US v. Rafael Chikvashvili
PUBLISHED AUTHORED OPINION filed. Originating case number: 1:14-cr-00423-JKB-1. . [16-4393]
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UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
UNITED STATES OF AMERICA,
Plaintiff - Appellee,
Defendant - Appellant.
Appeal from the United States District Court for the District of Maryland, at Baltimore.
James K. Bredar, District Judge. (1:14-cr-00423-JKB-1)
Argued: May 11, 2017
Decided: June 9, 2017
Before WILKINSON, KING, and WYNN, Circuit Judges.
Affirmed by published opinion. Judge Wilkinson wrote the opinion, in which Judge
King and Judge Wynn joined.
ARGUED: Booth Marcus Ripke, NATHANS & BIDDLE, LLP, Baltimore, Maryland,
for Appellant. Leo Joseph Wise, OFFICE OF THE UNITED STATES ATTORNEY,
Baltimore, Maryland, for Appellee. ON BRIEF: Robert W. Biddle, NATHANS &
BIDDLE, LLP, Baltimore, Maryland, for Appellant. Rod J. Rosenstein, United States
Attorney, P. Michael Cunningham, Assistant United States Attorney, OFFICE OF THE
UNITED STATES ATTORNEY, Baltimore, Maryland, for Appellee.
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WILKINSON, Circuit Judge:
Rafael Chikvashvili, the former CEO of diagnostic imaging company Alpha
Diagnostics, was charged with two counts of healthcare fraud resulting in death under 18
U.S.C. § 1347. At trial, the government alleged that Chikvashvili directed unqualified
radiologic technicians to interpret x-rays and billed Medicare as though licensed
physicians had performed the work. The government further contended that two patients
died because their x-rays were misread by Alpha technicians. A jury convicted
Chikvashvili on both counts.
Chikvashvili seeks acquittal on appeal. For criminal liability to attach under
Section 1347, he argues, the false billing—as opposed to the fraudulent scheme as a
whole—must be the “but-for” cause of death. Because the fraudulent billing did not cause
the deaths of the two patients, Chikvashvili concludes, this court ought to vacate the
“resulting in death” convictions. This same reasoning underlies his appeal of the district
court’s denial of his motion for acquittal and his challenge to the indictment and jury
instructions. He also appeals the admission of expert testimony on causation. We reject
his various challenges and affirm the judgment.
Chikvashvili founded Alpha Diagnostics and served as the company’s CEO.
Alpha provided portable, on-site diagnostic imaging services such as x-rays, sonograms,
and electrocardiograms. An Alpha technician would travel to the patient’s location,
perform the imaging requested by the patient’s attending physician, and transmit the
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results to a qualified doctor for interpretation. Alpha’s revenue came from its patients and
their insurers, including Medicare and Medicaid.
The government alleges that Chikvashvili supervised an elaborate, longstanding
conspiracy to cheat Medicare through an assortment of fraudulent practices. Three former
employees, all of whom worked as technicians, testified for the government. According
to these witnesses, Alpha routinely requested reimbursement for two x-ray images when
it had taken only one. Testimony also indicated that Alpha regularly charged excessive
transportation costs, pretending that technicians had made separate trips to serve different
patients at a single facility despite assisting multiple patients at a time. These accounts
were corroborated by another former employee who oversaw billing and office
administration. This employee also asserted that Alpha changed the attending physician’s
diagnosis or symptom codes so that the service would qualify for Medicare
This appeal concerns an even more dangerous form of healthcare fraud. According
to Chikvashvili’s former technicians, Chikvashvili directed them to interpret scans,
prepare reports, and submit the results to attending physicians while passing off their
handiwork as that of actual, board-certified radiologists and cardiologists. For some
reports, technicians signed with a doctor’s name; for others, Chikvashvili placed cut-outs
of physicians’ signatures on the documents. Alpha would then submit claims for
reimbursement to Medicare as though qualified physicians had examined the images. The
fraud was pervasive. One of the three technicians claimed that Chikvashvili directed them
to read as many scans as possible and that they were responsible for analyzing the vast
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majority of Alpha’s diagnostic images. Chikvashvili, for his part, kept a detailed log of
Alpha’s services. The technicians reported that he denoted fraudulent, in-house reads by
placing a “minus” sign next to the initials of the purported interpreting physician.
In many instances, the technicians made mistakes in interpreting the images. And
on two occasions, a patient died after an Alpha technician overlooked the congestive
heart failure documented in her x-ray. One patient, M.V.K., lived in a nursing home and
had a chest x-ray taken shortly before her death. Alpha performed a chest x-ray of
another patient, D.M.C., prior to D.M.C.’s elective surgery. D.M.C. bled profusely
following the surgery and died shortly thereafter. The government’s expert witnesses—
Dr. Sanjeev Bhalla and Dr. Philip Buescher—opined that Alpha’s reports on M.V.K and
D.M.C. failed to diagnose congestive heart failure in both patients.
Dr. Buescher also offered an opinion on causation. He testified that Alpha’s
misreads of the x-rays were the but-for causes of death for M.V.K. and D.M.C. In
M.V.K’s case, Dr. Buescher explained, diagnosing her congestive heart failure would
have led to treatment at a hospital, which would have alleviated her condition. And
diagnosing D.M.C.’s condition would have led her attending physician to postpone her
elective surgery until her heart condition had been addressed. In Dr. Buescher’s opinion,
neither patient would have died if their x-rays had been interpreted accurately.
The deaths of M.V.K. and D.M.C. formed the respective bases for Counts 2 and 3
of the indictment, which charged Chikvashvili with healthcare fraud resulting in death
under 18 U.S.C. § 1347. Chikvashvili was also charged with conspiracy to commit
healthcare fraud (Count 1); healthcare fraud (Counts 4-12); wire fraud (Counts 13-20);
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false statements relating to healthcare matters (Counts 21-31); and aggravated identity
theft (Counts 32-33).
Chikvashvili lodged a number of unsuccessful objections to the proceedings
below. First, before trial, Chikvashvili moved to exclude Dr. Buescher’s expert testimony
on causation with respect to Counts 2 and 3. The district court, however, ruled that Dr.
Buescher’s testimony was admissible. After the government closed its evidence,
Chikvashvili moved for a judgment of acquittal under Rule 29 of the Federal Rules of
Criminal Procedure, arguing that the evidence was legally insufficient for a conviction on
any count. The district court denied the motion. Finally, Chikvashvili objected to two
summation paragraphs in the jury instruction on Counts 2 and 3 but was again rebuffed.
A jury convicted Chikvashvili on all counts, and he was sentenced to a total of 120
months of imprisonment.
After Chikvashvili renewed his Rule 29 motion for acquittal, the district court
rejected his request once again. The court noted that the government had presented “a
mountain of evidence against Chikvashvili” in general as well as “ample evidence” that
“the health care fraud orchestrated and carried on by Chikvashvili was the but-for cause
of M.V.K.’s and D.M[.]C.’s deaths.” J.A. 964-65.
We begin with the proper reading of 18 U.S.C. § 1347. We hold that the execution
of a fraudulent scheme—not merely the submission of a false claim—may give rise to
liability under Section 1347 when execution of the scheme results in death. In light of this
holding, we conclude that there was sufficient evidence to sustain Chikvashvili’s
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convictions on Counts 2 and 3. We further hold that the district court did not err in
instructing the jury on those counts. Finally, we affirm the district court’s decision to
admit the expert testimony of Dr. Buescher on causation.
Congress established the crime of healthcare fraud in 18 U.S.C. § 1347:
Whoever knowingly and willfully executes, or attempts to execute, a
scheme or artifice-(1) to defraud any health care benefit program; or
(2) to obtain, by means of false or fraudulent pretenses, representations,
or promises, any of the money or property owned by, or under the
custody or control of, any health care benefit program,
in connection with the delivery of or payment for health care benefits,
items, or services, shall be fined under this title or imprisoned not more
than 10 years, or both.
18 U.S.C. § 1347(a). In addition, Congress authorized the imposition of a life sentence
where “the violation results in death.” Id.
Congress, of course, has the ultimate authority to determine what are elements of
an offense and what are sentencing factors and to demarcate the boundary between the
two. It was conceivable that “result[ing] in death” would be in the nature of a sentencing
enhancement, but that is not at all how the statute is constructed. Instead, “result[ing] in
death” for purposes of Section 1347 must be found by a jury as with any element beyond
a reasonable doubt.
Chikvashvili argues that a jury assessing whether a “violation result[ed] in death”
may consider only whether the submission of a fraudulent claim for reimbursement
caused the death in question. On his view, it is “legally insufficient” for purposes of
establishing criminal liability to prove “that a death happened in the course of a broader
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conspiracy or scheme to commit health care fraud.” Br. of Appellant at 23. As a result,
Chikvashvili suggests, he is entitled to acquittal on Counts 2 and 3 as a matter of law
because Alpha’s submission of false claims did not cause the deaths of M.V.K. and
The unambiguous statutory text, however, refutes Chikvashvili’s cramped
interpretation of Section 1347. To violate that provision, one must “knowingly and
willfully execut[e] . . . a scheme or artifice” to defraud a healthcare benefit program. 18
U.S.C. § 1347(a) (emphasis added). Further, this “scheme or artifice” must be connected
to either “the delivery of or payment for health care benefits, items, or services.” Id.
(emphasis added). When this “violation”—a fraudulent healthcare scheme taken as a
whole—“results in death,” the perpetrator may be punished by life imprisonment. Id.
The statute, then, does not cabin the term “scheme or artifice” to the formal act of
requesting reimbursement for some false or deceptive charge. While the “scheme or
artifice” culminates in the submission of a fraudulent claim, it is not restricted to that
event. This makes sense. As the government points out, Chikvashvili’s construction of
Section 1347 would eviscerate the statute: filing a claim with an insurer will seldom if
ever cause someone’s death. Instead, the proper focus of the causation inquiry is the
larger fraudulent scheme and, within that scheme, “the delivery of . . . health care” in
particular. 18 U.S.C. § 1347(a).
In his effort to isolate the submission of a false claim from the rest of the fraud,
Chikvashvili invokes the inapposite distinction between the execution of a scheme to
defraud and acts in furtherance of that scheme. He suggests that submitting the claim
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represents the execution of the scheme and that the events leading to submission are mere
acts in furtherance of the scheme. He cites two cases from our sister circuits to bolster his
conclusion that “acts in furtherance of a scheme are not violations of the statute.” Br. of
Appellant at 17 (citing United States v. Awad, 551 F.3d 930 (9th Cir. 2009); United
States v. Hickman, 331 F.3d 439 (5th Cir. 2003)).
But the authorities on which Chikvashvili relies did not concern the question
presented here. The defendant in Awad was charged with 24 counts of healthcare fraud,
which corresponded to his submission of 24 fraudulent claims. Awad, 551 F.3d at 937.
The defendant argued that the counts were multiplicitous because they charged “24 acts
in furtherance of a single scheme, rather than 24 separate executions of a scheme to
defraud.” Id. The Ninth Circuit rejected this theory, characterizing each claim as a
distinct scheme to defraud rather than an act in furtherance of a single scheme. Id. at 938.
The court concluded that the events surrounding each claim were separately chargeable.
Id. The Fifth Circuit held the same in Hickman. See 331 F.3d at 446. Because
Chikvashvili does not claim that Counts 2 and 3 are multiplicitous, Awad and Hickman—
and their distinction between a scheme’s execution and its constituent acts—are not
In this case, the government’s theory of fraud with respect to Counts 2 and 3
encompassed the use of a technician to analyze diagnostic images instead of qualified
personnel; the misrepresentation that a physician had performed the work; the resulting
x-ray misread; and the deceitful claim for reimbursement. This “scheme or artifice” may
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serve as the predicate violation of Section 1347 in a prosecution for healthcare fraud
resulting in death.
Chikvashvili next argues that there was insufficient evidence to support his
convictions on Counts 2 and 3. According to Chikvashvili, the government fell short on
Counts 2 and 3 because of the way those counts were charged in the indictment.
Chikvashvili claims that the indictment charged him with violating Section 1347 “by
submitting two claims to Medicare for payment.” Br. of Appellant at 18. He argues that
the government failed to prove that the deaths of M.V.K. and D.M.C. were caused by his
fraudulent billing and concludes that he is therefore entitled to acquittal.
The actual language of Counts 2 and 3, however, belies Chikvashvili’s
characterization of the indictment. To begin, both counts incorporate portions of the
conspiracy count (Count 1) that describe Chikvashvili’s role in the fraudulent scheme as
well as the manner and means by which the scheme was carried out. Counts 2 and 3 then
charge the following:
Alpha Diagnostics personnel took a chest X-ray of a patient . . . . The image
was not interpreted by a qualified radiologist. Instead, a non-physician
Alpha employee attempted to interpret the image and reported the image as
negative for any chronic conditions. In fact, the image revealed congestive
heart failure but the Alpha employee failed to detect it.
J.A. 624 (Count 2); see J.A. 626 (Count 3) (noting that “the image revealed mild
congestive heart failure”). Next, the counts explain that M.V.K. and D.M.C. would have
been treated differently had their heart failures been identified and would not have died in
the circumstances they did. Both counts charge that the failure to detect and report “the
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congestive heart failure shown on the chest X-ray resulted in the death of [the patient].”
J.A. 624 (Count 2); J.A. 626-27 (Count 3). Counts 2 and 3 conclude that Chikvashvili
did knowingly and willfully execute and attempt to execute the scheme and
artifice to defraud Medicare, and to obtain by means of materially false and
fraudulent pretenses, representations, and promises, money and property
owned by, and under the custody and control of Medicare, a health care
benefit program under 18 U.S.C. § 24(b), in connection with the delivery of
and payment for health care benefits, items and services in that the
defendant submitted and caused the submission of . . . a false and
fraudulent Medicare claim . . . representing that Alpha Diagnostics had
provided qualifying medical imaging services to [the patient], and that the
violation resulted in [the patient’s] death.
J.A. 625 (Count 2); J.A. 627 (Count 3).
The indictment thus plainly alleges that Chikvashvili directed unqualified
personnel to analyze x-rays for purposes of defrauding Medicare, that the technicians
overlooked serious heart conditions, and that the failure to identify these conditions
resulted in the deaths of M.V.K. and D.M.C. There is simply no merit to Chikvashvili’s
contention that Counts 2 and 3 characterize the predicate violations of Section 1347 as
the mere submission of the fraudulent claims. Chikvashvili was charged with directing a
larger fraudulent scheme that led to the deaths of two patients.
Chikvashvili dismisses the description of the fraudulent scheme in Counts 2 and 3
as part of the “narrative portion” of the counts, which he distinguishes from their
“operative” final paragraphs. Br. of Appellant at 19. According to Chikvashvili, he was
charged only with the following act: “[T]he defendant submitted and caused the
submission of . . . a false and fraudulent Medicare claim, representing that Alpha
Diagnostics had provided qualifying medical imaging services to [the patient], and that
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the violation resulted in [the patient’s] death.” See Reply Br. of Appellant at 5-6 (quoting
Counts 2 and 3).
But Chikvashvili offers no sound reason to recognize a narrative-operative
distinction in the indictment, and he utterly fails to support his theory that the “narrative”
components of a count may not clarify the scope of the charge. Indeed, this latter
assertion is refuted by the introductions of Counts 2 and 3, which state: “The Grand Jury
for the District of Maryland further charges that . . . .” J.A. 624 (Count 2) (emphasis
added); J.A. 626 (Count 3) (same). Counts 2 and 3 then specify the exact charges against
Chikvashvili and culminate in the identification of the precise statute—Section 1347—
that Chikvashvili’s conduct violated.
Chikvashvili also challenges the jury instructions on Counts 2 and 3. In evaluating
jury instructions, we review “the entire jury charge to determine whether the jury was
properly instructed on the elements of the offenses.” United States v. Herder, 594 F.3d
352, 359 (4th Cir. 2010). In other words, we must determine “whether, taken as a whole,
the instruction fairly states the controlling law.” United States v. Cobb, 905 F.2d 784, 789
(4th Cir. 1990).
Chikvashvili’s argument against the jury instructions on Counts 2 and 3 rests on
the same erroneous interpretation of the indictment that we have earlier rejected. He
challenges two paragraphs in particular, which summarized the charges contained in
Counts 2 and 3:
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[A]s to Count 2, the indictment alleges the following: That the chest x-ray
taken of M.V.K. on April 17, 2012, was not interpreted by a qualified
radiologist; that instead, a non-physician Alpha Diagnostics employee
attempted to interpret it but failed to detect M.V.K.’s congestive heart
failure; that because M.V.K.’s image was not properly read, she remained
in a rehabilitative nursing home rather than being transferred, according to
standard medical practice, to an acute care facility; that M.V.K. died four
days later on April 21, 2012; and that the failure to identify M.V.K.’s
congestive heart failure resulted in her death at that time.
J.A. 917. The paragraph on Count 3 recounts D.M.C.’s story in the same fashion.
According to Chikvashvili, these summaries “improperly over-emphasized a
factual theory that could not support a conviction of Counts 2 and 3 as those counts were
charged” and thus “constructively amend[ed]” the indictment “by broadening the basis
for which the defendant could be convicted.” Br. of Appellant at 41. And a constructive
amendment, he observes, “destroy[s] the defendant’s substantial right to be tried only on
charges presented in an indictment returned by a grand jury.” United States v. Floresca,
38 F.3d 706, 712 (4th Cir. 1994) (quoting Stirone v. United States, 361 U.S. 212, 217
(1960)) (emphasis omitted).
There was no constructive amendment here. The paragraphs challenged here
conform perfectly to the charges in Counts 2 and 3. As noted, those counts charged
Chikvashvili with executing a scheme that encompassed the fraudulent analysis of
diagnostic images by technicians, the mistaken interpretations of M.V.K.’s and D.M.C.’s
x-rays, the submission of false claims for reimbursement, and the deaths that resulted
from this whole course of action. The portions of the instructions to which Chikvashvili
now objects simply recapped these charges. Moreover, Chikvashvili knew full well what
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he was charged with and what he needed to do to defend against those charges. The
district court did not err in instructing the jury as to the charges in Counts 2 and 3.
Finally, Chikvashvili argues that the district court erred in admitting Dr.
Buescher’s expert opinion on causation for Counts 2 and 3. In particular, Chikvashvili
contends that Rule 702 of the Federal Rules of Evidence barred the opinion because it
was not relevant, not based on sufficient facts and data, and not a reliable application of
Dr. Buescher’s methodology to the facts at hand.
We review a district court’s ruling on expert testimony for abuse of discretion.
United States v. Johnson, 617 F.3d 286, 292 (4th Cir. 2010). An abuse of discretion
occurs where a decision “is guided by erroneous legal principles . . . or rests upon a
clearly erroneous factual finding.” Westberry v. Gislaved Gummi AB, 178 F.3d 257, 261
(4th Cir. 1999).
Dr. Buescher concluded that the x-ray misreads were the but-for causes of death
for M.V.K. and D.M.C. In preparation for his testimony, he reviewed their medical
records and x-rays. His testimony on Counts 2 and 3 essentially consisted of two parts.
First, he explained that standard medical procedures would have averted the deaths of
each patient had their x-rays been properly analyzed and their congestive heart failures
detected. Second, he employed a differential diagnosis methodology to rule out other
potential causes of death.
If M.V.K.’s condition had been identified, Dr. Buescher testified, she would have
been hospitalized instead of remaining at her nursing home and treatment would have
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remedied her heart failure. Dr. Buescher also excluded other potential causes. M.V.K.’s
death certificate attributed her death to chronic obstructive pulmonary disease (COPD).
But the physician who completed the certificate did not have access to M.V.K.’s x-ray
and instead relied only on Alpha’s inaccurate report. Dr. Buescher explained that COPD
was inconsistent with M.V.K.’s medical records and the circumstances surrounding her
death: COPD causes a prolonged death due to the gradual loss of pulmonary function, but
M.V.K. died suddenly. Dr. Buescher’s diagnosis comported with the testimony of
M.V.K.’s daughter on M.V.K.’s relatively normal functioning prior to her death.
Dr. Buescher testified that D.M.C.’s elective surgery would have been postponed
if her attending physician had known that she was experiencing congestive heart failure.
D.M.C.’s attending physician corroborated this opinion, testifying that he would not have
cleared her for surgery. Dr. Buescher opined that D.M.C.’s congestive heart failure
caused her to bleed excessively following the surgery and ultimately resulted in the
failure of other organs. He ruled out sepsis, the cause of death recorded on the death
certificate, based on D.M.C.’s medical records and lab tests performed prior to her death.
Under Rule 702, a qualified expert may offer an opinion if four conditions are
(a) the expert’s scientific, technical, or other specialized knowledge will
help the trier of fact to understand the evidence or to determine a fact in
(b) the testimony is based on sufficient facts or data;
(c) the testimony is the product of reliable principles and methods; and
(d) the expert has reliably applied the principles and methods to the facts of
Fed. R. Evid. 702.
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Chikvashvili first argues that Rule 702(a) blocks Dr. Buescher’s testimony. He
claims that any opinion on the medical causes of death for M.V.K. and D.M.C. is not
relevant because the jury’s causation inquiry concerned only the billing fraud, not the
x-ray misreads. We once again reject this mischaracterization of the indictment. Dr.
Buescher’s testimony assisted the jury in determining whether Chikvashvili’s fraud
“resulted in death” under Section 1347.
Next, Chikvashvili claims that Dr. Buescher’s analysis on other potential causes of
death was not based on sufficient facts or data as required by Rule 702(b). Dr. Buescher
employed a differential diagnosis methodology, which is “a standard scientific technique
of identifying the cause of a medical problem by eliminating the likely causes until the
most probable one is isolated.” Westberry, 178 F.3d at 262. This court has explained that
“[a] reliable differential diagnosis typically, though not invariably, is performed after
‘physical examinations, the taking of medical histories, and the review of clinical tests,
including laboratory tests.’” Id. (quoting Kannankeril v. Terminix Int’l, Inc., 128 F.3d
802, 807 (3d Cir. 1997). Although Dr. Buescher did not conduct a physical examination
of M.V.K. or D.M.C., he testified that he considered their x-rays and medical histories in
developing his opinion. Further, he drew out the connection between these sources and
his opinion for the jury, explaining why these materials supported his conclusion. There
is little merit to Chikvashvili’s suggestion that Dr. Buescher’s testimony was not based
on sufficient facts and data.
Finally, Chikvashvili objects to the manner in which Dr. Buescher applied the
differential diagnosis methodology. In particular, Chikvashvili complains that Dr.
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Buescher did not adequately consider and exclude other reasons why M.V.K. and D.M.C.
died. A differential diagnosis that “fails to take serious account of other potential causes
may be so lacking that it cannot provide a reliable basis for an opinion on causation.” Id.
at 265. But a court should not exclude an expert’s testimony “because he or she has failed
to rule out every possible alternative cause” of a medical event. Id. (quoting Heller v.
Shaw Indus., Inc., 167 F.3d 146, 156 (3d Cir. 1999)) (emphasis added). It is enough to
eliminate potential causes “until reaching one that cannot be ruled out or determining
which of those that cannot be excluded is the most likely.” Id. at 262. Any “alternative
causes suggested by a defendant ‘affect the weight that the jury should give the expert’s
testimony and not the admissibility of that testimony,’ unless the expert can offer ‘no
explanation for why she has concluded [that an alternative cause] was not the sole
cause.’” Id. at 265 (quoting Heller, 167 F.3d at 156-57) (citations omitted).
The above framework leaves the trial court some leeway in assessing the adequacy
of differential diagnosis. Here, as noted earlier, Dr. Buescher considered and ruled out
other potential causes for the deaths of M.V.K. and D.M.C., including the conditions
listed on their death certificates. He elaborated on the reasons why the medical evidence
supported his opinion. Chikvashvili’s objections to his testimony go to weight, not
admissibility. The district court did not err, let alone abuse its discretion, in admitting his
opinion on causation.
Insurers are not the only victims of fraudulent billing schemes, and medical fraud
can do more than drain our healthcare system of badly needed funds. As Chikvashvili’s
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story illustrates, deceit and falsehood in the delivery of healthcare can pose a real danger
to the patient victims of fraud, whose very lives may be put at risk by the perpetrator’s
avarice. To guard against these hazards, Congress criminalized healthcare fraud and
authorized steep penalties where the fraud results in death. But Chikvashvili’s
confinement of Section 1347 to mere acts of paper filings ignores both the language of
the statute and the real-world consequences of devious schemes and artifices that
Congress had in mind. The prosecution offered evidence sufficient for the jury to
conclude that Chikvashvili’s fraud was the but-for cause of death for the patients in
Counts 2 and 3. We can discern no error in the district court’s jury instructions or its
decision to admit Dr. Buescher’s testimony. The judgment is in all respects
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