Court Opinion

ID: 4167356
Source: CourtListenerOpinion
Date Created: 2017-05-09 23:13:15.265843+00
Date Added: 2024-06-11T14:38:30.790907
License: Public Domain

SYLLABUS

(This syllabus is not part of the opinion of the Court. It has been prepared by the Office of the Clerk for the
convenience of the reader. It has been neither reviewed nor approved by the Supreme Court. Please note that, in the
interest of brevity, portions of any opinion may not have been summarized.)

              Allstate Insurance Company v. Northfield Medical Center, P.C. (A-27-15) (076069)

Argued January 4, 2017 -- Decided May 4, 2017

LaVecchia, J., writing for a unanimous Court.

         In this appeal, the Court reviews the Appellate Division’s determination that the trial court erred in finding
a knowing violation of the Insurance Fraud Prevention Act (IFPA), N.J.S.A. 17:33A-1 to -30. After a bench trial,
Robert P. Borsody, Esq., a New York attorney, and Daniel H. Dahan, a California chiropractor, were found to have
violated the IFPA to the extent they promoted and assisted in the creation of a practice structure designed to
circumvent regulatory requirements with respect to the control, ownership, and direction of a medical practice.

         N.J.A.C. 13:35-6.16(f), codified in 1992, explicitly provides that a medical doctor with a plenary scope of
practice may not be employed by a licensee with a more limited scope of practice, such as a chiropractor. In 1995,
the Executive Director of the State Board of Medical Examiners (Board), issued a letter-opinion in response to a
hypothetical scenario in which a professional association was divided between a chiropractor holding a seventy-
percent interest and a doctor holding a thirty-percent interest. The director wrote that “[The Board] would find it
inappropriate for a physician with a plenary scope of practice (M.D./D.O.) to be in a position where the practitioner
with a limited scope of practice (here, a [chiropractor]) can compel—by the simple fact of majority voting rights—
the medical doctor to accept contracts for the provision of all manner of services.”

         In the 1990s, Dahan began organizing a series of lectures throughout the country through his company,
“Practice Perfect.” Practice Perfect lectures were marketed toward chiropractors and focused on the creation of
multi-disciplinary practices in which chiropractors work with physicians and other medical professionals. Borsody
made presentations at Practice Perfect lectures on the legal issues arising from such multi-disciplinary practices.

         In late 1996, New Jersey-licensed chiropractor John Scott Neuner attended a two-day Practice Perfect
seminar at which both Dahan and Borsody presented. The practice model, developed by Borsody and pitched at
Dahan’s programs, included a number of safeguards to prevent the nominal doctor-owner of the medical corporation
from seizing control of the practice from the real investor—the chiropractor. Prior to the seminar attended by
Neuner, Borsody wrote at least one trade article that correctly stated that New Jersey requires a majority of the
ownership interest in a medical corporation to be owned by medical doctors.

         In March 1997, after attending the Practice Perfect seminar described above, Neuner signed a contract with
Dahan to become a client of Practice Perfect. Neuner hired Dr. Robban A. Sica, M.D., as the initial doctor-owner of
Northfield. Neuner also hired several doctors to work at Northfield who held no ownership interest in the practice.

          In late 1998, Allstate, which had been receiving insurance claims for treatment provided at Northfield,
began investigating the legality of Northfield’s practice structure. Neuner retained Borsody to represent him and, in
January 1999, Borsody wrote that because the doctors hired to work at Northfield did not own stock in the medical
practice, Neuner’s employment of those doctors likely violated existing guidance from the Board. As a result of its
investigation, Allstate refused payment on approximately $330,000 in claims of patients treated by Northfield.

         Allstate filed the instant action on October 19, 1999, against Neuner, Northfield, Dahan, Borsody, and a
number of additional defendants. Neuner settled with Allstate early in the proceedings, in part in exchange for his
agreement to testify against his co-defendants. For present purposes, the salient charges of the complaint allege that
Borsody and Dahan (collectively, defendants) violated the IFPA by knowingly assisting Neuner in the creation and
operation of a multi-disciplinary practice whose insurance claims were fraudulent under the IFPA. Allstate’s theory
of the case relies on the practice’s failure to comply with governing standards on the corporate practice of medicine,
a necessary precondition to a valid insurance claim.

         The trial court found that Borsody and Dahan violated the IFPA when they “knowingly assisted, conspired
with and urged Neuner to operate in a fashion that violated the law.” In an unpublished opinion, the Appellate
Division reversed, concluding that the evidence did not support a finding that defendants knowingly violated the
IFPA. The Court granted Allstate’s petition for certification. 223 N.J. 555 (2015).

HELD: Defendants extensively promoted a professional practice structure that a fact-finder could reasonably conclude
was little more than a sham intended to evade well-established prohibitions and restrictions governing ownership and
control of a medical practice by a non-doctor. In light of the broad anti-fraud liability imposed under the IFPA, holding
defendants responsible for promoting and assisting in the formation of an ineligible medical practice was not a novel or
unanticipated application of the statute. The trial court correctly applied a plain-language understanding of “knowing,”
and its finding of a knowing violation of the IFPA is amply supported in this record.

1. N.J.S.A. 17:33A-4(b) instructs that “[a] person or practitioner violates [the IFPA] if he knowingly assists,
conspires with, or urges any person or practitioner to violate any of the provisions of this act.” Defendants were
found to have knowingly assisted or conspired with Neuner in violating the IFPA by promoting and helping Neuner
with the construction of an impermissible professional practice structure that enabled the chiropractor to benefit
from proceeds derived from his submission of medical claims for reimbursement, in violation of N.J.S.A. 17:33A-
4(a), (c). Proof of such violation need only be found to exist based on a preponderance of the evidence. (pp. 24-26)

2. This is not a criminal case. The trial court rightly did not import aspects of a “knowing” mens rea from the
Criminal Code into the civil liability section of the IFPA at issue. Rather, the court correctly applied a plain-
language understanding of “knowing,” which is well understood to be an awareness or knowledge of the illegality of
one’s act. That knowledge need not come from a prior decision holding that the precise conduct at issue gives rise
to a violation of a legal requirement. There is ample precedent supporting the proposition that a party’s knowledge
as to the falsity or illegality of his conduct may be inferred from the surrounding factual circumstances. (pp. 26-35)

3. Defendants claim that they could not have knowingly violated the IFPA because it was not clear that compliance
with practice-structure regulations was “material” to insurance submissions. The Court does not accept that a
reasonable actor would not have known that compliance with the regulatory provisions governing the organization,
supervision, and control of a medical practice was material to an insurance submission by that medical practice.
Health care services are highly regulated. One cannot claim, or feign, ignorance of those regulatory requirements
and restrictions until there is an express command applicable to a precise set of facts. (pp. 35-38)

4. The Court reviews the regulatory requirements in place governing the lawful structures for medical practices
when Borsody and Dahan promoted their practice model and notes that the 1995 letter makes plain that the Board
would allow no subterfuge to shield the existence of a real or potential corrupting influence that could be exercised
by a management company or by a professional association where a licensee with a lesser scope of practice, like a
chiropractor, could actually wield control over the practice of medicine by a plenary licensee. (pp. 38-40)

5. Based on the regulations in effect at the time and the testimony at trial, the trial court here could reasonably
conclude that Borsody, as well as Dahan, knew of the regulatory requirements at issue, promoted a practice scheme
specifically designed to circumvent those requirements while appearing compliant, and therefore knowingly assisted
in the provision of services, the foreseeable result of which was the submission of invalid and misleading claims
under the IFPA. The documents and structure promoted and designed by defendants accomplished what the
regulations sought to avoid. They placed control over the medical practice in the hands of a chiropractor, subjecting
plenary licensees to his effective control. The lengths that defendants went to in shielding the true controller of this
practice from view undermine any basis for interfering with the trial court’s assessment of the mixed question of fact
and law that was presented to the court. (pp. 40-44)

         The judgment of the Appellate Division is REVERSED. The case is REMANDED to the Appellate
Division for proceedings consistent with this opinion.

     CHIEF JUSTICE RABNER and JUSTICES PATTERSON, FERNANDEZ-VINA, SOLOMON, and
TIMPONE join in JUSTICE LaVECCHIA’s opinion. JUSTICE ALBIN did not participate.

                                                           2
                                      SUPREME COURT OF NEW JERSEY
                                        A-27 September Term 2015
                                                 076069

ALLSTATE INSURANCE COMPANY,
ALLSTATE INDEMNITY COMPANY,
ALLSTATE NEW JERSEY INSURANCE
COMPANY,

    Plaintiffs-Appellants,

         v.

NORTHFIELD MEDICAL CENTER,
P.C.; ROBBAN ARIEL SICA, M.D.;
SCOTT DAVID, D.O.; J. SCOTT
NEUNER, D.C.; JSM MANAGEMENT
COMPANY, INC.; TILTON
CHIROPRACTIC CENTER, P.C.;
TILTON CHIROPRACTIC CENTERS,
SOUTH DIVISION, P.C.; ARNOLD
BACARRO, M.D.; PANKAJ ANAND
AGRAWAL, M.D. a/k/a “PANKAJ
ANAND”; ALAN CARR, D.O.;
VORRIE MACOM, M.D.; ALONSO V.
CORREA, M.D.; ALONSO V.
CORREA, M.D., P.C.; CORREA
MEDICAL DIAGNOSTICS, P.C.;
MEDICAL INNOVATIONS, INC.,

    Defendants,

         and

DANIEL H. DAHAN, D.C.; PRACTICE
PERFECT; MEDICAL NEUROLOGICAL
DIAGNOSTICS, INC.,

    Defendants-Respondents,

         and

ROBERT P. BORSODY, ESQ.,

    Defendant-Respondent,

         and
                                  1
AMERICAN ARBITRATION
ASSOCIATION,

    Defendant in Interest.

         Argued January 4, 2017 – Decided May 4, 2017

         On certification to the Superior Court,
         Appellate Division.

         Thomas J. Hall argued the cause for
         appellants (McGill & Hall and Pashman Stein,
         attorneys; Mr. Hall and Michael S. Stein, on
         the briefs).

         Lawrence S. Lustberg argued the cause for
         respondent Robert P. Borsody, Esq. (Gibbons,
         attorneys; Mr. Lustberg and Amanda B.
         Protess, on the briefs).

         Christopher B. Turcotte argued the cause for
         respondents Daniel H. Dahan, D.C., Practice
         Perfect and Medical Neurological
         Diagnostics, Inc.

         John Zen Jackson argued the cause for amici
         curiae Medical Society of New Jersey and the
         American Medical Association (McElroy,
         Deutsch, Mulvaney & Carpenter, attorneys).

         Arthur Meisel submitted a brief on behalf of
         amicus curiae New Jersey Dental Association.

    JUSTICE LaVECCHIA delivered the opinion of the Court.

    Plaintiff Allstate Insurance Company (Allstate) filed a

complaint alleging statutory claims of insurance fraud against

defendants Robert P. Borsody, Esq., a New York attorney, and

Daniel H. Dahan, a California chiropractor (collectively,

defendants).   After a bench trial, defendants were found to have

violated the Insurance Fraud Prevention Act (IFPA), N.J.S.A.
                                 2
17:33A-1 to -30, by assisting a New Jersey chiropractor in the

late 1990s in the creation of an unlawful multi-disciplinary

practice, which submitted medical insurance claims to Allstate.

The trial court determined that Borsody and Dahan violated the

IFPA to the extent they promoted and assisted in the creation of

a practice structure that was designed to circumvent regulatory

requirements with respect to the control, ownership, and

direction of a medical practice.

    The Appellate Division reversed that judgment.    In doing

so, the panel relied on defendants’ arguments that Allstate had

not established that defendants actually knew that their

practice model violated regulatory requirements governing the

lawful ownership and control of a medical practice, and that,

even if evidence of such knowledge could be found in this

record, Allstate had not established that defendants knew that a

violation of those regulatory requirements could constitute

insurance fraud under the provision of the IFPA that creates

liability for one who “knowingly assists, conspires with, or

urges any person or practitioner to violate any of the

provisions of [the IFPA].”   N.J.S.A. 17:33A-4(b).   The Appellate

Division concluded that the trial court erred in finding a

knowing IFPA violation on the facts presented.

    Allstate sought our review of that determination, and we

now reverse.

                                   3
    Defendants extensively promoted a professional practice

structure that a fact-finder could reasonably conclude was

little more than a sham intended to evade well-established

prohibitions and restrictions governing ownership and control of

a medical practice by a non-doctor.   Further, in light of the

broad anti-fraud liability imposed under the IFPA, holding

defendants responsible for promoting and assisting in the

formation of an ineligible medical practice -- created for the

obvious purpose of seeking reimbursement for medical care

delivered by that practice -- was not a novel or unanticipated

application of the statute.   We conclude that the trial court’s

finding of a knowing violation of the IFPA is amply supported in

this record, which contains compelling evidence demonstrating

how the structure shielded from view its effective circumvention

of regulatory rules.

    For the reasons that follow, we reverse on the sole issue

found to be determinative by the Appellate Division.    Because

there were other issues not reached by the panel, we remand to

the Appellate Division to allow for their evaluation.

                              I.

    Fair consideration of this matter necessitates, first and

foremost, an understanding of the rules and requirements for

ownership, control, and direction of a physician’s practice.

                                4
Accordingly, before addressing the facts, we identify the

requirements in place at the time relevant to this appeal.

                                 A.

    The State Board of Medical Examiners (Board) -- the entity

responsible for establishing standards for professional practice

by licensed physicians -- has addressed the permissible types of

professional practice forms.     A regulation, adopted by the Board

in 1992 and codified at N.J.A.C. 13:35-6.16, figures prominently

in this matter.

    With the codification of N.J.A.C. 13:35-6.16, the Board

established limits on the corporate practice of medicine.

Section 6.16(f) lists the appropriate types of private practices

-- for example, solo practice, partnership, and medical

corporation -- and explicitly provides that a medical doctor

with a plenary scope of practice may not be employed by a

licensee with a more limited scope of practice, such as a

chiropractor.     In directing the proper structure of a medical

practice, the regulation provides that

         [a] practitioner may practice solo and/or may
         employ or otherwise remunerate other licensed
         practitioners to render professional services
         within the scope      of practice of each
         employee’s license, but which scope shall not
         exceed that of the employer’s license.     The
         practitioner   may   employ   ancillary   non-
         licensed staff in accordance with Board rules,
         if any, and accepted standards of practice.

         [N.J.A.C. 13:35-6.16(f)(1).]

                                   5
Subsection (f)(2) directs that

         [a]   practitioner   may    practice   in   a
         partnership, professional association, or
         limited liability company, but such entity
         shall be composed solely of health care
         professionals, each of whom is duly licensed
         or otherwise authorized to render the same or
         closely allied professional service within
         this State.

         [N.J.A.C. 13:35-6.16(f)(2).]

    Next, subsection (f)(3) defines employment as “an ongoing

associational relationship between a licensee and professional

practitioner(s) or entity on the professional practice premises

for the provision of professional services, whether the licensee

is denominated as an employee or independent contractor, for any

form of remuneration.”   N.J.A.C. 13:35-6.16(f)(3).   Thereafter,

subsection f(3)(i) provides that

         [a] practitioner may be employed, as so
         defined,    within    the   scope    of    the
         practitioner’s licensed practice and in
         circumstances where quality control of the
         employee’s professional practice can be and is
         lawfully supervised and evaluated by the
         employing practitioner. Thus, a practitioner
         with a plenary license shall not be employed
         by a practitioner with a limited scope of
         license, nor shall a practitioner with a
         limited license be employed by a practitioner
         with a more limited form of limited license.
         By way of example, a physician with a plenary
         license may be employed by another plenary
         licensed physician, but an M.D. or D.O. may
         not be employed by a podiatrist (D.P.M.) or
         chiropractor (D.C.) or midwife or certified
         nurse midwife (R.M., C.N.M.).     A podiatrist
         may not employ a chiropractor. This section
         shall not preclude any licensee from employing
         licensed personnel such as nurses, x-ray
                                   6
         technologists,      physical      therapists,
         ophthalmic    dispensers    and    ophthalmic
         technicians, etc., as appropriate to the
         primary practice of the employer.

         [N.J.A.C. 13:35-6.16(f)(3)(i).]

    In addition to the above-mentioned parts of section 6.16,

N.J.A.C. 13:35-6.17 bears noting, specifically subsections (h)

and (i), which permit administrative contracts between a

management company and a professional practice.   The

permissibility of a medical practice’s use of a management

company was also addressed, to an extent, in a 1983 Appellate

Division decision.

    In Women’s Medical Center v. Finley, the Appellate Division

considered whether three obstetrics and gynecological practices

that were performing on-site abortions were subject to the

Health Care Facilities Planning Act, N.J.S.A. 26:2H-1 to -26, or

instead were exempt as a “private practice,” a term not defined

under that Act.   192 N.J. Super. 44 (App. Div. 1983), certif.

denied, 96 N.J. 279 (1984).   The Appellate Division held that

medical practices contracting with outside management companies

“for the provision of a full range of non-professional office

management services” were properly considered private medical

practices under New Jersey regulatory law.   Id. at 48.

Anticipating the importance of physician control over the

practice, the panel reasoned that

                                 7
         [i]f the manner of [the services’] performance
         does not impinge upon the ordinary patient-
         private physician relationship and does not
         impinge upon professional control by the
         physicians of the medical practice and does
         not affect the essential character and
         commonly understood attributes of private
         practice, then it is evident that the “in-
         house” versus “out-of-house” business and
         administrative management of the practice has
         no fundamental impact on the . . . delivery of
         health care services.

         [Id. at 58.]

                               B.

    In addition to the administrative regulations governing the

subject of ownership and control of a physician’s medical

practice, there are also other forms of guidance issued for the

benefit of members of the public and regulated entities.

Consistent with its administrative responsibility for licensure

and oversight of the practice of medicine, the Board has on

several occasions issued informal guidance in response to

inquiries on the propriety of particular practice arrangements.

The following informal opinions bear on the dispute at hand.

    On November 16, 1995, the Board’s Executive Director, Kevin

B. Earle, issued an extensive letter-opinion in response to a

hypothetical scenario in which a professional association was

divided between a chiropractor holding a seventy-percent

interest and a doctor holding a thirty-percent interest.    It is

the most comprehensive letter-opinion issued on the subjects

involved in this appeal.   In that letter-opinion (hereinafter
                                 8
“Earle I”), the director noted that the Board had not “had

occasion to consider a specific shareholder arrangement

involving unequal ownership within a practice.”       However,

Director Earle wrote that, in the context suggested by the

inquiry, the Board “would find that division especially

questionable and inappropriate.”       Because of its importance, we

quote the explanation in full:

         [The Board] would find it inappropriate for a
         physician with a plenary scope of practice
         (M.D./D.O.) to be in a position where the
         practitioner with a limited scope of practice
         (here, a [chiropractor]) can compel -- by the
         simple fact of majority voting rights -- the
         medical doctor to accept contracts for the
         provision of all manner of services to the
         Professional Association. The potential for
         override of the physician’s professional
         judgment, as well as the determination as to
         how the practice shall be conducted, is deemed
         to be even more inappropriate where the
         management company itself is wholly owned by
         the 70% shareholder of the Professional
         Association who is a limited licensee.

         Further, your scenario appears to contemplate
         that other physicians shall be hired by the
         Professional Association.       Current Board
         [R]ule       N.J.A.C.      13:35-6.16(f)(3)(i)
         specifically prohibits the hiring of a plenary
         licensed physician by a limited licensed
         practitioner. While we recognize that it is
         nominally the Professional Association which
         is    the   “employer”    rather    than   the
         chiropractor, for our purposes that would be
         a distinction without a difference. For that
         quality control reason, the Board has always
         held that a multi-disciplinary practice cannot
         employ physicians who are not themselves
         shareholders in the practice.

                                   9
         You have also indicated that the other
         licensed professionals who would be employed
         by this Professional Association would not
         necessarily be under the supervision of the
         medical doctor/Medical Director. We find this
         to be inappropriate. Employees of any form of
         professional practice, whether independently
         licensed or not, are expected to remain under
         the general supervision of the employer,
         including a Medical Director, if any.     See
         Board [R]ule N.J.A.C. 13:35-6.16(b), (d) and
         (e).

    Earle I also touches on administrative contracts between

the proposed practice and management company, noting that,

although “N.J.A.C. 13:35-6.17(h) and (i) specifically permit[]”

administrative contracts between a management company and a

professional practice, the Board nevertheless “expects that a

licensee shall retain the right to terminate any such contract

for legally permissible reasons including for cause.”

Summarizing the advice on such arrangements, Earle I states that

the Board would find it “highly imprudent for a physician

(through the Professional Association) to enter into a contract

with the same management company which also leases space and

equipment and provides administrative services” because (1) “the

physician would be subject to coercive influences including

foreseeable total disruption of an ongoing professional practice

if the physician later sought to cease using the management

company to provide any of those individual services”; and (2)

“termination might well be impossible because of the 70%

ownership in the Professional Association of the person who also
                               10
owns the management company.”   The Earle I advisory letter

underscored the need to neuter any coercive influences by

cautioning that, at a minimum, “each such contract should be

separate and without any interlocking features.”

    Finally, the Earle I letter addressed a proposal to allow

the management company to make above-market-rate loans to the

practice, calling that proposal particularly concerning to the

Board because it created “a clear potential to adversely affect

the professional judgment of the minority shareholder in

numerous ways.”   The Earle I document added that designating the

minority shareholder physician as the Medical Director “cannot

save the scenario from the potential abuse and coercion inherent

in the various circumstances described.”

    A few weeks before the incorporation of the disputed

practice at issue here, Director Earle issued a second advisory

letter (hereinafter “Earle II”) on April 28, 1997, confirming

the opinion-seeker’s interpretation “that a medical doctor and a

chiropractor [may] form a professional corporation and both may

own shares in such a corporation,” but that the medical doctor,

as the licensee with a plenary scope of practice, must own a

majority of the stock in the corporation.

    After the incorporation of the practice involved in this

appeal, another advisory letter touching on the topic at hand

was written on June 11, 1997, by a Deputy Attorney General in

                                11
her capacity as a counsel to the Board.   That letter stated that

a chiropractor and a medical doctor may join their practices in

a professional corporation, but that “it is important to note

that the licensees must maintain professional discretion of

their judgment in the rendering of professional services.”     The

letter also noted that “[t]here is no statutory or regulatory

provision requiring that the licensee with the greater scope of

practice hold a majority of the stock in the professional

corporation.”

    With that state regulatory background in mind, we turn to

the record in this matter.

                                II.

                                 A.

    Defendants’ appeal comes to us on the basis of a completed

bench trial.    The backdrop to this matter involves actions taken

by a New Jersey-licensed chiropractor, John Scott Neuner.

Neuner testified in the trial of the IFPA complaint filed by

Allstate against the multi-disciplinary practice that he had

incorporated as Northfield Medical Center (Northfield), as well

as the various other professional entities and persons named as

defendants.    To set the stage for the issue determined to be

dispositive by the Appellate Division, we begin by summarizing

how Neuner and the two defendants came into contact with one

another, leading to the incorporation of Northfield and how it

                                 12
was structured and operated.    We recite the facts giving due

respect to the trial court’s findings of fact, which

incorporated credibility determinations.

                                1.

    In the 1990s, Dahan, a chiropractor licensed in California,

began organizing a series of lectures throughout the country

through his company, “Practice Perfect.”    Practice Perfect

lectures were marketed toward chiropractors and focused on the

creation of multi-disciplinary practices in which chiropractors

work with physicians and other medical professionals.     Borsody,

a New York-based healthcare attorney, made presentations at

Practice Perfect lectures on the legal issues arising from such

multi-disciplinary practices.

    In late 1996, Neuner attended a two-day Practice Perfect

seminar at which both Dahan and Borsody presented.     According to

Neuner, Borsody explained that a chiropractor may not own a

majority interest in a medical practice, may not split fees with

a doctor, and must refrain from self-referrals and kickbacks.

Borsody proposed a model form of practice that he had developed

for a multi-disciplinary center, which allowed an investing

chiropractor to retain control of the finances of a medical

practice.   Borsody’s practice model relied on a series of

contracts between a management company owned by the investing

chiropractor and a separate medical corporation owned by a

                                 13
doctor.     The stated goal of the interconnected contracts was to

protect the chiropractor’s financial investment in the medical

practice.

    Borsody’s model included three key types of contracts:       (1)

space rental leases, (2) equipment leases, and (3) management

contracts.     The overarching purpose of each of those contracts

was to allow the chiropractor-owned management company to

extract profits from and maintain control over the affiliated

medical corporation.     Borsody explained that a majority of the

stock in the medical corporation should be owned by a medical

doctor, but he clarified that this doctor need not participate

in the day-to-day treatment of patients.    Separately, other

doctors would be employed by the medical corporation to see and

treat patients.     All profits from the endeavor would be paid to

the management company, which would be owned by the

chiropractor, in exchange for the provision of management

services, leased space, and leased equipment.

    The practice model, developed by Borsody and pitched at

Dahan’s programs, included a number of safeguards to ensure

continued control of the practice by the chiropractor-manager.

First, the doctor designated as the owner of the medical

corporation would be asked to sign an undated resignation

letter.   Second, the doctor would be asked to sign an undated

“AFFIDAVIT OF NON ISSUED OR LOST CERTIFICATE,” bearing an

                                  14
unexecuted notary attestation for the doctor’s signature and the

date.   Through those two documents, the chiropractor could, if

necessary, remove the doctor from his or her position and have

it appear that the controlling interest in stock certificates

previously held by the doctor was being transferred from the

departing physician to another physician.1   Third, Borsody told

lecture participants that the leases between the management

company and the medical corporation should include a “break fee”

of $100,000 to penalize the medical practice’s doctor-owner for

breaking the lease.   That combination of measures was intended

to prevent the nominal doctor-owner of the medical corporation

from seizing control of the practice from the real investor --

the chiropractor.

     In addition to hearing Neuner’s description of the

information conveyed at the lecture on how the practice

structure was designed to operate and hearing a tape from

another Practice Perfect seminar -- described by Neuner as

“substantially” the same in its content -- the trial court also

admitted into the record a descriptive article authored by

Borsody.   Specifically, prior to the seminar attended by Neuner,

Borsody wrote at least one trade article discussing the law of

1  That “AFFIDAVIT OF NON ISSUED OR LOST CERTIFICATE” enabled the
chiropractor to maintain control and never be forced to trust
the removed doctor to actually transfer to another doctor stock
that either was never issued or purportedly was lost.
                                15
multi-disciplinary practices, including the legal requirements

for ownership.     That article, which the trial court had before

it, correctly stated that New Jersey requires a majority of the

ownership interest in a medical corporation to be owned by

medical doctors.    Borsody stated in the article that this rule

is in place because non-doctor ownership “would risk

interference with clinical decisions of [doctors] employed in

those practices.”    Addressing the contractual relationships

between practices and outside management companies, Borsody

wrote that courts have “smile[d] upon contracts which make

clearly nonprofessional services available on an arms-length

basis” and “[f]rowned upon . . . contracts that show excessive

control over the corporate activities of the [practice] (e.g.,

the right to replace the shareholder); that show control over

hiring, firing and disciplining of employed [doctors]; and that

have excessive control over financial affairs of the

[practice].”     Borsody’s article warned that concentration of

nonprofessional services in a management company, and inclusion

of those “frowned upon” contractual provisions, would be

“fraught with peril.”

                                  2.

    On March 28, 1997, after attending the Practice Perfect

seminar described above, Neuner signed a contract with Dahan to

become a client of Practice Perfect.    Neuner spoke with Borsody

                                  16
about establishing a medical corporation and management company

as had been described.     He learned that Borsody’s fee to set up

a multi-disciplinary practice would be about $9000.     When Neuner

relayed that fee information to Dahan, the latter called the fee

“outrageous” and provided Neuner with a phone number that he

could call to obtain form documents for the creation of the

necessary entities.   Neuner ultimately paid $2600 for those form

documents.   Unbeknownst to Neuner, the source of those documents

was a separate firm owned by Dahan that was reproducing and

distributing contracts previously drafted by Borsody, without

Borsody’s knowledge or permission.     Neuner used the forms to

incorporate JSM Management, a management company, and

Northfield, a medical corporation.     Neuner also consulted a New

Jersey attorney but was advised by Dahan that it was not

necessary to “reinvent the wheel” by having an attorney redraft

legal documents already included in the forms provided by

Dahan’s consulting firm.

    Neuner hired Dr. Robban A. Sica, M.D., as the initial

doctor-owner of Northfield.    Neuner had never met Dr. Sica

before Dahan referred Neuner to her.     Neuner also hired several

doctors to work at Northfield.    Those doctors held no ownership

interest in the practice.     In April 1998, due to a disagreement

between Dr. Sica and Neuner, Neuner replaced her with a new

doctor-owner.   According to the new owner, Dr. Scott David,

                                  17
D.O., he was told that he “could be like a hired CEO, [or] like

a figure head on a board, and [he] would get compensation for

that with limited time.”    Dr. David also testified that Borsody

told him that he did not need malpractice insurance because he

would not be treating patients at Northfield.

    In late 1998, Allstate, which had been receiving insurance

claims for treatment provided at Northfield, began investigating

the legality of Northfield’s practice structure and ceased

paying claims to the practice.    Neuner retained Borsody to

represent him with respect to the investigation.     On January 28,

1999, Borsody wrote to Neuner, informing him that because the

doctors hired to work at Northfield did not own stock in the

medical practice, Neuner’s employment of those doctors likely

violated existing guidance from the Board.

    As a result of its investigation, Allstate refused payment

on approximately $330,000 in claims of patients treated by

Northfield.

                                 B.

                                 1.

    Allstate filed the instant action on October 19, 1999,

against Neuner, Northfield, JSM Management, Dahan, Borsody, and

a number of additional defendants.     The matter has a tortuous

procedural history, and not all of its details are relevant to

the issue in this appeal.   However, we note that Neuner settled

                                  18
with Allstate early in the proceedings, in part in exchange for

his agreement to testify against his co-defendants.   For present

purposes, the salient charges of the complaint allege that

Borsody and Dahan violated the IFPA by knowingly assisting

Neuner in the creation and operation of a multi-disciplinary

practice whose insurance claims were fraudulent under the IFPA.

Allstate’s theory of the case relies not on any false claim

submitted by Neuner’s practice, but on the practice’s failure to

comply with governing standards on the corporate practice of

medicine, a necessary precondition to a valid insurance claim.

                               2.

    At the bench trial, Neuner and others testified to the

facts already described about the lectures, the roles that

Borsody and Dahan played in the establishment and structure of

the Northfield practice, and the respective roles of the various

parties.   Borsody also testified about his knowledge of relevant

legal restrictions concerning multi-disciplinary practices,

which testimony deserves separate attention.

    Borsody described the information he conveyed in his

lectures at Practice Perfect seminars.   He stated that he

covered “the legal aspect of the multi-disciplinary structures,”

including the decision in Finley and a case from Texas that he

deemed relevant.   Specifically, Borsody referenced Flynn Bros.,

Inc. v. First Medical Associates, 715 S.W.2d 782 (Tex. App.

                                19
1986), which involved the issue of whether, as a result of a

management company’s inappropriate influence over a medical

practice, the management company effectively engaged in the

unlicensed practice of medicine.2

     Borsody acknowledged in his testimony that he was familiar

with the Earle I letter and had considered it when developing

the material covered in the lectures.   He described the lectures

as covering the corporate-practice-of-medicine doctrine,

including its application in New Jersey, although he stated that

he did not discuss N.J.A.C. 13:35-6.16 specifically.

     In his testimony, Borsody explained that he developed the

practice model after a previous experience in which chiropractor

clients of his lost their investment in a multi-disciplinary

practice because the doctor they were working with “walked off

with the practice.”   Accordingly, the model Borsody developed to

prevent that from happening again relied on terms in the

equipment lease, property lease, and management contract between

the medical corporation and the management company, which

2  The opinion in Flynn Bros., supra, explains that under Texas
law, “when a corporation comprised of lay persons employs
licensed physicians to treat patients and the corporation
receives the fee, the corporation is unlawfully engaged in the
practice of medicine.” 715 S.W.2d at 785. Although the doctor
in that case was not an employee under the management agreement,
the court found that “the practical effect was the same” because
the contractual arrangements between the doctor’s practice and
the management company “[were] developed to do indirectly that
which [the company’s owners] freely concede[d] they could not do
directly under the Medical Practices Act.” Ibid.
                                20
“[made] it look as tough as possible” for the designated medical

director to take control of the practice.   Those provisions,

which were implemented in Northfield’s governing documents,

included a security interest held by the management company in

all of the medical corporation’s assets and a $100,000

termination penalty should the medical corporation breach its

lease.

     Borsody asserted that he believed his model was lawful

based on his reading of Finley and the laws of various states

where he advocated that model.   He testified that, during the

period at issue, “most states” required “the medical practice

[to be] under the supervision and control of a licensed medical

doctor” and “every State, including New Jersey, prohibited

chiropractors from employing medical doctors.”   However, he

testified that he thought that vesting “bare legal title” of the

medical practice in a medical doctor was sufficient to comply

with those prohibitions.   According to Borsody, it was not clear

that medical practices using his model might violate New Jersey

law until the Law Division issued its decision in Allstate

Insurance Co. v. Schick, 328 N.J. Super. 611 (Law Div. 1999).3

Borsody also emphasized that he advised Practice Perfect

3  Schick, supra, held that medical corporations violate the IFPA
if they submit claims to insurers while under the “dominion and
control” of non-physicians. 328 N.J. Super. at 628.
                                21
attendees to retain local counsel who could confirm that his

model complied with local law.

    In addition to hearing testimony from Borsody, as well as

Dahan, the court heard from a number of experts on the

healthcare laws at issue.

                                 C.

    Based on the record presented, the trial court found that

Borsody and Dahan violated the IFPA when they “knowingly

assisted, conspired with and urged Neuner to operate in a

fashion that violated the law.”       The trial judge rejected

defendants’ argument that, because the law was unclear prior to

the Law Division’s decision in Schick, the evidence did not

establish a knowing violation of the Act.       In doing so, the

court made combined conclusions of law and findings of fact that

were, in part, credibility-based.

    The judge observed that both Flynn Bros. and the Earle I

letter, each of which Borsody was admittedly familiar with,

established “the clear proposition that subterfuge in developing

medical practices is untenable.”       The court focused on the facts

showing that a chiropractor was really in control of this

medical practice, although on paper there was a trail suggesting

otherwise.   Despite Borsody’s claimed lack of knowledge of a

violation of regulatory requirements, or that a regulatory

misstep would provide a platform for a finding of an IFPA

                                  22
violation for assisting another to submit fraudulently

ineligible medical claims, the trial court found the evidence

otherwise.    In a Statement of Reasons, the trial court set forth

the essence of its determination:

            Borsody and Dahan promoted what they knew was
            essentially a lie.    The business model they
            promoted was intended to appear to be one way
            and yet, in reality, be another way.      They
            both were motivated to provide to the
            chiropractor the ability to manage a practice
            which included medical doctors.     Dahan knew
            that a chiropractor could not own a majority
            interest of a multi-disciplinary practice
            since   his    California    corporation   was
            established so that he was a minority
            shareholder himself. Borsody knew that he was
            placing in the hands of the chiropractor the
            control that was lacking in his first
            experience in New York. The simple fact that
            the practice was intended to look as though a
            medical doctor was in control yet, with
            various   side   agreements,    he   was  not,
            constitutes a sufficient basis for the Court
            to conclude that Borsody knew what he was
            doing was not proper.

    The trial judge rejected defendants’ claimed reliance on

the Deputy Attorney General’s guidance letter, issued after

Northfield was established, and found that, at best, defendants

had exhibited “willful blindness” to the illegality of the model

at issue.

    In an unpublished opinion, the Appellate Division reversed

the trial court’s judgment based on the panel’s conclusion that

the evidence did not support a finding that defendants knowingly

violated the IFPA.    The panel noted that in his lectures Borsody

                                 23
discussed the requirement that only a medical doctor was

permitted to own the majority share of a medical corporation and

that, in light of the existing case law and informal guidance,

Borsody had a basis to believe his model was lawful.4    The

Appellate Division found it relevant that the practice model

“was similar to others used in business between corporations to

enable the exercise of economic control.”   Expanding its

discussion to Dahan, and noting that the IFPA does not define

“knowing,” the Appellate Division concluded that “[t]here is not

sufficient evidence that New Jersey law at the time was settled

enough to hold [him] responsible for knowing that the corporate

structure he was advocating was illegal.”

     We granted Allstate’s petition for certification.      223 N.J.
555 (2015).   Amicus curiae status was granted to the Medical

Society of New Jersey, the American Medical Association, and the

New Jersey Dental Association.

                                 III.

                                  A.

     In relevant part, the IFPA provides as follows:

          a. A person or a practitioner violates this
          act if he:

               (1) Presents or causes to be
               presented any written or oral

4  Like the trial court, the Appellate Division correctly placed
no stock in defendants’ arguments based on the letter-opinion
issued by the Deputy Attorney General after the incorporation of
Northfield.
                                24
              statement as part of, or in support
              of or opposition to, a claim for
              payment or other benefit pursuant to
              an   insurance    policy    or   the
              “Unsatisfied Claim and Judgment
              Fund Law,” P.L.1952, c. 174 (C.39:6-
              61 et seq.), knowing that the
              statement contains any false or
              misleading information concerning
              any fact or thing material to the
              claim; or

              (2) Prepares or makes any written or
              oral statement that is intended to
              be presented to any insurance
              company, the Unsatisfied Claim and
              Judgment Fund or any claimant
              thereof in connection with, or in
              support of or opposition to any
              claim for payment or other benefit
              pursuant to an insurance policy or
              the “Unsatisfied Claim and Judgment
              Fund Law,” P.L.1952, c. 174 (C.39:6-
              61 et seq.), knowing that the
              statement contains any false or
              misleading information concerning
              any fact or thing material to the
              claim; or

              (3) Conceals or knowingly fails to
              disclose the occurrence of an event
              which affects any person’s initial
              or continued right or entitlement to
              (a) any insurance benefit or payment
              or (b) the amount of any benefit or
              payment to which the person is
              entitled.

         [N.J.S.A. 17:33A-4(a)(1)-(3) (emphases
         added).]

    N.J.S.A. 17:33A-4(b) further instructs that “[a] person or

practitioner violates this act if he knowingly assists,

conspires with, or urges any person or practitioner to violate

any of the provisions of this act.”   Furthermore, N.J.S.A.
                               25
17:33A-4(c) provides that “[a] person or practitioner violates

this act if, due to the assistance, conspiracy or urging of any

person or practitioner, he knowingly benefits, directly or

indirectly, from the proceeds derived from a violation of this

act.”

    In pertinent part, defendants were found to have knowingly

assisted or conspired with Neuner in violating the IFPA under

N.J.S.A. 17:33A-4(b) by promoting and helping Neuner with the

construction of an impermissible professional practice structure

that enabled the chiropractor to benefit from proceeds derived

from his submission of medical claims for reimbursement, in

violation of the act, N.J.S.A. 17:33A-4(a), (c).   Proof of such

violation need only be found to exist based on a preponderance

of the evidence.   See Liberty Mut. Ins. Co. v. Land, 186 N.J.
163, 174-75 (2006) (holding that “the proper standard of proof

is a preponderance of the evidence” as opposed to “clear and

convincing evidence”).

                                B.

    The parties’ disagreement before this Court centers on the

standard for a knowing violation under the IFPA and its

application in this instance.

                                1.

    Allstate focuses on the error it perceives in the standard

applied by the Appellate Division, which hinged on whether there

                                 26
was any dispositive case or interpretive guide to instruct

defendants that (1) the practice structure involved here

contravened medical practice requirements or restrictions, and

(2) the regulatory failing would provide a basis to support a

knowing IFPA violation for promoting and assisting in the

construction of such an impermissible practice used to submit

medical insurance claims.

    Allstate maintains that the trial court had sufficient

evidence to support the finding of a knowing violation of the

IFPA.   It urges application of a plain-meaning understanding of

the term “knowing” using the concept of awareness of illegality,

taking into account the reasonableness of the basis for

defendants’ claimed lack of knowledge of illegality.

    Allstate argues that the trial court had ample evidence

from which to infer defendants’ knowledge that their practice

model, denoted by Allstate as the “Doc-in-the-Box” model,

violated the permissible medical practice requirements in New

Jersey as those standards were stated in regulation and

explained by regulatory agents, in particular through the Earle

I letter-opinion.   Moreover, Allstate points to the trial

court’s reliance on defendants’ efforts to conceal the real

impact of the chiropractor-owner’s control over the medical

practice in theory and in reality through the interconnected

                                27
management and other contracts and agreements, supporting a

knowing violation of the IFPA.

     In rebutting defendants’ arguments, Allstate argues that

although Schick “was the first case to hold expressly that

[d]efendants’ sham Doc-in-the-Box scheme was illegal in New

Jersey,” nothing in that opinion “suggest[ed] that the [issue]

was a difficult or even a close call.”5   Schick involved many of

the same players involved in this action, but Allstate claims

that defendants do not get a free pass until the Schick court

declared them to have engaged in an illegal practice scheme.    In

a similar vein, Allstate points to Varano, Damian & Finkel,

L.L.C. v. Allstate Ins. Co., 366 N.J. Super. 1 (App. Div. 2004),

as further demonstrating that the illegality of defendants’

“Doc-in-the-Box” scheme was not a close question.   As in Schick,

the Varano matter involved Dr. Sica as the “nominal” owner of a

medical practice, Ramsey Medical, which, like Northfield, was

5  Allstate would have us note that the Schick matter involved
similar facts to the present case: (1) Dr. Sica was the nominal
owner of five of the “sham medical centers”; (2) Dr. Sica signed
“undated resignation letters and stock assignments”; and (3) the
Schick “[d]efendants used management companies and service
agreements similar to those used by Neuner . . . to control the
hiring of physicians and to extract all of the profits from the
medical centers.” As Allstate notes in its briefing to this
Court, the Schick court concluded that “[i]t would be difficult
to conceive of a network of healthcare and management facilities
better designed to facilitate the funneling of PIP benefits into
the hands of non-licensees than the complex enterprises devised
and operated by the defendants herein” (quoting Schick, supra,
328 N.J. Super. at 621).
                                28
controlled by a chiropractor through the use of a management

company and service contract.   Allstate contends that the

Appellate Division readily found the practice structure in

Varano illegal.   Allstate relies on language in Varano that

“[i]t [was] apparent from even a cursory review of Allstate’s

allegations and the relevant case law that plaintiffs’ conduct,

as portrayed by Allstate, constituted a serious breach of law

and policy.”   Varano, supra, 366 N.J. Super. at 8.   According to

Allstate, “[t]he fact that the Schick and Varano decisions were

not handed down until after the Practice Perfect Seminar

[attended by Neuner] cannot override the obvious fact that the

corporate structure advocated by Borsody and Dahan relied on

subterfuge.”

                                2.

    As defendants see it, the Appellate Division rightfully

expressed concern that an ordinary-meaning definition of

“knowing” -- one that considers whether defendants were “aware

of” or “had knowledge” of the illegality of their actions --

might not establish, through proof by a preponderance of the

evidence, a knowing violation of the IFPA under N.J.S.A. 17:33A-

4(b) and (c), where the alleged violators made no direct

submission to the insurer themselves.   Defendants stress that

violation of the IFPA would require their knowledge both of the

illegality of the practice structure they are charged with

                                 29
promoting and assisting Neuner in establishing and that

promotion and assistance with that non-compliant medical

practice would lead to an IFPA violation based on the practice’s

submission of insurance claims.

    Although the panel stated that it did not adopt the

Criminal Code definition of “knowing” found in N.J.S.A. 2C:2-

2(b)(2), which defendants had urged before the panel,

defendants’ argument before us in essence continues to rely on

the meaning of “knowing” in the Criminal Code.   Defendants argue

that a demonstration of actual knowledge or awareness of

illegality is the level of knowledge that should be necessary

under an ordinary-meaning application of “knowing” in this

context.   In the alternative, defendants contend that under the

Criminal Code’s requirement in N.J.S.A. 2C:2-2(b)(2), a

defendant must be shown to have (a) acted “knowingly with

respect to the nature of his conduct or the attendant

circumstances,” and (b) acted “knowingly with respect to a

result of his conduct,” requiring proof that he was “aware that

it is practically certain that his conduct will cause such a

result.”   Defendant Borsody, in particular, contends that

Allstate could not show that his conduct was practically certain

to cause Neuner and Northfield to file false or misleading

claims, or that he was practically certain at the time of his

                                  30
conduct that the false or misleading information in those claims

would be material to an insurer such as Allstate.

    Defendants now ask this Court to endorse the standard that

the panel utilized, which would require Allstate’s proofs to

establish that Borsody and Dahan had to know, from dispositive

case law or other binding interpretive action, that the practice

model defendants devised and promoted for use by Neuner violated

New Jersey statute or regulation.    According to the panel, that

standard was not met in this matter.    The panel also rejected

willful blindness as an acceptable standard for a knowing

violation when the violation involves the interpretation of a

statutory or regulatory requirement.

    In urging this Court to affirm the proof standard applied

by the Appellate Division, defendants assert that, until the

definitive 1999 decision in Schick declared the practice

structure at issue to be in violation of law, defendants could

not, and should not, be held to have knowingly violated the

IFPA.   Further, defendants maintain that, until Allstate

Insurance Co. v. Orthopedic Evaluations, Inc., 300 N.J. Super.
510 (App. Div. 1997), no defendant would have known that a mere

violation of regulatory restrictions applicable to the business

structure of a medical practice could render invalid and

ineligible a medical-service insurance claim, and thus place at

                                31
risk the third party who assisted in the promotion and

construction of that form of medical practice.

    Amicus New Jersey Dental Association urges the Court to

import the Legislature’s definition of “knowing” from New

Jersey’s False Claims Act, N.J.S.A. 2A:32C-1 to -15, -17 to -18,

or, alternatively, to apply the Criminal Code definition.   The

remaining amici argue against application of the False Claims

Act definition and emphasize that a plain-language understanding

of “knowing” does not include concepts of recklessness or

constructive knowledge.

                              IV.

                               A.

    The standards we apply in reviewing the findings and

conclusions of a trial court following a bench trial are well-

established:

         [W]e give deference to the trial court that
         heard the witnesses, sifted the competing
         evidence, and made reasoned conclusions. See
         Rova Farms Resort v. Investors Ins. Co., 65
N.J. 474, 483-84 (1974). Reviewing appellate
         courts should “not disturb the factual
         findings and legal conclusions of the trial
         judge” unless convinced that those findings
         and    conclusions   were    “so    manifestly
         unsupported by or inconsistent with the
         competent, relevant and reasonably credible
         evidence as to offend the interests of
         justice.” Id. at 484 (citation and internal
         quotation marks omitted); see, e.g., Seidman
         v. Clifton Sav. Bank, 205 N.J. 150, 169 (2011)
         (same).

                               32
         [Griepenburg v. Township of Ocean, 220 N.J.
239, 254 (2015); see also H.S.P. v. J.K., 223
N.J. 196, 215 (2015).]

Questions of law receive de novo review.      Manalapan Realty, L.P.

v. Twp. Comm. of Manalapan, 140 N.J. 366, 378 (1995).

                                  B.

    In this matter, we are called on to assess the trial

court’s application of a “knowing” standard that is required for

a violation of the IFPA, specifically N.J.S.A. 17:33A-4(b)

(instructing that “[a] person or practitioner violates this act

if he knowingly assists, conspires with, or urges any person or

practitioner to violate any of the provisions of this act”); see

also N.J.S.A. 17:33A-4(a), (c).

    This is not a criminal case.       And, the Legislature did not

incorporate the criminal definition of a “knowing” mens rea in

its adoption of a knowing violation for IFPA civil liability, as

is applicable in criminal insurance fraud prosecutions.      See

N.J.S.A. 2C:21-4.6.     The trial court rightly did not import

aspects of a “knowing” mens rea from the Criminal Code into the

civil liability section of the IFPA at issue.      Rather, the court

correctly applied a plain-language understanding of “knowing” as

a term of normal language usage for the Legislature to have

employed in the IFPA.     There is no need for contortions in

understanding the word.     “Knowing” is well understood to be an

awareness or knowledge of the illegality of one’s act.      See

                                  33
Knowing, Black’s Law Dictionary 950 (9th ed. 2009) (“[h]aving or

showing awareness or understanding; well-informed”).    That

knowledge need not come from a prior decision holding that the

precise conduct at issue gives rise to a violation of a legal

requirement.

    There is ample precedent supporting the proposition that a

party’s knowledge as to the falsity or illegality of his conduct

may be inferred from the surrounding factual circumstances.

This Court has held, in a prosecution for false swearing, that

proof that a defendant’s statement was knowingly false “need not

be met by direct evidence.   The intent may be inferred from the

circumstances surrounding the occurrence, the defendant’s

demeanor, his intellect, etc.”    State v. Haines, 18 N.J. 550,

562 (1955) (applying N.J.S.A. 2A:131-6 (repealed 1978) (current

version at N.J.S.A. 2C:28-2)).    “[A]s has oftentimes been

stated, circumstantial evidence is not only sufficient but may

also be ‘more certain, satisfying and persuasive than direct

evidence.’”    State v. Goodman, 9 N.J. 569, 581 (1952) (quoting

State v. O’Connor, 134 N.J.L. 536, 539 (Sup. Ct. 1946)).

    “Inferring mental state from circumstantial evidence is

among the chief tasks of factfinders.”    United States v. Wright,

665 F.3d 560, 569 (3d Cir. 2012) (explaining that jury may

permissibly rely on circumstantial evidence to reach verdict on

federal conspiracy and fraud charges); see also United States v.

                                 34
Brodie, 403 F.3d 123, 147 (3d Cir. 2005) (“A jury may infer a

willful violation of a known legal obligation from the facts and

circumstances surrounding the case.”).   In the criminal context,

the prosecution “can prove the requisite mental state through

either direct evidence or circumstantial evidence.”    McFadden v.

United States, 576 U.S. ___, 135 S. Ct. 2298, 2304 n.1, 192 L.

Ed. 2d 260, 269 n.1 (2015).   In a civil action under the IFPA,

no less than in a criminal trial, the defendant’s knowledge of a

violation may be proven by circumstantial evidence.

    With that standard in mind, we turn to defendants’ argument

that knowledge in this instance could come only from a prior

decision that would have, or should have, informed defendants of

the certainty of the illegality of their practice model.   And,

further, we address the argument that defendants similarly

required a definitive holding that would have informed them that

a regulatory business-practice requirement, relating to

permissible practice models, could provide the platform from

which a knowing violation of the IFPA could emanate.    We address

the latter first.

                              V.

                              A.

    Defendants claim that, even if their practice model

violated the Board’s regulations governing the permissible

business structures for the organization of a medical practice,

                                35
defendants could not have knowingly violated the IFPA because it

was not clear at the time that compliance with those practice-

structure regulations was “material” to insurance claims

submissions.   See N.J.S.A. 17:33A-4.   Defendants seemingly

concede that the Appellate Division’s May 1997 decision in

Orthopedic Evaluations, Inc., supra, 300 N.J. Super. at 516-17,

at about the time that Northfield was being incorporated, was

the earliest point at which practitioners could have known that

the Board’s regulatory provisions are material for purposes of

insurance coverage.

    We do not accept the proposition that, prior to Orthopedic

Evaluations, Inc., a reasonable actor would not have known that

compliance with the regulatory provisions governing the

organization, supervision, and control of a medical practice was

material to an insurance submission by that medical practice.

Addressing coverage under the Automobile Reparation Reform Act,

N.J.S.A. 39:6A-1 to -35, the appellate panel in Orthopedic

Evaluations, Inc., supra, observed that “[a] fair reading of the

Act . . . requires the conclusion that any healthcare service

authorized by the Act, in order to be eligible for recognition,

must also comply with any other significant qualifying

requirements of law that bear upon rendition of the service.”
300 N.J. Super. at 516.   As a matter of public policy, “[t]he

law should accord no recognition to such entities and operations

                                36
which place the public at risk by failing to provide the

professional supervision and control deemed essential by the

Board.”   Id. at 517.   See also Varano, supra, 366 N.J. Super. at

6 (same); Prudential Prop. & Cas. Ins. Co. v. Midlantic Motion

X-Ray, Inc., 325 N.J. Super. 54, 60 (Law Div. 1999) (“The

failure of a [healthcare] provider or service to adhere to

[N.J.A.C. 13:35-2.5(b)], or any other significant state statute

or agency regulation, renders that provider or service

ineligible for reimbursement under [N.J.S.A. 39:6A-1 to -35].”).

The theory of all those cases reflects that in New Jersey a

practice entity must comply with all statutes and regulations

governing the permissible structures for control, ownership, and

direction of a medical practice, including the use of

professional services interconnected with a medical practice.

    Health care services are highly regulated, and

professionals engaged in the provision of health care --

including persons such as defendants, who undertook to

facilitate that activity -- are on notice of the legal

requirements applicable to their practice and operations.

Material Damage Adjustment Corp. v. Open MRI of Fairview, 352
N.J. Super. 216, 227 (Law Div. 2002).   We do not deal here with

an honest mistake made in the course of completing a

reimbursement form submitted to an insurer.   This case goes to

the basic structure of a practice and how it is owned,

                                 37
controlled, and directed.   Those concerns go to the core of who

may practice medicine in this State.   The practice of medicine

is a privilege to be exercised in accordance with all licensing

and practice requirements and restrictions.   One cannot claim,

or feign, ignorance of those regulatory requirements and

restrictions until there is an express command applicable to a

precise set of facts.

    Accordingly, we turn next to the regulatory requirements in

place governing the lawful structures for medical practices when

Borsody and Dahan promoted their practice model and the manner

in which their model was constructed to work on paper and in

practice.

                                B.

    As previously discussed, N.J.A.C. 13:35-6.16 establishes

the proper structure of a medical practice and incorporates the

manner in which the corporate practice of medicine may be

employed.   See N.J.A.C. 13:35-6.16(f)(1)-(3).   Subsection (f)(3)

defines employment as “an ongoing associational relationship

between a licensee and professional practitioner(s) or entity on

the professional practice premises for the provision of

professional services, whether the licensee is denominated as an

employee or independent contractor, for any form of

remuneration.”   In adopting section 6.16 in 1992, the Board

explained that subsection (f)(3) bars “a licensee with a more

                                38
limited scope of practice -- however competent within the scope

of license -- [from] professionally supervis[ing] the quality of

work of a plenary licensee.”    24 N.J.R. 626, 630 (1992).

N.J.A.C. 13:35-6.16(f)(3)(i) states simply and without ambiguity

that a practitioner with a plenary license “shall not be

employed by a practitioner with a limited scope of license.”

    Although N.J.A.C. 13:35-6.16 allows for a solo practice as

well as a partnership or professional association, employment is

broadly defined to include even an ongoing associational

relationship between a licensee and a professional practitioner

or entity on the professional practice premises for the

provision of professional services, regardless of whether the

plenary licensee is labelled an employee or independent

contractor.   Within the breadth of the concept of “employment,”

the regulation reinforces the theme of maintaining professional

discretion in form and substance, depriving anyone or any

corporate entity of the opportunity to control or attempt to

exert control over the exercise of professional discretion by a

plenary licensee.   See ibid.   That protection against control

over the plenary licensee is brought about through the clear

prohibitions expressed through the concept of employment in the

regulation.   In addition, the Earle I opinion also clearly

states the same.

                                 39
    In answering the question put to the Board, the Earle I

letter addresses many ways in which the formal design of a

corporate medical practice would have an impermissible corrosive

effect on the professional discretion expected to be exercised

by the plenary licensee.    The guidance informs that the formal

design of the relationship is not dispositive of whether there

is the risk of inappropriate encroachment on a plenary

licensee’s discretion.     The letter states expressly, “[w]hile we

recognize that it is nominally the Professional Association

which is the ‘employer’ rather than the chiropractor, for our

purposes that would be a distinction without a difference.”     The

thrust of the entire Earle I letter makes plain that the Board

would allow no subterfuge to shield the existence of a real or

potential corrupting influence that could be exercised by a

management company or by a professional association where a

licensee with a lesser scope of practice, like a chiropractor,

could actually wield control over the practice of medicine by a

plenary licensee.

                                 C.

    Based on the regulations in effect at the time and the

testimony at trial, the trial court here could reasonably

conclude that Borsody, as well as Dahan, knew of the regulatory

requirements at issue, promoted a practice scheme specifically

designed to circumvent those requirements while appearing

                                  40
compliant, and therefore knowingly assisted in the provision of

services, the foreseeable result of which was the submission of

invalid and misleading claims under the IFPA.

    Based on the plain language of the regulation and the

clarity of expression in the guidance of Earle I, we find no

basis for crediting the argument that defendants could not have

known that their structure violated the Board’s regulatory

requirements.   The documents and structure promoted and designed

by defendants accomplished what the regulations sought to avoid.

They placed control over the medical practice in the hands of a

chiropractor, subjecting plenary licensees to his effective

control through interconnected contracts and the imposition of

the threat of substantial monetary penalties.   Importantly, the

plan sought to conceal those features to appear compliant.

    The scheme vested bare legal title in a physician.

However, the physician, besides being subject to direction and

financial control by a chiropractor-owner of a management

company, in reality was a stranger to the medical practice and

was not operationally in control, having been demonstrated to

have “sold” her license to multiple practices utilizing the so-

called “Doc-in-the-Box” structure in New Jersey and many other

states.   In fact, she was recommended to Neuner for use as the

nominal medical owner of Northfield.   And, when she and Neuner

had a disagreement, the veneer of her “control” over the

                                41
practice was shattered.    The chiropractor exercised his ability

to utilize her previously required, undated resignation form and

affidavit of non-issued or lost certificate to make it appear

that she voluntarily transferred her “ownership” in Northfield

to the next medical doctor, who was selected by Neuner to own

the medical practice.

    That structure was found by the trial court to have

violated the requirements governing ownership, control, and

direction of a medical practice.      The trial court reached its

conclusions based on those harsh facts, having heard the

witnesses and examined the structure of this practice design,

formulated in such a way as to make it appear that a medical

doctor was “in charge” of the Northfield practice.

    Clearly, with the 1999 decision in Schick, supra, the

practice structure at issue here was first held to constitute

both a violation of N.J.A.C. 13:35-6.16’s form-of-practice

requirements and a potential avenue for finding an IFPA

violation. 328 N.J. Super. at 621.     As noted in the parties’

arguments, following that decision, other courts have reasoned

similarly.   See, e.g., Varano, supra, 366 N.J. Super. at 6 (“A

provider in violation of N.J.A.C. 13:35-6.16 is not eligible to

receive PIP benefits.”).   That said, we reject the contention

that the Schick decision was required to have been issued in

order to render the practice structure here incompatible with

                                 42
regulatory requirements and to provide a platform for a

conclusion that a knowing IFPA violation could be proved under

N.J.S.A. 17:33A-4(b).

    Here, there was an abundance of proof that the contracts

and penalties -- imposed on the doctor named as nominal owner in

title of this practice -- placed control of the medical practice

in the hands of a chiropractor.    That clearly supported finding

is not overcome by any form-over-substance argument based on the

placement of bare legal title in the plenary licensee who

participated in this scheme.   The trial court demonstrated

clarity of vision in recognizing that this medical practice

structure violated both the letter and spirit of the Board’s

rule.

    Moreover, the lengths that defendants went to in shielding

the true controller of this practice from view undermine any

basis for interfering with the trial court’s assessment of the

mixed question of fact and law that was presented to the court.

It is apparent to us, as a reviewing court, that the fact-finder

was also incorporating credibility findings in assessing the

reasonableness of the scheme defendants were seeking to defend

in this IFPA matter.    We extend a wide berth of deference to the

fact-finder in such matters.   Considering all of the

circumstances involved in defendants’ interactions with Neuner,

the trial court could reasonably conclude that defendants

                                  43
knowingly assisted Neuner in violating the Board’s rules and

submitting ineligible and fraudulent medical claims for

reimbursement through that practice structure, contrary to law.

    In conclusion, knowledge or a “knowing” state of mind for

purposes of a statutory civil violation under the IFPA may be

inferred here.   We find ample evidence to support the trial

court’s finding of the existence of an IFPA violation on this

record.

                                VI.

    The judgment of the Appellate Division is reversed, and the

case is remanded for proceedings consistent with this opinion.

     CHIEF JUSTICE RABNER and JUSTICES PATTERSON, FERNANDEZ-VINA,
SOLOMON, and TIMPONE join in JUSTICE LaVECCHIA’s opinion. JUSTICE
ALBIN did not participate.

                                44