MVRA Restitution for Standalone 18 U.S.C. § 1035 Convictions Requires Proof of Actual Causation (Not Mere Materiality)

Introduction

In United States v. Lawrence Alexander (11th Cir. Mar. 24, 2026), the Eleventh Circuit reviewed the conviction and sentencing of Lawrence Alexander, an orthopedic surgeon linked to a durable medical equipment (DME) company, Silent Hill Bracing and Orthopedic Supplies, LLC. Alexander was charged with (i) conspiracy to defraud the United States and to pay health care kickbacks under 18 U.S.C. § 371 and (ii) making a false statement relating to health care matters under 18 U.S.C. § 1035. A jury acquitted him on the conspiracy count but convicted him on the § 1035 count based on a January 2019 CMS Form 855S submission that falsely listed his mother as Silent Hill’s sole owner/manager.

On appeal, Alexander raised seven issues: venue, sufficiency of the indictment, sufficiency of evidence (including aiding-and-abetting), jury instructions (materiality and deliberate ignorance), forfeiture, and restitution. The court affirmed across the board except restitution, which it vacated and remanded.

Summary of the Opinion

  • Venue: Proper in the Southern District of Florida based on circumstantial evidence tying the offense to the district.
  • Indictment: Sufficient; it tracked § 1035 and alleged facts showing how CMS 855S enrollment information relates to Medicare billing privileges.
  • Evidence: Sufficient to prove materiality for § 1035 and to support aiding-and-abetting liability.
  • Jury instructions: Materiality challenge barred by invited error; deliberate ignorance challenge waived (raised too late).
  • Forfeiture: Affirmed; the Rule 32.2 timing defect was harmless under Supreme Court authority; traceability shown by a preponderance.
  • Restitution: Vacated; the government failed to prove that the specific § 1035 false statement actually caused Medicare’s payment losses.

Analysis

Precedents Cited

1) Venue and proof standards

  • United States v. Muench: De novo review of venue determinations.
  • United States v. Burroughs: Government must prove venue by a preponderance; evidence viewed in government’s favor.
  • United States v. Bradley: Venue may be supported by circumstantial evidence as a whole.

Applying these standards, the court found that the company’s location, the defendants’ residence, and testimony that Waxman’s office filed the forms reasonably supported the inference that the offense occurred in the Southern District of Florida.

2) Indictment sufficiency

  • United States v. Gbenedio: De novo review of whether an indictment states an offense; abuse-of-discretion review of denial of dismissal.
  • United States v. Jordan: Indictment tracking statutory language is sufficient if accompanied by facts giving notice.
  • United States v. Sharpe: Indictments need not plead detailed evidentiary proof.

The court emphasized that Count 19 identified the allegedly false certification and explained how CMS 855S enrollment relates to obtaining and retaining a provider number and billing privileges—enough under Jordan and Sharpe.

3) Sufficiency of evidence

  • United States v. Morley: De novo review; evidence viewed in light most favorable to government.
  • United States v. Smith: Verdict stands unless no reasonable construction supports it.
  • United States v. Tampas: Government need not exclude every hypothesis of innocence.

4) Materiality doctrine (for conviction)

  • Kungys v. United States: Materiality = natural tendency or capability to influence a decisionmaker.
  • United States v. Henderson: No need to prove actual reliance; capability to influence suffices; statement may be material even if decisionmaker knew it was false.
  • United States v. Gaudin: Frames materiality around what was said and what decision the agency was making.
  • United States v. Clay: Reinforces that actual misleading is not required for materiality.

The court relied on expert testimony that CMS 855S ownership disclosures bear on Medicare’s ongoing decision to “obtain and retain” billing privileges, and that false ownership information could trigger termination—supporting materiality under Kungys/Henderson.

5) Aiding and abetting

  • United States v. Margarita Garcia: Three elements—substantive offense by someone, defendant’s act furthered it, and intent to aid.
  • United States v. Seabrooks: Aiding-and-abetting need not be charged if instructed and supported by evidence.
  • Rosemond v. United States: Intent satisfied by active participation with full knowledge of circumstances.
  • United States v. Beaufils: Knowledge/intent may be proved circumstantially.

The court found evidence that Alexander originated the “mother-as-owner” structure, supplied her identifiers and signature authorization, and consented to submissions as part of routine operations—supporting the Margarita Garcia elements.

6) Jury instructions, waiver, and invited error

  • United States v. Prather: De novo review of legal correctness; abuse-of-discretion review of phrasing.
  • United States v. Gibson: Reversal only if instructions misstated law or misled the jury to prejudice.
  • United States v. Silvestri: Invited error waives appellate challenge.
  • United States v. Maradiaga: Confirms “textbook” invited error when appellant proposed the instruction.
  • Big Top Koolers, Inc. v. Circus-Man Snacks, Inc.: Arguments first properly raised in a reply brief are waived.

Because Alexander proposed the materiality instruction essentially adopted by the court, Silvestri/Maradiaga barred review. His deliberate-ignorance challenge was deemed waived under Big Top Koolers.

7) Forfeiture procedure and harmless error

  • United States v. Esformes: Standard of review—clear error for facts, de novo for law (used for forfeiture and restitution).
  • United States v. Hasson: Forfeiture findings under § 982(a) by a preponderance.
  • United States v. Farias: Rule 32.2 steps and timing for preliminary forfeiture orders.
  • McIntosh v. United States: Failure to enter a preliminary forfeiture order before sentencing is subject to harmless-error review; not automatically fatal.

The panel treated the timing defect as harmless because Alexander had repeated notice and a full post-sentencing opportunity to litigate forfeiture, and the amount remained $125,000.

8) Restitution: actual loss and causation limits

  • United States v. Martin: Restitution aims to make victims whole, not punish or provide windfalls.
  • United States v. Huff: Restitution must reflect loss the defendant’s conduct “actually caused.”
  • United States v. Young: Restitution should start with amounts paid in a fraud scheme, but defendants may offset medically necessary value; courts must account for value conferred.
  • United States v. Collins: Restitution principles in a conspiracy context (distinguished because Alexander was acquitted of conspiracy).
  • Hughey v. United States: Restitution cannot expand beyond the scope of the offense of conviction.
  • United States v. Robertson: Clear-error review; findings clearly erroneous if record lacks substantial evidence.
  • United States v. Stein: Government must establish by a preponderance that victims relied on fraudulent information (used here to support the causation requirement).

These authorities framed the opinion’s core limitation: even if § 1035 materiality supports conviction without proof of actual reliance, MVRA restitution requires proof that the false statement directly and proximately caused the claimed losses.

Legal Reasoning

1) The court’s central doctrinal move: separating “materiality” (conviction) from “actual causation” (restitution)

The panel stressed that the government’s burden to convict under § 1035 differs from its burden to obtain restitution under the MVRA:

  • For § 1035 guilt: the statement must be material—capable of influencing Medicare, not necessarily relied upon.
  • For MVRA restitution: the loss must be actually and proximately caused by the offense of conviction.

The district court, in the panel’s view, effectively treated the conviction as establishing that Medicare’s later payments were the “natural consequence” of the false statement. The Eleventh Circuit rejected that inference as unsupported on this record because the parties stipulated there was no evidence of receipt/processing by the Medicare contractor and no evidence showing when (or whether) the changed enrollment information was reviewed.

2) Offense-of-conviction boundary: acquittal on conspiracy matters

The government’s restitution theory effectively sought to tie all post-January 2019 payments to Alexander. But Alexander was acquitted of the broader § 371 conspiracy. Relying on Hughey v. United States, the panel emphasized that restitution must remain tethered to the “offense of conviction.” That offense was a single false CMS 855S submission (and aiding/abetting it), not a scheme-based conspiracy count.

3) Evidentiary gap that defeated restitution

Even crediting Young’s observation that a fraud conviction “inherently means” some loss, the panel held that the government still must prove which losses were caused by this defendant’s this offense. Here, the record did not establish a causal chain: the government argued Medicare would have terminated enrollment if it had known the truth, but the panel treated that as speculation absent evidence of review, action, or reliance connected to the January 2019 form. Under Stein, reliance/cause must be shown by a preponderance for restitution.

4) A second restitution defect flagged by the court: value conferred

The panel also noted that the district court “failed to account for any value” Silent Hill’s claims may have provided, as required by Young. This reinforces that even where some causation is shown, MVRA restitution may need offsets for legitimate, medically necessary goods or services.

Impact

  • New practical rule for MVRA restitution in § 1035-only cases: The government cannot obtain restitution for all program payments merely by showing the false statement was material (capable of influencing); it must prove by a preponderance that the false statement actually caused the claimed losses (including evidence of review/reliance/action linking the statement to payments), especially where the defendant was acquitted of conspiracy.
  • Limits on “but-for enrollment” restitution theories: Arguments that Medicare “would have” revoked billing privileges may be insufficient without concrete evidence that the false statement played a real role in Medicare’s payment decisions for the charged time period.
  • Restitution litigation will become more granular: Future cases may require proof of (i) contractor processing timelines, (ii) audit/enrollment decision points, and (iii) whether payments were attributable to the misrepresentation rather than independent grounds.
  • Offsets for value conferred are not optional: The opinion underscores that courts must address whether the government received any legitimate value from items/services paid—even in fraud-adjacent contexts.
  • Procedure matters, but harmlessness may save forfeiture: Post-McIntosh v. United States, Rule 32.2 timing errors will often be litigated as prejudice/notice questions rather than treated as automatic reversals.

Complex Concepts Simplified

  • Materiality (criminal guilt): A false statement is “material” if it could influence an agency’s decision—not if it actually did.
  • Actual and proximate cause (restitution): To make a defendant repay money, the government must show the money was lost because of the specific crime the defendant was convicted of—not simply because the defendant did something wrong in the same general business.
  • Offense of conviction limitation: Restitution cannot be based on conduct the jury rejected (e.g., acquitted conspiracy) or on broader wrongdoing not proven as the conviction.
  • Aiding and abetting: You can be guilty even if you did not personally submit the document, if you intentionally helped and furthered its submission.
  • Invited error: If you propose the jury instruction and the court uses it, you typically cannot challenge it on appeal.
  • Deliberate ignorance: A doctrine allowing knowledge to be inferred where someone consciously avoids confirming what is obvious; arguments must be timely raised.
  • Forfeiture vs. restitution: Forfeiture strips proceeds traceable to the offense (a remedial/punitive tool); restitution compensates victims for actual losses. They have different purposes and proof requirements.

Conclusion

United States v. Lawrence Alexander draws a sharp and consequential line between what is sufficient to convict under § 1035 and what is sufficient to recoup money under the MVRA. While the government may prove § 1035 materiality without showing actual reliance, it cannot convert that materiality finding into a sweeping restitution award absent proof that the specific false statement actually and proximately caused Medicare’s losses—particularly where the defendant was acquitted of conspiracy and the restitution theory would effectively reintroduce scheme-wide liability through sentencing. The decision is likely to force more disciplined proof of causal linkage (and value offsets) in restitution proceedings arising from enrollment-related false statements.