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

I. Introduction

United States v. Lawrence Alexander (11th Cir. Mar. 24, 2026) addresses the boundary between (a) what the government must prove to convict a defendant of making a materially false statement in a health care matter under 18 U.S.C. § 1035 and (b) what it must prove to recover restitution under the Mandatory Victims Restitution Act (“MVRA”).

The defendant, Lawrence Alexander, an orthopedic surgeon, helped form a durable medical equipment (“DME”) company, Silent Hill Bracing and Orthopedic Supplies, LLC. Silent Hill submitted a CMS Form 855S (an enrollment/maintenance form for Medicare suppliers) that falsely listed Alexander’s mother as the business owner. A jury acquitted Alexander on a broader conspiracy charge (18 U.S.C. § 371) but convicted him of a false statement relating to health care matters (18 U.S.C. § 1035).

On appeal, Alexander raised seven issues, including venue, the sufficiency of the indictment and evidence, jury instructions, forfeiture, and restitution. The Eleventh Circuit affirmed nearly everything—but vacated the restitution order and remanded, holding that the restitution record did not establish that Medicare actually relied on (or acted upon) the false CMS 855S submission in a way that directly and proximately caused the claimed losses.

II. Summary of the Opinion

  • Venue: Affirmed; circumstantial evidence supported that the offense occurred in the Southern District of Florida.
  • Indictment: Affirmed; Count 19 tracked § 1035 and alleged sufficient facts to state an offense.
  • Sufficiency of evidence: Affirmed; evidence supported materiality and aiding-and-abetting liability.
  • Jury instructions: Affirmed; materiality challenge was barred by invited error; deliberate-ignorance challenge was waived.
  • Forfeiture: Affirmed; Rule 32.2 timing error was harmless; proceeds were traceable by a preponderance.
  • Restitution: Vacated and remanded; materiality/capability of influence was not enough—MVRA required proof of actual loss causation, and the record lacked evidence that Medicare processed or relied upon the January 2019 855S.

III. Analysis

A. Precedents Cited

1. Venue

  • United States v. Muench: Provided the de novo standard of review for venue.
  • United States v. Burroughs: Articulated that the government must prove venue by a preponderance and that review favors the verdict.
  • United States v. Bradley: Confirmed that circumstantial evidence may reasonably support venue.

Applying these cases, the court relied on Silent Hill’s location, the defendants’ residence, and testimony that Waxman’s office “was filing the applications.”

2. Indictment sufficiency under § 1035

  • United States v. Gbenedio: Supplied review standards for indictment sufficiency and dismissal.
  • United States v. Jordan: Reiterated that tracking statutory language plus notice-giving facts suffices.
  • United States v. Sharpe: Emphasized indictments need not plead the government’s evidentiary “proof.”

The indictment’s inclusion of Medicare enrollment mechanics (855S requirement, ownership disclosure, provider number enabling reimbursement claims) was pivotal in rejecting Alexander’s “change of hours only” framing.

3. Sufficiency of evidence and materiality

  • United States v. Morley, United States v. Smith, United States v. Tampas: Set the highly deferential sufficiency framework—reasonable constructions supporting the verdict must be upheld.
  • Kungys v. United States, United States v. Henderson: Defined materiality as “capable of influencing” agency decisionmaking.
  • United States v. Gaudin: Anchored materiality to (i) what was said and (ii) what decision the agency was making.
  • United States v. Clay (quoted via Henderson): Clarified materiality does not require actual reliance.

These authorities allowed the court to affirm the conviction despite limited proof that Medicare actually acted on the form—because conviction requires only capability to influence, supported by the expert’s testimony that ownership disclosures affect ongoing enrollment and billing privileges.

4. Aiding and abetting

  • United States v. Margarita Garcia: Provided the three-part aiding-and-abetting test.
  • United States v. Seabrooks: Confirmed aiding and abetting need not be pleaded if the jury is instructed and evidence supports it.
  • Rosemond v. United States: Explained intent as active participation with full knowledge of the circumstances of the offense.
  • United States v. Beaufils: Allowed knowledge/intent to be proven circumstantially.

The court found Alexander’s provision of his mother’s identifying information and the business’s routine practice of obtaining his consent supported the inference that he intentionally furthered the false submission.

5. Jury instructions (invited error and waiver)

  • United States v. Prather: Provided the de novo/abuse-of-discretion split for instruction review.
  • United States v. Gibson: Framed reversal as requiring a substantial doubt the jury was properly guided.
  • United States v. Silvestri: Established invited error when a party accepts an instruction.
  • United States v. Maradiaga: Applied invited error as “textbook” where the defendant proposed the instruction.
  • Big Top Koolers, Inc. v. Circus-Man Snacks, Inc.: Treated arguments first raised in a reply brief as waived.

Materiality instruction review was foreclosed because Alexander proposed the same language; deliberate ignorance was waived because it was not properly presented in the opening brief.

6. Forfeiture procedure and harmless error

  • United States v. Esformes: Provided standards of review for forfeiture/restitution issues.
  • United States v. Hasson: Set the preponderance standard for § 982(a) forfeiture findings.
  • United States v. Farias: Described Rule 32.2’s forfeiture steps and timing expectations.
  • McIntosh v. United States: Held failure to enter a preliminary forfeiture order is not automatically fatal; harmless-error review applies.

The court treated the timing defect as harmless because Alexander had repeated notice and a dedicated post-sentencing hearing to contest the amount and basis.

7. Restitution limits under the MVRA—causation and reliance

  • United States v. Martin: Restitution makes victims whole; it is not punishment or a windfall.
  • United States v. Huff: Required restitution to reflect loss the defendant’s conduct “actually caused.”
  • United States v. Young: Addressed offsets/value conferred and vacated restitution where the record did not support the “loss” theory; also discussed the fraud-case presumption of some loss.
  • United States v. Collins: Discussed restitution in a conspiracy posture; distinguished here because Alexander was acquitted of conspiracy.
  • Hughey v. United States: Limited restitution to the scope of the offense of conviction.
  • United States v. Robertson: Stated clear-error review and required “substantial evidence” support.
  • United States v. Stein: Required proof—by a preponderance—that victims relied on fraudulent information for restitution purposes.

These cases drove the opinion’s central innovation: while § 1035 conviction may rest on “capable of influencing,” MVRA restitution requires a tighter causal chain— proof that the false statement actually caused the payments at issue.

B. Legal Reasoning

1. The court’s key doctrinal separation: conviction materiality vs restitution causation

The opinion draws a sharp line between two legal standards:

  • § 1035 materiality (for guilt): The falsehood must be capable of influencing Medicare—no proof of actual reliance is required (per Kungys v. United States and United States v. Henderson).
  • MVRA restitution (for money owed): The government must prove actual loss directly and proximately caused by the offense of conviction, and (on this record) that meant showing Medicare reviewed/acted on the false CMS 855S in a way that caused the later payments (consistent with United States v. Huff, United States v. Martin, and United States v. Stein).

The district court, in the Eleventh Circuit’s view, collapsed these standards by treating the conviction itself—and the “natural consequence” of maintaining billing privileges—as enough. The appellate panel rejected that move: capability to influence is not proof of reliance or causation.

2. Why acquittal on conspiracy mattered

The government sought restitution equal to Medicare payments for claims submitted after the January 2019 form. But the court emphasized that Alexander was acquitted of the larger conspiracy, and thus restitution could not simply sweep in all downstream claims as scheme losses. Citing Hughey v. United States, the court treated the offense of conviction as a single false statement, requiring proof that the statement caused the specific losses claimed.

3. The evidentiary gap that defeated restitution

The record contained joint stipulations that: (i) the government had not produced a receipt or processing letter for the January 2019 855S, and (ii) the government did not present trial evidence showing when the Medicare contractor reviewed the changed enrollment information. The Eleventh Circuit held that likelihood or speculation that Medicare “would have” revoked privileges if it saw the truth did not substitute for proof it did review and rely on the false statement in a way that caused the payments.

4. Additional restitution defect flagged: failure to account for value conferred

The panel also noted (citing United States v. Young) that the district court did not account for any value that the billed items/services may have conferred—an independent requirement that can reduce restitution even when some fraud occurred.

C. Impact

  • Restitution in § 1035-only cases becomes harder to prove: Prosecutors seeking restitution based solely on a § 1035 conviction must build a record of actual causal linkage—e.g., evidence that Medicare processed the form, maintained enrollment because of it, paid claims because of that maintained status, or would have denied/revoked privileges upon truthful disclosure within the relevant time.
  • Charging decisions and trial strategy: Where the government anticipates a restitution theory tied to broader scheme payments, conspiracy or other scheme-based counts may be more important to preserve restitution scope. This opinion underscores that an acquittal on conspiracy can sharply narrow restitution exposure to the convicted conduct.
  • Administrative “paperwork fraud” and downstream payment theories: The decision limits a common inference—that a false enrollment/maintenance statement automatically taints all subsequent reimbursements—unless the government proves the administrative decisionmaking link on the facts.
  • Sentencing hearings will require better agency-proof: Expect increased use of contractor logs, processing timestamps, revocation criteria applied to facts, and testimony linking specific administrative actions to payment authority.

IV. Complex Concepts Simplified

  • Materiality: A lie is “material” if it could matter to the agency’s decision—even if the agency never actually reads it.
  • Restitution causation (MVRA): To make a defendant repay money, the government must show the lie actually caused the loss (directly and proximately), not merely that it could have.
  • Invited error: If you propose (or agree to) the jury instruction, you generally cannot complain about it on appeal.
  • Deliberate ignorance: A jury may be told it can treat purposeful “looking the other way” as knowledge—but appellate courts often require the argument to be properly preserved in the opening brief.
  • Forfeiture vs. restitution: Forfeiture takes proceeds of the crime from the defendant; restitution repays the victim’s proven loss. They serve different purposes and have different proof requirements.

V. Conclusion

United States v. Lawrence Alexander affirms broad principles of § 1035 prosecution—materiality is “capable of influencing,” and aiding-and-abetting may be proven circumstantially. But it simultaneously tightens MVRA restitution practice in the § 1035 context: restitution cannot be based on materiality alone and cannot presume that all subsequent Medicare payments are losses without proof that the false statement actually caused them. The decision’s practical message is clear: conviction standards and restitution standards are not interchangeable, and sentencing records must independently establish causation, scope, and offsets.