Court Opinion

ID: 9398512
Source: CourtListenerOpinion
Date Created: 2023-05-31 16:01:52.067931+00
Date Added: 2024-06-11T17:19:34.154078
License: Public Domain

USCA11 Case: 21-10461    Document: 74-1      Date Filed: 05/31/2023   Page: 1 of 28

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

                           ____________________

                                 No. 21-10461
                           ____________________

        UNITED STATES OF AMERICA,
                                                       Plaintiﬀ-Appellee,
        versus
        CARLOS ALFREDO VERDEZA,

                                                   Defendant- Appellant.

                           ____________________

                  Appeal from the United States District Court
                      for the Southern District of Florida
                     D.C. Docket No. 1:19-cr-20470-JEM-1
                           ____________________
USCA11 Case: 21-10461     Document: 74-1     Date Filed: 05/31/2023    Page: 2 of 28

        2                     Opinion of the Court                21-10461

        Before WILLIAM PRYOR, Chief Judge, and ROSENBAUM and MARCUS,
        Circuit Judges.
        ROSENBAUM, Circuit Judge:
              For over a year, physician assistant Carlos Verdeza evalu-
        ated patients and prescribed them physical therapy. The clinics
        where Verdeza worked then billed the patients’ health insurance
        both for the evaluations and for the subsequent physical therapy.
        The problem—for Verdeza and for the health-insurance com-
        pany—was that the “patients” didn’t really need the physical ther-
        apy and didn’t actually receive any treatment. When the health-
        insurance company grew suspicious of the abnormally high rate of
        physical-therapy prescriptions from the clinics, it cooperated with
        an FBI investigation into the clinics.
               That investigation led a grand jury to indict Verdeza on
        eight healthcare-fraud-related charges. After a trial, a jury con-
        victed Verdeza on three counts. Now on appeal, Verdeza raises
        several challenges to his conviction—sufficiency, evidentiary, and
        instructional—and to his sentence. After a thorough review of the
        record and with the benefit of oral argument, we affirm.

                             I. BACKGROUND
                              A. Factual History
             In November 2016, Carlos Verdeza, a physician assistant, be-
        gan working at two clinics in the South Florida area: Guerra
USCA11 Case: 21-10461         Document: 74-1         Date Filed: 05/31/2023         Page: 3 of 28

        21-10461                   Opinion of the Court                                3

        Medical Center and Double R Therapy Center. 1 Neither clinic was
        a real healthcare facility. Rather, both were fronts for fraud. The
        clinics—run by the same ownership group—used recruiters to ﬁnd
        and entice people with Blue Cross Blue Shield (“BCBS”) health in-
        surance to come to the clinics. To persuade people to be “patients,”
        the clinics paid them kickbacks.
               When the “patients” arrive[d] for their “treatment,” Verdeza
        would brieﬂy see them, perform no (or very little) examination,
        and prescribe physical therapy. For instance, in one instance,
        Verdeza asked the “patient” only two questions before prescribing
        physical therapy. The “patients” didn’t return to the clinic and gen-
        erally didn’t receive physical therapy. Yet at the clinic, “patients”
        signed dozens of forms attesting that they had received treatment.
        Because one evaluation justiﬁed only a limited number of treat-
        ments, Verdeza often signed two or three forms falsely stating that
        he had “reevaluated” the “patients” and that they needed more
        physical therapy—even though he never saw the “patients” again.
               Between November 2016 and January 2018, Guerra and
        Double R billed BCBS for $3.4 million and received around $1.2
        million in reimbursement. But eventually, BCBS grew suspicious.
        It noticed that Guerra and Double R billed for a lot more physical

        1 We take these facts from the evidence presented at trial, viewed in the light
        most favorable to the verdict. See United States v. Takhalov, 838 F.3d 1168, 1169
        (11th Cir. 2016).
USCA11 Case: 21-10461       Document: 74-1      Date Filed: 05/31/2023      Page: 4 of 28

        4                       Opinion of the Court                  21-10461

        therapy (and more expensive physical therapy) than did peer clin-
        ics.
              So BCBS asked for supporting documentation. The clinics
        submitted “cookie cutter” forms—that is, they “used the same in-
        formation over and over again.” So BCBS denied the claims.
               Separately and coincidentally, the FBI learned of the clinics’
        existence through its biller, Rafael Izquierdo. As it turned out,
        Izquierdo had been arrested and agreed to cooperate in a diﬀerent
        healthcare fraud investigation.
                               B. Procedural History
               The United States indicted Verdeza on eight counts of
        healthcare fraud. Count I charged conspiracy to commit
        healthcare fraud and wire fraud, in violation of 18 U.S.C. § 1349,
        and Counts II through VIII alleged substantive healthcare fraud
        linked to particular claims for reimbursement, in violation of
        § 1347. Counts II, V, and VII were for fraudulent claims for reim-
        bursement submitted for treating “patients” E.G., N.T., and S.B, re-
        spectively.
                                        1. Trial
                Verdeza’s case proceeded to a six-day jury trial. In its case in
        chief, the government—without objection—used the FBI case
        agent to summarize the scheme. The agent explained that recruit-
        ers found and paid “patients” with BCBS insurance to go to the
        clinics and sign undated forms indicating that they had received
        physical therapy. A co-conspirator then ensured the forms matched
        the bills that the clinics eventually submitted. The FBI case agent
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023     Page: 5 of 28

        21-10461               Opinion of the Court                         5

        also mentioned other members of the conspiracy who hadn’t yet
        testiﬁed (and some who never testiﬁed), like the clinic’s owners and
        the physician who nominally “supervised” Verdeza. Besides this,
        the government introduced patient ﬁles from ﬁve of the six “pa-
        tients” mentioned in the indictment.
                During the FBI case agent’s testimony, the government
        sought to introduce Exhibit 22, which had four subparts. Verdeza
        didn’t contest the admission of Exhibit 22A or Exhibit 22B. Exhibit
        22A was a Final Order from the Florida Board of Medicine accept-
        ing a settlement agreement with Verdeza in 2006. Exhibit 22B was
        a settlement agreement in which Verdeza both admitted to the
        facts alleged in an administrative complaint ﬁled against his medical
        license and agreed to pay restitution and perform community ser-
        vice.
              But Verdeza objected to the admission of Exhibit 22C and
        Exhibit 22D as unnoticed Rule 404(b) evidence. Exhibit 22C was
        the administrative complaint that resulted in the 2006 Final Order.
        That administrative complaint alleged that Verdeza had signed
        evaluation forms for patients he didn’t actually see or treat. Exhibit
        22D was the corresponding investigative report. In Verdeza’s view,
        the evidence was unnoticed Rule 404(b) evidence because, even
        though the government had previously provided him with the
        complaint and report, it hadn’t told him it planned to introduce the
        documents at trial. The district court overruled the objection and
        admitted the administrative complaint and investigative report into
        evidence.
USCA11 Case: 21-10461       Document: 74-1       Date Filed: 05/31/2023      Page: 6 of 28

        6                       Opinion of the Court                    21-10461

               The government also introduced testimony from Verdeza’s
        alleged co-conspirators. For instance, Hernandez testiﬁed that she
        helped ensure that the “patients” treatment records matched the
        billing (as the billing records were created ﬁrst). Hernandez ﬁrst
        met Verdeza at a separate clinic named Culumbia. She vouched for
        Verdeza with the owners of Guerra and Double R because she
        knew that Verdeza would engage in fraud and “could do the paper-
        work in a much better fashion.” While at the clinics, Hernandez
        met with Verdeza several times a week to ﬁll in information on pa-
        tient charts to match what the clinic’s biller had decided to charge.
        Hernandez later opened her own medical clinic—named Es-
        meralda—to commit fraud. She hired Verdeza to do the same
        thing for her—“examine” “patients” and prescribe them physical
        therapy.
               Along the same lines, Jesus Kenny Rosario, one of the clin-
        ics’ owners, testiﬁed that he’d hired Verdeza—on Hernandez’s rec-
        ommendation—because Verdeza would “be willing to kind of
        work with” the fraudsters. For example, at one point, a physical
        therapist demanded to see the “patients” every visit, and Verdeza
        complained to Rosario that “the [physical therapist] should kind of
        know what this business entails and he should be okay with it as
        well, and . . . . play ball like that.” Rosario explained that, if Verdeza
        had similarly refused to “play ball”—i.e., refused to sign reevalua-
        tion forms for “patients” he hadn’t seen—he would have ﬁred
        Verdeza. Rosario said that anyone at the clinic would have been
        suspicious of the fact that there were a lot of patient charts and
USCA11 Case: 21-10461      Document: 74-1     Date Filed: 05/31/2023     Page: 7 of 28

        21-10461               Opinion of the Court                        7

        very few patients. Even though not everyone in the clinic knew
        about the fraud, he said, Verdeza did.
               Next, Rafael Izquierdo, the clinic’s billing person, testiﬁed
        that he did the clinic’s paperwork and ﬁlled in diagnoses and treat-
        ment codes, rather than a doctor. He said that, at a real clinic, the
        physician would make that determination. Finally, ﬁve “patients”
        testiﬁed that they had gone to the clinic, met with Verdeza, signed
        thirty or more forms attesting to “treatment” they received, and
        never went back.
              When it came time for the district court to charge the jury,
        the court gave an instruction on deliberate indiﬀerence over
        Verdeza’s objection. The district court also instructed the jury that
        leading questions weren’t evidence.
              Ultimately, the jury convicted Verdeza on three substantive
        counts and acquitted him on the conspiracy charge as well as four
        substantive counts.
                                   2. Sentencing
               The Presentencing Investigative Report (“PSI”) initially at-
        tributed to Verdeza a loss amount of $5.2 million and concluded
        that Verdeza owed restitution in the amount of $1.75 million.
        Verdeza objected. He asserted that his loss amount should reﬂect
        only the amount billed for the three “patients” for which he was
        convicted—or $165,310. He also objected to the lack of a minor-
        role reduction. The government conceded that, given that Verdeza
        joined the conspiracy after it began, the proper loss amount should
        be $3.4 million, and his total restitution owed was $1.195 million.
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023      Page: 8 of 28

        8                      Opinion of the Court                  21-10461

               Although the district court overruled the objections, it ac-
        cepted the concessions. In explaining its reasons for overruling the
        loss-related objections, the district court ﬁrst recognized that the
        jury had acquitted Verdeza on some of the counts because it didn’t
        believe that evidence beyond a reasonable doubt established the al-
        leged violations. Even so, the district court found that a prepon-
        derance of the evidence supported the (acquitted) counts and held
        Verdeza responsible for $3.4 million in loss. Given those determi-
        nations, the district court calculated Verdeza’s ﬁnal oﬀense level as
        24 and his criminal history category as I, which gave Verdeza a
        Guidelines range of 51 to 63 months. The district court departed
        downward and sentenced Verdeza to 48 months’ incarceration and
        ordered $1.195 million in restitution. Verdeza timely appealed.

                         II. STANDARD OF REVIEW
               In evaluating whether suﬃcient evidence supports a convic-
        tion, we view the evidence in the light most favorable to the pros-
        ecution and draw all reasonable inferences and credibility choices
        in favor of the jury verdict. United States v. Takhalov, 838 F.3d 1168,
        1169 (11th Cir. 2016). And unless no reasonable construction of
        the evidence supports the jury’s guilty verdict beyond a reasonable
        doubt, we must aﬃrm a conviction. Id. We review for an abuse of
        discretion preserved evidentiary rulings. United States v. Hill, 643
        F.3d 807, 840 (11th Cir. 2011). We review unpreserved objections
        for plain error. Greer v. United States, 141 S. Ct. 2090, 2096 (2021).
               When we review a trial court’s jury instructions, “[w]e apply
        a deferential standard of review.” United States v. Puche, 350 F.3d
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023      Page: 9 of 28

        21-10461               Opinion of the Court                          9

        1137, 1148 (11th Cir. 2003) (internal citations omitted). We reverse
        only if our review leaves us “with a substantial and eradicable
        doubt as to whether the jury was properly guided in its delibera-
        tions.” Id. In making this evaluation, we consider the jury charge
        as a whole. Id.
                We review for clear error a district court’s decision as to
        whether a defendant qualiﬁes for an adjustment under the Guide-
        lines. United States v. Boyd, 291 F.3d 1274, 1277 (11th Cir. 2002). We
        also review for clear error an amount-of-loss determination. United
        States v. Medina, 485 F.3d 1291, 1297 (11th Cir. 2007). As to the le-
        gality of a restitution order, we review that de novo, but we review
        for clear error the factual ﬁndings underlying it. United States v.
        Brown, 665 F.3d 1239, 1252 (11th Cir. 2011). Finally, we review the
        substantive reasonableness of a sentence for an abuse of discretion.
        United States v. Irey, 612 F.3d 1160, 1188–89 (11th Cir. 2010) (en
        banc).

                               III. DISCUSSION
               Verdeza makes four arguments on appeal. First, Verdeza as-
        serts that the evidence was insuﬃcient to support his convictions.
        Second, he argues that the district court made erroneous eviden-
        tiary rulings that prejudiced his right to a fair trial. Third, he con-
        tends that the district court erred in giving a deliberate-indiﬀerence
        jury instruction. And fourth, Verdeza says that the district court
        erred in sentencing him in denying him a minor-role reduction, cal-
        culating his loss amount, determining his restitution, and imposing
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023     Page: 10 of 28

        10                     Opinion of the Court                  21-10461

        a substantively unreasonable sentence. We consider each argu-
        ment in turn.
                             A. Suﬃciency of the Evidence
               Verdeza makes a three-pronged attack on the suﬃciency of
        the evidence. First, he argues that what he did didn’t advance the
        fraud. Second, in Verdeza’s view, even if his actions did further the
        fraud, his help did so only after the fraud had been committed. So,
        Verdeza says, he cannot be liable as a principal, only as an (un-
        charged) accessory after the fact. And third, Verdeza asserts that
        suﬃcient evidence fails to support the jury’s ﬁnding of his intent to
        commit fraud.
         1. Aider and Abettor Liability and Accessory-After-the-Fact Lia-
                                          bility
               Verdeza contends that the fraud—which he concedes oc-
        curred—consisted of ﬁlling out and submitting fraudulent bills,
        but he insists that he had no part in either of those activities. Ac-
        cording to Verdeza, falsifying evaluations didn’t aid the creation of
        the fake bills. And importantly, in Verdeza’s view, the patient ﬁles
        were never submitted to BCBS for review. In the alternative,
        Verdeza says that, if backdating patient charts after the bill was sub-
        mitted did advance the fraud, then he was only an accessory after
        the fact, not an aider and abettor—which was a theory under which
        he wasn’t charged. We are not persuaded.
              Verdeza was convicted of three counts of healthcare fraud.
        The healthcare fraud statute criminalizes “knowing[] and willful[]
        execut[ion], or attempt[ed] . . . execut[ion], [of ] a scheme or
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023     Page: 11 of 28

        21-10461               Opinion of the Court                         11

        artiﬁce” to either (1) “defraud any healthcare beneﬁt program” or
        (2) “to obtain, by means of false or fraudulent pretenses, represen-
        tations, or promises, an of the money” of a healthcare program.
        18 U.S.C. § 1347. Because of the “knowing[] and willful[]” mental
        state required, “in a health care fraud case, the defendant must be
        shown to have known that the claims submitted were, in fact,
        false.” United States v. Medina, 485 F.3d 1291, 1297 (11th Cir. 2007).
        A person makes a false claim if the treatments that were billed were
        “not medically necessary[ ] or were not delivered to the patients.”
        Id. at 1304.
                Verdeza was charged as an aider or abettor, which describes
        one who “aids, abets, counsels, commands, induces or procures [a
        crime’s] commission” or who “willfully causes an act to be done,”
        and directs that he is guilty as a principal. 18 U.S.C. § 2. Aider-and-
        abettor liability is distinct from accessory-after-the-fact liability,
        which occurs when someone, “knowing that an oﬀense against the
        United States has been committed, receives, relieves, comforts or
        assists the oﬀender in order to hinder or prevent his apprehension,
        trial or punishment[.].” Id. § 3. So an aider and abettor assists the
        commission of a crime, but an accessory after the fact participates
        in only the crime’s cover-up.
                Here, suﬃcient evidence supported the jury’s verdict be-
        cause Verdeza aided and abetted the scheme in three ways. First,
        he performed (cursory) examinations and recommended unneces-
        sary physical therapy for the “patients.” The “examinations” were
        critical to the fraud because they enabled the clinic’s owners to bill
USCA11 Case: 21-10461     Document: 74-1      Date Filed: 05/31/2023     Page: 12 of 28

        12                     Opinion of the Court                 21-10461

        for physical therapy. In other words, the “examinations” them-
        selves were helpful. Indeed, Izquierdo and the FBI case agent both
        testiﬁed that the “examinations” allowed the clinic to perform the
        fraud in a more credible way. And the false notes aided the fraud
        because, if BCBS questioned the clinics, the documentation would
        (in theory) support payment. Put diﬀerently, the “examinations”
        and the false notes gave the fraud ring the ability and conﬁdence to
        submit a stream of false claims over the more-than-yearlong period
        of the fraud.
               Second, Verdeza gave BCBS fake reports that Verdeza had
        reevaluated the “patients” and they needed more physical therapy.
        But in reality, Verdeza never saw any of the “patients” again. In-
        deed, Rosario testiﬁed that Verdeza signed the reevaluation reports
        even though he hadn’t seen the “patient” again. The reevaluations
        were important because they allowed the clinics to bill for twelve
        more sessions per “patient” per reevaluation.
               And, third, Hernandez testiﬁed that she met with Verdeza
        every few weeks to go over the paperwork and ensure that the med-
        ical charts matched the bills before the bills were submitted. So
        Verdeza was directly involved in falsifying the claims forms.
               Verdeza’s assertion that his evaluations assisted the fraud
        only after the fact is similarly unpersuasive for the same reasons. In
        particular, Verdeza signed forms attesting falsely that he had reeval-
        uated “patients,” and those forms were then used to bill for more
        physical therapy. That is, those falsiﬁed reevaluation forms were
        necessarily created and submitted before the bills for extra physical-
USCA11 Case: 21-10461     Document: 74-1      Date Filed: 05/31/2023    Page: 13 of 28

        21-10461               Opinion of the Court                       13

        therapy sessions were submitted. In other words, Verdeza’s con-
        duct advanced the fraud before it was consummated, not merely af-
        terward.
                                     2. Intent
               Verdeza also argues that insuﬃcient evidence proves that he
        acted knowingly and willfully as the statute requires. We disagree.
               First, clinic owner Rosario testiﬁed that he hired Verdeza be-
        cause Hernandez said that Verdeza would “be willing to kind of
        work with [them].” And indeed he was: Verdeza did perfunctory
        physical examinations (if any). Verdeza told Rosario that—in ref-
        erence to another physical therapist who insisted on seeing “pa-
        tients” every time they came in—that the physical therapist “should
        kind of know what this business entails and he should be okay with
        it as well [and] play ball like that.” Rosario said he knew that
        Verdeza knew the whole practice was fraudulent because
        “[Verdeza] would still sign the exam form,” even if he hadn’t reex-
        amined the “patient.”
               There’s more still. Hernandez testiﬁed that she recom-
        mended Verdeza because she had committed healthcare fraud with
        him in a prior clinic and knew that he would commit fraud without
        asking any questions. And Verdeza settled a case with the Florida
        Board of Medicine for signing exam forms for “patients” he hadn’t
        treated—this exact same fact pattern. While that fact isn’t proba-
        tive of whether he did that this time, a scheme with the same mo-
        dus operandi can show intent, knowledge, plan, and lack of mis-
        take. See FED. R. EVID. 404(b); United States v. Williams, 527 F.3d
USCA11 Case: 21-10461     Document: 74-1      Date Filed: 05/31/2023     Page: 14 of 28

        14                     Opinion of the Court                 21-10461

        1235, 1247 (11th Cir. 2008) (history of non-compliance with federal
        grant regulations was admissible to prove intent to defraud).
               In short, suﬃcient evidence allowed the jury to ﬁnd beyond
        a reasonable doubt that Verdeza knew the bills were fraudulent.
                                 B. Evidentiary Rulings
                Verdeza also challenges some of the district court’s eviden-
        tiary rulings. First, he says the district court erred in allowing the
        FBI agent to introduce summary testimony. Second, he contends
        that the district court improperly admitted extrinsic evidence of
        prior bad acts under Rule 404(b). And, third, he argues that the dis-
        trict court erred in allowing the government to rely heavily on lead-
        ing questions.
                              1. Summary Testimony
               Verdeza argues that the district court should not have al-
        lowed the FBI case agent to testify as a “summary” witness about
        things she didn’t personally know and about things that had not yet
        been presented to the jury. The government responds that Verdeza
        never objected to this testimony, so we should review for (at most)
        plain error.
               We agree with the government that Verdeza did not pre-
        serve this objection. The FBI case agent testiﬁed for an hour and
        forty minutes on direct examination. Verdeza objected for the ﬁrst
        time, over an hour into her testimony, to argue that he wasn’t asso-
        ciated with Guerra and Double R clinics in September 2017. He
        objected again two minutes later for hearsay. Neither objection
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023      Page: 15 of 28

        21-10461                Opinion of the Court                         15

        alerted the district court that Verdeza thought the summary nature
        of the FBI case agent’s testimony was improper.
                Given Verdeza’s failure to preserve this argument, we review
        it for plain error only. United States v. Presendieu, 880 F.3d 1228,
        1237–38 (11th Cir. 2018). Under the plain-error standard, a defend-
        ant must establish (1) an error; (2) that is plain; (3) that aﬀects the
        defendant’s substantial rights; and (4) that seriously aﬀects the fair-
        ness, integrity, or public reputation of judicial proceedings. Id. Be-
        cause we’ve never held that summary testimony, in and of itself, is
        improper, see United States v. Khan, 794 F.3d 1288, 1300 (11th Cir.
        2015); United States v. Ransfer, 749 F.3d 914, 927 & n.14 (11th Cir.
        2014), any error cannot be plain. United States v. Chau, 426 F.3d
        1318, 1322 (11th Cir. 2005) (“[W]here the explicit language of a stat-
        ute or rule does not speciﬁcally resolve an issue, there can be no
        plain error where there is no precedent from the Supreme Court
        or this Court directly resolving it.”) (citation omitted). For that rea-
        son, Verdeza’s argument necessarily fails.
                                  2. Prior Bad Acts
               Verdeza makes three distinct arguments related to the Rule
        404(b) evidence the government introduced. First, he says that the
        government failed to provide him with notice of how it intended
        to use the evidence. Second and third, he contends that the evidence
        of his prior bad acts with Hernandez at the Culumbia clinic and the
        Esmerelda clinic were improper propensity evidence. None of
        Verdeza’s arguments have merit.
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023     Page: 16 of 28

        16                     Opinion of the Court                  21-10461

                As to his ﬁrst argument, Verdeza relies on the wrong version
        of the Federal Rules of Evidence. Under the 2011 version—in ef-
        fect at his trial—the government was not required to provide notice
        of the purpose for which it intended to use Rule 404(b) evidence.
        FED. R. EVID. 404(b)(2) (2011). It was only in 2020 that Rule
        404(b)(3) was added, requiring the government to articulate the
        permitted purpose for which it intended to use the evidence. FED
        R. EVID. 404 (committee notes on 2020 amendment) (explaining
        that “Rule 404(b) has been amended principally to impose addi-
        tional notice requirements on the prosecution in a criminal case.”).
               As to Verdeza’s second and third arguments—relating to his
        time working with Hernandez committing healthcare fraud at
        other clinics—we conclude that the evidence that Verdeza worked
        with Hernandez at a separate clinic had a proper Rule 404(b) pur-
        pose—knowledge, lack of mistake, and plan. See Rule 404(b). As
        we’ve mentioned, Verdeza’s defense was that he just happened to
        be at a clinic with Ibelis Hernandez at which massive amounts of
        healthcare fraud happened, outside his knowledge. So the fact that
        Verdeza worked with Hernandez at other clinics where healthcare
        fraud occurred was probative of whether Verdeza knew healthcare
        fraud was occurring at this clinic. Cf. United States v. Pepe, 747 F.2d
        632, 670 (11th Cir. 1984) (explaining that the evidence “showed that
        Facchiano committed prior acts suﬃciently similar to one or more
        crimes charged in the indictment to permit the inference that he
        intended to commit such crime.”).
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023      Page: 17 of 28

        21-10461                Opinion of the Court                         17

                              3. Leading Questions
              Finally, Verdeza complains that the government asked too
        many leading questions. We are unpersuaded that the leading
        questions made a diﬀerence in the outcome of the trial.
                Rule 611 of the Federal Rules of Evidence provides that
        “[l]eading questions should not be used on direct examination ex-
        cept as necessary to develop the witness’s testimony.” FED. R. EVID.
        611(c).
               While the government asked at least eighteen leading ques-
        tions over the course of the trial, the district court sustained sixteen
        of the eighteen objections for leading questions. Here are the re-
        maining objected-to-as-leading questions that the district court al-
        lowed into evidence. Of the BCBS Investigator, the government
        asked,
               Q:     And does Medicare or does Blue Cross Blue Shield
                      reimburse for services that were never actually
                      provided or rendered?
               A:     Absolutely not.
                      [Objection overruled and not re-asked because it had
                      already been answered]
        And of co-conspirator Hernandez, the government inquired,
               Q:     Prior to coming to court today, how many times have
                      you met me?
               A:     I believe it was two times.
USCA11 Case: 21-10461        Document: 74-1    Date Filed: 05/31/2023      Page: 18 of 28

        18                      Opinion of the Court                  21-10461

               Q:     And the ﬁrst was on Thursday August 1, 2019?
                      [Objection]
               Q:     Do you recall having testiﬁed before a federal grand
                      jury on August 1, 2019?
               A:     Yes.
        Even assuming the questions were leading (not necessarily a cor-
        rect assumption as to the ﬁrst question), neither question was sub-
        stantive nor changed the result in any way. On top of that, the dis-
        trict court instructed the jury that the lawyer’s questions weren’t
        evidence. We presume jurors follow a judge’s instructions.
        Raulerson v. Wainwright, 753 F.2d 869, 876 (11th Cir. 1985) (“Jurors
        are presumed to follow the law as they are instructed.”). And
        Verdeza emphasized the number of leading questions in his clos-
        ing. In his words, “[The prosecutor] had to get up and he had to
        say to him, oh you meant the physical therapy notes didn’t you?
        And he had to keep leading his witnesses. He had to keep spoon-
        feeding him the testimony that he wanted them to spit back at
        you.” So besides the fact that Verdeza objects on appeal to only
        two purported leading questions that didn’t add to the govern-
        ment’s case, his discussion of the leading questions in his closing
        played right into the district court’s instructions to the jury that the
        lawyers’ questions weren’t evidence.
               In short, the minimal leading questions Verdeza points to
        here do not allow Verdeza to overcome the overwhelming evidence
        of his guilt at trial.
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023     Page: 19 of 28

        21-10461               Opinion of the Court                         19

                                C. Jury Instruction
               Next, Verdeza argues that the district court erred in giving a
        deliberate-ignorance instruction because no evidence suggested
        that Verdeza had deliberately avoided learning of the scheme.
        Given the split verdict—Verdeza was acquitted of the conspiracy
        charge and some of the substantive counts—–he asserts, the error
        wasn’t harmless.
                We’ve explained that “deliberate ignorance of criminal ac-
        tivity [is] the equivalent of knowledge.” United States v. Maitre, 898
        F.3d 1151, 1157 (11th Cir. 2018). But “[a] deliberate ignorance in-
        struction is appropriate only when there is evidence in the record
        showing the defendant purposely contrived to avoid learning the
        truth.” United States v. Stone, 9 F.3d 934, 937 (11th Cir. 1993) (cita-
        tion omitted). We have explained that a court errs in giving the
        instruction “when the evidence only points to either actual
        knowledge or no knowledge on the part of the defendant.” Id. But
        “when the evidence could support both actual knowledge or delib-
        erate ignorance and the jury was instructed on both,” giving a de-
        liberate instruction is not error. Maitre, 898 F.3d at 1157.
               Verdeza’s argument lacks persuasive force for two reasons.
        For one, the record contains evidence that would have allowed the
        jury to conclude that Verdeza deliberately put his head in the sand.
        For instance, the “patients” testiﬁed that Verdeza did minimal (or
        no) examinations on them. One construction of this fact is that
        Verdeza did this to avoid learning that his “patients” weren’t actu-
        ally injured. In addition, the clinic owner Rosario testiﬁed that
USCA11 Case: 21-10461       Document: 74-1     Date Filed: 05/31/2023   Page: 20 of 28

        20                       Opinion of the Court              21-10461

        there were “many charts but very few patients walking through the
        door.” In other words, the circumstances were quite suspicious.
        And the jury could have chosen not to credit the evidence support-
        ing the notion that Verdeza had actual knowledge. So we cannot
        say that the district court erred in giving the deliberate-ignorance
        instruction.
               And second, because the evidence suﬃciently supported a
        ﬁnding of actual knowledge, any error in giving the deliberate-ig-
        norance instruction was harmless. Indeed, clinic owner Rosario
        testiﬁed that Verdeza knew about the scheme:
              Q:     Now, you had other conversations with [Verdeza]
                     about signing forms when patients weren’t present,
                     did you not?
              A:     Yes.
              Q:     That’s fraud, isn’t it?
              A:     Yes, sir.
              …
              Q:     Now, you mentioned the [principals] were the ones
                     who knew fraud was being committed. And who
                     were the people who knew fraud was being commit-
                     ted?
              A:     [Listing people]
              Q:     Carlos Verdeza?
              A:     Yeah. Yes, he did know.
USCA11 Case: 21-10461     Document: 74-1      Date Filed: 05/31/2023     Page: 21 of 28

        21-10461               Opinion of the Court                        21

        Given our ruling in Maitre that there is no error to give a deliberate
        ignorance instruction when the evidence “could support both ac-
        tual knowledge or deliberate ignorance,” we ﬁnd no error here.
        Maitre, 898 F.3d at 1157.
                                  D. Sentencing Issues
               We next turn to Verdeza’s challenges to his sentence. First,
        Verdeza asserts that the district court erred in calculating his loss
        amount because it held him accountable for conduct for which he
        was acquitted. Second, Verdeza takes issue with the district court’s
        decision not to award a minor-role reduction. Third, Verdeza com-
        plains that the district court clearly erred when it ordered him to
        pay $1.195 million in restitution. And fourth, Verdeza contends that
        his sentence was substantively unreasonable.
                                   1. Loss Amount
                Verdeza ﬁrst complains about the loss amount of $3.4 mil-
        lion. He argues that his acquittal on several substantive counts and
        the conspiracy charge deprived the district court of the ability to
        include losses ascribed to the conduct charged in those counts. Ra-
        ther, Verdeza posits, the district court should have used one of sev-
        eral diﬀerent numbers. The lowest number Verdeza urges is
        $1,040, or the amount the clinics received for the three visits listed
        in the indictments. His next lowest alternative is the amount for all
        the “patients” he saw at Guerra and Double R —$118,918 in billing
        or the $21,793 that was actually paid. Finally, he proﬀers that he
        should be held liable for the total amounts billed or received for the
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023      Page: 22 of 28

        22                      Opinion of the Court                  21-10461

        three “patients” identiﬁed in the counts on which he was con-
        victed—$165,310 billed or $64,801 received.
               When we heard this case, the answer to Verdeza’s challenge
        was straightforward under our precedent. Guidelines § 2B1.1 en-
        hanced his oﬀense level for the “loss” caused. We then turned to
        the commentary to the Guidelines for the meaning of “loss” as
        § 2B1.1 employs the term. United States v. Orton, 73 F.3d 331, 333
        (11th Cir. 1996). The commentary, in turn, explains that the “loss”
        is the greater of the actual or intended loss. U.S.S.G. cmt 3(A)(ii);
        United States v. Moran, 778 F.3d 942, 973 (11th Cir. 2015). And given
        that defendants in a jointly undertaken criminal activity—whether
        or not charged as a conspiracy—can be held liable for all acts and
        omissions of the others, Verdeza’s challenges lacked merit.
        U.S.S.G. §1B1.3(a)(1)(B). Verdeza could be held liable for his cocon-
        spirator’s acts, even though he was acquitted of the conspiracy
        charge, and he could be held liable for the amount that the schemes
        intended to steal.
                But after we heard oral argument on this case, our decision
        became a little bit trickier. That’s because in United States v. Dupree,
        we overruled our precedent on how the Guidelines and the com-
        mentary interact. 57 F.4th 1269 (11th Cir. 2023) (en banc). Before
        Dupree, the commentary was binding on federal courts unless the
        commentary was “plainly erroneous or inconsistent with the
        guideline itself, a federal statute[,] or the Constitution.” United
        States v. Wilson, 993 F.2d 214, 216 (11th Cir. 1993) (citing Stinson v.
        United States, 508 U.S. 36, 45 (1993)). But in Dupree, we held that
USCA11 Case: 21-10461      Document: 74-1      Date Filed: 05/31/2023      Page: 23 of 28

        21-10461                Opinion of the Court                         23

        after Kisor v. Wilkie, 139 S. Ct. 2400, 2408–09 (2019), courts could
        defer to the commentary only when the regulation is “genuinely
        ambiguous,” Dupree, 57 F.4th at 1275–78, after “exhaust[ing] all the
        ‘traditional tools’ of construction,” id. at 1275 (quoting Kisor, 139
        S. Ct. at 2415).
               Still, though, Verdeza did not preserve the question of
        whether § 2B1.1’s deﬁnition of “loss” is ambiguous and thus re-
        quires resort to the Guidelines commentary. So we must consider
        that question under plain-error review. See United States v. Sanchez,
        940 F.3d 526, 537 (11th Cir. 2019). And that’s where the answer
        becomes clear.
               As we have explained, “[a]n error cannot be plain unless the
        issue has been speciﬁcally and directly resolved by . . . on point prec-
        edent from the Supreme Court or this Court.” Id. But whatever
        else Dupree did, it did not “speciﬁcally and directly resolve[]” the
        question of whether § 2B1.1’s deﬁnition of “loss” is ambiguous. So
        it did not “speciﬁcally and directly resolve[]” that Orton’s holding
        that “loss” means the greater of intended or actual loss is wrong.
                Because Dupree didn’t “speciﬁcally and directly resolve[]”
        that Orton’s holding is wrong, we must follow Orton in our plain-
        error review. Del Castillo, 26 F.4th at 1223. And Orton requires dis-
        trict courts to consider the intended loss amount when calculating
        the loss attributable to the defendant for the purposes of determin-
        ing his Guidelines range. See Orton, 73 F.3d at 333. So the district
        court did not err in attributing a loss amount of $3.4 million based
        on what it found to be the loss amount Verdeza intended.
USCA11 Case: 21-10461     Document: 74-1     Date Filed: 05/31/2023    Page: 24 of 28

        24                    Opinion of the Court                21-10461

                             2. Minor-Role Reduction
               Next, Verdeza argues that the district court clearly erred in
        denying his request for a minor-role reduction. Verdeza contends
        that he didn’t have a proprietary role in the scheme; he didn’t own
        or manage the clinics; he didn’t submit fraudulent bills; he didn’t
        pay kickbacks; he didn’t help organize the scheme; and he didn’t
        recruit any “patients.” Not only that, Verdeza urges, but he adds
        that a medical doctor supervised him, and almost all the gains came
        from fraudulent billing for physical therapy, not his evaluations.
        Finally, he notes that he made $130,000 over two years—a mere
        fraction of the $1.2 million paid out to the scheme and even less
        compared to the $3.4 million for which he is being held responsible.
               The Guidelines provide a two-level reduction for “minor”
        participants and a four-level reduction for “minimal” participants.
        U.S.S.G. § 3B1.2. But that’s all § 3B1.2 says. The commentary
        ﬂeshes out what those terms mean. See United States v. De Varon,
        175 F.3d 930, 939 (11th Cir. 1999) (describing commentary). So this
        issue may seem like it presents another Dupree problem. But as it
        turns out, we needn’t decide whether Dupree’s admonition that
        commentary can be used only when the Guideline is ambiguous
        abrogates our precedent on § 3B1.2 because, whether we rely on
        the Guideline text or the commentary, the district court did not
        clearly err in denying the reduction.
              On the one hand, if Dupree abrogated our precedent and the
        term “minor” is unambiguous (meaning we cannot consider the
        commentary), then the district court did not clearly err in denying
USCA11 Case: 21-10461        Document: 74-1         Date Filed: 05/31/2023         Page: 25 of 28

        21-10461                   Opinion of the Court                               25

        the reduction. “Minor” means “inferior in importance, size, or de-
        gree: comparatively unimportant.” Minor, MERRIAM-WEBSTER’S
        DICTIONARY ONLINE, https://www.merriam-webster.com/dic-
        tionary/minor (last accessed May 8, 2023). That does not describe
        Verdeza’s role in the scheme. For over a year, Verdeza held himself
        out as a physician, interacted with “patients,” doctored notes, pre-
        scribed physical therapy, and wrote fake reevaluations—crucial for
        another cycle of billing. We cannot say the district court clearly
        erred in ﬁnding that those facts meant that Verdeza’s role wasn’t
        “comparatively unimportant.”
                On the other hand, if Dupree abrogated our precedent and
        the term “minor” is ambiguous (or if Dupree didn’t abrogate our
        precedent), then we can continue to rely on our precedent (which
        relies on the commentary). 2 In determining whether a defendant
        is entitled to a role reduction, the district court must consider (1)
        the defendant’s role measured against the relevant conduct for
        which he has been held accountable at sentencing, and (2) his role
        as compared to other participants in that relevant conduct. See
        United States v. Rodriguez, 751 F.3d 1244, 1258 (11th Cir. 2014).
               Here, the scheme involved many uncharged, less culpable
        participants—the “patients” who came in for kickbacks as well as
        the recruiters and the physician who supervised Verdeza. See, e.g.,
        United States v. Zaccardi, 924 F.2d 201, 203 (11th Cir. 1991) (“It is

        2It’s also possible that we’ve readopted our precedent. See United States v.
        Gruezo, --- F.4th ---, 2023 WL 3263506, at *7 (Mar. 30, 2023) (relying on Section
        3B1.2’s commentary).
USCA11 Case: 21-10461      Document: 74-1       Date Filed: 05/31/2023      Page: 26 of 28

        26                      Opinion of the Court                   21-10461

        entirely possible for conspiracies to exist in which there are no mi-
        nor participants or for which the least culpable participants, for
        whatever reason, were not indicted. In either case, the fact that a
        particular defendant may be least culpable among those who are
        actually named as defendants does not establish that he performed
        a minor role in the conspiracy.”). And as we’ve mentioned, Verdeza
        (1) met with patients, (2) doctored treatment notes, (3) falsiﬁed
        evaluations, (4) made up reevaluations, and (5) ensured that bills
        matched treatment notes. We cannot say that the district court
        clearly erred in ﬁnding that Verdeza’s role was more than “minor.”
               Given that Verdeza doesn’t argue that the district court fo-
        cused exclusively on one factor or the wrong facts, and evidence
        supports the district court’s choice, the district court didn’t clearly
        err. See United States v. Valois, 915 F.3d 717, 732 (11th Cir. 2019) (af-
        ﬁrming denial of minor role reduction for drug transporters who
        (1) only transported drugs and (2) weren’t even the master of the
        ship and (3) had no propriety ownership in the scheme or decision-
        making capacity).
                                  3. Restitution
               Third, Verdeza argues that the district court clearly erred in
        requiring him to pay $1.195 million in restitution—jointly and sev-
        erally with his codefendants—to BCBS. Instead, he says, he can be
        held responsible for repaying only the amount caused by his con-
        duct.
               The Mandatory Victim Restitution Act provides that district
        courts must order restitution in crimes against property cases equal
USCA11 Case: 21-10461     Document: 74-1      Date Filed: 05/31/2023     Page: 27 of 28

        21-10461               Opinion of the Court                        27

        to the value of the lost property. 18 U.S.C. § 3663A(b). Unlike with
        the Guidelines adjustment for loss amount, we consider only the
        amount that the victim actually lost. United States v. Martin, 803
        F.3d 581, 595 (11th Cir. 2015). Indeed, restitution is based on “a
        victim’s actual loss directly and proximately caused by the defend-
        ant’s oﬀense of conviction.” United States v. Collins, 854 F.3d 1324,
        1336 (11th Cir. 2017) (citations omitted). However, if more than
        one defendant contributes to the loss of a victim, the court may
        make each defendant liable for the payment of the full amount of
        restitution. 18 U.S.C. § 3664(i). A district court can consider un-
        charged conduct for purposes of restitution—even conduct that is
        outside the statute of limitations—as long as the losses were “from
        the defendant’s conduct in the course of the scheme.” United States
        v. Dickerson, 370 F.3d 1330, 1342 (11th Cir. 2004).
                This argument doesn’t warrant much discussion. The dis-
        trict court didn’t err in ordering Verdeza to pay restitution (jointly
        and severally) with the others in his scheme because § 3664(i) al-
        lows district courts to order members of a scheme to jointly repay
        victims. 18 U.S.C. § 3664(i). Verdeza doesn’t challenge on appeal
        the evidence supporting the claimed amount. And under our prec-
        edent, it was not error to consider uncharged conduct that was part
        of the scheme. See id.
                          4. Substantive Reasonableness
              Finally, Verdeza contends that his sentence was substantively
        unreasonable.
USCA11 Case: 21-10461     Document: 74-1      Date Filed: 05/31/2023     Page: 28 of 28

        28                     Opinion of the Court                 21-10461

               When we review the reasonableness of a sentence, we must
        “consider the totality of the facts and circumstances.” Irey, 612 F.3d
        at 1189. Here, the district court sentenced Verdeza to 48 months—
        below his Guidelines range of 51–63 months. Given that Verdeza
        had previously participated in very similar schemes, been investi-
        gated by the Florida regulatory board for similar conduct, and had
        attempted to defraud the victim of millions of dollars, we can’t say
        that the 48-month sentence the district court imposed—slightly be-
        low the Guidelines range—was an abuse of discretion.

                             IV. CONCLUSION
               For the reasons we have explained, we aﬃrm Verdeza’s con-
        victions and sentence.
               AFFIRMED.