United States v. Rafael Chikvashvili
859 F.3d 285
4th Cir.2017Background
- Rafael Chikvashvili, CEO of Alpha Diagnostics, was convicted on multiple counts including two counts of health-care fraud resulting in death under 18 U.S.C. § 1347, after a jury found Alpha technicians misread chest x‑rays and false claims were submitted to Medicare.
- Evidence at trial: technicians routinely performed and reported image interpretations in place of qualified radiologists, forged or placed doctors’ signatures, upcoded services, and documented billing irregularities; detailed logs indicated fraudulent in‑house "reads."
- Two patients (M.V.K. and D.M.C.) died after technicians purportedly failed to detect congestive heart failure on chest x‑rays; government experts opined the misreads were but‑for causes of death.
- Counts 2 and 3 charged a scheme encompassing the use of unqualified personnel to interpret images, misreads that failed to detect congestive heart failure, submission of false Medicare claims, and that the scheme "resulted in" each patient’s death.
- District court admitted expert causation testimony (Dr. Buescher), denied Rule 29 motions for acquittal, instructed the jury consistent with the indictment, and sentenced Chikvashvili to 120 months; the Fourth Circuit affirmed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Scope of § 1347 "resulting in death" element | "Resulting in death" requires proof that the act of submitting a false claim (the billing) was the but‑for cause of death | The statute's element reaches the execution of the fraudulent scheme (including delivery of health care); causation focuses on the scheme and delivery, not just the paper claim | Affirmed: § 1347 covers the execution of a fraudulent scheme (including misreading images); if the scheme results in death, element is satisfied and must be found by a jury |
| Sufficiency of indictment / evidence on Counts 2 & 3 | Indictment only charged submission of fraudulent Medicare claims; government failed to prove the billing caused deaths, so convictions insufficient | Counts incorporated the conspiracy narrative describing the scheme (unqualified reads, misreads, false claims) and alleged the scheme's failure to detect CHF resulted in death; evidence supported but‑for causation | Affirmed: indictment alleged the broader scheme; evidence (expert opinion, records) was sufficient to support but‑for causation findings |
| Jury instructions / constructive amendment | Jury summaries in charge impermissibly broadened the operative allegations and constructively amended the indictment | Instructions simply recapped the indictment’s narrative describing the scheme and consequences; defendant knew the charges and defense needed | Affirmed: no constructive amendment; instructions fairly stated controlling law and matched the counts |
| Admissibility of expert causation testimony (Rule 702) | Dr. Buescher’s causation opinion was unreliable: not relevant to billing‑only theory, lacked sufficient facts, and failed to exclude alternatives | Expert used differential diagnosis, reviewed records/x‑rays, explained why alternatives (including death certificates) were unlikely; testimony was relevant to whether the scheme resulted in death | Affirmed: district court did not abuse discretion; testimony was relevant, based on sufficient data, and adequately applied differential diagnosis—challenges went to weight, not admissibility |
Key Cases Cited
- United States v. Awad, 551 F.3d 930 (9th Cir. 2009) (distinguishing treatment of discrete false‑claim counts vs. single‑scheme multiplicitous charges)
- United States v. Hickman, 331 F.3d 439 (5th Cir. 2003) (similar analysis on separate claim counts and scheme execution)
- Westberry v. Gislaved Gummi AB, 178 F.3d 257 (4th Cir. 1999) (standards for admissibility and reliability of differential diagnosis under Rule 702)
- United States v. Floresca, 38 F.3d 706 (4th Cir. 1994) (constructive amendment and the defendant’s right to be tried on grand‑jury charges)
- Stirone v. United States, 361 U.S. 212 (1960) (defendant’s right not to be convicted on charges different from those returned by the grand jury)