United States v. Lopez-Diaz
794 F.3d 106
1st Cir.2015Background
- José (physician) submitted 10,231 Medicare CMS‑1500 claims (≈$3.5M billed; ≈$700K paid) for services he did not provide; many claims were internally inconsistent (e.g., urological procedures for women, claims for deceased beneficiaries).
- Carlos (dentist) ran a mobile dental clinic serving nursing homes and similar facilities; his staff collected patient histories, consent forms, and health‑coverage information.
- The brothers implemented a protocol in which Carlos's dental assistants recorded patients' vital signs for José to review as a consulting physician; Carlos sometimes paid assistants to record vitals when José was unavailable.
- José used information from Carlos’s patient files to complete and submit CMS‑1500 forms (with Williams and Rodríguez doing billing entry); Carlos did not sign or prepare José’s CMS‑1500 forms and received no proven proceeds from José’s billing.
- A jury convicted José of health‑care fraud, conspiracy to commit health‑care fraud, and aggravated identity theft; the jury convicted Carlos of conspiracy and aggravated identity theft but acquitted him of substantive health‑care fraud.
- The First Circuit affirmed José’s convictions but reversed Carlos’s convictions for insufficient evidence because the government failed to prove Carlos knew (or was willfully blind to) that José had no lawful basis to bill Medicare for the services claimed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Sufficiency of evidence to convict Carlos of conspiracy and aggravated identity theft | Gov: Carlos knew or was willfully blind to José's fraud because he gave access to patient files and sometimes paid staff to record vitals | Carlos: No evidence he knew José was billing for nonbillable services or received any proceeds; protocol could legitimize file review billing | Reversed Carlos’s convictions — evidence insufficient to prove knowledge or willful blindness beyond a reasonable doubt |
| Validity of aggravated identity theft counts in indictment (predicate felony not separately charged) | Gov: §1028A requires proof of a predicate felony, not a separate charging/conviction; indictment notified defendant the predicate (health‑care fraud) was not charged separately | José: Counts defective because corresponding §1347 predicate not separately charged/convicted | Affirmed — indictment adequate; predicate need not be separately charged or convicted |
| Brady/in‑camera review of MCS search materials | José: MCS search warrant materials might contain exculpatory evidence corroborating his billing explanations | Gov: Materials unlikely relevant; district court reviewed in camera and found no relevance | Affirmed — district court acted within discretion; defendant’s request was speculative |
| Jury instructions: prior knowledge requirement and other errors (Rosemond, typographical cross‑reference, conspiracy success) | José: Needed instruction that aiding/abetting aggravated identity theft required prior knowledge that identifying info was obtained without lawful authority; also objected to typo and wanted proof of conspiracy success | Gov: Current instructions sufficient; prior‑knowledge element not required for the particular §1028A element; typo harmless; success of conspiracy need not be proved | Affirmed — no reversible instructional error; Rosemond prior‑knowledge rule inapplicable to the claimed §1028A element; typographical slip and conspiracy success contentions fail |
Key Cases Cited
- United States v. Flores-Rivera, 787 F.3d 1 (1st Cir.) (standard for reviewing sufficiency of evidence)
- United States v. Spinney, 65 F.3d 231 (1st Cir.) (permissible reliance on circumstantial inferences; limits on stacking inferences)
- United States v. Appolon, 695 F.3d 44 (1st Cir.) (willful blindness test)
- United States v. Stepanian, 570 F.3d 51 (1st Cir.) (§1028A predicate need not be separately charged)
- Rosemond v. United States, 134 S. Ct. 1240 (Sup. Ct.) (advance knowledge requirement for aiding and abetting §924(c) offenses)
- United States v. Savarese, 686 F.3d 1 (1st Cir.) (indictment sufficiency: notice and double‑jeopardy concerns)
- United States v. Burgos, 703 F.3d 1 (1st Cir.) (caution against stacking inference upon inference)