United States’ Opposition to Defendant’s Motion for Judgment of Acquittal or, in the Alternative, for a New Trial — No. 1:22-CR-00146 (Dkt. 85, D. Md.)
Summary
The United States asks the District of Maryland to deny Ron Elfenbein’s motion for judgment of acquittal or a new trial in this opposition, filed September 1, 2023 by the U.S. Attorney’s Office and the Justice Department’s Fraud Section. Elfenbein, an owner and the medical director of Drs ERgent Care, was convicted on August 4, 2023 of all five counts of health care fraud after a three-week jury trial. The government says the insurer of nearly every patient who came to the clinic for a COVID-19 test was also billed for an evaluation and management visit of purportedly 30 or more minutes, while Elfenbein instructed providers that patients should be seen in five minutes or less. It argues that the visits were not Level 4 services, that Elfenbein’s testimony was not credible, and that the exclusion of three defense email exhibits and the voir dire process were proper.
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UNITED STATES DISTRICT COURT
DISTRICT OF MARYLAND
UNITED STATES OF AMERICA,
v. CASE NO. 1:22-CR-00146-JKB
RON ELFENBEIN,
Defendant.
_____________________________/
UNITED STATES’ OPPOSITION TO DEFENDANT’S MOTION FOR JUDGMENT OF
ACQUITTAL OR, IN THE ALTERNATIVE, FOR A NEW TRIAL
GLENN S. LEON, CHIEF
CRIMINAL DIVISION, FRAUD SECTION
U.S. DEPARTMENT OF JUSTICE
EREK L. BARRON
UNITED STATES ATTORNEY
Matthew P. Phelps
Assistant United States Attorney
D. Keith Clouser
U.S. Department of Justice
Criminal Division, Fraud Section
1400 New York Avenue, N.W.
Washington, D.C. 20005
david.clouser@usdoj.gov
COUNSEL FOR THE UNITED STATES
TABLE OF CONTENTS
PROCEDURAL AND FACTUAL BACKGROUND.................................................................... 1
I. THE COURT SHOULD DENY DEFENDANT’S MOTION FOR JUDGMENT OF
ACQUITTAL ...................................................................................................................... 2
1. Defense expert, Hugh Hill, MD, told the jury everything it needed
to know about whether the Defendant’s providers were providing
a Level 4 service. ........................................................................................ 4
2. The code is written in English and the Defendant’s instructions do not
meet the definition of a Level 4. ................................................................. 5
3. Expert testimony that is based on inaccurate, vague, and misleading
medical records has no value. ..................................................................... 7
4. Hybrid expert witnesses and fact witnesses testified that Dr. Elfenbein’s
practitioners were not providing a Level 4 service. .................................... 9
5. Evidence of the defendant’s intent is relevant to falsity. .......................... 12
6. The patients who testified about the charged counts reported brief
encounters that were consistent with the Defendant’s instructions and
inconsistent with Level 4 visits. ................................................................ 13
II. THE COURT SHOULD DENY DEFENDANTS MOTION FOR A NEW TRIAL ....... 15
A. The Weight of the Evidence Supports the Jury’s Verdict..................................... 15
1. The Testimony Of The Government’s Witnesses Was Credible, And
Established The Defendant’s Guilt Beyond A Reasonable Doubt. .......... 16
2. The Defendant’s Testimony Was Not Credible. ....................................... 22
B. The Court’s Evidentiary Rulings Were Correct.................................................... 26
1. The Defendant’s Three Proposed Email Exhibits Were
Properly Excluded ..................................................................................... 27
2. The Court Properly Admitted The Testimony Of A.H. ............................ 33
C. The Court’s Voir Dire Process Did Not Violate Defendant’s Sixth Amendment
Rights .................................................................................................................... 38
CONCLUSION ............................................................................................................................. 40
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INDEX OF EXHIBITS
Exhibit Number Description
Exhibit 1 .............. July 17, 2023 Trial Transcript (Day 1)
Exhibit 2 .............. July 18, 2023 Trial Transcript (Day 2)
Exhibit 3 .............. July 19, 2023 Trial Transcript (Day 3)
Exhibit 4 .............. July 20, 2023 Trial Transcript (Day 4)
Exhibit 5 .............. July 24, 2023 Trial Transcript (Day 5)
Exhibit 6 .............. July 25, 2023 Trial Transcript (Day 6)
Exhibit 7 .............. July 26, 2023 Trial Transcript (Day 7)
Exhibit 8 .............. July 27, 2023 Trial Transcript (Day 8)
Exhibit 9 .............. July 31, 2023 Trial Transcript (Day 9)
Exhibit 10 ............ August 1, 2023 Trial Transcript (Day 10)
Exhibit 11 ............ August 2, 2023 Trial Transcript (Day 11)
Exhibit 12 ............ Government’s Trial Exhibit 137
Exhibit 13 ............ Excerpt from Government’s Trial Exhibit 402
Exhibit 14 ............ Excerpt from Government’s Trial Exhibit 402
Exhibit 15 ............ Excerpt from Government’s Trial Exhibit 402
Exhibit 16 ............ Excerpt from Government’s Trial Exhibit 402
Exhibit 17 ............ Government’s Trial Exhibit 403
Exhibit 18 ............ Government’s Trial Exhibit 404
Exhibit 19 ............ Government’s Trial Exhibit 407
Exhibit 20 ............ Government’s Trial Exhibit 408
Exhibit 21 ............ Government’s Trial Exhibit 409
Exhibit 22 ............ Government’s Trial Exhibit 410
Exhibit 23 ............ Government’s Trial Exhibit 413
Exhibit 24 ............ Government’s Trial Exhibit 414
Exhibit 25 ............ Government’s Trial Exhibit 415
Exhibit 26 ............ Government’s Trial Exhibit 501
Exhibit 27 ............ Government’s Trial Exhibit 502
Exhibit 28 ............ Government’s Trial Exhibit 601
Exhibit 29 ............ Government’s Trial Exhibit 605
Exhibit 30 ............ Government’s Trial Exhibit 606
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Exhibit Number Description
Exhibit 31 ............ Government’s Trial Exhibit 607
Exhibit 32 ............ Government’s Trial Exhibit 608
Exhibit 33 ............ Government’s Trial Exhibit 609
Exhibit 34 ............ Government’s Trial Exhibit 614
Exhibit 35 ............ Government’s Trial Exhibit 617
Exhibit 36 ............ Government’s Trial Exhibit 626
Exhibit 37 ............ Government’s Trial Exhibit 628
Exhibit 38 ............ Government’s Trial Exhibit 629
Exhibit 39 ............ Government’s Trial Exhibit 631
Exhibit 40 ............ Government’s Trial Exhibit 635
Exhibit 41 ............ Government’s Trial Exhibit 638
Exhibit 42 ............ Government’s Trial Exhibit 643
Exhibit 43 ............ Government’s Trial Exhibit 644
Exhibit 44 ............ Government’s Trial Exhibit 645
Exhibit 45 ............ Government’s Trial Exhibit 646
Exhibit 46 ............ Government’s Trial Exhibit 647
Exhibit 47 ............ Government’s Trial Exhibit 654
Exhibit 48 ............ Government’s Trial Exhibit 658
Exhibit 49 ............ Government’s Trial Exhibit 938
Exhibit 50 ............ Defendant’s Trial Exhibit 51
Exhibit 51 ............ Defendant’s Trial Exhibit 214
Exhibit 52 ............ Defendant’s Trial Exhibit 219
Exhibit 53 ............ Defendant’s Trial Exhibit 255
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The United States of America, through undersigned counsel, hereby opposes and responds
to Defendant’s Motion For Judgment Of Acquittal Or, In The Alternative, For A New Trial, ECF
78. For the reasons stated below, the Court should deny Defendant’s motion.
PROCEDURAL AND FACTUAL BACKGROUND
On January 11, 2023, Defendant was charged in a Superseding Indictment with five counts
of execution of a health care fraud scheme, in violation of 18 U.S.C. § 1347. See ECF 29. The
Superseding Indictment alleges that Defendant was an owner and the medical director of Drs
ERgent Care, an urgent care clinic in Maryland that provided drive-through COVID-19 testing. In
addition to billing individuals’ insurance for COVID-19 tests, Defendant required that the COVID-
19 tests and reporting of results be bundled with more lucrative evaluation and management
services that were not provided as represented. That is, the insurance carrier of nearly every patient
who came to Defendant’s clinic for a COVID-19 test was also billed for an evaluation and
management visit of purportedly 30 or more minutes in duration or involving moderate or high
levels of medical decision making. Rather than providing such evaluation and management visits,
Defendant instructed providers that patients were there only to be tested, that the providers were
not there to address complex medical issues, and that patients should be seen in five minutes or
less. Defendant nevertheless instructed the providers to bill for high-level office visits.
On August 4, 2023, following a three-week jury trial during which the government
presented twelve witnesses and introduced more than 120 exhibits and the defense presented
several witness including the Defendant and additional exhibits, Defendant was convicted of all
five counts of health care fraud. Defendant filed a motion for judgment of acquittal or, in the
alternative, for a new trial on August 18, 2023. See ECF 78.
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I. THE COURT SHOULD DENY DEFENDANT’S MOTION FOR
JUDGMENT OF ACQUITTAL
A. Rule 29 Standard
Federal Rule of Criminal Procedure 29 permits a defendant to move for a judgment of
acquittal, or renew such motion, after a guilty verdict. Fed. R. Crim. P. 29(c). In evaluating a
Rule 29 motion, a jury’s verdict commands the respect of the reviewing court, United States v.
Siegelman, 640 F.3d 1159, 1164 (11th Cir. 2011) (noting that jurors are asked to sit through “long
days” of testimony and “pore over countless documents to decide what happened”), and their
judgment is entitled to great deference. United States v. Hicks, 368 F.3d 801, 804 (7th Cir. 2004);
United States v. Mercado, 610 F.3d 841, 845 (3d Cir. 2010) (“We apply a particularly deferential
standard when determining if a jury verdict rests on sufficient evidence”). The task of a defendant
who challenges the sufficiency of the evidence is accordingly a daunting one. United States v.
Curtis, 324 F.3d 501, 505 (7th Cir. 2003); United States v. Seawood, 172 F.3d 986, 988 (7th Cir.
1999) (a defendant making a sufficiency of the evidence challenge bears a heavy burden and faces
a nearly insurmountable hurdle”); United States v. Zambrano, 776 F.2d 1091, 1094 (2d Cir. 1985)
(such challenges are “seldom successful”).
The jury’s verdict must be sustained if there is substantial evidence in the record to support
it. Glasser v. United States, 315 U.S. 60, 80 (1942); United States v. Wilson, 198 F.3d 467, 469
(4th Cir. 1999). In determining whether the evidence in the record is substantial, the court must
view the evidence in the light most favorable to the government, drawing all reasonable inferences
from the evidence in its favor. United States v. Harvey, 532 F.3d 326, 333 (4th Cir. 2008); United
States v. Moye, 454 F.3d 390, 394 (4th Cir. 2006); Hicks, 368 F.3d at 804; United States v.
Tresvant, 677 F.2d 1018, 1021 (4th Cir. 1982) (the government is granted “the benefit of all
reasonable inferences from the facts proven to those sought to be established”). A judgment of
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acquittal should be granted only if “there is no interpretation of the evidence that would allow a
reasonable jury to find the defendant guilty . . . .” United States v. Gomez, 165 F.3d 650, 654 (8th
Cir. 1999) (emphasis added); Moye, 454 F.3d at 394 (conviction can be reversed based upon
insufficiency of the evidence only where the government’s failure is clear); United States v. Jones,
735 F.2d 785, 791 (4th Cir. 1984). If any rational trier of fact could have found the essential
elements of the crime beyond a reasonable doubt, then the jury’s verdict must be sustained.
Jackson v. Virginia, 443 U.S. 307, 319 (1979); Tresvant, 677 F.2d at 1021. Where the evidence
supports differing reasonable interpretations, it is the jury’s responsibility to determine which
interpretation to accept. Moye, 454 F.3d at 394; Wilson, 118 F.3d at 234. And in particular, intent
to defraud may be inferred from the totality of the circumstances, and need not be proven by direct
evidence. Harvey, 532 F.3d at 334.
B. The Government did not need an expert audit to show that Level 4 was
incorrect.
The Defendant claims he is entitled to an acquittal because the Government did not offer
expert testimony that the Defendant’s Level 4 billings for the charged patient encounters were
false. Although the Defendant offered his own expert, Michael Miscoe, his opinions were based
on an audit of inaccurate, vague, and misleading medical records that did not accurately reflect the
interactions between patients and providers at Defendant’s clinic. The Government, by contrast,
adduced evidence that the Level 4 billing was false based on what actually occurred during these
patient encounters. As explained below, the Government offered evidence of falsity through the
Defendant’s own instructions, through testimony from the patients, through testimony from the
Defendant’s employees, and through the sheer volume of the Defendant’s mass-testing operation.
In addition, the inaccurate, vague, and misleading nature of the medical records demonstrated that
the Defendant’s providers were not offering a Level 4 service to their patients.
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1. Defense expert, Hugh Hill, MD, told the jury everything it needed to
know about whether the Defendant’s providers were providing a Level 4
service.
Defense expert, Hugh Hill, MD (“Dr. Hill”), was an emergency room physician at Johns
Hopkins Bayview, and he testified about the level of care and decision-making needed for patients
during the pandemic. Dr. Hill’s testimony showed that the Defendant’s providers could not have
provided a Level 4 service to their patients.
The trial evidence showed that the Defendant’s providers could see more than 100 hundred
patients in one day. One email from the Defendant stated that two providers saw 350 patients in
one day. Exhibit 41 (Gov’t Trial Ex. 638). Before Dr. Hill testified on Monday, July 31st, defense
witness Steven Carroll testified that he saw as many as 170 patients in one day. Exhibit 9 (7/31/23
Tr.) at 15. Dr. Hill responded in disbelief when he was confronted with these facts. See id. at 106.
Dr. Hill testified as follows:
Q. And you’re aware that Dr. Elfenbein’s providers could see
in excess of 150 patients in a day?
A. I doubt if they were seeing that many personally. I do know
that the statistics on this say that a small percentage of
providers can see 5o to 60 patients in a day, depending on
the circumstances.
Q. So you don’t actually believe that they actually – that a single
provider actually saw 150 patients in a day?
A. I do not.
Q. Why not?
A. Because it seems like that’s an excessive burden. …
...
Q. That one nurse practitioner, you would not expect that nurse
practitioner to see 150 patients in a day, would you?
A. I would not.
4
Q. Okay. Why not?
A. Because that’s too many to have time for, even if you’re
working, you know, a 24-hour shift.
Id. at 106-07. But the evidence showed that is exactly what Defendant was telling insurance
companies that his providers were doing—conducting moderate complexity, level 4 office visits
on hundreds of patients a day at drive-through COVID-19 testing sites. See, e.g., Exhibit 41 (Gov’t
Trial Ex. 638) (“Our volumes continue to explode. Jimmy and Crystal yesterday s[aw] over 350
people. It was amazing.”), Exhibit 42 (Gov’t Trial Ex. 643) (“EH opened this week and we are
already seeing over 150[.]”). Defendant even offered bonuses to providers who saw more than
100 people in a day. Exhibit 43 (Gov’t Trial Ex. 644) (“Additionally and this is in perpetuity, we
will pay $5/patient for every patient you see over 100.”); Exhibit 44 (Gov’t Trial Ex. 645) (“If you
see more then 100 patients you get 1 hour of paid time to chart. If you see more than 150 patients
you get 1 more hour to chart.”). Dr. Hill’s testimony, without more, shows that the Defendant’s
Level 4 billing scheme was false.
2. The code is written in English and the Defendant’s instructions do not
meet the definition of a Level 4.
Defense counsel told the jury during closing argument that the jury should not use common
sense to evaluate this case. That is because the Defendant’s billing instructions were not consistent
with a common-sense reading of the CPT Code and its accompanying resources.
For example, the 2020 CPT code for 99204 required “moderate complexity” decision
making and, “typically,” the visit was expected to last 45 minutes. ECF 78, Ex. 3 (2020 CPT
Manual) at 13. The 2021 CPT code for 99204 required a “moderate level” of medical decision
making. ECF 78, Ex. 4 (2021 CPT Manual) at 19. By contrast, the Defendant told his providers
that “[w]e are not there to solve complex medical issues, etc… Just to test them.” and “we want
them in and out of the tent in under 5 minutes total.” Exhibit 47 (Gov’t Trial Ex. 654). Both the
5
2020 and 2021 CPT Codes for 99202 (Level 2) required “straightforward” medical decision-
making. See ECF 78, Ex. 3 at 13, Ex. 4 at 18. Dr. Elfenbein told one of his providers, “the patients
are all here for one reason . . . . simple and straightforward-to get tested[.]” Exhibit 45 (Gov’t
Trial Ex. 646). A common-sense application of the CPT Code to the defendant’s billing
instructions shows that Level 4 billing was false.
The CPT Coding resources cited by the defense also showed that the defendant’s billing
instructions were false. Both the Novitas and AMA scoring sheets provide for moderate
complexity decision making when treating an “undiagnosed new problem with uncertain
prognosis.” The example offered in both the Novitas scoring sheet and in the 2021 CPT Code is
“lump in breast.” To justify his coding instructions, Dr. Elfenbein had to equate a healthy,
asymptomatic, vaccinated person who just needed a test for an administrative reason with a patient
who had a lump in their breast. See Exhibit 11 (8/2/23 Tr.) at 126-27. Similarly, Dr. Elfenbein
testified that a patient who had been diagnosed with COVID-19 and needed a test to return to work
had an “undiagnosed new problem.”1 Id. at 171.
The Defendant’s explanations were not credible. His explanations were pretext for billing
a level 4 when, in fact, the Defendant knew he was churning through patients like a “herd of cattle.”
See Exhibit 48 (Gov’t Trial Ex. 658) (provider stating “I feel there is constant pressure of moving
a herd of cattle through a pass at 60 heads per minute!!”)
1
The defense further argues that the ICD 10 diagnosis code for exposure to COVID-19 mandated
a finding that a patient had an “undiagnosed new problem.” See ECF 78 at 26-27. This mandate
does not appear anywhere. The only people to suggest such a “mandate” are the defendant and his
expert. As explained in several places herein, the defendant’s theory that every patient who
showed up for testing had an “undiagnosed new problem of uncertain prognosis” was not credible.
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3. Expert testimony that is based on inaccurate, vague, and misleading
medical records has no value.
The evidence showed that the medical records—which were templates created by the
Defendant—were inaccurate, vague, and misleading. Neither the Government nor the Defendant
could not have obtained a reliable expert opinion based on these records, and the jury agreed.
The trial evidence showed that the medical records were inaccurate. Patient A.H. disagreed
with significant portions of her records. Exhibit 3 (7/19/23 Tr.) at 108-110. Patient W.R.’s record
is an in-person record with a full physical exam even though the visit took place by video and the
“physical exam” consisted of Patient S.T. leaning back in her seat so that Provider Kathy Wrona
could see W.R. on the screen across the car. See Exhibit 19 (Trial Ex. 407)2 at 6-9; Exhibit 5
(7/24/23 Tr.) at 99-102. D.M.’s medical record indicated that she was negative for COVID-19 but
later the record stated she was positive. Exhibit 18 (Trial Ex. 404) at 4-6. The medical records
often stated that a patient was exposed to person with COVID-19 when hand-written registration
documents completed by the patient indicated that they were not exposed.
The medical records were also vague. Defendant’s templated language for the medical
records contained generic descriptions of patient encounters that did not inform what treatment, if
any, was provided to a particular patient. The Government showed that the same care plan was
used for multiple patients, each of whom had a different presentation. See, e.g., Exhibit 13
(Excerpt from Gov’t Trial Ex. 402) at 5; Exhibit 14 (Excerpt from Gov’t Trial Ex. 402) at 4; Exhibit
15 (Excerpt from Gov’t Trial Ex. 402) at 3; Exhibit 16 (Excerpt from Gov’t Trial Exhibit 402) at
5. Two of the patients were sick, one needed a test to travel, and one needed a test prior to
2
Although redacted versions of each of the patient records was discussed in open court during
trial, the government has applied additional redactions to these records for purposes of this filing
to remove patient identifying information including full names.
7
undergoing surgery. Id. Every care plan contained generic phrases like “patient to follow current
CDC guidelines,” “advised patient to monitor AM and PM temps,” “Tylenol prn fever and
bodyaches,” “Full PPE was worn,” “All questions asked and answered.” Id.
Finally, the medical records were misleading. The Government introduced multiple emails
written by the Defendant where he implored his providers to document “SOMETHING” about
why the patient is there to be tested. See, e.g., Exhibit 29 (Gov’t Trail Ex. 605); Exhibit 31 (Gov’t
Trial Ex. 607); Exhibit 33 (Gov’t Trial Ex. 609). Deborah Needle testified that these emails were
“concerning” because “it implies that we need to find something to document even if it’s not
there.” Exhibit 5 (7/24/23 Tr.) at 143. This is likely why the template was drafted to state that a
patient was exposed to COVID-19 when, in fact, many patients were seen for administrative
reasons such as for work or travel.
The call-back records are perhaps the best examples of the misleading records. Here is the
medical record related to a phone call that A.H. testified “couldn’t have been more than one
minute”:
Exhibit 17 (Gov’t Ex. 403) at 6; Exhibit 3 (7/19/23 Tr.) at 111. This misleading, vague medical
gibberish becomes even more absurd in light of the repeated usage of this language. Patient S.T.
received one phone call to report the results for her family, but the medical records claim that S.T.
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and each of her triplets spoke “at length” with the provider and that “[i]n excess of 32 minutes”
was spent on various issues for each patient. See Exhibit 20 (Gov’t Trial Ex. 408) at 6; Exhibit 21
(Gov’t Trial Ex. 409) at 6; Exhibit 22 (Gov’t Trial Ex. 410) at 12; and Exhibit 23 (Gov’t Trial Ex.
413) at 31.
4. Hybrid expert and fact witnesses testified that Dr. Elfenbein’s
practitioners were not providing a Level 4 service.
Fact witnesses who possess training and skill beyond that of a lay person, but who are not
otherwise designated as experts, are often considered “hybrid” experts. See, e.g., Adell Plastics,
Inc. v. Mt. Hawley Ins. Co., 2019 WL 2359441, *1 (D. Md. June 4, 2019) (describing hybrid
expert/fact witnesses as giving testimony “arising out of personal observations made in the normal
course of duty.”) (internal quotation marks omitted). Several witnesses with such training and
skill testified at trial, including Cathy Raymond, Courtney Sinagra (as a representative of
CareFirst), Steven Carroll, and Suzanna Silva.
Cathy Raymond was a Certified Professional Coder who worked for the Defendant from
2017 until she quit in protest in October 2020. See Exhibit 4 (7/20/23 Tr.) at 79, 85. She testified
that she told the Defendant that she was seeing unsupported level 4 and level 5 office visits. See
id. at 84. During cross-examination, the defense highlighted that Raymond did not specifically
address the Defendant’s use of Level 4 billing, but Raymond clarified that while she may not have
used the words “Level 4,” she raised issues with the “pattern” of billing, and that pattern included
Level 4 and Level 5. See Exhibit 5 (7/24/23 Tr.) at 55, 90.
The Defendant reduces Raymond’s concerns to “documentation” concerns, suggesting that
her concerns were just a matter of paperwork and not a concern about medical decision making.
Raymond’s concerns, however, go to the heart of the Government’s fraud theory. Raymond saw
systemic billing of Level 4 and Level 5 office visits that were not supported by the medical records.
9
The obvious explanation for her observations was that the Defendant’s providers were each
churning through more than 100 patients per day.
The Government also called Courtney Sinagra, as a representative of CareFirst Blue
Cross/Blue Shield to testify about two audits of First Call performed by CareFirst. CareFirst’s
second audit was performed by a Certified Professional Coder and a Registered Nurse. See Exhibit
27 (Gov’t Trial Ex. 502) at 2; Exhibit 53 (Def. Trial Ex. 255). Courtney Sinagra was also a
Certified Professional Coder and she testified on behalf of CareFirst that, as to the second audit in
particular, none of the 89 patient records reviewed met the Level 4 billing criteria. Exhibit 6
(7/25/23 Tr.) at 21, 56-57. The medical records reviewed by CareFirst during the second audit
were similar to the medical records for the charged encounters; they contained inaccuracies and
generic care plans that gave no meaningful insight into the care provided to the patient. See, e.g.,
Exhibit 13 (Excerpt from Gov’t Trial Ex. 402) at 5; Exhibit 14 (Excerpt from Gov’t Trial Ex. 402)
at 4; Exhibit 15 (Excerpt from Gov’t Trial Ex. 402) at 3; Exhibit 16 (Excerpt from Gov’t Trial
Exhibit 402) at 5. The jury was entitled to rely on Ms. Sinagra’s testimony and on the CareFirst
audit to conclude that the five charged encounters were false.
Two providers called by the defense, Steven Carroll and Suzanna Silva, also had billing
training and admitted that using Level 4 for every patient visit was not appropriate. Carroll, for
example, admitted that Defendant’s “in and out of the tent in under 5 minutes” instruction did not
describe a level 4 encounter. Exhibit 9 (7/31/23 Tr.) at 40-41. The Government also cross-
examined Carroll with this own treatment records for a patient who came to First Call regularly to
be tested for work. He testified as follows:
Q. And why did the patient come to FirstCall?
A. Needs a test for work.
Q. How’d you code the office visit?
10
A. 99214.
Q. And is the care plan identical to the last care plan we just
saw?
A. Yes.
Q. Do you think that’s a level 4 decision making, Mr. Carroll?
A. No.
Q. This visit should not have been a level 4.
A. No.
Id. at 43.
Suzanna Silva testified that she received training on medical billing at her previous
employer, and she testified that she—not the defendant—decided how to code her office visits.3
Exhibit 10 (8/1/23 Tr.) at 105-06. She testified that when she saw patients in-person at the FedEx
Field location, she coded the office visit as a level 3: “if the patient circumstance was extremely
straightforward, such as they simple needed a test for travel or work and were having absolutely
no symptoms, I didn’t need to take time consulting with them, helping them with any concerns,
then I might code those as a level 3.” Id. at 110. Ms. Silva added that she “may have billed more
3s at Earleigh Heights given that my exam was more limited.” Id. Defendant, in contrast,
instructed one of his providers that Level 3 was “never” appropriate. Exhibit 39 (Gov’t Trial Ex.
631).
Fact witnesses also supplied evidence that the billing was false. Deborah Needle, another
provider at First Call, testified that she had some familiarity of medical billing, and that she did
not think it was appropriate to bill all asymptomatic patients as a level 4 and all symptomatic
3
Silva also joined the practice 18 months after the pandemic began.
11
patients as a level 5. See Exhibit 5 (7/24/23 Tr.) at 139 (“I didn’t feel that an asymptomatic patient
warranted a level 4.”) Needle also provided key testimony about the Defendant’s billing scheme.
When Needle initially confronted the Defendant and expressed disagreement, he told her to “do
what [she] felt was appropriate.” Id. at 151. Yet, “that same day [Defendant] sends out an e-mail
again with the guidelines of level 4s and 5s.” Id.
David Turner, the owner and President of BlueFish Medical, also provided evidence that
Dr. Elfenbein’s billings were false. Centennial Medical Group was the management company for
the Defendant’s medical practice and also for a much larger medical practice led by Dr. Rajeev
Dua. Dr. Dua’s practice also provided COVID-19 testing services in Maryland. BlueFish
provided services to both Dr. Dua’s practice and Defendant’s practice, and Turner testified that
Dr. Dua’s E/M coding practices “were more conservative.” Exhibit 3 (7/19/23 Tr.) at 181. The
jury could have relied on this testimony to determine that the five charged patient encounters were
false.
5. Evidence of the defendant’s intent is relevant to falsity.
The jury could also have also determined that the claims for the five charged encounters
were false because the defendant intended to submit false claims. In other words, when evaluating
falsity, the jury was not limited to the four corners of the medical records. The jury could
reasonably infer that the claims were false because the evidence of the Defendant’s intent showed
that he intended to submit false claims. Evidence of the defendant’s intent is more-thoroughly
discussed in the response to the Motion for a New Trial, but the Government showed at trial,
among other things, that: (1) the defendant acted with a financial motive; (2) the defendant’s claim
to have used the Novitas and AMA scoring sheets was uncorroborated by any witness, email, or
document; (3) the Defendant disregarded billing recommendations from his business partner and
his Certified Professional Coder; and (4) when confronted by Cathy Raymond or Deborah Needle
12
he either told them to bill what they felt was appropriate only to follow up with an email directing
his level 4 billing or her ignored them. See Exhibit 28 (Gov’t Trial Ex. 601) (“there has to be a
way to bill higher level”); Exhibit 11 (8/2/23 Tr.) at 187 (“Q. And we don’t see any e-mails where
you use the phrase ‘new undiagnosed problem with uncertain prognosis’? We haven’t seen any
of those e-mails, have we? . . . A. I don’t think so.”); Exhibit 32 (Gov’t Trial Ex. 608) (“let’s try
it”); Exhibit 5 (7/24/23 Tr.) (Needle testifying that she “felt like [she] was being avoided.”);
Exhibit 4 (7/20/23 Tr.) at 84 (Raymond testifying “After the first time I raised a concern, he
acknowledged my concern and he had backed off . . . However, a couple weeks later, he was back
at it[.]”).
6. The patients who testified about the charged counts reported brief
encounters that were consistent with the Defendant’s instructions and
inconsistent with Level 4 visits.
The grand jury charged the Defendant with five separate executions of his scheme, four of
which related to patients who testified at trial. Four of the patients testified at trial, and one of the
patients, S.T., testified about the fifth patient, W.R., who was her father. Each patient had different
circumstances that brought them to First Call, but they all recounted the same perfunctory
encounter that did not rise to a level 4 service.
A.H. testified that the person who swabbed her nose only asked a few questions but did not
provide any substantive care. See Exhibit 3 (7/19/23 Tr.) at 106. S.T., who was vaccinated and
asymptomatic, testified that the examination and discussion for her and her three children lasted a
combined 10 minutes, even though Defendant’s company billed their insurance company for Level
4 visits for all of them. Exhibit 5 (7/24/23 Tr.) at 99-102. S.T. testified that W.R.’s visit, at which
S.T. was present, lasted less than five minutes and the provider’s exam of W.R. consisted of S.T.
leaning back in the driver’s seat of her car so the provider on the screen could see W.R. in the
passenger seat across the car. Id. at 108-09. D.M., who was vaccinated and asymptomatic,
13
testified that she spoke to a provider on a screen for about five minutes. See Exhibit 4 (7/20/23
Tr.) at 68-70. J.J., who was experiencing symptoms and had a history of asthma, testified that she
spoke to a provider for 2 minutes. See Exhibit 6 (7/25/23 Tr.) at 6, 12
Their collective experience mirrored the Defendant’s instructions to his providers to see
patients in under five minutes, that these were “simple and straightforward” encounters, and that
providers were not to solve complex medical issues. See Exhibit 45 (Gov’t Trial Ex. 646); Exhibit
46 (Gov’t Trial Ex. 647). The defendant’s statement that “[p]atients just want to get tested and go
home” was largely correct. See Exhibit 45 (Gov’t Trial Ex. 646). S.T. had three young children
and wanted the convenience of a drive-thru. See Exhibit 5 (7/24/23 Tr.) at 98. J.J. testified that
she did not go to First Call to see a doctor, she went there to get a COVID-19 test. See Exhibit 6
(7/25/23 Tr.) at 20. (“Q. Ms. Jones, were you going to Earleigh Heights to see a doctor? A. No.
Q. What were you going to Earleigh Heights for? A. To get tested for COVID.”)
The Defendant commonly refers to the medical records as evidence that medical decisions
must have been made by the provider. See, e.g., ECF No. 78 at 22. But the template medical
records, which were vague, misleading, and inaccurate, and which were “100% done for you,” do
not prove that medical decision making was actually rendered by the provider. See Exhibit 48
(Gov’t Trial Ex. 658) (“the template I built for this is 100% done for you. How much simpler can
that get?”) Even Mr. Miscoe admitted that medical decision making is the “cognitive labor a
provider puts into the encounter.” No such cognitive labor was expended by the providers here.
The Defendant also points to each patient’s “limited recollection” of the encounter. See,
e.g., ECF No. 78 at 21. Their recollections were limited because the encounters were so brief.
Presumably, if the patient had met with an oncologist about a lump in their breast, then they would
have a better memory of it.
14
The Defendant also argues that he is entitled to an acquittal as to patient A.H. because A.H.
testified that she never saw a provider, and the Defendant never instructed his providers to test
patients without seeing them. The Defendant implemented a scheme to bill for level 4 office visits
that he knew were not occurring, and that was just has much true for A.H. as it was for any of the
other charged patient encounters. Further, that his providers may have seen a patient so quickly
that the patient did not perceive it as a provider encounter is a foreseeable consequence of the
Defendant’s instructions. See, e.g., Exhibit 35 (Gov’t Trial Ex. 617) (“[E]ntire patient encounter
and chart took 20 seconds”).
II. THE COURT SHOULD DENY DEFENDANT’S MOTION FOR A NEW
TRIAL
The Court should reject the Defendant’s Motion for a New Trial because the weight of the
evidence supports the jury’s verdict, the evidentiary rulings by the Court were consistent with the
law and the facts of the case, and conducting voir dire without public spectators does not violate
the Defendant’s Sixth Amendment right to a public trial. Federal Rule of Criminal Procedure 33
permits a defendant to move for a new trial “if the interest of justice so requires.” Fed. R. Crim.
P. 33(a). For these reasons, the Defendant’s motion should be denied.
A. The Weight of the Evidence Supports the Jury’s Verdict
As explained above, the evidence presented at trial was more than sufficient for a
reasonable juror to conclude the defendant committed each count of conviction. The Fourth
Circuit has explained that to determine whether a new trial is warranted based on the weight of the
evidence, “the court examines the evidence as a whole to determine whether it ‘preponderates
sufficiently heavily against the verdict that a serious miscarriage of justice may have occurred.’”
United States v. Rafiekian, 68 F.4th 177, 189 (4th Cir. 2023). “District courts should grant new
trials based on the weight of the evidence only in ‘rare’ instances.” Rafiekian, 68 F.4th at 186.
15
“Merely believing that the case could have come out the other way is not enough to warrant a new
trial.” Rafiekian, 68 F.4th at 186. “A district court should grant a new trial based on the weight
of the evidence ‘only when the evidence weighs heavily against the verdict.” United States v.
Saint Louis, 889 F.3d 145, 157 (4th Cir. 2018); United States v. Wilson, 118 F.3d 228, 237 (4th
Cir. 1997) (“[D]istrict court should exercise its discretion to grant a new trial ‘sparingly’”).
Because “’determining witness credibility and weighing conflicting evidence are the responsibility
of the factfinder,’ [] ‘the standard for jettisoning a jury verdict in favor of a new trial’ is
‘demanding.’” Rafiekian, 68 F.4th at 186-87 (quoting United States v. Arrington, 757 F.2d 1484,
1485 (4th Cir. 1985) and United States v. Millender, 970 F.3d 523, 532 (4th Cir. 2020)) (internal
citations and some quotation marks omitted).
No new trial is warranted here. The evidence presented at trial, taken as a whole,
establishes that Defendant engaged in a scheme to defraud Medicare and other insurers by billing
those insurers for high-level office visits that did not occur as represented for every patient who
came to the Defendant’s clinic for a COVID-19 test. The Defendant decided on the level of office
visit he was going to bill before the patient ever presented for service, without regard to the
patient’s health or reason for testing. This was a one-size-fits-all billing scheme.
The evidence demonstrates that the claims submitted by Defendant’s company for level 4
office visits for COVID-19 testing patients was false and fraudulent, and that Defendant knew and
intended that these claims were false.
1. The Testimony Of The Government’s Witnesses Was Credible, And
Established The Defendant’s Guilt Beyond A Reasonable Doubt.
As discussed above in Section I, the Government introduced ample evidence from which
the jury found the Defendant guilty beyond a reasonable doubt. This included testimony from
Defendant’s former employees, testimony from a representative of the third-party billing company
16
used by Defendant to submit claims, testimony from representatives of Medicare and CareFirst,
and testimony from patients who went to Defendant’s COVID-19 drive-through testing site for
COVID-19 tests. In addition, the government presented documentary evidence, including claims
data, medical records, and e-mails showing the scheme. This evidence demonstrated that the
claims submitted at Defendant’s direction were false, that Defendant knew they were false, and
that Defendant intended to submit false claims to obtain higher reimbursement.
The evidence presented by the Government was credible and consistent, and strongly
supported the verdict rendered by the jury. In contrast, the Defendant’s testimony was not credible,
and the Defendant’s expert, Michael Miscoe, rendered an opinion that was based on inaccurate
medical records and defies logic. The evidence presented does not “preponderate sufficiently
heavily against the verdict,” and the Defendant’s motion for a new trial should be denied.
a) Defendant Implemented a Scheme To Defraud
The evidence presented at trial established that Defendant implemented a plan to bill for
Level 4 visits for every COVID-19 test with an additional level 4 visit. Defendant did so by
instructing his providers repeatedly to code all COVID-19 testing patients with additional Level 4
office visits, and creating templated medical records that included the Level 4 codes. In email
after email, starting as early as April 25, 2020, the Defendant instructed his employees that every
asymptomatic COVID-19 testing patient should be billed at level 4. See Exhibit 29 (Gov’t Trial
Ex. 605), Exhibit 30 (Gov’t Trial Ex. 606), Exhibit 31 (Gov’t Trial Ex. 607), Exhibit 34 (Gov’t
Trial Ex. 614), Exhibit 36 (Gov’t Trial Ex. 626), Exhibit 37 (Gov’t Trial Ex. 628), Exhibit 38
(Gov’t Trial Ex. 629), Exhibit 39 (Gov’t Trial Ex. 631), Exhibit 40 (Gov’t Trial Ex. 635), Exhibit
47 (Gov’t Trial Ex. 654); see also Exhibit 5 (7/24/23 Tr.) at 138-39 (Provider Needle testifying
that Defendant instructed her to bill all COVID-19 patients for Level 4 E/M visit). The evidence
also confirmed that Defendant prepared templated medical records and instructed providers to use
17
the templates. For example, in an email to one of his providers, Defendant stated that “the template
[he] built for this is 100% done for you. How much simpler can that get?” Exhibit 48 (Gov’t Trial
Ex. 658).
And the employees followed Defendant’s instructions. The Defendant was the medical
director of the clinic. See, e.g., Exhibit 48 (Gov’t Trial Ex. 658) (Defendant’s email stating “I am
medical director and will change the process when I feel it best—that is my prerogative and
responsibility.”). The testimony from the providers confirms that they relied on Defendant’s
instructions, and coded COVID-19 testing patients for an additional level 4 office visit. See, e.g.,
Exhibit 9 (7/31/23 Tr.) at 27 (Provider Carroll testifying that the Defendant instructed him by email
to bill COVID-19 test patients at level 4, and he followed that instruction); Exhibit 7 (7/26/23 Tr.)
at 36 (Provider Wrona testifying that she relied on the emails from Defendant and the templated
CPT coding). The claims data corroborates their testimony. See, e.g., Exhibit 12 (Gov’t Trial Ex.
137) (summary chart showing nearly every COVID-19 test was billed with Level 4 office visit).
Nearly every patient who received a COVID-19 test at Defendant’s clinic was billed on that same
day for a level 4 office visit. Id.
The evidence also showed that Defendant decided on his scheme to bill every
asymptomatic COVID-19 testing patient for an additional Level 4 office visit early in the pandemic
in order to increase the amount of money he would get from insurers. For example, as early as
March 18, 2020, Defendant’s former biller, Cathy Raymond, suggested using level 1 evaluation
and management coding for COVID-19 testing patients. Exhibit 28 (Gov’t Trial Ex. 601)
(suggesting 99201 code). Defendant responded that “[t]here has to be a way to bill higher level
on these” to increase reimbursement. Id. The Government also introduced several emails in which
Defendant confirmed that reimbursement rates were the motive for billing Level 4 visits. For
18
example, Defendant repeatedly confirmed that evaluation and management coding was the “bread
and butter” of how they get paid, See, e.g., Exhibit 37 (Gov’t Trial Ex. 628), Exhibit 40 (Gov’t
Trial Ex. 635), and “a 99202 pays way less than a 99204.” Exhibit 40 (Gov’t Trial Ex. 635).
Defendant was telling his providers to raise the level of coding because “[t]he difference in coding
of one level can be over a hundred dollars, so it is not inconsequential.” Exhibit 39 (Gov’t Trial
Ex. 631).
By instructing his providers to code every COVID-19 testing patient for a level 4 office
visit in addition to the COVID-19 test, Defendant was telling Medicare and other insurers that
every patient was receiving an “office or other outpatient visit for the evaluation and management
of a [new or existing] patient, which requires a medically appropriate history and/or examination
and moderate level of medical decision making.” See ECF 78, Ex. 4 at 19 (2021 CPT Code
Manual) (also introduced as Gov’t Trial Ex. 903).4 As discussed above in Section I, the evidence
presented at trial established that the services being provided at Defendant’s direction were not
moderate complexity office visits. The Government presented evidence of the E/M code
definition, and what services were being represented by the Level 4 E/M codes. The Government
presented testimony from patients and providers who testified the services provided were not Level
4 E/M visits. The Government presented testimony from CareFirst regarding its audits of
Defendant’s billing, in which multiple certified professional coders concluded the services
4
In 2020, the guidelines for CPT codes 99204 and 99214 similarly involved medical decision
making of moderate complexity. See ECF 78, Ex. 3 at 13 (2020 CPT Code Manual) (also
introduced as Gov’t Trial Exhibit 902). In the 2020 guidelines, the CPT manual provides “typical”
times—for 99204, “typically, 45 minutes are spent face-to-face with the patient and/or family” and
for 99215, “typically, 25 minutes are spent face-to-face with the patient and/or family.” Id. at 13-
14. The CPT manual states that “[t]he inclusion of time as an explicit factor beginning in CPT
1992 is done to assist in selecting the most appropriate level of E/M services.” Id. at 8.
19
provided by Defendant’s company were not Level 4 E/M visits. And the Government presented
emails from the Defendant instructing his providers to provide services inconsistent with Level 4
E/M visits. All of this evidence strongly supports the jury’s determination that the claims
submitted by Defendant’s company were false.
b) Defendant’s Acted Knowingly and Willfully
The evidence showed that Defendant acted knowingly and willfully in pursuing this
scheme to defraud. As discussed above, the evidence presented at trial established that Defendant
was the person who decided what codes to bill, and was telling his providers to bill for moderate
complexity, Level 4 E/M visits. See Exhibit 29 (Gov’t Trial Ex. 605), Exhibit 30 (Gov’t Trial Ex.
606), Exhibit 31 (Gov’t Trial Ex. 607), Exhibit 34 (Gov’t Trial Ex. 614), Exhibit 36 (Gov’t Trial
Ex. 626), Exhibit 37 (Gov’t Trial Ex. 628), Exhibit 38 (Gov’t Trial Ex. 629), Exhibit 39 (Gov’t
Trial Ex. 631), Exhibit 40 (Gov’t Trial Ex. 635), Exhibit 47 (Gov’t Trial Ex. 654); see also Exhibit
5 (7/24/23 Tr.) at 138-39 (Provider Needle testifying that Defendant instructed her to bill all
COVID-19 patients for Level 4 E/M visit). At the same time, Defendant was telling his providers
that they were “not there to solve complex medical issues, etc… Just to test them.” Exhibit 46
(Gov’t Trial Ex. 647). The patient “is there for one reason only-to be tested. Goal is to get them
seen and out quickly (we want them in and out of the tent in under 5 minutes total).” Id. “Speed
here is key.” Exhibit 45 (Gov’t Trial Ex. 646). “The patients are all here for one reason…. simple
and straightforward-to get tested.” Id.
Multiple employees, including Defendant’s at-the-time certified professional coder, raised
concerns about the level of coding Defendant was instructing providers to use for COVID-19
testing patients. For example, Cathy Raymond was Defendant’s biller, and a certified professional
coder that had worked for Defendant for several years prior to the COVID-19 pandemic. See
Exhibit 4 (7/20/23 Tr.) at 79. Raymond testified that during the pandemic, for the first time,
20
Defendant was instructing patients on what codes to bill for patients. Id. at 83-84. Raymond
testified that she raised concerns about the coding instructions to Defendant multiple times,
verbally and in writing. Id. at 84. The concern she raised was with the pattern of over-coding she
was seeing—that every COVID-19 testing patient was being billed for level 4 and level 5 office
visits. Exhibit 5 (7/24/23 Tr.) at 20-23, 55 (“The pattern included that level 4, though.”); Id. at 90
(“[T]here was a consistent pattern of level 4s and level 5s being billed but without the appropriate
documentation level to support it.”). Raymond testified that Defendant ignored her concerns, and
continued to instruct providers to bill COVID-19 testing patients for level 4 and level 5 office
visits in addition to COVID-19 tests. See Exhibit 4 (7/20/23 Tr.) 84-86; Exhibit 5 (7/24/23 Tr.) at
11-12. Ultimately, Raymond testified, she reported her concerns to the government and resigned
from her position because “the situation that was going on with the over coding was not a situation
that [she] could stay in.” Exhibit 5 (7/24/23 Tr.) at 11, 16-17.
Provider Deborah Needle, a nurse practitioner who worked for Defendant’s clinic, testified
that Defendant gave instructions on how to code COVID-19 testing patients, and that his
instruction was to code all COVID-19 testing patients at level 4 at the very least. See id. at 138-
139. Needle did not agree with those instructions. Id. at 139. Needle testified that she raised her
concerns about the coding level with Defendant, and he responded by reiterating his instruction
that all COVID-19 testing patients should be billed for an additional level 4 office visit at a
minimum. Id. at 139-140. Needle testified that Defendant was “never available” to answer her
concerns, and she “felt like [she] was being avoided.” Id. at 146.
Defendant’s company was audited twice during the scheme. Exhibit 26 (Gov’t Trial Ex.
501), Exhibit 53 (Def. Trial Ex. 255); Exhibit 6 (7/25/23 Tr.) at 28. In both audits, CareFirst
determined that the Defendant’s company was billing for services not provided as represented.
21
Exhibit 26 (Gov’t Trial Ex. 501), Exhibit 53 (Def. Trial Ex. 255); Exhibit 6 (7/25/23 Tr.) at 33-34,
53-57. These audit results were communicated to the Defendant’s company. See Exhibit 26
(Gov’t Trial Ex. 501), Exhibit 53 (Def. Trial Ex. 255); Exhibit 6 (7/25/23 Tr.) at 33 (first audit
report sent to Defendant’s company address).
The evidence presented at trial strongly supports the jury’s determination that the
Defendant acted knowingly and willfully.
2. The Defendant’s Testimony Was Not Credible.
Defendant’s contention that every patient encounter in which a patient received a COVID-
19 test at his clinic qualified to be coded at level 4 is not supported by the evidence and is not
credible. Defendant and his expert, Michael Miscoe, testified that every patient encounter
involving a rapid and PCR COVID-19 test automatically qualifies for level 4 coding. Exhibit 10
(8/1/23 Tr.) at 63 (Michael Miscoe testimony: “Q. Your opinion is that every patient who got a
COVID test and got two tests with one reviewed, regardless of status, regardless of diagnosis,
regardless of risk, necessarily involved the second-highest level of medical decision making, right?
A. That’s the way it scores out.”); Exhibit 11 (8/2/23 Tr.) at 182 (Defendant testimony: “Q. Is there
moderate decision making with respect to every patient who walks in the door during the
pandemic? A. According to the chart, yes. Q. So everywhere in this country during the pandemic,
as soon as [the] patient walks in the door, regardless of what they’re there for, because they existed
in society, they at least get that new problem with uncertain prognosis? A. If they’re getting two
tests for COVID and it’s in 2021, yes.”).
There is not a shred of evidence that corroborates that opinion. In fact, the evidence showed
precisely the opposite. Guidance issued during the pandemic (and on which Defendant and his
22
expert purported to rely in part)5 made clear that COVID-19 testing in and of itself did not
automatically qualify every encounter as level 4. See, e.g., Exhibit 51 (Def. Trial Ex. 214) (CMS
Transmittal: “Physician’s and NPPs must use CPT code 99211 to bill for a COVID-19 symptom
and exposure assessment and specimen collection provided by clinical staff . . . incident to the
physician’s or NPP’s services.”), Exhibit 52 (Def. Trial Ex. 219) (CMS Interim Final Rule: “For
the duration of the COVID-19 PHE, we are therefore finalizing on an interim basis that when the
services described by CPT code 99211 for a level 1 E/M visit are furnished for the purpose of a
COVID-19 assessment and specimen collection, the code can be billed for both new and
established patients. We believe this policy will support expanded access to COVID-19 testing,
and provide appropriate payment for COVID-19 test-related services furnished by physician and
other practitioners.”) (emphasis added). The contention that every individual who received a
COVID-19 test always qualified for a Level 4 evaluation and management visit does not pass the
smell test. For example, as Defendant’s expert was forced to concede, such an interpretation would
necessarily mean that it would not matter if the provider saw the patient for 20 seconds. See
Exhibit 10 (8/1/23 Tr.) at 33-35 (Defendant’s expert suggesting a 20 second encounter could be
Level 4), 50 (“Q. [] So your opinion that your expressing to the jury today is, if a medical assistant
at a drive-through COVID testing site does a swab, and does a symptom and exposure assessment,
if the provider is on a screen for 20 seconds or 40 seconds just to look at that patient, it all of a
5
Defendant could not decide whether he did or did not search for relevant CPT code guidance
when he was purportedly determining the coding level. Compare Exhibit 11 (8/2/23 Tr.) at 132
(Defendant Direct Testimony that “there was a new table that was being put out by the American
Medical Association, along with the CPT guidelines” and Defendant “conduct[ed] an analysis”
using that chart) and 136 (Defendant Direct Testimony that he “started to Google other sources”)
with Exhibit 11 (8/2/23 Tr.) at 161-162 (Defendant Cross Testimony that “I looked for a lot of
things. I don’t remember specific looking for the AMA guidelines on coding.”) and 168
(Defendant Cross Testimony that he doesn’t specifically recall guidance from the AMA).
23
sudden goes from a level 1 visit as instructed by CMS to a moderate complexity office visit, the
second-highest level of office visit[?] A. As soon as the provider gets involved. I mean, that’s
just the way the medical decision making scores. I didn’t write the rules.”).
Moreover, Defendant’s testimony was directly contradicted by the testimony of other fact
witnesses and was inconsistent with his own emails. For example, Defendant testified that Cathy
Raymond never expressed any concerns with Defendant about coding levels. Exhibit 11 (8/2/23
Tr.) at 49 (“Q. Did she ever express any concerns to you about coding levels? A. No, she did
not.”). In contrast, Ms. Raymond testified that she repeatedly raised concerns about the pattern of
coding at Defendant’s company. Exhibit 4 (7/20/23 Tr.) at 84-86. That “pattern” of coding
included billing COVID-19 testing patients for Level 4 E/M visits. Exhibit 5 (7/24/23 Tr.) at 20-
23, 55 (“The pattern included that level 4, though.”); Id. at 90. Dr. Elfenbein also testified that
Deborah Needle never expressed any concerns with Defendant about his billing instructions.
Exhibit 11 (8/2/23 Tr.) at 161 (“Q. And Deborah Needle expressed the same concern about your
billing instructions, correct? A. She did not. Q. So she did not express concerns with your billing
instructions? A. Not to me, she did not.”). Again, in contrast, Ms. Needle testified that she did
raise her concerns with the Defendant. Exhibit 5 (7/24/23 Tr.) at 139-140 (“Q. Did you ever tell
Dr. Elfenbein that you disagreed with his instructions? A. I told him that I had questions and
concerns, yes. Q. And what exactly did you tell him? A. I told him that I felt like the codes didn’t
– I felt that the level was higher than it should be, and I was looking for some clarification because
I was concerned.”).
Defendant also testified that he used the AMA’s medical decision making chart and the
Novitas calculator to conclude that every COVID-19 testing patient should be coded with a Level
4 E/M visit. Exhibit 11 (8/2/23 Tr.) at 134-137. But no email or other evidence corroborates
24
Defendant’s testimony that he looked at this chart at the time. And evidence presented conflicts
with Defendant’s testimony that he used these charts. On cross-examination, Defendant was
confronted with his own email indicating that sometimes Defendant’s company did not perform
two tests—and in those circumstances even under Defendant’s purported calculation he could not
have billed a Level 4 visit. Id. at 171-72; Exhibit 49 (Gov’t Trial Ex. 938). But the claims data
shows that the Defendant did not change the coding in those circumstances. See Exhibit 12 (Gov’t
Trial Ex. 137); Exhibit 8 (7/27/23 Tr.) at 16-19. He did not ever change the coding. That evidence
calls into serious question the veracity of Defendant’s testimony.
In United States v. Janati, the Fourth Circuit affirmed conviction for health care fraud in
similar circumstances. See 237 F. App’x 843, 847 (4th Cir. 2007). In that case, defendants were
convicted of health care fraud for, among other things, “upcod[ing] office visits, meaning that
when they billed insurers, they represented that an office visit was more involved or complex than
it actually was, justifying a higher billing rate.” Id. at 845. The evidence in that case showed that
the defendants billed virtually all office visits using the highest code, CPT 99215, without regard
to the seriousness of the patient’s problem or the complexity of the visit.” Id. There, the defendant
claimed the coding was too vague to sustain the conviction. Id. The Court rejected the argument
and affirmed conviction, explaining that the evidence “overwhelmingly demonstrates” that the
defendants knowingly used improper coding “if for no other reason that the fact that they altered
their forms to eliminate even the option of billing at a level lower than Code 99214.” Id. at 847.
In addition, the Court noted that the defendants previously billed differently, that they billed every
visit at the highest level, that the government’s expert testified that none of the charges came “even
close” to warranting the billing level, and that the defendants continued to bill falsely “even after
25
being specifically warned by Medicare officials and other insurers that their billing was improper.”
Id.
Here, the evidence is even more comprehensive. Although the Government did not present
a hired expert to testify about the CPT codes used, two certified professional coders testified
regarding opinions rendered at the time and communicated to the Defendant that these COVID-19
testing visits did not qualify as level 4 office visits. Providers testified that the services they were
providing were not level 4 office visits. And Defendant caused his company to bill nearly every
patient for level 4 office visits, “without regard to the seriousness of the patient’s problem or the
complexity of the visit.” See Janati, 237 F. App’x at 845. The facts in Janati also did not occur
during a pandemic. In other words, the patients seen by Janati were likely sick. Here, many of
Defendant’s patients were healthy, asymptomatic, and later in 2021, vaccinated.
The weight of the evidence establishes that the codes submitted by Defendant’s company
at Defendant’s direction were false, that Defendant knew they were false, and that he intended to
defraud Medicare and other insurers. The Defendant’s motion for a new trial should be denied.
B. The Court’s Evidentiary Rulings Were Correct
The Court’s evidentiary rulings on Defendant’s three proposed exhibits and on the
testimony of A.H. were consistent with the evidentiary rules on hearsay, and Defendant’s
arguments should be rejected. Federal Rule of Evidence 801 defines hearsay as a statement that
“(1) the declarant does not make while testifying at the current trial or hearing; and (2) a party
offers in evidence to prove the truth of the matter asserted in the statement.” Fed. R. Evid. 801(c).
Hearsay statements made by a defendant, if offered by that defendant, are inadmissible unless they
fit within a specific hearsay exception. See United States v. Gearheart, --- F. Supp. 3d ---, 2023
WL 4106252 (W.D. Va. June 21, 2023); cf. United States v. Conto, 2022 WL 228845, *1 (4th Cir.
2022) (Rule 106 does not “require the admission of self-serving, exculpatory statements made by
26
a party which are being sought for admission by that same party.”) (internal quotation marks
omitted). The Rules of Evidence provide an exception to hearsay for statements made by the
Defendant or his agent, if offered against the Defendant. Fed. R. Evid. 801(d)(2).
In addition, evidentiary rulings are also subject to a harmless error analysis. United States
v. Gordon, 754 F. App’x 171, 177 (4th Cir. 2018) (citing United States v. Medford, 661 F.3d 746,
751 (4th Cir. 2011)). “An ‘error, defect, irregularity, or variance that does not affect substantial
rights must be disregarded.’” Id. (quoting Fed. R. Crim. P. 52(a)). “An error is harmless if it did
not affect the verdict.” Id. Thus, “if the evidence is not merely sufficient, but so powerful,
overwhelming, or cumulative that the error simply could not reasonably be said to have
substantially swayed the jury’s judgment, then the error is not harmful.” Id. (quoting Cooper v.
Taylor, 103 F.3d 366, 370 (4th Cir. 1996)). When applying a harmless error analysis, the Fourth
Circuit has held that “‘[e]vidence erroneously admitted will be deemed harmless if a reviewing
court is able to ‘say, with fair assurance, after pondering all that happened without stripping the
erroneous action from the whole, that the judgment was not substantially swayed by the error.’’”
United States v. Hanna, 353 F. App’x 806, 809 (4th Cir. 2009) (citing United States v. Abu Ali,
528 F.3d 210, 231 (4th Cir. 2008)).
1. The Defendant’s Three Proposed Email Exhibits Were Properly
Excluded.
Each of the three proposed exhibits Defendant claims should have been admitted are
inadmissible hearsay and were properly excluded.
Defendant argues that these emails fall within the hearsay exception for statements
regarding a declarant’s state of mind. ECF 78 at 32-33. Federal Rule of Evidence 803(3) provides
an exception to the hearsay rule for “[a] statement of the declarant’s then-existing state of mind
(such as motive, intent, or plan) or emotional, sensory, or physical condition (such as mental
27
feeling, pain, or bodily health), but not including a statement of memory or belief to prove the fact
remembered or believed unless it relates to the validity or terms of the declarant’s will.” Fed. R.
Evid. 803(3). “Rule 803(3) explicitly excludes hearsay statements about memories offered ‘to
prove the fact remembered.’” United States v. Liu, 654 F. App’x 149, 155 (4th Cir. 2016)
(rejecting argument that statements fit within 803(3) because they would have described state of
mind “hours or days earlier, rather than a ‘then-existing’ state of mind”). “Where state of mind
itself is in issue . . . the court must determine if the declarant’s state of mind at the time of the
declaration is relevant to the declarant’s state of mind at the time at issue.” United States v.
Srivastava, 411 F. App’x 671, 684 (4th Cir. 2011). Of course, even if evidence falls within a
hearsay exception, it must be relevant to be admissible. Fed. R. Evid. 803.
Defendant’s contention that these three emails were being offered to show Defendant’s
state of mind was properly rejected. First, Defendant initially sought to introduce these emails as
business records. Second, the emails do not speak to Defendant’s state of mind with respect to
any relevant issue. Third, Defendant cannot introduce his own, self-serving hearsay statements.
a) DX77
Defendant’s proposed exhibit DX77 is an email dated December 18, 2021 (approximately
21 months after the pandemic began, and long after Defendant hatched the scheme) that is a post-
mortem look back on the pandemic. ECF 78, Ex. 9. The Defendant’s contention that the email
reflects Defendant’s motive for billing COVID-19 testing patients for level 4 office visits is wrong.
Nothing in the email addresses billing or coding. Instead, it is a motivational speech to his
employees. Such general character evidence is not admissible under Rule 404(a)(1). Even if the
email could be read to suggest that Defendant’s decision to offer COVID-19 tests to patients at his
mass testing sites was motivated by a desire to help people, that says nothing about the Defendant’s
28
motive for billing every one of those patients for an additional, Level 4 office visit that was not
performed as represented.
Moreover, the vast majority of the email has nothing to do with Defendant’s state of mind.
The very first paragraph of the email highlights that: “I know this week and last has been CRAZY.
Volumes are unexpected and obviously unpredictable. I want to first off thank you for all your
hard work under extraordinary and incredibly difficult circumstances. We on the management
side have done and continue to do whatever we can to alleviate provider burden and make it as
easy as possible for everyone.” See ECF 78, Ex. 9. The second paragraph that Defendant
highlights in his motion similarly includes statements of purported fact unrelated to Defendant’s
state of mind: “We opened the doors to Gambrills in 2016. We saw more patients at all our
combined sites this past week alone then we did in the entirety of 2018. Yesterday, not counting
E-visits we saw almost 1,000 people (including E-visits we were well over 1400).” Id. Other
examples abound: “Some of you are new grads and you are being inundated by a tidal wave of
people-many of them sick and many angry and frustrated.” Id. These do not reflect Defendant’s
state of mind.
Finally, as the Defendant noted in his motion, the Court provided an alternative to DX77—
the Defendant could be asked about his motivations for billing level 4 office visits on the stand.
Defendant’s contention that this email provides “crucial corroboration of [Defendant’s] testimony
about his state of mind at the time” cannot be squared with the fact that Defendant decided to bill
every COVID-19 testing patient for a level 4 office visit in early 2020, and this email is dated
December 2021. The Court’s ruling excluding this exhibit was correct, and Defendant’s motion
should be denied.
29
b) DX60
Defendant’s proposed exhibit 60 was properly excluded as irrelevant and inadmissible
hearsay. ECF 78, Ex. 7. It describes a one-off circumstance in February 2021, almost a year after
Defendant determined that every COVID-19 testing patient was to be billed for a level 4 office
visit, in which a patient returned for a re-swab as a result of some undisclosed issue with the PCR
swab.6 That Defendant expressed concern about billing for a second Level 4 E/M visit for the
same patient is not relevant to whether Defendant had intent to defraud with respect to billing for
level 4 office visits in the first instance. There was no allegation that the scheme involved charging
patients for a second Level 4 E/M visit when there was an issue with a previous swab.
The second portion of the email addresses another one-off situation in which a patient left
the line and did not receive any test or services at all. This is not relevant to the scheme or
Defendant’s state of mind. The Government did not contend that Defendant was billing for
patients who never came to get tested, or that patients who were billed did not receive tests and
briefly see a provider. Instead, the Defendant was charged with billing for services that were not
provided as represented—that is, patients who came for COVID-19 tests were seen briefly by
providers, in a perfunctory manner, and billed for a level 4 office visit. The circumstance described
in the Defendant’s proposed exhibit 60 is irrelevant to the charges in this case.
Moreover, it contains hearsay statements, both by Defendant and others, that are not subject
to an exception. For example, in the top email in the chain, Defendant says “as of now there is an
EM code of 99204.” ECF 78, Ex. 7. That is an out of court statement that is offered for the truth
6
Claims data reflects that this patient had an encounter on January 25, 2021, at which she was
charged for a COVID test and a level 4 office visit. This email relates to a return visit this patient
made on January 28, 2021, to get re-swabbed. Thus, the e-mail is not relevant to the decision to
bill every patient who came for a COVID-19 test for an additional level 4 office visit.
30
about what was included in the billing. Lower in the chain, Defendant again is describing
information purportedly contained in a chart.
The Court correctly excluded this proposed exhibit.
c) DX66
Defendant’s proposed exhibit 66 is dated March 13, 2021, addressing circumstances
unrelated to billing COVID-19 testing patients for level 4 office visits. ECF 78, Ex. 8. Instead,
the email addresses whether a provider was allowed to bill for infusion medication and critical
care time when providing infusions. This evidence is irrelevant to the charged criminal scheme.
The defendant offered the email to bolster his character, suggesting that he did not commit fraud
with respect to infusion billing. But that is not an exception to hearsay—nor is it appropriate use
of character evidence. The Defendant is permitted to testify that when he saw issues with coding,
he raised concerns about fraudulent billing, but he may not introduce self-serving hearsay not
subject to any exception.
Moreover, the email contains self-serving hearsay offered by the defendant that is not
subject to any exception. For example, the email states: “I have spent a lot of time speaking to
billers, coders, Connor, Erin, the state and the feds.” ECF 78, Ex. 8. The Court properly excluded
this document.
d) If the Court improperly excluded the evidence, then the error
was harmless.
Even assuming, arguendo, that the Court improperly excluded Defendants proposed
exhibits DX77, DX60, and DX66, the error was harmless. As discussed above, the evidence
presented at trial of Defendant’s intent was substantial. The exclusion of three emails, two of
which occurred months after the coding decisions were made and the scheme was put into motion
by Defendant, and none of which address the coding decisions at issue in this case, “did not affect
31
the verdict.” See Gordon, 754 F. App’x at 177. Moreover, Defendant did introduce at trial emails
that covered the same ground. For example, admitted exhibit DX51 covers much of the same
ground as Defendant’s proposed exhibit DX66, but in the context of the COVID-19 testing at issue
in the case rather than with respect to infusions. Compare Exhibit 50 (Def. Trial Ex. 51) (“the MA
can only pull template over AFTER you have made contact with the patient. . . Doing so
beforehand generates too much a possibility of accidental fraudulent billing . . .”) with ECF 78,
Ex. 8 (“I know you are trying to help . . . . but lots of unintended consequences . . . By adding in
the medication (the BAM), that is committing fraud[,] for example.”). In addition, like
Defendant’s proposed exhibit DX60, DX51 addresses not billing for encounters that did not occur.
Compare Exhibit 50 (Def. Trial Ex. 51) (“Doing so beforehand generates too much a possibility
of accidental fraudulent billing and too much work on the back end to delete all the encounters
that are filled out (and indistinguishable form ones that were actually seen/connected) but not real
encounters.”) with ECF 78, Ex. 7 (“Ok for Sweeney…Andre, delete that encounter please. Please
keep a log of who you see to avoid things like this. Had you accidentally billed that chart it would
be fraudulent billing.”).
With respect to Defendant’s proposed exhibit DX77, which Defendant asserted was
intended to show that Defendant was “motivated to help patients, not to make money[,]” ECF 78
at 34, other admitted emails contain the same sentiment. See, e.g., Exhibit 31 (Gov’t Trial Ex.
607) (“Hope this finds everyone well. First off, GREAT work everyone. These are tough times
and you guys are rocking it. I am in awe of you guys and the work everyone is doing-truly! We
are the only game in town . . . truly TAKING CARE of people[.]”); Exhibit 41 (Gov’t Trial Ex.
638) (“Our volumes continue to explode. Jimmy and Crystal yesterday s[aw] over 350 people. It
was amazing.”); id. (“Thank you all for your continued dedication and hard work. As always,
32
ANY questions, let me know. Stay safe and thank you truly for all the hard work and dedication
you bring every day!”).
The exclusion of Defendant’s proposed exhibits DX77, DX60, and DX66 “could not
reasonably be said to have substantially swayed the jury’s judgment,” and therefore “is not
harmful.’” See Gordon, 754 F. App’x at 177 (quoting Cooper, 103 F.3d at 370). In light of the
extensive evidence of intent, and the fact that other emails were admitted that included similar
language in relevant context, the Court can conclude “with fair assurance, after pondering all that
happened without stripping the erroneous action from the whole, that the judgment was not
substantially swayed by the error.” See Hanna, 353 F. App’x at 809 (internal quotation marks
omitted). The Defendant testified for several hours over two days. There is no reason to believe
that these three emails would have impacted the jury’s assessment of the defendant’s mental state
after hearing him testify.
2. The Court Properly Admitted The Testimony Of A.H.
The Court properly permitted beneficiary witness A.H. to testify regarding her recollection
of a phone call with an individual who she understood to be an agent of the Defendant. Federal
Rule of Evidence 801(d) provides that a statement is not hearsay if “offered against the opposing
party and . . . was made by the party’s agent or employee on a matter within the scope of that
relationship and while it existed[.]” Fed. R. Evid. 801(d)(2)(D). Thus, an employee of
Defendant’s company, speaking on a matter within the scope of that employment, is admissible
non-hearsay if offered against the Defendant. See United States v. Poulin, 461 F. App’x 272, 282
(4th Cir. 2012) (citing United States v. Portsmouth Paving Corp., 694 F.2d 312, 321 (4th Cir.
1982) (“This exclusion applies whenever an employee makes a statement ‘about a matter within
the scope of her employment,’ even if she is not authorized to speak on the matter.”).
33
First, the testimony about which Defendant objects was not given in the presence of the
jury. See ECF 78 at 41 (citing 7/19/23 Tr. 119:11-120:21 (foundational testimony outside the
presence of the jury)). Defendant objects to the statement “this is how we bill,” which was testified
to by A.H. during foundational testimony outside the presence of the jury. See Exhibit 3 (7/19/23
Tr.) at 119-120. Nevertheless, the government assumes Defendant intended to raise its objection
to the testimony that was before the jury, in which A.H. stated:
Q. [A.H.] when you spoke to this person on the phone, what did they
tell you?
A. They told me that that's just what we do.
Id. at 122. This testimony was properly admitted for the reasons stated by the Court on the record,
and as discussed below. See id. at 121-122.
During A.H.’s testimony, she testified that in response to receiving a notice from Medicare
about the services billed to Medciare for her COVID-19 test, A.H. called the number on the
explanation for Drs ERgent Care that was listed on her explanation of benefits. A.H. testified that
“[s]omeone answered the phone, and I explained who I was, gave them my name. I told them that
I’d received a summary notice that showed that they had billed and been paid [for] services
provided by Dr. Elfenbein, whom I had never met, had never seen, neither have I seen him nor
anyone else at Drs ERgent Care, and that they have to have made a mistake.” Id. at 115. A.H.
testified about what the individual on the phone said in response, an objection was interposed and
the Court excused the jury. Id. at 116-118. Outside the presence of the jury, additional questioning
was conducted by government counsel to lay foundation for the testimony under Fed. R. Evidence
801(d)(2)(D). A.H. testified:
Q. [A.H.], who did you call that day?
A. I called the phone number on the explanation of Medicare
benefits.
34
Q. Okay. And did you have an understanding of who you were
speaking with when you had that phone call?
A. It was whoever answered the phone. I don't know who that was.
Q. Did --
A. They gave me a first name, but I don't remember it.
Q. Okay. Could you explain the substance -- do you believe that you
actually were speaking to a person who was affiliated with the
company that rendered you service when you went to get your
COVID test?
A. Yes, because -- would you ask me the question again, please?
Q. Sure. Did anybody on the phone tell you that you had called the
wrong number?
A. No.
Q. Did anybody tell you that you were not actually one of their
patients?
A. No, they did not.
Q. Did whoever you spoke to actually confirm that you were a
patient of theirs?
A. No, they did not.
Q. Okay. Well, then, why do you think -- why do you think you were
talking to somebody about the bill you were disputing?
A. Because the phone number was on the Medicare explanation of
benefits.
Q. Okay. And what did you -- what did that person ultimately tell
you?
A. What they said was, that's just what we do, when I told them that
they had billed me for services that were not furnished and that I had
received the COVID test on the date of the first service for which
they claimed I received.
Q. They said, this is how we bill?
A. This is how we bill, yes.
35
Q. Okay. And the bill you got was from Drs ERgent Care, at least
according to the notice?
A. Well, the explanation of Medicare benefits said it was Drs
ERgent Care who filed the claim and was paid on behalf of and
spoke to an individual she understood to be an employee of that
company.
Dr. Elfenbein.
Q. And they didn't say you called the wrong number?
A. They did not say I called the wrong number.
Id. at 119-121. Defense counsel opted not to ask any voir dire questions of the witness at that
time. Id. at 121. The foundation provided by A.H. was sufficient to establish that the statement
was made by an agent of the defendant for purposes of admissibility. A.H. testified that she called
the number associated with Drs ERgent Care listed on the explanation of benefits and spoke to an
individual who answered the phone. Id. at 119. She testified that the individual did not indicate
that she had the wrong number, or otherwise indicate that she was not speaking with someone
associated with Drs ERgent Care. Id. at 120. A.H. testified that the individual responded
substantively to her inquiry, saying “[t]his is how we bill.” Id. at 20-21. In addition, the
explanation of benefits indicates that services were provided by Drs Ergent Care LLC, and the
provider who purportedly provided the services was the Defendant. Exhibit 24 (Gov’t Trial Ex.
414), Exhibit 25 (Gov’t Trial Ex. 415). Defendant was an owner and the Medical Director of Drs
ERgent Care at the time of the phone call. Exhibit 10 (8/1/23 Tr.) at 119-120 (Defendant testimony
that he was owner and medical director of Drs ERgent Care), Exhibit 2 (7/18/23 Tr.) at 83
(ownership disclosure to Medicare of Drs ERgent Care did not change).
This evidence is sufficient to establish foundation for admission of the hearsay statement
under Rule 801(d)(2)(D). The Fourth Circuit in Portsmouth affirmed evidentiary rulings under
Rule 801(d)(2)(D) in similar circumstances. 694 F.2d at 321. In that case, the district court
36
permitted a witness to testify about statements made to him by an individual who answered a phone
at the Defendant’s office. The Fourth Circuit explained: “First, [the witness] testified that he
‘called [the defendant’s] office.’ Not only does this testimony authenticate the occurrence of the
telephone call in accordance with the standard illustrated by Rule 901(b)(6),[] but the testimony
also supports the inference that the one who answered the telephone was [defendant’s] agent. One
would usually and properly assume upon the dialing of a business office phone number that the
person who answers is employed by and has the authority to speak for the business.” Portsmouth
Paving, 694 F.2d at 322. Although Defendant contends that other evidence suggests the number
listed on the explanation of benefits was a fax number, A.H.’s testimony that she called the number
listed for Drs ERgent Care and received an answer supports the finding that she spoke with an
agent of Drs ERgent Care.7 Further, her testimony that the individual on the phone did not indicate
a wrong number had been called, or that she was not a patient of the company, and instead that the
individual substantively responded supports the finding.
The testimony of A.H. was properly admitted under Federal Rule of Evidence
801(d)(2)(D). Moreover, in light of the extensive evidence about the coding practices at
Defendant’s company, and specifically the practice of coding and billing patients who receive a
COVID-19 test at Defendant’s company for an additional level 4 office visit—the same code
contained in A.H.’s summary notice—any error in admitting the evidence is harmless. See United
States v. Gordon, 754 F. App’x 171, 177 (4th Cir. 2018) (“An error is harmless if it did not affect
the verdict.”).
7
Fax machines use phone lines and can have telephone receivers.
37
C. The Court’s Voir Dire Process Did Not Violate Defendant’s Sixth Amendment
Rights.
The Court’s voir dire process, which followed the Court’s standard practice, satisfies
constitutional scrutiny. While the Defendant enjoys the right to a public trial under the Sixth
Amendment, which includes voir dire, “[t]he right to an open trial may give way in certain cases
to other rights or interests, such as the defendant’s right to a fair trial or the government’s interest
in inhibiting the disclosure of sensitive information.” Presley v. Georgia, 558 U.S. 209, 213
(2010). Here, the Court’s determination to exclude members of the public from the courtroom
during the individual Q&A portion of juror voir dire does not warrant a new trial.
“[N]ot every public-trial violation will in fact lead to a fundamentally unfair trial.” Weaver
v. Massachusetts, 582 U.S. 286, 300 (2017). In Weaver, the Supreme Court addressed the question
of whether exclusion of the public during voir dire warranted relief where counsel did not object
to the public-trial violation, Id. at 301-302, and held that “[a]lthough the petitioner’s mother and
her minister were indeed excluded from the courtroom for two days during jury selection,
petitioner’s trial was not conducted in secret or in a remote place. [] The closure was limited to
the jury voir dire; the courtroom remained open during the evidentiary phase of the trial; the
closure decision was apparently made by court officers rather than the judge, there were many
members of the venire who did not become jurors but who did observe the proceedings; and there
was a record made of the proceedings that does not indicate any basis for concern, other than the
closure itself.” Weaver, 582 U.S. at 304.
The Fourth Circuit similarly has affirmed closure of the courtroom and in camera voir dire
of potential jurors. In In re South Carolina Press Ass’n, the Fourth Circuit explained:
As we stated in In re Greensboro News Co., 727 F.2d 1320, 1325
(4th Cir.1984): “A careful and exhaustive voir dire is crucial to
ensure that these defendants will be tried by an impartial jury which
will render its verdict on the basis of evidence adduced at trial rather
38
than information from the newspapers or television.” In Greensboro
News, we also concluded that a trial judge’s in camera voir dire of
potential jurors in a criminal prosecution so as to ensure frank and
forthcoming responses was not an unusual practice, “nor viewed
with suspicion.” Id. at 1323.
In re South Carolina Press Ass’n, 946 F.2d 1037, 1041 (4th Cir. 1991); see also Woodson v.
Hutchinson, 52 F. App’x 195, 198-99 (4th Cir. 2002) (rejecting ineffective assistance of counsel
claim for failure to object to closure of courtroom during voir dire, and confirming space
considerations may be proper basis for closure during jury selection process).
Here, the Court’s closure of the courtroom during voir dire was consistent with those
interests—the closure of the courtroom encouraged “frank and forthcoming responses” from the
jurors about their personal information, education and employment history, as well as medical
histories pertinent to the case. The interest in obtaining frank and honest answers to such inquiry
warranted closure of the courtroom. See id.; cf. Weaver, 582 U.S. at 298 (“It would be
unconvincing to deem a trial fundamentally unfair just because a judge omitted to announce factual
findings before making an otherwise valid decision to order the courtroom temporarily closed.”).
The Court explained on the record that “[g]enerally speaking, we treat the individual voir dire as
being the equivalent of our former practice of brining the prospective juror to the bench. So all on
the record, but not public. Accordingly, my preference would be to exclude from the courtroom
anyone who is not a direct participant in the trial.” Exhibit 1 (7/17/23 Tr.) at 31. This practice
protects the Defendant’s rights by encouraging the jurors answer candidly to follow-up voir dire
questions posed by the Court and the parties.
Moreover, as the Defendant concedes in his motion, counsel for the Defendant “agreed that
it was acceptable.” ECF 78 at 44 (citing 7/17/23 Tr. 33:5-9). Nor can Defendant contend that it
did not have time to lodge an objection to the process. See ECF 78 at 44 (“The acquiescence by
defense counsel, after the Court had stated how it would proceed, does not cure this structural
39
error.”). This process was proposed by the parties in its Joint Proposed Voir Dire filing. ECF 35
at 1 (parties’ jointly proposed prefatory voir dire instruction: “After I have asked all of my
questions, you will leave the Courtroom and wait in the hallway and vestibule areas, just outside
the Courtroom door. Then you will be brought back to the Courtroom, one-by-one, to meet with
me and to review the answers that you have provided on your answer sheet. Once you are back in
the Courtroom, only court staff, the parties, the lawyers, and I will be present. No one else will
hear the answers that you provide.”). The Court adopted the parties’ proposed process, notifying
the parties weeks in advance of trial that it would follow that process. ECF 43-1 (July 6, 2023
Voir Dire Questions Court Intends To Employ At Trial). Defendant’s contention that the process
he jointly proposed, and to which he did not raise any objection, should be rejected.
Defendant has not shown that the closure of the courtroom during voir dire warrants a new
trial, and his motion should be denied.
CONCLUSION
For the reasons stated above, the United States respectfully requests that the Court deny
Defendant’s Motion for Judgment of Acquittal or, in the Alternative for a New Trial, ECF 78, in
its entirety.
Respectfully Submitted,
GLENN S. LEON, CHIEF
CRIMINAL DIVISION, FRAUD SECTION
U.S. DEPARTMENT OF JUSTICE
EREK L. BARRON
UNITED STATES ATTORNEY
/s/
Matthew P. Phelps
Assistant United States Attorney
D. Keith Clouser
U.S. Department of Justice
40
Criminal Division, Fraud Section
1400 New York Avenue, N.W.
Washington, D.C. 20005
david.clouser@usdoj.gov
COUNSEL FOR THE UNITED STATES
41
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that on September 1, 2023, I electronically filed the foregoing with
the Clerk of the Court by using the CM/ECF system which will send a notice of electronic filing
to all counsel of record.
By: /s/ Matthew Phelps
42
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