Factual Context and Trial Themes

• Sherry-Ann, unlicensed in Ohio, performed cognitive testing, made diagnoses (including Alzheimer’s), and ordered brain PET scans; bills went out under Oliver’s NPI.
• “Incident to” and “general supervision” were initially explored internally as pathways to billing, but the Clinic’s compliance director (Lancaster) later recognized she had overlooked regulatory requisites (direct supervision; licensed providers for psychological services) inconsistent with what the Cognitive Center was doing.
• Evidence of concealment and misrepresentation included Oliver’s instruction to represent the Cognitive Center as a “neuro-otology” division to an insurer (a fictitious division), and Sherry-Ann’s efforts to prevent skeptical clinicians from reading scans or to limit patient consultations with others.
• Peer-review letters flagged diagnosing and ordering radiology as improper for Sherry-Ann, and ultimately the Clinic shuttered the Center.
• Patients testified they believed Sherry-Ann was a physician and would not have sought or paid for care had they known she was unlicensed; billing inflated call durations; PET scan volume spiked from a few per year to 10–15 per week.

Precedents Cited and Their Influence

• Sufficiency and standards:
  • United States v. Potter, 927 F.3d 446 (6th Cir. 2019); United States v. Paige, 470 F.3d 603 (6th Cir. 2006): de novo sufficiency review; rational trier of fact standard.
  • United States v. Hinojosa, 67 F.4th 334 (6th Cir. 2023): resolve conflicts in favor of the verdict.
  • United States v. Ouedraogo, 531 F. App’x 731 (6th Cir. 2013); United States v. Sliwo, 620 F.3d 630 (6th Cir. 2010): avoid stacking inferences; but circumstantial evidence can sustain verdicts (also United States v. Hughes, 505 F.3d 578 (6th Cir. 2007)).
• Conspiracy under § 1349:
  • United States v. Betro, 115 F.4th 429 (6th Cir. 2024); United States v. Palma, 58 F.4th 246 (6th Cir. 2023): agreement to commit fraud, joined knowingly and voluntarily.
  • United States v. Pearce, 912 F.2d 159 (6th Cir. 1990); United States v. Conatser, 514 F.3d 508 (6th Cir. 2008): tacit agreement and participation may be inferred from conduct.
  • United States v. Rogers, 769 F.3d 372 (6th Cir. 2014): § 1349 does not require an overt act.
• Mental-state comparators:
  • Liparota v. United States, 471 U.S. 419 (1985); Rehaif v. United States, 588 U.S. 225 (2019): knowledge elements can extend beyond conduct to attendant circumstances (cited by appellants; the panel emphasizes, for conspiracy, knowledge of unlawful aims).
• Fraud elements and intent:
  • United States v. Singh, No. 24-3655, 2025 WL 2268031 (6th Cir. Aug. 8, 2025): health-care fraud’s “knowingly and willfully” standard.
  • United States v. Merklinger, 16 F.3d 670 (6th Cir. 1994); United States v. Castile, 795 F.2d 1273 (6th Cir. 1986): mail fraud; parallel rules for wire fraud (18 U.S.C. §§ 1341, 1343).
  • United States v. Frost, 125 F.3d 346 (6th Cir. 1997); United States v. Smith, 39 F.3d 119 (6th Cir. 1994): specific intent in mail fraud.
  • United States v. Daniel, 329 F.3d 480 (6th Cir. 2003): specific intent in wire fraud.
  • United States v. Davis, 490 F.3d 541 (6th Cir. 2007): intent may be inferred from concealment, misrepresentations, knowledge, and profits.
• Good-faith reliance:
  • United States v. Rozin, 664 F.3d 1052 (6th Cir. 2012); United States v. Duncan, 850 F.2d 1104 (6th Cir. 1988): defense requires full disclosure of pertinent facts and good-faith reliance on advice.
• Deliberate ignorance (willful blindness):
  • United States v. Warshawsky, 20 F.3d 204 (6th Cir. 1994), superseded on other grounds by U.S.S.G. § 2B1.1: permissible for knowledge of unlawful aims in conspiracy; cannot prove voluntary agreement.
  • United States v. Evans Landscaping Inc., 850 F. App’x 942 (6th Cir. 2021): error to let willful blindness prove agreement (contrasting instruction; not plain error there).
  • United States v. Lee, 991 F.2d 343 (6th Cir. 1993); United States v. Matthews, 31 F.4th 436 (6th Cir. 2022); United States v. Smigiel, 173 F.3d 857, 1999 WL 196575 (6th Cir. 1999): pattern instruction acceptable; no need for extra limiting language when clearly tied to knowledge.
  • United States v. Griffin, 524 F.3d 71 (1st Cir. 2008); United States v. Alston-Graves, 435 F.3d 331 (D.C. Cir. 2006): circuits uniformly approve willful blindness in specific-intent crimes when used for knowledge elements.
  • United States v. Bohn, 281 F. App’x 430 (6th Cir. 2008); United States v. Williams, 117 F.3d 1421, 1997 WL 369436 (6th Cir. 1997): approved use in mail/wire fraud on knowledge components.
  • United States v. Chen, 913 F.2d 183 (5th Cir. 1990): caution that willful blindness to facts cannot alone prove the distinct “purpose” element when a statute requires a specific objective.
• Instructional standards and preservation:
  • United States v. Mitchell, 681 F.3d 867 (6th Cir. 2012): abuse of discretion standard; preserved objections.
  • United States v. Budd, 496 F.3d 517 (6th Cir. 2007); United States v. Sloman, 909 F.2d 176 (6th Cir. 1990): waiver through acquiescence.
  • United States v. Frederick, 406 F.3d 754 (6th Cir. 2005); Barnes v. Owens-Corning, 201 F.3d 815 (6th Cir. 2000): instructions reviewed as a whole.
  • United States v. Gandy, 926 F.3d 248 (6th Cir. 2019); United States v. Wood, 364 F.3d 704 (6th Cir. 2004): plain-error review where unpreserved; grave miscarriage standard.
• Unindicted co-conspirator instruction:
  • United States v. Ashrafkhan, 964 F.3d 574 (6th Cir. 2020); United States v. Eaton, 784 F.3d 298 (6th Cir. 2015); United States v. Morrison, 594 F.3d 543 (6th Cir. 2010); United States v. Lawrence, 735 F.3d 385 (6th Cir. 2013): abuse-of-discretion standard; pattern instruction acceptable when theory of defense implicates others.
  • United States v. Chavez, 951 F.3d 349 (6th Cir. 2020); United States v. Frady, 456 U.S. 152 (1982): plain-error standard for unobjected-to prosecutorial comments.
• Evidentiary rulings and the right to present a defense:
  • United States v. Dixon, 413 F.3d 540 (6th Cir. 2005); United States v. Wagner, 382 F.3d 598 (6th Cir. 2004); Romstadt v. Allstate, 59 F.3d 608 (6th Cir. 1995): broad discretion under Rule 403; cumulative evidence may be excluded.
  • Crane v. Kentucky, 476 U.S. 683 (1986): right to present a defense; balanced against evidence rules.
  • United States v. Blackwell, 459 F.3d 739 (6th Cir. 2006); Holmes v. South Carolina, 547 U.S. 319 (2006); Montana v. Egelhoff, 518 U.S. 37 (1996): no unfettered right to admit otherwise inadmissible evidence; cumulative exclusions permissible.
  • Fed. R. Evid. 403: exclude relevant evidence if probative value substantially outweighed by risk of confusion, waste, or needless cumulation.

Legal Reasoning and Application

1) Conspiracy: Agreement and Knowledge of Unlawful Aims

The panel emphasized that § 1349 conspiracy may be proved through circumstantial evidence and does not require an overt act. While defendants argued that they were transparent with Clinic leadership and believed their plan lawful—invoking cases like Liparota and Rehaif to stress knowledge beyond mere conduct—the court highlighted trial evidence permitting jurors to find that:

• Oliver misrepresented Sherry-Ann’s credentials and the scope of her role (including diagnosing and ordering PET scans) to key Clinic actors.
• Patients were led to believe Sherry-Ann was a physician; billing was done under Oliver’s NPI despite his lack of involvement.
• When questioned by an insurer, Oliver directed staff to portray the Center as a “neuro-otology” division that did not exist.
• Sherry-Ann sought to silence or sideline dissenting clinicians and encouraged patients to continue frequent, billed contacts.

From this, a rational jury could infer both knowledge of the conspiracy’s unlawful objective and a voluntary agreement to pursue it, notwithstanding some evidence consistent with mistake. The panel underscored that its role is not to reweigh evidence but to assess whether a reasonable juror could find guilt beyond a reasonable doubt when viewing evidence in the government’s favor.

2) Good-Faith Reliance on Compliance/Legal Advice

To establish good-faith reliance, defendants must show full disclosure of all pertinent facts and actual reliance on advice permitting the challenged conduct. The record demonstrated:

• Lancaster’s early, mistaken exploration of “incident-to” and general supervision for neuropsychological testing did not authorize unlicensed diagnosis or ordering of PET scans, and later analysis clarified the need for direct supervision and licensure (as reflected in Medicare local coverage determinations).
• Trudel (Clinic counsel) did not review the entire business plan and understood that diagnoses would be made by Oliver or the referring physician, not by Sherry-Ann.

Because advice did not cover the conduct the jury found fraudulent—and because the jury could conclude that defendants failed to fully disclose material facts to advisors—the defense did not defeat the government’s proof of intent. The panel also catalogued classic circumstantial indicia of fraudulent intent present here: concealment, misrepresentations, and financial benefit.

3) Jury Instructions

Three instruction-related issues were raised; the court rejected each.

• Deliberate ignorance (conspiracy):
  • Under Warshawsky, a willful-blindness instruction may be used to establish knowledge of the conspiracy’s unlawful purpose, but not to prove voluntary agreement to join. The district court’s instruction reflected the Sixth Circuit’s Pattern Instruction and was “clearly directed” to knowledge of the conspiracy’s purpose; no additional limiting language was required, and there was no suggestion that the jury could use willful blindness to find agreement.
  • The panel contrasted Evans Landscaping, where an instruction improperly allowed willful blindness to stand in for voluntary agreement; that error did not occur here.
• Deliberate ignorance (mail, wire, and health-care fraud):
  • There is no per se bar to willful-blindness instructions in specific-intent crimes; they may be used to prove knowledge of key facts (e.g., falsity of claims) so long as they do not collapse the separate “specific intent to defraud” element.
  • The district court properly instructed that deliberate ignorance could support a finding that defendants knew claims were false, while separately requiring the jury to find a specific “intent to deceive or cheat” for financial gain/loss. Thus, the instruction did not “back door” the specific intent element and was not plain error.
• Unindicted co-conspirator instruction and closing:
  • Given the defense theory that Clinic leadership was culpable, the neutral pattern instruction on unindicted co-conspirators was fitting and not prejudicial.
  • The prosecution’s brief suggestion in closing that Clinic personnel could be co-conspirators was not plain error; it tracked the instruction and did not preclude fair consideration of the good-faith theory.

4) Evidentiary Ruling: Limiting the 544-Page Compliance Research File (Rule 403)

The district court allowed the defense to use and display the binder’s heft, introduce selected excerpts, and examine witnesses extensively about the research and timeline. It excluded wholesale admission under Rule 403 as cumulative and potentially confusing. The Sixth Circuit affirmed:

• Trial testimony already covered the substance and chronology of the compliance work; full admission would “data dump” the jury with marginal additional probative value.
• No due process or Sixth Amendment violation occurred; the defense lacked an entitlement to introduce voluminous cumulative evidence when its points were otherwise fully presented.
• Any error would have been harmless because the binder would not change the critical fact that no one authorized the unlicensed diagnosing or ordering of PET scans.

Practical Impact and Forward-Looking Implications

• Willful blindness in the Sixth Circuit—fine-grained boundaries:
  • Conspiracy: juries may consider willful blindness for knowledge of unlawful aims, but not to prove voluntary agreement.
  • Specific-intent fraud: prosecutors may use willful blindness to establish knowledge (e.g., falsity of claims), provided the court separately instructs and the jury separately finds the distinct “intent to defraud.”
• Advice-of-compliance is not a safe harbor:
  • Reliance on internal compliance or counsel requires full disclosure of all material facts; defendants cannot cherry-pick advice or rely on advisors’ limited assumptions about scope of services.
  • Where advisors expressly or implicitly limit what is permissible (e.g., testing but not diagnosing or ordering radiology), defendants proceed at risk if they go beyond that advice.
• Healthcare billing mechanics receive renewed scrutiny:
  • “Incident-to” billing for psychological/neuropsychological services requires direct supervision and proper licensure; unlicensed individuals cannot cloak clinical diagnosing or PET ordering under another’s NPI based on general supervision.
  • Local Coverage Determinations (LCDs) and Medicare rules—not internal interpretations—govern; compliance programs must keep current and accurate.
• Rule 403 in complex white-collar trials:
  • Courts may exclude voluminous cumulative materials where testimony and excerpts capture the probative essence; parties should consider summaries, stipulations, and demonstratives rather than wholesale document dumps.
• Institutional oversight as evidence of knowledge and intent:
  • Peer-review letters, insurer queries, and internal pushback can be powerful evidence of notice, knowledge of risk or impropriety, and potential concealment when defendants respond by evasion or misrepresentation.
• Preservation matters:
  • Partial concessions about instructional applicability can waive challenges; where not waived, unpreserved objections face stringent plain-error review.

Although the opinion is unpublished and thus non-precedential, it synthesizes and applies existing Sixth Circuit principles in a way that will resonate in future health-care fraud, mail/wire fraud, and conspiracy prosecutions.