Justia White Collar Crime Opinion Summaries

Joe May was indicted for conspiracy to commit wire fraud, mail fraud, and violations of the Anti-Kickback statute, among other charges, related to defrauding TRICARE. May, a medical doctor, was recruited to sign prescriptions for compounded drugs without evaluating patients. He signed 226 prescriptions, mostly without determining medical necessity. May received cash payments for his participation. When investigated, May created false medical records and lied to the FBI.The United States District Court for the Eastern District of Arkansas convicted May on all counts and sentenced him to 102 months imprisonment, ordering restitution of over $4.6 million. May appealed, challenging the admission of business records, limitations on cross-examination, jury instructions, the government's closing argument, and the sufficiency of evidence for certain charges.The United States Court of Appeals for the Eighth Circuit reviewed the case. The court found no abuse of discretion in admitting business records or limiting cross-examination. The court upheld the jury instructions and found no error in the government's closing argument. The court determined there was sufficient evidence for the conspiracy, mail fraud, and kickback charges. However, the court found plain error in one count of aggravated identity theft related to Perry Patterson, as the jury was not instructed on the correct underlying offense.The Eighth Circuit reversed the conviction on the aggravated identity theft count related to Patterson, remanded to vacate the special assessment for that count, and affirmed all other aspects of the case. View "United States v. May" on Justia Law

Sardar Ashrafkhan owned and operated a fraudulent medical practice where doctors wrote and billed Medicare for fake prescriptions. These prescriptions were filled at specific pharmacies, which paid Ashrafkhan kickbacks. The scheme resulted in millions of dollars in fraudulent Medicare claims and the illegal sale of opioid-based drugs. Ashrafkhan was indicted in 2013 and tried in 2015, where the government presented evidence that he masterminded the scheme. The jury convicted him of drug conspiracy, health care fraud conspiracy, and money laundering. At sentencing, he received an adjustment for being an organizer or leader of a criminal activity involving five or more participants.The United States District Court for the Eastern District of Michigan sentenced Ashrafkhan to 276 months of imprisonment, varying downward from the guidelines range of 600 months. Ashrafkhan appealed, and the United States Court of Appeals for the Sixth Circuit affirmed his conviction and sentence. After his sentencing, the United States Sentencing Commission promulgated a new guideline, USSG § 4C1.1, which provides a two-point reduction in the offense level for defendants with no criminal history points, known as "zero-point offenders." Ashrafkhan moved for a sentence reduction under this new guideline, but the district court denied his motion, reasoning that his aggravating role adjustment rendered him ineligible for the reduction.The United States Court of Appeals for the Sixth Circuit reviewed the case and affirmed the district court's decision. The court held that to be eligible for the zero-point offender reduction under USSG § 4C1.1, a defendant must not have received an aggravating role adjustment and must not have engaged in a continuing criminal enterprise. Since Ashrafkhan received an aggravating role adjustment, he was ineligible for the reduction, regardless of whether he engaged in a continuing criminal enterprise. The court's interpretation was based on the plain text and context of the guideline, as well as precedent from similar cases. View "United States v. Ashrafkhan" on Justia Law

Elizabeth Holmes and Ramesh "Sunny" Balwani, founders of Theranos, were convicted of defrauding investors about the capabilities of their company's blood-testing technology. Theranos claimed it could run accurate tests with just a drop of blood, attracting significant investments. However, the technology was unreliable, and the company misled investors about its financial health, partnerships, and the validation of its technology by pharmaceutical companies.The United States District Court for the Northern District of California severed their trials due to Holmes's allegations of abuse by Balwani. Holmes was convicted on four counts related to investor fraud, while Balwani was convicted on all counts, including conspiracy to commit wire fraud against investors and patients. Holmes was sentenced to 135 months, and Balwani to 155 months in prison. The district court also ordered them to pay $452 million in restitution.The United States Court of Appeals for the Ninth Circuit reviewed the case. The court affirmed the convictions, sentences, and restitution order. It held that the district court did not abuse its discretion in admitting testimony from former Theranos employees, even if some of it veered into expert territory. The court found any errors in admitting this testimony to be harmless due to the weight of other evidence against the defendants.The Ninth Circuit also upheld the district court's decision to admit a report from the Center for Medicare and Medicaid Services, finding it relevant to Holmes's knowledge and intent. The court rejected Holmes's argument that the district court violated her Confrontation Clause rights by limiting cross-examination of a former Theranos lab director. Additionally, the court found no merit in Balwani's claims of constructive amendment of the indictment and Napue violations. The court concluded that the district court's factual findings on loss causation and the number of victims were not clearly erroneous and affirmed the restitution order. View "USA V. HOLMES" on Justia Law

The case involves the United States government alleging that Regeneron Pharmaceuticals violated the Anti-Kickback Statute (AKS) by covering copayments for patients prescribed Eylea, a drug used to treat wet age-related macular degeneration. The government contends that this action induced doctors to prescribe Eylea, leading to Medicare claims that were "false or fraudulent" under the False Claims Act (FCA) because they "resulted from" the AKS violation.The United States District Court for the District of Massachusetts reviewed the case and agreed with Regeneron's interpretation that the phrase "resulting from" in the 2010 amendment to the AKS requires a but-for causation standard. This means that the government must prove that the AKS violation was the actual cause of the Medicare claims. The district court noted the conflict in case law and sought interlocutory review, which was granted.The United States Court of Appeals for the First Circuit affirmed the district court's ruling. The court held that the phrase "resulting from" in the 2010 amendment to the AKS imposes a but-for causation requirement. The court reasoned that the ordinary meaning of "resulting from" requires actual causality, typically in the form of but-for causation, unless there are textual or contextual indications to the contrary. The court found no such indications in the 2010 amendment or its legislative history. Therefore, to establish falsity under the FCA based on an AKS violation, the government must prove that the kickback was a but-for cause of the submitted claim. View "United States v. Regeneron Pharmaceuticals, Inc." on Justia Law

Conduent State Healthcare, LLC (Conduent) was hired by the State of Texas to administer its Medicaid program. In 2012, Texas began investigating Conduent for allegedly helping orthodontics offices overbill for services. Texas sued several orthodontic providers in 2014, and the providers sued Conduent. Texas terminated its contract with Conduent and sued Conduent under the Texas Medicaid Fraud Prevention Act. Conduent was insured by AIG Specialty Insurance Company, ACE American Insurance Company, and Lexington Insurance Company, among others. The insurers provided defense coverage for the provider actions but denied coverage for the state action, claiming it involved fraudulent conduct excluded by the policies.The Superior Court of Delaware found that the insurers breached their duty to defend Conduent in the state action. The court also ruled that Conduent was relieved of its duties to cooperate and seek consent before settling with Texas due to the insurers' breach. The jury found that Conduent acted in bad faith and fraudulently arranged the settlement but did not collude with Texas or settle unreasonably. The Superior Court granted a new trial due to evidentiary issues and the jury's inconsistent verdicts.The Supreme Court of Delaware affirmed the Superior Court's rulings. It held that the insurers' breach of their duty to defend excused Conduent from its duties to cooperate and seek consent. The court also ruled that the policy's fraud exclusion did not bar indemnity coverage because the settlement was allocated to breach of contract damages. The court found that the evidentiary issues and the jury's inconsistent verdicts justified a new trial to prevent manifest injustice. View "AIG Specialty Insurance Company v. Conduent State Healthcare, LLC" on Justia Law

Dr. Anita Jackson, an otolaryngologist, was convicted of various offenses related to her private medical practice in North Carolina. She was the leading Medicare biller for balloon sinuplasty surgery, a procedure treating chronic sinusitis. Jackson reused single-use medical devices, specifically the Entellus XprESS Multi-Sinus Dilation Tool, on multiple patients without proper sterilization, leading to potential contamination. She also incentivized employees to recruit Medicare patients for the procedure, often bypassing proper medical assessments. Additionally, Jackson falsified documents and patient signatures in response to Medicare audits.The United States District Court for the Eastern District of North Carolina convicted Jackson on all counts, including violating the Food, Drug, and Cosmetics Act (FDCA) by holding for resale adulterated medical devices, violating the federal anti-kickback statute, making materially false statements, committing aggravated identity theft, mail fraud, and conspiracy. Jackson was sentenced to twenty-five years in prison and ordered to pay over $5.7 million in restitution. She moved for a judgment of acquittal and a new trial, which the district court denied.The United States Court of Appeals for the Fourth Circuit reviewed the case. Jackson argued that the devices were not "held for sale" under the FDCA, that her actions were protected under 21 U.S.C. § 396, and that the Government relied on a defective theory of per se adulteration. She also challenged the exclusion of certain evidence and jury instructions. The Fourth Circuit found no reversible error in the district court's rulings, holding that the devices were indeed "held for sale," that § 396 did not protect her conduct, and that the Government's theory was valid. The court also upheld the exclusion of evidence and the jury instructions. Consequently, the Fourth Circuit affirmed all of Jackson's convictions. View "United States v. Jackson" on Justia Law

Humana, a health insurance company and Medicare Part C and Part D sponsor, filed a lawsuit against Biogen, a drug manufacturer, and Advanced Care Scripts, Inc. (ACS), a specialty pharmacy, in the District of Massachusetts. Humana alleged that Biogen and ACS engaged in fraudulent schemes involving three multiple sclerosis drugs, violating the civil RICO statute. Humana claimed that Biogen "seeded" the market with these drugs, funneled patients into Medicare, and indirectly funded patient copays through third-party patient-assistance programs (PAPs). Humana also alleged that ACS aided Biogen's scheme by steering patients and acting as an intermediary between Biogen and the PAPs, causing the submission of false certifications to Humana.The district court dismissed the case, ruling that Humana lacked standing to bring RICO claims because it was an indirect purchaser and failed to plead the RICO claims with particularity as required by Federal Rule of Civil Procedure 9(b). The court found that Humana did not specify the time, place, and content of the alleged fraudulent communications and failed to detail the false certifications' language, timing, and context. Humana's motion for leave to amend the complaint was also denied.The United States Court of Appeals for the First Circuit reviewed the case. The court affirmed the district court's dismissal, agreeing that Humana failed to meet the heightened pleading standard of Rule 9(b) for its RICO claim. The court held that Humana did not provide specific details about the fraudulent certifications or the use of mail or wire communications in furtherance of the scheme. The court also upheld the denial of leave to amend, citing undue delay and the inefficiency of seeking amendment after dismissal. View "Humana Inc. v. Biogen, Inc." on Justia Law

Julian Omidi and his business, Surgery Center Management, LLC (SCM), were involved in a fraudulent scheme called "Get Thin," which promised weight loss through Lap-Band surgery and other medical procedures. Omidi and SCM defrauded insurance companies by submitting false claims for reimbursement, including fabricated patient data and misrepresented physician involvement. The scheme recruited patients through a call center, pushing them towards expensive medical tests and procedures regardless of medical necessity.A grand jury indicted Omidi and SCM for mail fraud, wire fraud, money laundering, and related charges. After extensive pretrial litigation and a lengthy jury trial, both were convicted on all charges. The district court sentenced Omidi to 84 months in prison and fined SCM over $22 million. The government sought forfeiture of nearly $100 million, arguing that all proceeds from the Get Thin scheme were derived from fraud. The district court agreed, finding that even proceeds from legitimate procedures were indirectly the result of the fraudulent scheme.The United States Court of Appeals for the Ninth Circuit reviewed the case. The court affirmed the district court's forfeiture judgment, holding that under 18 U.S.C. § 981(a)(1)(C), all proceeds directly or indirectly derived from a health care fraud scheme must be forfeited. The court rejected the argument that only proceeds from fraudulent transactions should be forfeited, noting that the entire business was permeated with fraud. The court concluded that there is no "100% Fraud Rule" in forfeiture cases seeking proceeds of a fraud scheme, and all proceeds from the Get Thin scheme were subject to forfeiture. View "United States V. Surgery Center Management, LLC" on Justia Law

Sekhar Rao was involved in a scheme to defraud TRICARE, a federal health benefit plan, by ordering medically unnecessary toxicology and DNA cancer screening tests. These tests were billed to TRICARE through a shell company, ADAR Group, LLC, which set up fraudulent testing sites. Rao, a physician, was hired to sign off on these tests without reviewing patient medical information or meeting the patients. He was paid per test ordered. The scheme involved using a signature stamp of Rao’s signature to sign requisition forms, which Rao allegedly knew about and consented to.In the United States District Court for the Northern District of Texas, Rao was acquitted of conspiracy to commit health care fraud but was convicted of two counts of substantive health care fraud related to specific fraudulent claims submitted to TRICARE. The district court sentenced him to 48 months of imprisonment, followed by three years of supervised release, and calculated the loss amount under the United States Sentencing Guidelines based on the intended loss.The United States Court of Appeals for the Fifth Circuit reviewed the case. Rao raised three issues on appeal: the sufficiency of the evidence for his convictions, the exclusion of testimony regarding statements made to him by the scheme’s leader about legal vetting, and the calculation of the loss amount under the Sentencing Guidelines. The Fifth Circuit found no reversible error in the district court’s decisions. The court held that there was sufficient evidence for a reasonable jury to conclude that Rao caused the submission of the fraudulent claims and that he knew about and authorized the use of his signature stamp. The court also held that the district court did not plainly err in excluding the testimony about legal vetting and did not err in calculating the intended loss amount. The Fifth Circuit affirmed Rao’s convictions and sentence. View "United States v. Rao" on Justia Law

The case involves Amaka Oji and Oji Fit World, LLC (OFW), who were approved as Medicaid providers by the D.C. Department of Health Care Finance (DHCF) in 2011. Between 2012 and 2015, they submitted over 24,000 claims for reimbursement for wellness services provided to Medicaid beneficiaries. Investigations by DHCF, the Office of the Inspector General for the Centers for Medicare and Medicaid Services, and the FBI revealed that Oji and OFW regularly overbilled Medicaid, often charging for a full hour of service regardless of the actual time spent or whether the service was provided at all.The District of Columbia filed a lawsuit in April 2021 under the D.C. False Claims Act and the common law doctrine of unjust enrichment. The Superior Court of the District of Columbia granted summary judgment in favor of the District, finding that Oji and OFW had submitted false claims and falsified records. The court awarded the District $1,001,362.50 in treble damages and $497,000 in civil penalties. Oji and OFW's various procedural defenses, including claims of laches and statute of limitations, were deemed waived due to their failure to raise them in a timely manner.The District of Columbia Court of Appeals reviewed the case and affirmed the summary judgment order. However, the court remanded the case for further consideration of the damages and penalties. The appellate court found that the Superior Court had not provided sufficient explanation or analysis for the awarded amounts, making it difficult to review the decision. The appellate court emphasized the need for the trial court to explain its reasoning in detail to permit adequate appellate review. View "Oji Fit World, LLC v. District of Columbia" on Justia Law