[PUBLISH] In the United States Court of Appeals For the Eleventh Circuit

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No. 21-10461 ____________________

UNITED STATES OF AMERICA, Plaintiff-Appellee, versus CARLOS ALFREDO VERDEZA,

Defendant- Appellant.

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Appeal from the United States District Court for the Southern District of Florida D.C. Docket No. 1:19-cr-20470-JEM-1 ____________________ USCA11 Case: 21-10461 Document: 74-1 Date Filed: 05/31/2023 Page: 2 of 28

2 Opinion of the Court 21-10461

Before WILLIAM PRYOR, Chief Judge, and ROSENBAUM and MARCUS, Circuit Judges. ROSENBAUM, Circuit Judge: For over a year, physician assistant Carlos Verdeza evalu- ated patients and prescribed them physical therapy. The clinics where Verdeza worked then billed the patients’ health insurance both for the evaluations and for the subsequent physical therapy. The problem—for Verdeza and for the health-insurance com- pany—was that the “patients” didn’t really need the physical ther- apy and didn’t actually receive any treatment. When the health- insurance company grew suspicious of the abnormally high rate of physical-therapy prescriptions from the clinics, it cooperated with an FBI investigation into the clinics. That investigation led a grand jury to indict Verdeza on eight healthcare-fraud-related charges. After a trial, a jury con- victed Verdeza on three counts. Now on appeal, Verdeza raises several challenges to his conviction—sufficiency, evidentiary, and instructional—and to his sentence. After a thorough review of the record and with the benefit of oral argument, we affirm.

I. BACKGROUND A. Factual History In November 2016, Carlos Verdeza, a physician assistant, be- gan working at two clinics in the South Florida area: Guerra USCA11 Case: 21-10461 Document: 74-1 Date Filed: 05/31/2023 Page: 3 of 28

21-10461 Opinion of the Court 3

Medical Center and Double R Therapy Center. 1 Neither clinic was a real healthcare facility. Rather, both were fronts for fraud. The clinics—run by the same ownership group—used recruiters to find and entice people with Blue Cross Blue Shield (“BCBS”) health in- surance to come to the clinics. To persuade people to be “patients,” the clinics paid them kickbacks. When the “patients” arrive[d] for their “treatment,” Verdeza would briefly see them, perform no (or very little) examination, and prescribe physical therapy. For instance, in one instance, Verdeza asked the “patient” only two questions before prescribing physical therapy. The “patients” didn’t return to the clinic and gen- erally didn’t receive physical therapy. Yet at the clinic, “patients” signed dozens of forms attesting that they had received treatment. Because one evaluation justified only a limited number of treat- ments, Verdeza often signed two or three forms falsely stating that he had “reevaluated” the “patients” and that they needed more physical therapy—even though he never saw the “patients” again. Between November 2016 and January 2018, Guerra and