United States v. Singh: Sixth Circuit Mandates a “Bryan-Level” Willfulness Instruction and Reinforces Evidentiary Guardrails in Healthcare-Fraud Prosecutions

Introduction

In United States v. Ankita Singh, No. 24-3655 (6th Cir. Aug. 8, 2025), the U.S. Court of Appeals for the Sixth Circuit vacated the healthcare-fraud convictions of a telehealth physician and remanded for retrial. The panel (Clay, Gilman, and Bloomekatz, JJ.) found three independent, non-harmless errors in the district court’s handling of the case:

Erroneous jury instructions that omitted the heightened “willfulness” scienter required by 18 U.S.C. § 1347.
Erroneous exclusion of Dr. Singh’s contemporaneous exculpatory statements to an insurance investigator, admissible under Fed. R. Evid. 803(3).
Erroneous admission of lay-opinion testimony concerning medical necessity that should have been presented, if at all, through qualified expert witnesses under Fed. R. Evid. 702.

The decision clarifies the mental-state burden the government must carry in healthcare-fraud trials and tightens evidentiary expectations for both prosecutors and trial judges in cases involving complex medical and regulatory issues.

Summary of the Judgment

Applying Supreme Court precedent on “willfulness,” the court ruled that a conviction under § 1347 requires proof that the defendant knew her conduct was unlawful, not merely that she acted “voluntarily and intentionally.” Because the district court’s pattern instruction omitted that element—and the government affirmatively argued to the jury that Singh’s ignorance of the rules was irrelevant—the instruction was reversible error.

The panel also held that Singh’s recorded statements to an Optum investigator—made mid-scheme and describing her belief that prior providers had already examined patients—fit squarely within Rule 803(3)’s state-of-mind exception. Excluding those statements deprived the jury of critical evidence on intent.

Finally, the court ruled that testimony about what Medicare or medical-practice standards require is “specialized knowledge” under Rule 702. Allowing three unqualified lay witnesses to opine that a physician must personally examine a patient to determine medical necessity was an abuse of discretion.

Because each error independently undermined the verdict and none was harmless, the court VACATED all six convictions and REMANDED for further proceedings.

Analysis

1. Precedents Cited and Their Influence

Bryan v. United States, 524 U.S. 184 (1998): Defined “willfully” as acting with knowledge that the conduct is unlawful. Singh extends Bryan’s reading to healthcare fraud, aligning § 1347 with other “willfulness” statutes (e.g., Arms Export Control Act, FECA).
Ratzlaf v. United States, 510 U.S. 135 (1994): Early articulation of the “willfulness” requirement for currency-structuring; used in Bryan and echoed here to protect defendants from convictions based on inadvertent violations of opaque regulations.
United States v. Roth, 628 F.3d 827 (6th Cir. 2011) and progeny: Sixth Circuit cases adopting Bryan’s standard in diverse contexts; supplied persuasive authority for importing the same scienter into § 1347.
United States v. Mendez, 303 F. App’x 323 (6th Cir. 2008): Relied on below to exclude Singh’s statements; distinguished because Singh’s remarks described her present beliefs during an ongoing scheme, not a past event.
United States v. Lang, 717 F. App’x 523 (6th Cir. 2017); United States v. Hunt, 521 F.3d 636 (6th Cir. 2008); United States v. Volkman, 797 F.3d 377 (6th Cir. 2015): Illustrate the Sixth Circuit’s expectation that expert, not lay, testimony establish medical necessity in healthcare-fraud cases.

2. Legal Reasoning

a. Scienter (“Willfulness”). The panel reasoned that Congress used a dual mens-rea formulation—“knowingly and willfully”—in § 1347. Under Bryan, “willfully” carries independent meaning: knowledge of illegality. The pattern instruction’s conflation of “knowingly” and “willfully” erased that heightened element and risked convicting defendants who merely breached professional norms or Medicare rules unknowingly.

b. Rule 803(3) State-of-Mind Exception. Singh’s statements that she believed patients were already examined were not backward-looking narratives but direct declarations of current belief. Rule 803(3) expressly allows such statements to show the declarant’s then-existing mental state. The district court misapplied Mendez, which concerned a defendant recounting past fears two days after a kidnapping.

c. Lay vs. Expert Testimony. Determining whether Medicare requires an in-person exam for DME orders involves “specialized knowledge” in medicine and regulatory compliance. Rule 701 prohibits lay opinions rooted in technical expertise; Rule 702 requires a qualified expert subjected to Daubert reliability screening. Absent such an expert, the government’s case leaned on impermissible lay conclusions.

3. Impact on Future Litigation and Healthcare Law

Heightened Prosecutorial Burden. The government must now request (and district courts must give) an explicit Bryan-style willfulness instruction in Sixth Circuit healthcare-fraud trials. Pattern Instruction 10.05 will likely be revised.
Telehealth Context. As remote care proliferates, prosecutors cannot assume that failure to see a patient in person equates to fraud. Expert testimony will be indispensable for proving medical necessity where standards are evolving.
Rule 803(3) Revitalized. Defendants may more confidently invoke the state-of-mind exception for contemporaneous statements reflecting belief or intent made during ongoing conduct, even when self-serving.
Trial-Practice Ripple. The opinion underscores that motions in limine may preserve objection for appeal only when the ruling is “explicit, definitive, and unconditional,” guiding litigants on preservation strategy.
Comparative Statutory Interpretation. Singh’s application of Bryan to § 1347 invites similar arguments in circuits that have not squarely decided the issue, potentially leading to inter-circuit alignment or conflict warranting Supreme Court review.

Complex Concepts Simplified

Knowingly vs. Willfully: “Knowingly” means the defendant understood what she was doing; “willfully” means she also understood it was against the law.
State-of-Mind Hearsay (Rule 803(3)): Normally, out-of-court statements are inadmissible hearsay. An exception exists for statements showing what the speaker was thinking or feeling at that moment (e.g., “I believe these charts are legitimate”).
Lay vs. Expert Opinion (Rules 701/702): A lay witness can describe what they personally perceived (e.g., “the brace looked brand new”) but cannot offer professional conclusions (e.g., “the brace was not medically necessary”) unless qualified as an expert.
Continuing Offense: Some crimes, like fraud schemes, span time. A statement during the scheme can illuminate intent for the entire period.
Harmless-Error Standard: Even if a trial judge errs, a conviction stands unless the appellate court lacks “fair assurance” that the verdict was unaffected. Here, each error was deemed outcome-determinative.

Conclusion

United States v. Singh is a robust reaffirmation of due-process protections in white-collar and healthcare-fraud prosecutions. The Sixth Circuit:

Elevated the scienter bar by requiring juries to find knowledge of illegality under § 1347.
Clarified the admissibility of contemporaneous exculpatory statements under Rule 803(3).
Reinforced the necessity of qualified expert testimony when the government seeks to establish professional or regulatory standards.

Practitioners should recalibrate charging decisions, jury-instruction requests, and evidentiary strategies in light of Singh. For defendants, the decision offers a sharper toolset to contest intent and reliability of government evidence. For the broader legal community, Singh illustrates the ongoing judicial effort to balance aggressive fraud enforcement with fundamental fairness in an increasingly complex healthcare landscape.