Dr. Dan-
        ziger would have discussed at trial beyond “best practices,”
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        23-10182               Opinion of the Court                        27

        indicating that he was suﬃciently apprised of Dr. Danziger’s testi-
        mony through the work of the joint defense team. Malone’s deci-
        sion not to have another medical expert review additional ﬁles re-
        ﬂected Malone’s reasonable investigation of the documents and
        Malone’s understanding that a second medical expert would not
        have been able to rebut any allegations about Miller’s supervision
        of the recruiters from the patient ﬁles, thereby making any addi-
        tional investigation into patient ﬁles unnecessary and unproductive
        in defending Miller. And as for the remaining witnesses who testi-
        ﬁed that Malone did not contact them or only made a brief call, we
        have explained that counsel “need not interview every conceivable
        witness” to satisfy Strickland. Morrow v. Warden, 886 F.3d 1138, 1148
        (11th Cir. 2018); see also Chandler, 218 F.3d at 1317 (“[N]o absolute
        duty exists to investigate particular facts or a certain line of de-
        fense.”). Malone realized that none of those witnesses could rebut
        the critical evidence about the recruiters based on the detailed list
        of witnesses that Miller provided Malone. Finally, with regard to
        Hunter, he was represented by counsel, and Malone cannot be
        faulted for not contacting him directly or his counsel given that
        Malone does not have to pursue all leads, especially not a witness
        who had previously invoked his Fifth Amendment rights. Cf. Davis
        v. Laﬄer, 658 F.3d 525, 537 (6th Cir. 2011) (en banc) (concluding that
        counsel’s decision not to call a witness was a strategic choice based
        in part on the concern that witness “would exercise his Fifth
        Amendment right to remain silent if called”).
              Even if it is otherwise unclear how Malone spent the 1,200
        hours, whether he effectively used that time reviewing documents
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        28                      Opinion of the Court                  20-11988

        and interviewing additional witnesses, and why he did not discover
        that the government did not have certain patient files during that
        time, Malone’s inability to recollect the specifics of his investigation
        six-and-a-half years after the fact is not a sufficient ground to con-
        clude that his investigation was inadequate. Blankenship v. Hall, 542
        F.3d 1253, 1274 (11th Cir. 2008) (“[W]hen the evidence is unclear
        or counsel cannot recall specifics about his actions due to the pas-
        sage of time and faded memory, we presume counsel performed
        reasonably and exercised reasonable professional judgment.”); Har-
        vey v. Warden, Union Corr. Inst., 629 F.3d 1228, 1245 (11th Cir. 2011)
        (similar). As we stated previously, attorneys are entitled to the pre-
        sumption that their conduct was reasonable, and “[a]n ambiguous
        or silent record is not sufficient to disprove the strong and contin-
        uing presumption.” Chandler, 218 F.3d at 1314 n.15.
               We thus conclude that Malone suﬃciently investigated the
        witnesses and documents. Thus, his decision not to call additional
        witnesses was a strategic choice made after an adequate investiga-
        tion, which makes his decision “virtually unchallengeable.” Strick-
        land, 466 U.S. at 690; accord Conklin, 366 F.3d at 1204 (“Which wit-
        nesses, if any, to call, and when to call them, is the epitome of a
        strategic decision, and it is one that we will seldom, if ever, second
        guess.” (quoting Waters, 46 F.3d at 1511)).
              With this deferential standard in mind, we turn to whether
        Malone’s explanations for not calling witnesses were reasonable.
        Malone, an experienced criminal defense attorney, testiﬁed that he
        did not call Dr. Danziger because Dr. Danziger would have faced
USCA11 Case: 20-11988     Document: 84-1      Date Filed: 07/10/2023    Page: 29 of 30

        23-10182               Opinion of the Court                       29

        damaging cross-examination. Dr. Danziger reviewed only a few
        patient ﬁles and assumed the veracity of the patient ﬁles, which
        would have been revealed through cross-examination. And, as
        stated before, the government’s theory was not that Miller was
        only involved in the patient side of HP. The government’s theory
        was that Miller directed recruiters, which goes beyond patient care,
        and Dr. Danziger would not have been able to credibly testify about
        this allegation based on his limited review of patient ﬁles. In addi-
        tion, Dr. Danziger would not have been able to provide a satisfac-
        tory explanation for out-of-state patients coming to HP, but for the
        work of Miller’s recruiters. Thus, Malone’s decision not to call Dr.
        Danziger was reasonable.
                As for Malone’s decision not to call other witnesses, all of
        the potential witnesses would have similarly been unable to refute
        critical aspects of the government’s case and, as a result, would
        have been subject to damaging cross-examination. See Chandler,
        218 F.3d at 1321 (“[A] lawyer reasonably could also fear that char-
        acter evidence might, in fact, be counterproductive: it might pro-
        voke harmful cross-examination and rebuttal witnesses. Misgiv-
        ings about hurtful cross-examination and rebuttal witnesses have
        been decisive to the Supreme Court when it determined that coun-
        sel was eﬀective.” (footnote omitted)). Thus, we conclude that
        Malone’s decision not to call additional witnesses was reasonable,
        and that Miller has not adequately demonstrated that Malone was
        deﬁcient in his representation.
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        30                     Opinion of the Court                 20-11988

                              IV.    CONCLUSION
               For all these reasons, we affirm the district court’s denial of
        Miller’s § 2255 motion to vacate her conviction.
              AFFIRMED.