United States v. Sylvia Walter-Eze , 869 F.3d 891 ( 2017 )


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  •                      FOR PUBLICATION
    UNITED STATES COURT OF APPEALS
    FOR THE NINTH CIRCUIT
    UNITED STATES OF AMERICA,                          No. 15-50315
    Plaintiff-Appellee,
    D.C. No.
    v.                            14-CR-00259-
    RGK-1
    SYLVIA OGBENYEANU WALTER-EZE,
    AKA Sylvia O Okam,
    Defendant-Appellant.                    OPINION
    Appeal from the United States District Court
    for the Central District of California
    R. Gary Klausner, District Judge, Presiding
    Argued and Submitted February 7, 2017
    Pasadena, California
    Filed August 25, 2017
    Before: Sidney R. Thomas, Chief Judge, Jacqueline H.
    Nguyen, Circuit Judge, and Carol Bagley Amon,*
    District Judge.
    Opinion by Judge Amon;
    Concurrence by Judge Nguyen
    *
    The Honorable Carol Bagley Amon, United States District Judge for
    the Eastern District of New York, sitting by designation.
    2                UNITED STATES V. WALTER-EZE
    SUMMARY**
    Criminal Law
    The panel affirmed a jury conviction and sentence for
    health care fraud and conspiracy.
    The panel held that the defendant was not denied effective
    assistance of counsel when her attorney obtained only a short
    continuance of trial and declined the district court’s offer of
    a longer continuance conditioned on counsel’s paying the
    costs incurred by the continuance, including witness and jury
    fees. The panel held that both the threat of fees and the risk
    of a bar investigation and sanctions as a result of the fees
    created an actual conflict of interest that adversely affected
    counsel’s performance. The panel assumed without deciding
    that the rule of Cuyler v. Sullivan, 
    446 U.S. 335
    (1980),
    regarding a presumption of prejudice upon a showing of an
    actual conflict, can extend to a case of pecuniary conflict.
    Under the circumstances of this case, however, Sullivan did
    not control because the actual conflict was relegated to a
    single moment of the representation and resulted in a single
    identifiable decision that adversely affected the defendant,
    rather than tainting every interaction with or decision made
    by counsel. The defendant therefore was required to
    demonstrate that she was prejudiced by her counsel’s failure
    to obtain the longer continuance. The defendant did not make
    this showing, and thus failed to establish a Sixth Amendment
    violation.
    **
    This summary constitutes no part of the opinion of the court. It has
    been prepared by court staff for the convenience of the reader.
    UNITED STATES V. WALTER-EZE                      3
    The panel held that the district court did not abuse its
    discretion in ruling on the defendant’s morning-of-trial
    request for a fifth continuance.
    The panel held that the district court did not abuse its
    discretion in giving a deliberate ignorance jury instruction.
    Even though the government’s case-in-chief relied primarily
    on the claim that the defendant had actual knowledge of the
    health care fraud, the jury instruction had foundation in the
    evidence. The timing of the instruction, after the defense had
    already made its summation but before the government’s
    rebuttal, did not deprive the defendant of the right to fully
    defend herself.
    The panel held that the district court did not plainly err in
    its oral recitation of a jury instruction on the elements of
    health care fraud. The jury instructions as a whole properly
    conveyed the government’s burden of proof.
    The panel held that at sentencing, the district court did not
    err in calculating the amount of loss based on the total
    amount billed to Medicare and Medi-Cal. The district court
    did not plainly err in applying an enhancement for the
    defendant’s leadership role in a criminal activity involving
    five or more people. The district court also did not plainly err
    in calculating the amount of restitution.
    Concurring only in the judgment, Judge Nguyen joined
    fully in the majority’s conclusions. She wrote separately
    because she feared that the majority’s reasoning regarding
    conflicts of interests could create confusion in the court’s
    case law. Judge Nguyen would hold that there was no “actual
    conflict” that adversely affected counsel’s performance, and
    thus Sullivan’s presumed prejudice rule did not apply. Like
    4             UNITED STATES V. WALTER-EZE
    the majority, she would apply the prejudice standard and hold
    that the defendant could not show prejudice due to the
    overwhelming evidence against her.
    COUNSEL
    David J. Bernstein (argued), Law Office of David Jay
    Bernstein PA, Deerfield Beach, Florida, for Defendant-
    Appellant.
    Ellen R. Meltzer (argued), Special Counsel; Joanna K.W.
    Bowman, Alexander F. Porter, and Blanca Quintero,
    Assistant United States Attorneys; Sung-Hee Suh, Deputy
    Assistant Attorney General; Leslie R. Caldwell, Assistant
    Attorney General; Fraud Section, Criminal Division, United
    States Department of Justice, Washington, D.C.; for Plaintiff-
    Appellee.
    OPINION
    AMON, District Judge:
    Appellant Sylvia Walter-Eze stands convicted after a jury
    trial of one count of conspiracy to commit health care fraud
    in violation of 18 U.S.C. § 1349 (Count 1); four counts of
    health care fraud in violation of 18 U.S.C. § 1347 (Counts 2,
    3, 5, and 6); and one count of conspiracy to pay and receive
    health care kickbacks in violation of 18 U.S.C. § 371 (Count
    7). She was acquitted of one count of conspiracy to commit
    health care fraud in violation of 18 U.S.C. § 1347 (Count 4).
    Walter-Eze was sentenced to 97 months imprisonment and
    UNITED STATES V. WALTER-EZE                     5
    three years of supervised release and was ordered to pay
    restitution of $1,939,529.27.
    On appeal, Walter-Eze raises challenges to her conviction
    and sentence on the following grounds: (1) a conflict of
    interest created by the district court when it conditioned an
    adjournment on counsel’s paying jury costs and witness fees
    violated her Sixth Amendment right to counsel, and (2) the
    district court erred (a) in refusing to grant defense counsel’s
    morning-of-trial request for a continuance; (b) in giving a
    deliberate ignorance instruction; (c) in instructing the jury on
    the burden of proof; (d) in calculating the loss under United
    States Sentencing Guideline (“U.S.S.G.”) § 2B1.1(b)(1);
    (e) in applying a leadership role under U.S.S.G. § 3B1.1(a);
    and (f) in calculating restitution. Because we conclude that
    none of these claims is meritorious, we affirm.
    BACKGROUND
    I. Pre-Trial Continuances
    Walter-Eze was initially represented by a court-appointed
    attorney for whom the district court granted three separate
    trial continuances, on June 27, 2014 (continuing trial from
    July 1, 2014, to November 12, 2014), on November 4, 2014
    (continuing trial to January 13, 2015), and on January 7, 2015
    (continuing trial to March 3, 2015). In granting the last
    continuance, the district court found that counsel had not set
    forth any good cause for failing to be prepared for trial and
    found that counsel had not been diligent in handling the case.
    Nonetheless, in the interest of justice, the district court
    granted the third continuance, admonishing the parties that
    “you’re going to have a really hard time” convincing the
    court to continue the trial any further.
    6             UNITED STATES V. WALTER-EZE
    After three continuances over nearly eight months and
    only two weeks before trial, Walter-Eze filed a motion on
    February 17, 2015, to substitute in Christopher Darden and
    Oma Nkele as counsel. On February 18, 2015, the district
    court held a hearing on the motion. During this hearing, the
    district court expressed concern that Walter-Eze’s last-minute
    request to change attorneys was an attempt to delay trial even
    further. The district court therefore requested that before
    being substituted in, new counsel guarantee that they would
    be prepared to proceed on the current trial date, or at the
    latest, March 10, 2015. Although at first asserting that she
    would need another three months in order to deal with the
    over 21,000 pages of documents at issue, Nkele made an
    express commitment that she and the firm of Christopher
    Darden would be prepared to try the case no later than March
    10, 2015. On this representation, the district court allowed
    the substitution, retained the existing trial date of March 3,
    2015, and instructed counsel to let it know if they needed the
    extra week until March 10, 2015. On February 25, 2015,
    Walter-Eze filed a Motion to Continue Trial and the district
    court continued trial to March 10, 2015.
    II. Conflict of Interest
    On the morning of the first day of trial, March 10, 2015,
    Walter-Eze filed an Emergency Motion to Continue Trial.
    Appearing in court, defense counsel requested a continuance
    from March 10, 2015, to April 7, 2015, due to Nkele’s
    inability to prepare for trial as a result of an illness and
    alleged problems with the discovery materials. The district
    court reminded counsel of their prior representation that they
    would be prepared to try the case on March 10. The district
    court also expressed suspicion that Walter-Eze had used the
    substitution of counsel and other events in the preceding
    UNITED STATES V. WALTER-EZE                                7
    month as a delaying tactic, knowing that this was the only
    way it would agree to another continuance. Based on the
    events that had transpired, the district court found that
    defense counsel had made misrepresentations to the court.
    The district court nonetheless cautioned counsel that if
    they were unprepared, it was their duty to not proceed and
    trial would be continued to April 28, 2015, conditioned on
    counsel’s paying the costs incurred by the continuance,
    including witness and jury fees, which totaled approximately
    $3,600. Alternatively, the district court stated that if counsel
    could affirm that they could adequately represent their client,
    trial would commence that day and no fees would be
    assessed. Darden expressed his concern that the proposed
    fees might require reporting to the California State Bar
    Association.1 The district judge replied that, because he
    understood the reporting rule to only apply to sanctions, he
    would characterize the costs as fees if that would help avoid
    the issue. Recognizing the difficult position that counsel was
    in, the district court instructed counsel to discuss the matter
    before making their decision. After further discussion—and
    an initial statement that counsel were not prepared to try the
    case—Darden stated that he would be prepared to proceed but
    proposed that the district court empanel the jury that day
    (March 10), and then continue trial for two days. During the
    two days, Darden stated that he would familiarize himself
    with Nkele’s portion of the case in the event she became
    unavailable due to physical limitations. Based on Darden’s
    representation that he would be prepared to proceed on March
    1
    California law requires an attorney to report to the Bar Association
    “[t]he imposition of judicial sanctions against the attorney, except for . . .
    monetary sanctions of less than one thousand dollars.” Cal. Bus. & Prof.
    Code § 6068(o)(3).
    8               UNITED STATES V. WALTER-EZE
    12, 2015, the district court granted the fifth continuance of
    trial to March 12, 2015.
    III.       Evidence at Trial
    At trial, witnesses called by the government testified to a
    five-year scheme run by Walter-Eze through her company
    Ezcor-9000 (“Ezcor”) to fraudulently bill Medicare and
    Medi-Cal for durable medical equipment (“DME”) provided
    to patients who had no need for the devices.2 Recruiters
    would be paid kickbacks to find patients and doctors would
    be paid for prescriptions. Among the witnesses called were
    Wilmer Guzman and Elder Aguilar, workers for Walter-Eze,
    who explained the illegal kickback scheme and the provision
    of the DME; Dr. Edna Calaustro, who was paid by Ezcor to
    write prescriptions for unnecessary devices; and several
    beneficiaries (or their relatives) whose receipt of unnecessary
    devices served as the predicates for each of the substantive
    claims in Counts 2 through 6 of the indictment. The federal
    and state investigators who worked on the Ezcor case also
    testified.
    Walter-Eze testified in her own defense.               No other
    witnesses were called by the defense.
    The majority of the government’s evidence at trial
    pertained to one type of DME in particular—power
    wheelchairs—for which Medicare paid a particularly high
    rate of reimbursement and which, in order to be prescribed,
    required doctors to determine that their patients had such
    2
    Medi-Cal is California’s Medicaid program serving low-income
    individuals, which will reimburse the DME supplier up to 20 percent of
    the maximum allowable amount after Medicare pays.
    UNITED STATES V. WALTER-EZE                    9
    limited mobility that they lacked the ability to perform
    activities of daily living in the home. Over 50% of the
    $3,432,776 of claims that Walter-Eze submitted to Medicare
    and Medi-Cal through Ezcor were for these high-value power
    wheelchairs and wheelchair accessories. The fraudulent
    claims were not limited to these items, but included
    additional DME, such as hospital beds and knee and back
    braces, which accounted for an additional 33% of Ezcor’s
    business. Walter-Eze would pay recruiters such as Guzman
    kickbacks for each prescription that they brought in to Ezcor;
    the kickback amount would vary based on the reimbursement
    value of the piece of DME. Accordingly, the highest
    kickbacks were paid for power wheelchair prescriptions,
    followed by hospital beds, and knee and back braces. From
    January 2007 through early March 2012, Ezcor submitted
    $3,432,776 in reimbursement claims to Medicare and was
    paid $1,866,261. During this same period, Ezcor submitted
    claims to Medi-Cal totaling $89,011 and was paid $73,269.
    Walter-Eze denied that she paid kickbacks to recruiters,
    instead characterizing them as commissions paid to
    independent contractors. She also denied paying any money
    to Dr. Calaustro for prescriptions.
    IV.    Jury Instructions
    During the charging conference, the government
    requested a deliberate ignorance instruction based on
    Guzman’s testimony that he told Walter-Eze that Medicare
    beneficiaries were only accepting the power wheelchairs
    because Guzman was offering them money, to which
    Guzman said Walter-Eze replied “I don’t care. Just do what
    you have to do.” The district court replied that, “if that’s
    what she said, that’s part of the conspiracy,” and thus refused
    10            UNITED STATES V. WALTER-EZE
    to give that instruction.       Based on this ruling, the
    government’s summation focused on Walter-Eze’s actual
    knowledge of the fraud, and the defense’s summation
    centered almost entirely on the argument that Walter-Eze was
    a naïve businesswoman who unwittingly became involved
    with unsavory characters who were violating the law. After
    the defense completed its summation, the government
    renewed its request for the deliberate ignorance instruction,
    and the district court explained that, while it had previously
    believed that the instruction would not be relevant,
    “defendant’s theory in argument makes it relevant” because
    “after argument, the issue as to whether or not [Walter-Eze]
    was simply careless is directly in front of the Court.”
    Defense counsel argued that the instruction was not
    appropriate. The district court disagreed and instructed the
    jury regarding deliberate ignorance using Model Criminal
    Jury Instruction 5.7.
    V. Sentencing
    The district court calculated Walter-Eze’s sentencing
    range to be 97 to 121 months. In reaching this result, the
    district court found an intended loss of more than $2.5 million
    pursuant to U.S.S.G. § 2B1.1(b)(1) and also found that
    Walter-Eze was the leader of a scheme involving five or more
    participants pursuant to U.S.S.G. § 3B1.1(a). The district
    court sentenced Walter-Eze to 97 months in prison to be
    followed by a three-year term of supervised release, and
    ordered her to pay restitution of $1,939,529.27, which
    consisted of the $1,866,260.62 of payments Ezcor received
    from Medicare and the $73,268.65 it received from Medi-Cal.
    UNITED STATES V. WALTER-EZE                    11
    DISCUSSION
    I. Conflict of Interest
    The Sixth Amendment entitles criminal defendants to the
    effective assistance of counsel. To establish that counsel’s
    representation was constitutionally defective, a defendant
    must show both that counsel’s performance was deficient in
    that it “fell below an objective standard of reasonableness”
    and prejudice; namely, that there was a reasonable probability
    that but-for counsel’s unprofessional errors, the result of the
    proceedings would have been different. See Strickland v.
    Washington, 
    466 U.S. 668
    , 688–94 (1984). An exception to
    this general rule applies where “counsel is burdened by an
    actual conflict of interest.” 
    Id. at 692.
    In such cases, where
    it is often “difficult to measure the precise effect on the
    defense of representation corrupted by conflicting interests,”
    the Supreme Court has held that prejudice is presumed. 
    Id. Walter-Eze argues
    that the district court created a conflict
    between her and her counsel Darden by offering Darden the
    alternative of obtaining a requested continuance but paying
    fees and potentially facing some form of reprimand from the
    state bar or forgoing the continuance and avoiding the fees
    and possible sanctions. She asserts that a continuance would
    have been in her interest but was against Darden’s personal
    interests, and thus amounted to a conflict. Because counsel
    declined the continuance and began trial without having
    reviewed all the discovery, subpoenaed or spoken with
    potential defense witnesses, or prepared jury instructions, she
    claims her defense was compromised. She argues that Cuyler
    v. Sullivan, 
    446 U.S. 335
    (1980), dictates that this Court
    presume that she was prejudiced by the “actual conflict,” and
    must therefore vacate her conviction.
    12            UNITED STATES V. WALTER-EZE
    This case thus requires this Court to decide whether, after
    the Supreme Court’s decision in Mickens v. Taylor, 
    535 U.S. 162
    (2002), Sullivan—which set out the conditions under
    which a court should presume prejudice upon a showing of an
    actual conflict—applies to the circumstances of this case.
    Assuming without deciding that Sullivan’s rule of presumed
    prejudice as a matter of law can extend to a case of a
    pecuniary conflict, we hold that under the facts presented,
    Sullivan does not control this case. Accordingly, under the
    traditional analysis dictated by Strickland, Walter-Eze must
    demonstrate that she was prejudiced by her counsel’s failure
    to obtain the longer continuance which, on this record, she
    has failed to do.
    1. Actual Conflict
    “A claim that trial counsel had a conflict of interest with
    the defendant is a mixed question of law and fact and is
    reviewed de novo by the appellate court.” United States v.
    Nickerson, 
    556 F.3d 1014
    , 1018 (9th Cir. 2009). In Sullivan,
    a case where the alleged conflict of interest was based on
    counsel’s joint representation of multiple co-defendants, the
    Supreme Court found that if a defendant can show that his
    counsel operated under an “actual conflict of interest
    adversely affect[ing] his lawyer’s performance”—i.e. that
    counsel “actively represented conflicting interests”—the
    client need not demonstrate that he was prejudiced by the
    attorney’s 
    conflict. 446 U.S. at 350
    .
    “An actual conflict need not be a direct conflict, and it
    need not be established separately from adverse effect.
    Instead, an actual conflict ‘is a conflict of interest that
    adversely affects counsel’s performance.’” Hovey v. Ayers,
    
    458 F.3d 892
    , 908 (9th Cir. 2006) (quoting Mickens, 535 U.S.
    UNITED STATES V. WALTER-EZE                     13
    at 172 n.5) (internal citation omitted). “There is an actual,
    relevant conflict of interests if, during the course of the
    representation, the defendants’ interests do diverge with
    respect to a material factual or legal issue or to a course of
    action.” 
    Sullivan, 446 U.S. at 356
    n.3. In other words, an
    “actual conflict” is “a conflict that affected counsel’s
    performance—as opposed to a mere theoretical division of
    loyalties.” 
    Mickens, 535 U.S. at 171
    . The inquiry is
    accordingly fact specific and does not rely on the
    characterization or type of conflict presented: an “actual
    conflict is defined by its impact” on counsel’s representation.
    
    Hovey, 458 F.3d at 908
    .
    To establish an “adverse effect” a defendant must show
    “that some plausible alternative defense strategy or tactic
    might have been pursued but was not and that the alternative
    defense was inherently in conflict with or not undertaken due
    to the attorney’s other loyalties or interests.” United States v.
    Wells, 
    394 F.3d 725
    , 733 (9th Cir. 2005) (quoting United
    States v. Stantini, 
    85 F.3d 9
    , 16 (2d Cir. 1996)); see also
    McClure v. Thompson, 
    323 F.3d 1233
    , 1248 (9th Cir. 2003)
    (noting that to establish an adverse effect, a defendant “must
    demonstrate that his attorney made a choice between possible
    alternative courses of action that impermissibly favored an
    interest in competition with those of the client”).
    A showing of “adverse effect” is not the same as showing
    prejudice under the Strickland analysis. United States v.
    Miskinis, 
    966 F.2d 1263
    , 1268 (9th Cir. 1992). As this Court
    has explained, “overwhelming evidence of guilt might . . .
    make almost impossible a showing that a relatively minor
    error resulted in actual prejudice. But such evidence would
    be completely irrelevant to an inquiry whether the same error,
    if caused by an actual conflict of interest, showed an adverse
    14            UNITED STATES V. WALTER-EZE
    effect on counsel’s performance.” United States v. Hearst,
    
    638 F.2d 1190
    , 1194 (9th Cir. 1980). Accordingly, “[t]he
    strength of the prosecution’s case is not relevant to whether
    counsel’s performance was adversely affected.” United
    States v. Mett, 
    65 F.3d 1531
    , 1535 (9th Cir. 1995). Rather,
    “[t]o establish that a conflict of interest adversely affected
    counsel’s performance, the defendant need only show that
    some effect on counsel’s handling of particular aspects of the
    trial was ‘likely.’” 
    Miskinis, 966 F.2d at 1268
    (emphasis
    added); see also Lockhart v. Terhune, 
    250 F.3d 1223
    , 1231
    (9th Cir. 2001) (clarifying that to show an adverse effect, a
    defendant need “only to meet the lower standard of showing
    that ‘the attorney’s behavior seems to have been influenced’
    by the conflict” (quoting Sanders v. Ratelle, 
    21 F.3d 1446
    ,
    1452 (9th Cir. 1994))). That is to say, a defendant need not
    “show[] actual harm,” but just “actual conflict.” United
    States v. Finlay, 
    55 F.3d 1410
    , 1415 (9th Cir. 1995).
    When faced with a defendant’s claim that her counsel
    operated under an actual conflict, “[t]he central question that
    we consider in assessing a conflict’s adverse effect is ‘what
    the advocate [found] himself compelled to refrain from
    doing’ because of the conflict.” 
    Lockhart, 250 F.3d at 1231
    (alteration in original) (quoting United States v. Allen,
    
    831 F.2d 1487
    , 1497 (9th Cir. 1987)) (internal quotation
    marks omitted). This and other circuits have found that a
    conflict has adversely affected counsel’s representation in
    cases where, as a likely result of the conflict, counsel failed
    to put on certain defenses and witnesses, 
    Miskinis, 966 F.2d at 1268
    , failed to explore the possibility of a plea agreement,
    Mannhalt v. Reed, 
    847 F.2d 576
    , 582–83 (9th Cir. 1988), or
    failed to seek a continuance despite having taken the case
    only eight days earlier, United States ex rel. Duncan v.
    O’Leary, 
    806 F.2d 1307
    , 1315 (7th Cir. 1986).
    UNITED STATES V. WALTER-EZE                     15
    There are two bases for finding a conflict here: the
    imposition of the fees themselves, and the risk of a bar
    investigation and sanctions as a result of the fees. Without
    deciding whether such conflicts can amount to an “actual
    conflict” for the purposes of Sullivan’s presumption of
    prejudice, we hold that under the circumstances present here,
    both the threat of fees and the threat of potential sanctions
    created a conflict of interest that adversely affected counsel’s
    performance.
    2. Pecuniary Conflict
    As this Circuit has made clear, the mere fact that counsel
    has a profit motive in a representation is insufficient to show
    that counsel’s interests came in direct conflict with those of
    the client. “Lawyers almost always undertake representation
    of clients because of their desire to profit from the
    representation . . . . The fact that an attorney undertakes the
    representation of a client because of a desire to profit does not
    by itself create [a] direct ‘actual’ conflict of interest.” Bonin
    v. Calderon, 
    59 F.3d 815
    , 826 (9th Cir. 1995). Similarly, the
    fact that in a pro bono case a lawyer may have to pay expert
    witness fees does not without more raise a conflict of
    constitutional dimension when such witnesses are not
    retained. Williams v. Calderon, 
    52 F.3d 1465
    , 1473 (9th Cir.
    1995). If differences and commonplace disagreements
    between client and counsel over costs amounted to “actual
    conflicts” under Sullivan, “the rule would become hopelessly
    unworkable. As human beings, attorneys always have
    interests of their own independent of those of their clients.”
    
    Bonin, 59 F.3d at 827
    . Thus, courts have held that as a
    general matter, there is a “presumption that the lawyer will
    subordinate his pecuniary interests and honor his primary
    professional responsibility to his clients in the matter at
    16            UNITED STATES V. WALTER-EZE
    hand.” United States v. Jeffers, 
    520 F.2d 1256
    , 1265 (7th Cir.
    1975).
    This Court has nonetheless recognized instances wherein
    an attorney’s financial interests do result in a conflict with
    their client’s interests at trial. Although ultimately finding
    that no conflict existed, we noted in Bonin that an “actual”
    conflict does arise where circumstances “squarely place[] the
    interests of the client in opposition to those of the attorney,
    and [are] likely to compromise a reasonable attorney’s ability
    to comply with his legal and ethical obligation to represent
    his client with undivided 
    loyalty.” 59 F.3d at 827
    ; see also
    
    Hearst, 638 F.2d at 1193
    (remanding for a hearing where
    defendant claimed that her counsel had a conflict of interest
    because his publication rights to her story led him to, among
    other things, fail to seek a continuance). That is, the
    presumption of ethical behavior that we afford to attorneys
    must necessarily fade where, as it is argued here, counsel
    explicitly favors his own pecuniary interests above his
    client’s interests.
    3. Threat of Sanctions Conflict
    As a general matter, the threat of sanctions can influence
    an attorney’s conduct at trial; indeed, that is often their
    express purpose. See, e.g., In re DeVille, 
    361 F.3d 539
    , 553
    (9th Cir. 2004) (describing the purpose of sanctions as “to
    deter repetition of the conduct by the offending person or
    comparable conduct by similarly situated persons” (quoting
    Fed. R. Civ. P. 11 Advisory Committee’s Note to 1993
    amendment)).
    Although this Court has recognized the potential power of
    sanctions, it is not the case that a court necessarily creates a
    UNITED STATES V. WALTER-EZE                    17
    conflict of interest between an attorney and their client any
    time the court issues or threatens to issue sanctions. In most
    cases, a court’s imposition of sanctions can often help to
    better align the interests of a deficient attorney with those of
    their client by incentivizing counsel to handle the case with
    greater care. Nonetheless, Mickens’ directive that “an actual
    conflict is defined by its effect on counsel” requires courts to
    consider “the impact the conflict had on [counsel’s]
    performance.” Alberni v. McDaniel, 
    458 F.3d 860
    , 871 (9th
    Cir. 2006). The existence of a conflict must therefore be
    determined on a case-by-case basis, and where a threat of
    sanctions would instead serve to divorce counsel’s interests
    from those of their client, an actual conflict would exist.
    4. Darden’s Conflict
    In this case, the conflict was concretely manifest in real
    time, as Darden was called upon to choose between being
    fined and potentially facing a bar investigation or going to
    trial even though he and his co-counsel repeatedly indicated
    on the record that they were unprepared. For this reason, the
    government is wrong to assert that Darden was faced with
    only a “possible” conflict. In fact, the existence and impact
    of the conflict could not have been clearer.
    Even ignoring Darden’s vague protest that he was
    “conflicted” by the choice being put to him, he made plain to
    the district court that his decision was influenced by the
    pressures imposed by the fees and potential sanctions: “If I
    were forced to try the case, then I would try the case. If I
    were—if it came down to sanctions or try the case, I would
    try the case.” Darden thus perceived the district court’s
    proffered alternatives not so much as affording him a choice,
    but “compelling” him to try the case before he was fully
    18            UNITED STATES V. WALTER-EZE
    prepared, rather than face the district court’s stiff fines. Nor
    was this dilemma unapparent to the district court.
    Immediately after indicating that he would impose fees if
    counsel insisted on a continuance, the trial judge offered
    counsel time to consider his decision, noting that, “I
    appreciate and I feel sorry for the bind that you’re in here,”
    and that “it’s a tough, tough area that you’re in right now and
    a tough decision that you have to make.” And after hearing
    for the first time that obtaining a continuance for his client
    would require him to incur fines, Darden protested that this
    could require him to report to the state bar, adding that he has
    “worked awfully hard, and my family . . . .” Finally, while
    acknowledging that he had the responsibility to “protect [his]
    client’s rights,” he complained that to subordinate his own
    interests to those of his client’s in this case was “a sharp
    sword to fall on.”
    Ultimately, this led Darden to arrive at the compromise
    that the district court accepted: that the district court would
    choose the jury that day (Tuesday) and then continue the trial
    until Thursday afternoon, to afford Darden the opportunity to
    “catch up on the other part of the case that I’m not familiar
    with and be prepared to go forward.” Therefore, unlike in
    Bonin or Williams, where the Court found an undifferentiated
    and abstract interest in saving money insufficient to create an
    “actual” conflict, this case exhibits a definite and precisely
    articulated conflict that even according to the district court
    created a divergence between counsel’s and Walter-Eze’s
    interests.
    As a result of the conflict, Darden’s representation of
    Walter-Eze was adversely affected. Not only did the conflict
    lead Darden to forgo the plausible alternative tactic of
    accepting the district court’s offer of a longer continuance,
    UNITED STATES V. WALTER-EZE                    19
    but Walter-Eze alleges that as a result of the failure to obtain
    the lengthier continuance, counsel proceeded to trial without
    having subpoenaed defense witnesses or having fully engaged
    with the discovery materials. To establish that Darden’s
    conflict was “adverse,” Walter-Eze need not show that these
    shortcomings affected the outcome of the trial or even that
    counsel would have cured these failures if given more time,
    but only that they were the likely result of the conflict. See
    
    Miskinis, 966 F.2d at 1268
    ; 
    Finlay, 55 F.3d at 1415
    . She has
    adequately done so.
    Moreover, the facts here indicate that counsel was very
    concerned about the risk of bar reporting associated with the
    district court’s imposition of costs, regardless of the how the
    district court described them. It was counsel who first raised
    the issue of reporting. Recognizing the legitimacy of the
    concern and its impact on counsel’s decision whether to seek
    a continuance, the district court suggested that counsel utilize
    a brief recess to determine whether the fees would be
    reportable, and to make his decision based on whatever he
    learned. Contrary to the government’s contention, the fact
    that the negative effect on the lawyer is only a possibility
    does not make the conflict that arises out of counsel’s
    apprehension of that risk merely “potential.”
    The D.C. Circuit has held that an attorney-client conflict
    existed where appellate counsel was being sued for
    defamation by trial counsel for arguing on appeal that trial
    counsel was ineffective. This led appellate counsel to fear
    that in his continued representation of the appellant on
    remand to the district court, he would argue trial counsel’s
    errors less vigorously in order to protect himself against
    additional defamation claims. United States v. Hurt, 
    543 F.2d 162
    , 166–67 (D.C. Cir. 1976). The D.C. Circuit determined
    20            UNITED STATES V. WALTER-EZE
    that, although the defamation suit was almost surely
    meritless, appellate counsel was sincerely concerned about
    the potential consequences. Finding that, in the mind of
    counsel, “[t]he chance that the suit might be lost, though
    small, had not abated” and that “[t]he stakes, measured by the
    gravity of defamation of professional character, were high,”
    the court held that “however counsel’s apprehensions might
    appear to a disinterested observer, the record indulges only
    the conclusion that to counsel they were very real.” 
    Id. The record
    in this case likewise demonstrates counsel’s
    sincere concern regarding the potential of disciplinary
    consequences affecting his professional reputation. That
    sanctions might not be imposed did not mitigate the validity
    and urgency of counsel’s contemporaneous concerns. To the
    extent that a desire to avoid either the ultimate consequence
    or the headache associated with determining and limiting the
    extent of his exposure affected counsel’s decision-making
    with regard to seeking the continuance, such considerations
    self-evidently suffice to establish an “actual conflict” under
    this Circuit’s precedent.
    Because the district court’s ultimatum “squarely place[d]”
    Darden’s interests “in opposition” to Walter-Eze’s and
    explicitly “compromise[d Darden’s] ability to comply with
    his legal and ethical obligation to represent his client with
    undivided loyalty,” it created an “actual” conflict. 
    Bonin, 59 F.3d at 827
    . This Court must therefore decide whether,
    after Mickens and in light Sullivan’s reasoning, we should
    presume prejudice requiring that Walter-Eze’s conviction be
    vacated, or instead require that Walter-Eze establish that there
    is a “reasonable probability that, but for” this conflict, “the
    result of the proceeding would have been different.”
    
    Strickland, 466 U.S. at 694
    . As is discussed below, under the
    UNITED STATES V. WALTER-EZE                   21
    facts of this case, Walter-Eze must show that she was
    prejudiced by this actual conflict, and because she is unable
    to do so, we do not disturb the verdict.
    5. Sullivan and Presumed Prejudice
    In Mickens, the Supreme Court called into question the
    application of a presumed prejudice rule to conflicts other
    than those caused by the joint representation of two or more
    
    defendants. 535 U.S. at 174
    –75; see also Earp v. Ornoski,
    
    431 F.3d 1158
    , 1184 (9th Cir. 2005) (explaining that the
    Mickens Court “cautioned that its own conflict jurisprudence
    had not yet reached beyond joint representation”). The
    Mickens Court noted that lower courts had applied Sullivan’s
    presumed prejudice rule “unblinkingly to all kinds of alleged
    attorney ethical conflicts,” “even” including alleged conflicts
    involving counsel’s “personal or financial interests.”
    
    Mickens, 535 U.S. at 174
    (citations and internal quotation
    marks omitted). The Mickens Court emphasized that
    Sullivan required a showing that “counsel actively
    represented conflicting interests,” which did not support the
    expansive application to other sorts of conflicts or ethical
    violations, such as conflicts between a client’s welfare and
    counsel’s financial interests. 
    Id. at 175–76.
    Accordingly, this Circuit has noted that Mickens
    “explicitly concluded that [Sullivan’s presumption of
    prejudice] was limited to joint representation, and that any
    extension of Sullivan outside of the joint representation at
    trial context remained, ‘as far as the jurisprudence of [the
    Supreme Court was] concerned, an open question.’” Foote v.
    Del Papa, 
    492 F.3d 1026
    , 1030 (9th Cir. 2007) (quoting
    
    Earp, 431 F.3d at 1184
    ).
    22            UNITED STATES V. WALTER-EZE
    In Mickens, the Supreme Court explained that the
    presumed prejudice rule was needed in situations of multiple
    representations because of “the high probability of prejudice
    arising from multiple concurrent representation, and the
    difficulty of proving that prejudice,” but that “[n]ot all
    attorney conflicts present comparable 
    difficulties.” 535 U.S. at 175
    . In the multiple representation context, “[o]nce an
    actual conflict has been demonstrated, prejudice is presumed
    since the harm may not consist solely of what counsel does,
    but of ‘what the advocate finds himself compelled to refrain
    from doing, not only at trial but also’ during pretrial
    proceedings and preparation.” 
    Sanders, 21 F.3d at 1452
    (quoting Holloway v. Arkansas, 
    435 U.S. 475
    , 490 (1978));
    see also 
    Mickens, 535 U.S. at 168
    (“The presumption [of
    prejudice is] justified because joint representation of
    conflicting interests is inherently suspect, and because
    counsel’s conflicting obligations to multiple defendants . . .
    make it difficult to measure the precise harm arising from
    counsel’s errors.”); 
    Strickland, 466 U.S. at 692
    (“[I]t is
    difficult to measure the precise effect on the defense of
    representation corrupted by conflicting interests.”).
    As the Supreme Court explained in Holloway, when
    discussing the dangers inherent in cases of conflicting joint
    representation:
    [T]o assess the impact of a conflict of
    interests on the attorney’s options, tactics, and
    decisions in plea negotiations would be
    virtually impossible. Thus, an inquiry into a
    claim of harmless error here would require,
    unlike most cases, unguided speculation.
    UNITED STATES V. WALTER-EZE                   
    23 435 U.S. at 491
    . In other words, where counsel represents
    clients with conflicting interests throughout the trial, it is
    impossible to pinpoint at what point or to what extent
    counsel’s performance on behalf of one client was impaired,
    and consequently impossible to determine what impact such
    elusive defects had on the outcome of the trial. In such a
    case, a court faced with an actual conflict has no recourse but
    to assume that the defendant was prejudiced by counsel’s
    dual representation.
    In this case, however, “we do know precisely the impact
    of any conflict on the trial,” Bergman v. Witek, 99 F. App’x
    773, 775 (9th Cir. 2004) (Berzon, J., concurring)
    (memorandum). It was Darden’s decision to forgo the extra
    preparation that he could have been afforded by virtue of a
    longer continuance in order to avoid the monetary penalties
    and the risk of bar sanctions. Thus, even if Sullivan’s
    presumption of prejudice can extend, as a matter of law,
    beyond the case of multiple concurrent representations to the
    type of circumstances implicating counsel’s financial
    interests as are faced here, this is not a case where the
    presumption applies. This case does not present an example
    of a situation—present in the case of a joint representation—
    where every interaction with or decision made by counsel is
    tainted by the conflict. Rather, where, as here, the actual
    conflict is relegated to a single moment of the representation
    and resulted in a single identifiable decision that adversely
    affected the defendant, the Supreme Court’s reasoning
    regarding when prejudice should be presumed does not
    control. See 
    id. As the
    Supreme Court clarified in Mickens, the presumed
    prejudice rule was not intended “to enforce the Canons of
    Legal Ethics, but to apply needed prophylaxis in situations
    24            UNITED STATES V. WALTER-EZE
    where Strickland itself is evidently inadequate to assure
    vindication of the defendant’s Sixth Amendment right to
    
    counsel.” 535 U.S. at 176
    . It follows that where a case is
    sufficiently straightforward such that it can be resolved under
    Strickland’s familiar performance-and-prejudice framework,
    Sullivan’s rule of presumed prejudice does not apply.
    Strickland articulates the standard normally employed when
    assessing potential Sixth Amendment violations, and it
    directs courts to require the defendant to demonstrate how
    there is a reasonable probability that, but for this discrete
    adverse act, “the result of the proceeding would have been
    
    different.” 466 U.S. at 694
    . Accordingly, although Darden
    operated under an actual conflict, Walter-Eze must
    nonetheless show that Darden’s “defects in assistance [had a]
    probable effect upon the trial’s outcome.” 
    Mickens, 535 U.S. at 166
    .
    6. Prejudice
    Walter-Eze cannot, on this record, carry her burden to
    show that she was prejudiced by Darden’s actual conflict.
    United States v. Petersen, 
    777 F.2d 482
    , 484 (9th Cir. 1985)
    (per curium) (recognizing that defendants carry the burden of
    showing prejudice). She lists a litany of errors supposedly
    resulting from Darden’s unpreparedness: his failure to review
    all of the government’s exhibits; his failure to prepare jury
    instructions; his failure to complete a PowerPoint
    presentation, resulting in the district court refusing to allow
    it to be shown; his failure to secure the attendance of
    witnesses at trial; and his failure to provide the government
    with a timely list of witnesses and experts. However, with
    this catalogue of errors, Walter-Eze has merely identified a
    number of alleged deficiencies in counsel’s representation;
    she has not identified the prejudice that resulted therefrom.
    UNITED STATES V. WALTER-EZE                          25
    As the Supreme Court has reiterated, “[e]ven if a defendant
    shows that particular errors of counsel were unreasonable . . .
    the defendant must show that they actually had an adverse
    effect on the defense.” 
    Strickland, 466 U.S. at 693
    . Walter-
    Eze has not even attempted to do so.
    For instance, Walter-Eze has not provided any indication
    of what her “witnesses would have testified to, or how their
    testimony might have changed the outcome” of the trial.
    United States v. Berry, 
    814 F.2d 1406
    , 1409 (9th Cir. 1987).
    Nor has she indicated the detrimental effect, if any, of
    counsel’s alleged failure to review all the exhibits or to
    submit jury instructions. Regarding the exclusion of the
    PowerPoint presentation, the record reflects that the
    presentation was being prepared during trial for the purposes
    of counsel’s closing argument, and it was excluded because
    counsel failed to provide the final copy of the presentation to
    the government by 10:00 p.m. on the night before the closing,
    as the district court had required. There is no indication that
    counsel’s failure to disclose the presentation on time was at
    all related to the conflict of interest, and thus it cannot serve
    as an example of prejudice resulting from the conflict. See
    
    Strickland, 466 U.S. at 694
    (requiring a showing that the
    “specified errors resulted in the required prejudice”).
    Where there is no showing concerning what evidence
    could have been adduced to alter the outcome of the
    proceeding, Walter-Eze cannot demonstrate the prejudice
    necessary to succeed on an ineffectiveness claim on direct
    appeal. See 
    Berry, 814 F.2d at 1409
    .3
    3
    This Court’s review on direct appeal is limited to the trial record
    developed below. (Fed. R. App. P. 10(a) (“The following items constitute
    the record on appeal: (1) the original papers and exhibits filed in the
    26               UNITED STATES V. WALTER-EZE
    II. Walter-Eze’s Continuance Request
    A district court’s decision to deny a motion for a
    continuance is reviewed for abuse of discretion. United
    States v. Nguyen, 
    262 F.3d 998
    , 1002 (9th Cir. 2001).
    Walter-Eze argues that the district court abused its discretion
    by denying her morning-of-trial request for a continuance.
    The government responds that, to the contrary, the district
    court did not deny counsel’s request because it offered (albeit
    with the conditions discussed above) to continue the trial for
    over a month and a half—until April 28—and ultimately
    granted the two-day continuance that Darden requested.
    Indeed, although Walter-Eze continues to press this challenge
    in her Reply Brief, the brief opens by conceding that “[i]t is
    true that the trial court did not deny defense counsel’s
    continuance.” Because the district court not only offered to
    grant the longer continuance that Walter-Eze requested
    (which defense counsel rejected), but also ultimately gave a
    shorter two-day continuance upon defense counsel’s request,
    the district court plainly did not deny counsel’s request for a
    continuance.
    Even if this Court construes the district court’s
    conditioned grant of the requested one-month continuance to
    be effectively a denial of that request, this Court would still
    find no abuse of discretion. The Supreme Court has
    reiterated that “broad discretion must be granted trial courts
    district court; (2) the transcript of proceedings, if any; and (3) a certified
    copy of the docket entries prepared by the district clerk.”)). To the extent
    that Walter-Eze believes she can substantiate her allegations of prejudice
    through additional factual development beyond the record of the trial, the
    procedurally proper way to do so is by collaterally raising a claim for
    ineffective assistance of counsel under 28 U.S.C. § 2255. See, e.g.,
    Massaro v. United States, 
    538 U.S. 500
    , 504–06 (2003).
    UNITED STATES V. WALTER-EZE                   27
    on matters of continuances.” Morris v. Slappy, 
    461 U.S. 1
    ,
    11 (1983). This Court has therefore held:
    When the defendant’s sixth amendment right
    to counsel is implicated . . . a court must
    balance several factors to determine if the
    denial [of a continuance] was “fair and
    reasonable.” Among the factors are: whether
    the continuance would inconvenience
    witnesses, the court, counsel, or the parties;
    whether other continuances have been
    granted; whether legitimate reasons exist for
    the delay; whether the delay is the defendant’s
    fault; and whether a denial would prejudice
    the defendant.
    United States v. Studley, 
    783 F.2d 934
    , 938 (9th Cir. 1986)
    (quoting United States v. Leavitt, 
    608 F.2d 1290
    , 1293 (9th
    Cir. 1979) (per curiam)). In Studley, the Court affirmed the
    denial of a continuance even though it resulted in the
    defendant being unrepresented at trial, because, for among
    other reasons, the request for a continuance had not been
    made in good faith and trial had already been continued
    several times. 
    Id. at 939;
    see also United States v. Garrett,
    
    179 F.3d 1143
    , 1146–47 (9th Cir. 1999) (same where record
    demonstrated the “patience and consideration” the district
    court afforded to the defendant over a one-year period and the
    district court stated that the motion for continuance was being
    made to delay trial).
    Here, after four continuances over nearly nine months,
    Walter-Eze on the morning of trial sought a fifth continuance.
    This request came after the district court had expressly
    warned Walter-Eze and her counsel that it would only grant
    28             UNITED STATES V. WALTER-EZE
    her motion to substitute counsel if they represented that they
    would be prepared to go to trial on the date it was set. When
    Walter-Eze asked for another continuance on the morning of
    trial, the district court noted that “we have witnesses that
    come in again and again and again. They’re getting older.
    There’s been inconvenience, all caused by the defense.”
    Indeed, the government had advised the district court that Dr.
    Calaustro had suffered a stroke and that her attorney indicated
    that she would not be able to medically tolerate additional
    travel to appear at trial at a later date. The district court also
    explicitly noted its suspicion that the defendant herself was to
    blame for the delays in the trial and that it perceived the last-
    minute request to substitute counsel to be a part of these
    “dilatory” practices. The district court further expressed its
    doubt about the reasonableness of this additional request,
    given that counsel was aware of the scope of the evidence
    before taking the case and had been clearly warned by the
    district court that it would not allow a substitution if counsel
    could not be prepared by the day of trial. Finally, Walter-Eze
    has not established that she was prejudiced by the alleged
    failure to grant a continuance. Although Walter-Eze cites
    deficiencies in counsel’s performance that she asserts
    followed from the lack of a continuance, she has not shown
    that any of them affected the outcome of the trial. See United
    States v. George, 
    85 F.3d 1433
    , 1440 (9th Cir. 1996) (finding
    no prejudice where defendant has not “shown how a
    continuance would have assisted him”). This Circuit’s
    precedent and an analysis of the Studley factors dictate that if
    the district court’s actions are construed as in effect denying
    a continuance, it did not abuse its discretion.
    UNITED STATES V. WALTER-EZE                    29
    III.   Deliberate Ignorance Instruction
    Walter-Eze next argues that the trial court erred when
    after denying the government’s initial request to instruct the
    jury on “deliberate ignorance” and after the defense had
    already delivered its closing argument under the assumption
    that the instruction would not be given, the district court
    reversed itself, agreed to give the instruction, and allowed the
    government to argue deliberate ignorance in its rebuttal. We
    review the decision to give a deliberate ignorance
    instruction—also known as Jewell instruction, after United
    States v. Jewell, 
    532 F.2d 697
    (9th Cir. 1976) (en banc)—for
    abuse of discretion. United States v. Heredia, 
    483 F.3d 913
    ,
    922 (9th Cir. 2007).
    Walter-Eze makes two arguments related to the district
    court’s decision. First, she argues that because the
    government’s case-in-chief relied primarily on the claim that
    Walter-Eze had actual knowledge of the healthcare fraud, the
    deliberate ignorance instruction had no basis in the evidence,
    created the risk that the jury would convict her based simply
    on criminal negligence, and thus was improper. Second,
    Walter-Eze contends that the timing of the district court’s
    decision to give the instruction (after the defense had already
    made its summation, but before the government’s rebuttal),
    deprived Walter-Eze of the right to fully defend herself.
    Neither argument has merit.
    A Jewell instruction may be given “if the instruction is
    ‘supported by law and has foundation in the evidence.’”
    
    Heredia, 483 F.3d at 922
    (quoting Jones v. Williams,
    
    297 F.3d 930
    , 934 (9th Cir. 2002)). Jewell’s “core holding”
    was that, for the purposes of a criminal statute, an individual
    without “positive knowledge” can be found to have acted
    30            UNITED STATES V. WALTER-EZE
    “knowingly” if the individual “consciously avoided”
    obtaining actual knowledge. 
    Id. at 918
    (quoting 
    Jewell 532 F.2d at 702
    ). In deciding whether to give a Jewell
    instruction, “in addition to an actual knowledge instruction,
    the district court must determine whether the jury could
    rationally find willful blindness even though it has rejected
    the government’s evidence of actual knowledge. If so, the
    court may give a Jewell instruction.” 
    Id. at 922.
    It follows
    that, if the record contains evidence to support a deliberate
    ignorance instruction, it does not matter that the government
    primarily relied upon a theory of actual knowledge. See
    United States v. Ramos-Atondo, 
    732 F.3d 1113
    , 1120 (9th
    Cir. 2013) (“[N]o established principle of law declares that
    the deliberate ignorance instruction cannot be given unless
    deliberate ignorance is the main thrust of the government’s
    case-in-chief or closing argument. The law indeed is to the
    contrary.”).
    A review of the record shows that the district court acted
    within its sound discretion in giving a deliberate ignorance
    instruction. At trial, evidence was presented upon which a
    reasonable jury could have concluded that even if Walter-Eze
    did not know about the illegal kickbacks and healthcare fraud,
    she deliberately failed to investigate while being aware of a
    high probability of the fraud. Once the defense in their
    summation articulated their theory of the case, i.e. that
    Walter-Eze was caught up in other peoples’ schemes and had
    no knowledge of the criminal conduct, the district court
    rightly found that the defense had made the deliberate
    ignorance charge relevant to the entire course of conduct.
    In summation, in addressing the evidence that Dr.
    Calaustro was paid by Walter-Eze to write bogus
    prescriptions for power wheelchairs, the defense argued that
    UNITED STATES V. WALTER-EZE                    31
    there was no evidence that Walter-Eze ever went to Northern
    California to watch Dr. Calaustro examine a patient, denied
    that she ever spoke with Dr. Calaustro, and asserted that “she
    didn’t know” that Dr. Calaustro was “writing hundreds and
    hundreds and hundreds of wheelchair prescriptions for a
    hundred dollars each.” However, Brent Person, who works
    for the Centers for Medicare and Medicaid Services, testified
    that in his experience, “most physicians go their entire careers
    and only prescribe one or two power wheelchairs,” but that
    most of Ezcor’s power wheelchair prescriptions came from
    just four physicians, each of whom were “prescribing
    wheelchairs in the double-digits in only a few years.” Allison
    Davis, a Special Agent for the Department of Health and
    Human Services, testified that it was “unusual” and “defies
    common sense” to see a DME supplier in Southern California
    supply patients who live in Northern California.
    Given the unusually high number of high-value
    prescriptions that came from just four doctors, one of whom,
    Dr. Calaustro, was located far from Ezcor’s offices, a
    reasonable jury could find that Walter-Eze knew there was a
    high probability that the referrals were being obtained
    fraudulently but failed to investigate the matter to ascertain
    the truth. See, e.g., United States v. Nicholson, 
    677 F.2d 706
    ,
    710–11 (9th Cir. 1982) (finding deliberate ignorance
    instruction proper where the defendant remained willfully
    ignorant of the nature of his activity after the circumstances
    would “have put any reasonable person on notice that there
    was a ‘high probability’ that the [conduct] was illegal”).
    Walter-Eze’s additional contention that the instruction
    was inappropriate because it could have led the jury to
    convict based on simple negligence is unavailing. Walter-
    Eze does not claim that the charge itself was an incorrect
    32            UNITED STATES V. WALTER-EZE
    statement of the law, and the charge makes plain that
    negligence is not a sufficient basis for guilt. In Heredia, this
    Court unequivocally rejected the argument that “the Jewell
    instruction risks lessening the state of mind that a jury must
    find to something akin to recklessness or 
    negligence.” 483 F.3d at 924
    (“Recklessness or negligence never comes
    into play, and there is little reason to suspect that juries will
    import these concepts, as to which they are not instructed,
    into their deliberations.”).
    Walter-Eze’s second claim is that she was denied “the
    right to defend herself” because, in violation of Federal Rule
    of Criminal Procedure 30(b)’s requirement that courts
    “inform the parties before closing arguments how it intends
    to rule on the requested instructions,” the district court only
    decided to allow the deliberate ignorance instruction after the
    defense had already delivered its summation. As an initial
    matter, the district court correctly determined that defense
    counsel did make arguments in his summation which made a
    deliberate ignorance charge relevant, by asserting that
    Walter-Eze did not know and had no reason to know about
    her co-conspirator’s criminal conduct. Indeed, defense
    counsel explicitly argued this point at length:
    And if that person is taken to a licensed
    physician, and there’s no indication that these
    doctors were not licensed, and if that person
    gives a true and honest medical history which
    is then conveyed to my client, why should she
    think it’s fraudulent? Why should she think
    there’s no medical necessity? Why should she
    be convicted of Counts 2 through 6? It is
    ridiculous.
    UNITED STATES V. WALTER-EZE                    33
    It was therefore only as a result of defense counsel’s
    argument that the district court felt it necessary to allow the
    government to articulate a deliberate ignorance theory. That
    argument invited an explanation for why and how Walter-Eze
    missed all the warning signs that fraud was occurring under
    her watch.
    But even if defense counsel did not have the opportunity
    to directly address the instruction in his summation, Walter-
    Eze was not prejudiced by this limitation. “Failure to comply
    with [Federal Rule of Criminal Procedure] 30 is reversible
    error . . . only if counsel’s closing argument was prejudicially
    affected thereby,” meaning counsel “was unfairly prevented
    from arguing his or her defense to the jury or was
    substantially misled in formulating and presenting
    arguments.” United States v. Foppe, 
    993 F.2d 1444
    , 1451
    (9th Cir. 1993) (quoting United States v. Gaskins, 
    849 F.2d 454
    , 458 (9th Cir. 1988)). Walter-Eze has not indicated how
    her counsel’s summation would have been different had he
    known that the deliberate ignorance standard would apply.
    See United States v. Scott, 
    642 F.3d 791
    , 798 (9th Cir. 2011)
    (finding no prejudice where defendant does not articulate
    “any way in which his closing argument would have been
    different if the court had provided the instructions earlier”).
    As noted above, defense counsel already had argued not only
    that Walter-Eze did not know about her co-conspirators’
    scheme, but also that she had no reason to know of it, such
    that she should not be found guilty even under a deliberate
    ignorance theory. Because the inability to make additional
    argument to the jury did not “prevent [ ] defense counsel from
    making a point essential to the defense” that he did not
    already make, Walter-Eze was not prejudiced and the district
    court did not abuse its discretion in adding the deliberate
    ignorance instruction. United States v. Horton, 
    921 F.2d 540
    ,
    34            UNITED STATES V. WALTER-EZE
    547 (4th Cir. 1990) (alteration in original) (quoting United
    States v. Sawyer, 
    443 F.2d 712
    , 713 (D.C. Cir. 1971)).
    Finally, defense counsel never asked the district court for
    the opportunity to respond to the added instruction, which we
    have previously found precludes a challenge upon appeal.
    United States v. Fontenot, 
    14 F.3d 1364
    , 1368 (9th Cir.
    1994); see also United States v. James, 
    998 F.2d 74
    , 79 (2d
    Cir. 1993) (“Having failed to request additional argument and
    having thereby deprived [the district court] of the opportunity
    to correct any potential error, [defendant’s] argument on
    appeal that Fed. R. Crim. P. 30 was violated because he was
    never given the chance to reargue is without merit. . . .”).
    IV.    Burden of Proof Instruction
    Walter-Eze next challenges the district court’s oral
    recitation of a jury instruction. Because she did not object at
    trial, this Court reviews for plain error, which requires a
    showing that “(1) there is an error; (2) the error is clear or
    obvious, rather than subject to reasonable dispute; (3) the
    error affected [defendant’s] substantial rights, which in the
    ordinary case means it affected the outcome of the district-
    court proceedings; and (4) the error seriously affected the
    fairness, integrity, or public reputation of judicial
    proceedings.” United States v. Walls, 
    784 F.3d 543
    , 546 (9th
    Cir.), cert. denied, 
    136 S. Ct. 226
    (2015). “In reviewing jury
    instructions, the relevant inquiry is whether the instructions
    as a whole are misleading or inadequate to guide the jury’s
    deliberation.” United States v. Anderson, 
    741 F.3d 938
    , 947
    (9th Cir. 2013) (quoting United States v. Chao Fan Xu,
    
    706 F.3d 965
    , 985 (9th Cir. 2013)).
    UNITED STATES V. WALTER-EZE                   35
    When delivering its oral instructions on the elements of
    the health care fraud conspiracy charge (Count 1), the district
    court stated that “[i]n order for the defendant to be found
    guilty of this charge, the defendant must—or the government
    must prove each of the following elements beyond a
    reasonable doubt.” Walter-Eze thus claims that the district
    court thereby incorrectly placed the burden of proof beyond
    a reasonable doubt upon the defendant. The argument is
    meritless.
    When considered as a whole with the remainder of the
    district court’s instructions and the fact that the jury was
    provided a copy of the correct written instructions, the oral
    instruction did not constitute an error that “affected
    substantial rights.” Both before and after the misstatement,
    the district court read numerous other instructions to the jury
    that correctly articulated that the government bore the burden
    of proof. Here, the district court provided the jury members
    with proper written instructions and explicitly—both before
    reading the instructions, and later when the jury asked for
    clarification—directed the jury to reference these instructions
    during its deliberations. As such, the district court’s slip of
    the tongue was unlikely to have misled the jury or affected
    the outcome of the proceedings. See United States v. Soto,
    
    519 F.3d 927
    , 932 (9th Cir. 2008) (per curiam); see also
    United States v. Ancheta, 
    38 F.3d 1114
    , 1117 (9th Cir. 1994)
    (finding jurors not confused by district court’s slip of the
    tongue when reading oral instructions where they were
    thereafter provided with proper written instructions).
    36            UNITED STATES V. WALTER-EZE
    V. Guideline Range Calculation
    1. Intended Loss
    Walter-Eze next argues that the district court erred when
    it found based upon the total amount billed to Medicare and
    Medi-Cal that the scheme involved an intended loss of more
    than $2.5 million, adding an 18-point offense level increase
    to Walter-Eze’s guideline calculation pursuant to section
    2B1.1(b)(1) of the United States Sentencing Guidelines.
    Walter-Eze argues that this overestimates her intended loss
    because (1) she never actually expected that Medicare would
    pay the full value of the claims, and (2) the government failed
    to carry its burden to prove that all of Ezcor’s Medicare and
    Medi-Cal claims were fraudulent. These arguments fail.
    “A district court’s factual determinations, including the
    amount of loss in cases of fraud, are reviewed for clear error.”
    United States v. Popov, 
    742 F.3d 911
    , 914 (9th Cir. 2014).
    “Clear error review is ‘significantly deferential’ and requires
    us to accept the district court’s findings absent a ‘definite and
    firm conviction that a mistake has been committed.’” Leavitt
    v. Arave, 
    646 F.3d 605
    , 608 (9th Cir. 2011) (quoting Rhoades
    v. Henry, 
    596 F.3d 1170
    , 1177 (9th Cir. 2010)). A district
    court “need not make its loss calculation with absolute
    precision; rather, it need only make a reasonable estimate of
    the loss based on the available information.” United States v.
    Zolp, 
    479 F.3d 715
    , 719 (9th Cir. 2007) (citing U.S.S.G.
    § 2B1.1 cmt. n.3(C)). “[A]ll that is required is that the
    government prove the loss by a preponderance of the
    evidence.” United States v. Torlai, 
    728 F.3d 932
    , 946 n.13
    (9th Cir. 2013). Accordingly, in Popov, this Court ruled:
    UNITED STATES V. WALTER-EZE                    37
    In health care fraud cases, the amount billed
    to an insurer shall constitute prima facie
    evidence of intended loss for sentencing
    purposes. If not rebutted, this evidence shall
    constitute sufficient evidence to establish the
    intended loss by a preponderance of evidence.
    However, the parties may introduce additional
    evidence to support arguments that the
    amount billed overestimates or understates the
    defendant’s 
    intent. 742 F.3d at 916
    .
    Since Popov established this burden-shifting standard in
    the Circuit, this Court has rejected claims similar to Walter-
    Eze’s where the defendant does not present evidence at trial
    or sentencing to support the assertion that the total amount
    billed overestimated the defendant’s intent. See United States
    v. Agbu, 640 F. App’x 613, 616 (9th Cir. 2016)
    (memorandum); United States v. Adebimpe, 649 F. App’x
    449, 452 (9th Cir.) (memorandum), cert. denied, 
    137 S. Ct. 317
    (2016), and cert. denied sub nom. Abad v. United States
    (U.S. Dec. 12, 2016); United States v. Rush, No. 13-50169,
    
    2016 WL 7228826
    , at *2 (9th Cir. Dec. 14, 2016)
    (memorandum). Thus, because Walter-Eze failed to provide
    any evidence that she did not intend for Medicare and Medi-
    Cal to reimburse her for the full $3.5 million (or, indeed, even
    that she intended to be reimbursed for less than 72% of her
    claims, which would still amount to $2.52 million), the
    district court did not clearly err in relying upon the total
    amount billed to determine intended loss.
    Nor, we should add, do counsel’s arguments, unsupported
    by any evidence at trial or sentencing, that Walter-Eze was
    38              UNITED STATES V. WALTER-EZE
    familiar with Medicare’s reimbursement practices or that she
    did not expect to recoup the full billed amount suffice to rebut
    this presumption. The Court therefore denies Walter-Eze’s
    request that we remand to allow her the opportunity to present
    the sentencing court with evidence of her knowledge of
    Medicare’s reimbursement practices. Having already been
    afforded such an opportunity, and having declined to pursue
    it, Walter-Eze cannot now complain about this alleged
    sentencing error. Cf. United States v. Visman, 
    919 F.2d 1390
    ,
    1394 (9th Cir. 1990) (holding that a defendant waives the
    right to challenge sentence adjustments by failing to present
    the issue in district court).
    Walter-Eze further contends that even if the total amount
    billed is used, the government did not carry its burden at trial
    to show that all of the billed claims were fraudulent and
    should be counted as part of the intended loss under § 2B1.1.
    Although the government in presenting its case focused
    heavily on power wheelchairs, it presented sufficient
    evidence regarding the remainder of Walter-Eze’s business to
    permit the district court to make an inference that most, if not
    all, of Ezcor’s Medicare and Medi-Cal billing was tainted by
    fraud.4 See, e.g., United States v. Yi, 
    704 F.3d 800
    , 807 (9th
    Cir. 2013).
    Although it was the government’s burden to prove
    intended loss, Walter-Eze did not challenge the reasonable
    4
    The evidence at trial was not limited to power wheelchairs and their
    accessories. Patients who received power wheelchairs were often
    prescribed unneeded hospital beds and back and knee braces, which were
    prescribed by the same cadre of corrupt doctors. Recruiters were also paid
    kickbacks for these additional items. These items accounted for at least
    another 33% of Ezcor’s business.
    UNITED STATES V. WALTER-EZE                           39
    inferences drawn from the government’s proof. Despite
    knowing that the Pre-Sentence Report’s (“PSR”) loss
    calculations were based upon the view that all the sales were
    fraudulent and being afforded an opportunity at
    sentencing—three months after the trial—to rebut the
    government’s case and establish how much of Ezcor’s
    business was legitimate and untainted by the fraud, Walter-
    Eze provided no evidence to counter the government’s case
    or to further develop the record.5 Accordingly, the district
    court did not clearly err in making the “reasonable estimate
    . . . based on the available information” that over $2.5 of the
    $3.5 million that Ezcor billed to Medicare and Medi-Cal was
    connected to the fraud. See 
    Zolp, 479 F.3d at 719
    .6
    2. Enhancement for Scheme Involving Five or More
    Participants
    Walter-Eze also claims that the district court erred in
    applying a four-point Guidelines enhancement for Walter-
    Eze’s leadership role in a criminal activity involving five or
    more people because the district court never made explicit
    findings that the scheme involved five or more people.
    Although Walter-Eze at sentencing denied that she was the
    leader of the conspiracy, she never contested the conspiracy’s
    size; we therefore review this newly raised contention under
    5
    While Walter-Eze argues that she was barred from introducing
    evidence of her legitimate business activity by virtue of the government’s
    successful motion in limine preventing such testimony or evidence, there
    was nothing to prevent defendant from introducing that evidence as part
    of the sentencing hearing. See U.S.S.G. § 6A1.3(a).
    6
    Because the district court did not err in determining the intended
    loss, the Court need not address Walter-Eze’s request that a new judge be
    appointed for resentencing.
    40            UNITED STATES V. WALTER-EZE
    the plain error standard. See United States v. Carvajal,
    
    905 F.2d 1292
    , 1296 (9th Cir. 1990).
    The Sentencing Guidelines provide for an offense level
    enhancement of four points “[i]f the defendant was an
    organizer or leader of a criminal activity that involved five or
    more participants or was otherwise extensive.” U.S.S.G.
    § 3B1.1(a). As with other sentencing factors, the government
    must establish the enhancement by a preponderance of the
    evidence. United States v. Avila, 
    95 F.3d 887
    , 889 (9th Cir.
    1996). At trial, the government proved by a preponderance
    of the evidence that at least five individuals participated in
    the healthcare fraud. Aside from Walter-Eze herself who
    “may be included among the participants in the criminal
    activity for purposes of section 3B1.1(a),” United States v.
    Egge, 
    223 F.3d 1128
    , 1134 (9th Cir. 2000), the government
    showed that Guzman, Dr. Calaustro, Jean Aves, and Judith
    Estrella all participated in the scheme. Thus, even excluding
    the other recruiters listed on Walter-Eze’s contact sheet, the
    government presented sufficient evidence to support the
    district court’s conclusion that the scheme involved at least
    five participants.
    Nor does the district court’s failure to expressly make this
    finding on the record necessitate a remand for resentencing.
    At sentencing, Walter-Eze challenged that she was a “leader”
    of the scheme, but she did not contest the number of
    participants involved; indeed she conceded that the
    conspiracy consisted of “a number of members.” The PSR
    calculated that “approximately 17 other patient recruiters”
    were involved in the scheme, and defense counsel did not
    object. Accordingly, the fact that Walter-Eze’s scheme
    involved at least five individuals was not a disputed or
    “controverted matter” before the district court at sentencing,
    UNITED STATES V. WALTER-EZE                     41
    and thus did not trigger the court’s responsibility to make an
    explicit finding on the record under Federal Rule of Criminal
    Procedure 32(i)(3)(B). See United States v. Carter, 
    219 F.3d 863
    , 866 (9th Cir. 2000) (holding that except as where
    required by what is now Rule 32(i)(3), “[a] finding that a
    defendant is eligible for a sentence enhancement ordinarily
    does not require specific fact-finding”). The four-point
    enhancement was thus warranted and not plainly erroneous.
    VI.     Restitution Calculation
    Walter-Eze relatedly argues that, due to its alleged error
    in calculating the intended loss, the district court erred in
    calculating the restitution amount. Because Walter-Eze raises
    an objection to restitution for the first time on appeal, we
    review for plain error. United States v. Van Alstyne, 
    584 F.3d 803
    , 819 (9th Cir. 2009).
    For the same reasons discussed above in addressing
    Walter-Eze’s challenges to the loss calculation, the district
    court did not plainly err in determining that all of the
    reimbursements that Walter-Eze received from Medicare and
    Medi-Cal were fraudulently obtained and thus subject to
    restitution under the Mandatory Victims Restitution Act,
    18 U.S.C. § 3663A(a)(1) & (c)(1)(A)(ii). Walter-Eze did not
    object to the district court’s restitution calculations either at
    the sentencing hearing or in her pre-sentencing briefs. Given
    the government’s evidence at trial, the PSR, and Walter-Eze’s
    failure at sentencing to rebut the inferences raised therefrom,
    the district court’s finding by a preponderance of the evidence
    that all of Walter-Eze’s claims to Medicare and Medi-Cal
    were fraudulent or tainted by fraud and subject to restitution
    was not error. The district court reasonably ordered that
    42            UNITED STATES V. WALTER-EZE
    Walter-Eze repay $1,866,260.62 to Medicare and $73,268.65
    to Medi-Cal.
    CONCLUSION
    To summarize, we hold: (1) Walter-Eze failed to establish
    that she was denied her Sixth Amendment right to counsel
    because, although she established a conflict of interest, she
    failed to meet the prejudice prong of Strickland; (2) the
    district court did not erroneously fail to grant a continuance;
    (3) the jury instructions as a whole properly conveyed the
    government’s burden of proof; (4) it was not error to give a
    deliberate ignorance charge; (5) the district court properly
    calculated loss under U.S.S.G. § 2B1.1(b)(1); (6) the district
    court properly applied a leadership role enhancement
    pursuant to U.S.S.G. § 3B1.1(a); and (7) the district court did
    not err in calculating restitution based upon the entire amount
    of reimbursements received by the defendant from Medicare
    and Medi-Cal. Accordingly, we affirm.
    AFFIRMED.
    NGUYEN, Circuit Judge, concurring only in the judgment:
    I join fully in the majority’s conclusions. But I write
    separately because I fear that the majority’s reasoning could
    create confusion in our case law.
    I.
    As the majority explains, as a general matter a defendant
    must show “prejudice” under Strickland v. Washington,
    UNITED STATES V. WALTER-EZE                    43
    
    466 U.S. 668
    , 694 (1984), to establish that counsel was
    constitutionally defective. There is an exception, however,
    when counsel is burdened by an “actual conflict of interest.”
    
    Id. at 692.
    In such cases, prejudice is presumed. See Cuyler
    v. Sullivan, 
    446 U.S. 335
    (1980). As we have said in the past,
    an “actual conflict” is defined as a “conflict of interest that
    adversely affected counsel’s performance.” United States v.
    Miskinis, 
    966 F.2d 1263
    , 1268 (9th Cir. 1992). Under our
    case law, the term “actual conflict” is used in this context to
    mean the sort of conflict that requires the presumption of
    prejudice. See, e.g., Bonin v. Calderon, 
    59 F.3d 815
    , 826 (9th
    Cir. 1995); Hovey v. Ayers, 
    458 F.3d 892
    , 908 (9th Cir. 2006)
    (stating that an “actual conflict is defined by its impact”).
    Here, the majority analyzes at length whether Walter-
    Eze’s counsel was burdened by an “actual conflict” of
    interest—or simply put, one that adversely affected his
    performance—and answers resoundingly yes. See e.g. Op. at
    15 (“[W]e hold that under the circumstances present here,
    both the threat of fees and the threat of potential sanctions
    created a conflict of interest that adversely affected counsel’s
    performance.”); see also Op. at 20 (stating the circumstances
    “self-evidently suffice to establish an ‘actual conflict’ under
    this Circuit’s precedent”); see also Op. at 23 (describing the
    conflict as “[an] actual conflict [] relegated to a single
    moment of the representation and result[ing] in a single
    identifiable decision that adversely affected the defendant”).
    The majority’s conclusion that Walter-Eze’s counsel was
    burdened by an actual conflict, one that adversely affected his
    counsel’s performance, would appear to settle the matter
    under our case law. As we have repeatedly held, if an actual
    conflict exists that adversely affected counsel’s performance,
    we must presume prejudice.
    44            UNITED STATES V. WALTER-EZE
    Yet the majority goes on to hold that after determining
    that an “actual conflict” exists, it must then consider whether
    to apply Sullivan presumed prejudice or the Strickland
    standard for prejudice, ultimately deciding on the latter. This
    sequencing is confusing. The majority crafts a new rule
    without acknowledging our well-established precedent that
    prejudice is presumed when an “actual conflict” adversely
    affecting counsel’s performance exists. See, e.g., 
    Hovey, 458 F.3d at 907
    –08; Earp v. Ornoski, 
    431 F.3d 1158
    , 1183
    (9th Cir. 2005) (“In order to establish a . . . Sullivan
    exception, the defendant must demonstrate that an actual
    conflict of interest adversely affected his lawyer’s
    performance” (internal quotation marks omitted)); United
    States v. Wells, 
    394 F.3d 725
    , 733 (9th Cir. 2005) (holding
    that if a defendant “demonstrate[s] that an actual conflict of
    interest adversely affected his lawyer's performance . . .
    prejudice is presumed,” citing Sullivan); United States v.
    Rodrigues, 
    347 F.3d 818
    , 823 (9th Cir. 2003) (“prejudice is
    presumed if a defendant demonstrates that his counsel labored
    under an actual conflict of interest,” citing Sullivan (internal
    quotation marks omitted)); see also, e.g., United States v.
    Shwayder, 
    312 F.3d 1109
    , 1117 (9th Cir. 2002); 
    Bonin, 59 F.3d at 825
    . Even though the majority’s conclusion
    appears to satisfy the presumed prejudice test from Sullivan,
    the majority instead concludes that Sullivan does not apply.
    I find the majority’s approach difficult to reconcile with our
    many cases on this subject.
    II.
    Here, I would hold that there was no “actual conflict” that
    adversely affected counsel’s performance, and thus Sullivan’s
    presumed prejudice rule does not apply. Perhaps our
    precedents defining the term “actual conflict” to mean only
    UNITED STATES V. WALTER-EZE                   45
    a conflict of interest that requires a presumption of prejudice
    are confusing; there are certainly conflicts of interest that
    look “actual” in the colloquial sense that do not merit the
    application of Sullivan. The majority’s opinion, however,
    will only confuse further still.
    As I would find no “actual conflict” under Sullivan, like
    the majority I would apply the prejudice standard from
    Strickland and hold that Walter-Eze cannot show prejudice
    due to the overwhelming evidence against 
    her. 466 U.S. at 694
    .
    I respectfully concur in the judgment.
    

Document Info

Docket Number: 15-50315

Citation Numbers: 869 F.3d 891

Filed Date: 8/25/2017

Precedential Status: Precedential

Modified Date: 1/12/2023

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