Lawrence Alexander, an orthopedic surgeon, partnered with Jeremy Waxman to operate Silent Hill Bracing and Orthopedic Supplies, a durable medical equipment company. To reduce Medicare scrutiny, they listed Alexander's mother, Susan Alexander, as the sole owner on Medicare enrollment forms, despite her having no role in the business. In 2019, they submitted a CMS 855S form to update the company's hours of operations, falsely certifying Susan as the owner. Alexander was indicted for conspiracy and making false statements. A jury acquitted him of conspiracy but convicted him of the false statement count. He was sentenced to 33 months in prison, three years of supervised release, ordered to pay over $315,000 in restitution, and forfeit $125,000. Alexander appealed, challenging venue, the sufficiency of the evidence, jury instructions, and the restitution and forfeiture orders.
The Eleventh Circuit addressed seven issues on appeal. First, regarding venue, the court found overwhelming circumstantial evidence that the crime occurred in the Southern District of Florida, as the company was located there and the forms were submitted from Waxman's office. Second, the court affirmed the denial of the motion to dismiss, holding the indictment sufficiently tracked the statute and provided notice of the offense. Third, on sufficiency of the evidence, the court rejected Alexander's arguments that the false statement was not material or that he did not aid and abet the submission. The court clarified that materiality requires only that the statement had a natural tendency to influence the decisionmaker, not that it was actually relied upon. The evidence showed Alexander provided his mother's personal information and consented to the submission of forms. Fourth, the court found no reversible error in the jury instructions. The materiality instruction was 'invited error' because Alexander proposed the exact language he now challenges. The deliberate ignorance instruction was not raised in the opening brief and was therefore waived. Fifth, regarding forfeiture, the court acknowledged the district court failed to enter a preliminary forfeiture order before sentencing as required by Federal Rule of Criminal Procedure 32.2, but ruled this was harmless error because Alexander had fair notice and a full opportunity to contest the amount. Finally, on restitution, the court vacated the order. While a fraud conviction implies some loss, the government must prove actual loss directly caused by the specific offense of conviction. The record showed no evidence that Medicare reviewed or acted on the specific 2019 form, meaning the government failed to establish a causal link between the false statement and the payments made.
The decision clarifies the distinction between the materiality standard for conviction under 18 U.S.C. § 1035 and the causation standard required for restitution under the Mandatory Victims Restitution Act. While a false statement need only be capable of influencing a decision to secure a conviction, the government must prove actual reliance to recover restitution. The case is remanded to the district court to recalculate restitution based on specific losses caused by the false statement, rather than all claims submitted after the form. The forfeiture order remains in effect, and the conviction stands.