In the
United States Court of Appeals
For the Seventh Circuit
____________________
No. 17‐1714
UNITED STATES OF AMERICA,
Plaintiff‐Appellee,
v.
JENETTE GEORGE, also known as JIYE,
Defendant‐Appellant.
____________________
Appeal from the United States District Court for the
Northern District of Illinois, Eastern Division.
No. 1:12‐cr‐00559‐7 — Sara L. Ellis, Judge.
____________________
ARGUED DECEMBER 5, 2017 — DECIDED AUGUST 14, 2018
____________________
Before WOOD, Chief Judge, and ROVNER and HAMILTON,
Circuit Judges.
ROVNER, Circuit Judge. The defendant Jenette George was
charged along with three co‐defendants in an indictment al‐
leging violations related to a Medicare‐fraud scheme. The
indictment alleged a scheme whereby George received pay‐
ments from Rosner Home Health Care, Inc. (“Rosner”), for
each Medicare patient that she referred to it. George was
tried on two counts of receiving kickbacks for Medicare re‐
2 No. 17‐1714
ferrals on April 12, 2012, and May 17, 2012, in violation of 42
U.S.C. § 1320a‐7b(b)(1)(A) of the Anti‐Kickback Statute, and
with conspiracy to offer kickbacks beginning on or about
November 2010 to July 2012, in violation of 18 U.S.C. § 371
and 42 U.S.C. § 1320a‐7b(b)(2)(A). Two owners and an em‐
ployee of Rosner—Ana Tolentino, Frederick Magsino, and
Edgardo “Gary” Hernal—were also indicted on charges of
conspiracy and pled guilty prior to trial.
The district court found her guilty on the conspiracy
count and the counts alleging specific violations of the Anti‐
Kickback Statute Act after a bench trial, and also denied the
subsequent motion seeking a judgment of acquittal or a new
trial. The court sentenced George to six months of impris‐
onment with the substitution of imprisonment day for day at
the Salvation Army Community Confinement Center in Chi‐
cago, Illinois. George now appeals her conviction to this
court, arguing that there was insufficient evidence to sup‐
port the conviction, that the court erred in failing to limit the
cross‐examination of George to matters within her
knowledge as a layperson, and that the court erred in failing
to designate Gary Hernal as a missing witness.
The following facts were found by the court after a
bench trial, and set forth in its Memorandum Opinion and
Order at the conclusion of the trial. Dist. Ct. Mem. Op. and
Order of 3‐22‐16 at 2–6. George worked for a home health‐
care agency from around 2007, and in 2010 started her own
referral agency the Ttenej Senior Referral Agency, which ap‐
pears to be a variant of her first name, Jenette, spelled back‐
wards. George expressed an interest to Gary Hernal, who
worked for Rosner Home Health Care, Inc., in providing
marketing referrals for Rosner. Hernal and George signed a
No. 17‐1714 3
“Work for Hire Agreement” on November 17, 2010. That
agreement provided that Ttenej would organize and prepare
health fairs and visit doctors, hospital case managers, dis‐
charge planners, or social workers and convince them to re‐
fer patients to Rosner. The agreement provided for payment
to George in an amount equal to services rendered, and
specified that she would provide an independent referral
service and would not be an employee of Rosner. At one
point in March 2011, George sent an email to Hernal indicat‐
ing that she was concerned that their arrangement might not
be within the law, but George maintained that Hernal as‐
sured her at the time that the payments were allowed.
George began referring patients to Rosner and the evi‐
dence at trial, including George’s own admission, estab‐
lished that she was paid $500 for each person referred to
Rosner who was subsequently certified for admission. Her‐
nal began cooperating in an investigation of Rosner, and the
government obtained evidence including recordings made
in the course of that investigation, establishing those refer‐
rals and the payments made to George—in cash or check—
on a per person basis. In a conversation with Hernal on July
13, 2012, Hernal and George discussed George’s preference
as to payments. Hernal asked her why she preferred pay‐
ments by check, but George indicated that her referrals
could be all in cash. Hernal and George then discussed the
legality of the payments:
Hernal informed Defendant that two home
health agencies were “busted for exactly what
we’re doing here, you know, getting paid for,
for patients.” Defendant responded, “Right.”
Hernal informed Defendant that paying her
4 No. 17‐1714
per patient was illegal and told her to be care‐
ful. Defendant asked Hernal, “Okay, careful
how?” Defendant asked if she could be put on
payroll, but Hernal said that she could not be‐
cause she is a contractor. Defendant said that
was sending “mixed signals” because it was il‐
legal for her to be paid for doing referrals but
for other services people are paid from the
agency. Hernal again reiterated that being paid
per patient is illegal. Defendant responded,
“As long as it’s just between the two parties, it
shouldn’t be no [sic] problem.”
(citations omitted) Dist. Ct. Mem. Op. and Order of 3‐22‐16
at 4.
When George was questioned upon her arrest, she initial‐
ly stated that she received biweekly payments from Rosner
in the amount of $1,000, and that those payments were only
made by check. She further stated that the payments were
not for per‐patient referrals and that she knew it was illegal
to be paid per patient for referrals to home health agencies.
After the agent showed George the recordings that had been
made, George acknowledged that she had lied and that she
was paid $500, both by check and in cash, per patient that
enrolled at Rosner. She admitted that when she began re‐
ceiving payments in cash sometime around November 2011,
she realized that it was illegal to be paid per patient. Bank
records of cash and checks deposited in George’s bank ac‐
counts, as well as referral logs, corroborated those state‐
ments.
George first argues that insufficient evidence supported
the convictions. In considering a challenge to the sufficiency
No. 17‐1714 5
of the evidence, we examine the evidence “’in the light most
favorable to the government, drawing all reasonable infer‐
ences in the governmentʹs favor.’” United States v. Patel, 778
F.3d 607, 619 (7th Cir. 2015), quoting United States v. Lee, 558
F.3d 638, 641 (7th Cir. 2009). We will uphold the conviction
unless, after thus viewing the evidence in favor of the gov‐
ernment, no rational trier of fact could have found the essen‐
tial elements of the offense beyond a reasonable doubt. Id.;
Jackson v. Virginia, 443 U.S. 307, 319 (1979). The factual find‐
ings by the district court are sufficient to support the convic‐
tions in this case.
Under the Anti‐Kickback Statute, the government had to
demonstrate that George knowingly and willfully solicited
or received any remuneration in return for referring an indi‐
vidual to Rosner to provide services or arrange services, and
that those services may be paid at least in part under Medi‐
care. See 42 U.S.C. § 1320a‐7b(b)(1)(A). George argues that
the government failed to present sufficient evidence as to the
conspiracy count as well as the individual substantive
counts under that Anti‐Kickback Statute.
As to the conspiracy conviction, George argues that re‐
gardless of the legality of her referrals, the government
failed to introduce sufficient evidence that she joined the
Rosner conspiracy. Citing two of our cases relating to drug
conspiracy charges, United States v. Townsend, 924 F.2d 1385,
1394 (7th Cir. 1991) and United States v. Pulgar, 789 F.3d 807,
811–12 (7th Cir. 2015), she analogizes her actions with re‐
spect to Rosner as similar to the buyer‐seller relationship in
drug deals which we have found insufficient to constitute a
conspiracy. She maintains that her “marketing activities”
failed to place her within the general conspiracy alleged as
6 No. 17‐1714
she lacked any stake in the benefits which were billed to
Medicare.
“Proof of conspiracy may come from direct evidence or
circumstantial evidence, United States v. Hightower, 96 F.3d
211, 214 (7th Cir.1996), as well as ‘the reasonable inferences
... concerning the partiesʹ relationships, their overt acts, and
their overall conduct,’ United States v. Miller, 405 F.3d 551,
555 (7th Cir.2005) (quoting United States v. Navarrete, 125
F.3d 559, 562 (7th Cir.1997)).” United States v. Lomax, 816 F.3d
468, 474 (7th Cir. 2016) (citations in original). A jury could
properly conclude that the direct and circumstantial evi‐
dence in this case established beyond a reasonable doubt
that George was a participant in the Rosner conspiracy.
George had a written agreement with Rosner, she provided
referrals to Rosner on an ongoing basis, she was paid on a
per‐patient basis for those referrals, and her ability to obtain
payments for those referrals was dependent on the success
of the overall scheme. George did not get paid unless the
persons that she referred were admitted or readmitted to
Rosner. She had a stake in the success of the scheme because
the continuation of her business depended on it. The district
court properly held that there was sufficient evidence to
support the conspiracy conviction.
George also asserts that there was insufficient evidence to
support the convictions for violating the Anti‐Kickback Stat‐
ute. As to those convictions, she asserts that she cannot be
held liable because the statute applies only to “relevant deci‐
sionmakers” or persons in a position to influence the deci‐
sions, and she was not in that position. She also contends
that she did not act knowingly and willfully, and that she
had a reasonable basis to believe that she fell within the safe
No. 17‐1714 7
harbor provision of the statute. George points to evidence
that could cast doubt on the elements of the offense. In order
to succeed on her claims of insufficiency of the evidence,
however, George must do more than merely demonstrate
that evidence could have supported a finding of innocence;
she must demonstrate that evidence could not have allowed
a reasonable trier of fact to find her guilty. Jackson, 443 U.S.
at 319; Patel, 778 F.3d at 619.
George argues that the government failed to prove that
she fell within the terms of the statute. The statute provides
in relevant part:
(b) Illegal remunerations
(1) whoever knowingly and willfully solicits or
receives any remuneration (including any
kickback, bribe, or rebate) directly or indirect‐
ly, overtly or covertly, in cash or in kind—
(A) in return for referring an individual to a
person for the furnishing or arranging for the
furnishing of any item or service for which
payment may be made in whole or in part un‐
der a Federal health care program, …
shall be guilty of a felony … .
42 U.S.C.A. § 1320a‐7b(b)(1)(A). George’s conduct falls with‐
in the plain language of that provision. The evidence
demonstrated that she received remuneration for referring
individuals to Rosner for the provision of home health ser‐
vices that would be covered under Medicare.
George, however, argues that the statute is limited in its
application to persons who are the “relevant decisionmak‐
8 No. 17‐1714
ers” or who are at least persons in a similar position as the
relevant decisionmaker. She asserts that she did not fall
within that definition because the persons she referred had
to be certified by a physician before they could be admitted
to Rosner, and that she did not attempt to influence the doc‐
tors who certified the patients she referred. She relies for that
argument on the Fifth Circuit’s decision in United States v.
Miles, 360 F.3d 472 (5th Cir. 2004), in which the court held
that payments to a marketing firm which distributed adver‐
tisement brochures of the home health service provider to
physicians did not fall within the statute because they were
not payments made to the relevant decisionmaker as a kick‐
back for sending patients to the service provider.
The Fifth Circuit in a subsequent case, however, explicit‐
ly rejected a reading of Miles which would limit criminal lia‐
bility to persons who could be deemed “relevant deci‐
sionmakers:”
The district court … read United States v. Miles,
360 F.3d 472 (5th Cir. 2004), to limit drastically
the meaning of “any person,” such that liability
cannot attach unless the “person” who receives
remuneration is a “relevant decisionmaker”
with formal authority to effect the desired re‐
ferral or recommendation. … But as explained
below, Miles imposed no such limitation on the
meaning of “any person” and is wholly inap‐
plicable to this case. … , Miles drew a distinc‐
tion not between types of payees—“relevant de‐
cisionmakers” and others—but between a pay‐
erʹs intent to induce “referrals,” which is ille‐
No. 17‐1714 9
gal, and the intent to compensate advertisers,
which is permissible.
United States v. Shoemaker, 746 F.3d 614, 627–28 (5th Cir.
2014). The court held in Shoemaker that intent, and specifical‐
ly whether the evidence demonstrated an intent to induce
referrals, was the focus of the inquiry in Miles, and that such
a focus accords with Congress’ concerns in the statute with
imposing liability on operatives who “leverage fluid, infor‐
mal power and influence.” Id. at 629–30. Therefore, Miles
cannot be read in the manner that George suggests, and in
fact George’s conduct falls squarely within the statute as in‐
terpreted by those cases in that her conduct represented an
intent to induce referrals to Rosner.
Our case law is consistent with that interpretation of the
statute as well. For instance, in United States v. Polin, 194 F.3d
863 (7th Cir. 1999), we upheld a conviction in a factually
analogous case in which payments were made to a pace‐
maker sales representative for each Medicare patient that he
referred to the Center for Vascular Studies for pacemaker
monitoring services. The defendants were the ones who paid
the pacemaker representative, and they argued that the rep‐
resentative could not make a referral under the statute be‐
cause only a physician is capable of making a referral, rea‐
soning that the physician’s—not the sales representative’s—
permission was needed for services. Id. at 865. We held that
the conduct in that case was a classic case of an illegal kick‐
back under the statute. Id. at 867. Although in Polin the de‐
fendants were the ones paying for the referral rather than
making the referral and therefore convicted under subsec‐
tion (b)(2)(A) rather than (b)(1)(A) of § 1320a‐7b, there is no
basis whatsoever for defining the term “referral” differently
10 No. 17‐1714
in the two sub‐provisions. As in Polin, payments were made
in this case to refer a Medicare patient to a service provider,
and such conduct is prohibited under the plain language of
the statute. See also Patel, 778 F.3d at 618 (holding that the
concept of “referring” under the statute is broad and in‐
cludes conduct in which the defendant directed a person to a
particular provider or even where a physician through recer‐
tification allowed a patient to receive care from that provider
and was paid in return for those efforts). The district court
did not err in determining that the actions in this case fell
within the statute.
George also asserts that there was insufficient evidence
that she acted knowingly and willfully under the statute, but
this claim cannot withstand scrutiny. Her own words are
sufficient to demonstrate that she acted knowingly or will‐
fully. In her interview upon her arrest, George first stated
that she received only biweekly payments of $1,000 from
Rosner—made only by check—and that the payments were
not per‐patient. She admitted that she knew that it was ille‐
gal to be paid per patient for referrals to home health agen‐
cies. When confronted with the tape recordings demonstrat‐
ing that her characterization of the payments was a lie, she
acknowledged that she had lied and that she was paid $500,
both by check and in cash, per patient that she referred who
was admitted at Rosner. She had acknowledged that she re‐
ceived cash payments at least as of November 2011—at other
times indicating it began as early as March 2011—and admit‐
ted that, when she began receiving payments in cash, she
realized that it was illegal to be paid per patient. That is suf‐
ficient evidence to establish that she acted knowingly and
willfully in accepting the two payments on April 12, 2012,
and May 17, 2012. Her initial efforts to hide the nature and
No. 17‐1714 11
manner of the payments would alone constitute such evi‐
dence, but here we also have her outright admission that she
realized the payments were illegal when she began receiving
cash, and the cash payments began at a time period before
the payments that are the basis for the two substantive
charges here.
Although that evidence alone would be enough, other
evidence corroborates those incriminating statements, in‐
cluding bank records of cash and checks deposited in
George’s bank accounts, as well as referral logs. In addition,
that evidence as to her knowledge and willfulness was fur‐
ther bolstered by other testimony, including testimony as to
a book she claimed to have read in early 2011 called the Ul‐
timate Guide to Home Health Marketing which explained the
illegality of referral payments.
George brings a separate challenge as to the govern‐
ment’s questioning of her regarding this book, arguing that
the district court erred in allowing the government to ques‐
tion her as to whether she had read certain paragraphs in the
book, but that argument is without merit. First, George ad‐
mitted the book into evidence in her direct examination, and
testified that in early 2011 after reading the book she devel‐
oped concerns about how she and Rosner were doing busi‐
ness and sent an email to Hernal expressing her concerns.
She acknowledged reading enough of the book to have con‐
cerns about the legality of her arrangement with Rosner, but
denied reading sections that specifically discussed kick‐
backs. The government on cross‐examination first ques‐
tioned her as to the first page of the first chapter of that
book, which was an article entitled “Marketing Within the
Four Corners of the Law” and quite clearly stated that it was
12 No. 17‐1714
unlawful to receive payment for referrals of patients to such
providers. That was a legitimate area of cross‐examination
given that George had testified that she read parts of the
book that caused her to question the legality of the pay‐
ments, and given the location and subject matter of that par‐
agraph in the book. The subsequent questioning was also
limited to parts of the book that a person would be likely to
read if seeking information as to the legality of the arrange‐
ment. The district court did not abuse its discretion in allow‐
ing cross‐examination as to the book that George herself
raised in her direct examination and which she introduced
into evidence.
George’s only other challenge to cross‐examination is her
claim that the government improperly sought a legal opin‐
ion from her, a layperson, when it questioned her as to her
knowledge of the illegality of referral payments. George has
no authority for the proposition that a defendant cannot be
asked about her own knowledge or state of mind—a ques‐
tion which she is uniquely positioned to answer—and which
seeks factual information not a conclusion as to its legal sig‐
nificance.
Accordingly, the district court properly determined that
sufficient evidence supported all of the elements of the of‐
fense under the Anti‐Kickback Statute, and did not err in its
decision as to cross‐examination. George nevertheless con‐
tends that she established a good faith belief that the safe
harbor provisions of the statute applied.
Once the government establishes the elements of a viola‐
tion of the Anti‐Kickback Statute, the burden shifts to a de‐
fendant to demonstrate by a preponderance of the evidence
that her conduct fell within the safe harbor provision of the
No. 17‐1714 13
statute. United States v. Jumah, 493 F.3d 868, 873 (7th Cir.
2007); United States v. Vernon, 723 F.3d 1234, 1269–71 (11th
Cir. 2013). George argues that two safe harbor provisions are
applicable. The first provides in relevant part that the Anti‐
Kickback Statute does not apply as to payments made be‐
tween “a health center entity described under clause (i) or
(ii) of section 1396d(l)(2)(B) of this title” and any individual
or entity providing services to that health center pursuant to
an agreement if that agreement contributes to the ability of
the health center to “maintain or increase the availability, or
enhance the quality, of services provided to a medically un‐
derserved population served by the health center entity.”
42 U.S.C. § 1320a‐7b(b)(3)(I). The provision applies only to
Federally‐qualified health centers as defined in clauses (i) or
(ii) of 42 U.S.C. § 1396d(l)(2)(B), and George presented no
evidence at trial that Rosner was a health center that fell
within that definition. She therefore has failed to meet her
burden to demonstrate that applicability of that safe harbor
provision.
The only other safe harbor provision she asserts applies
only to “any amount paid by an employer to an employee
(who has a bona fide employment relationship with such
employer) for employment in the provision of covered items
or services.” 42 U.S.C. § 1320a‐7b(b)(3)(B). George points to
her written agreement with Rosner, but that agreement spec‐
ifies that George is acting as an independent referral agency
with respect to employment and not an employee. Moreo‐
ver, George admitted that she was not an employee and that
she was an independent contractor. In addition, as the dis‐
trict court pointed out, George was paid for referrals and not
for the provision of items or services covered by Medicare,
as required for that safe harbor provision to apply. The dis‐
14 No. 17‐1714
trict court properly held that George did not establish that
her conduct fell within the safe harbor provisions of the
statute.
George’s final contention is that Hernal should have been
considered a “missing witness” because he was not called by
the government. She argues that the district court erred in
failing to accept her proposed missing witness instruction,
which would have allowed the court to infer from Hernal’s
absence that Hernal would have provided information unfa‐
vorable to the government’s case. See United States v. Tava‐
rez, 626 F.3d 902, 904 (7th Cir. 2010). The missing witness in‐
struction is disfavored in our circuit but may be given in un‐
usual circumstances. Id.; United States v, Wright, 722 F.3d
1064, 1068 (7th Cir. 2013). A defendant seeking such an in‐
struction must show: “(1) that if called the witness would
have been able to provide relevant, noncumulative testimo‐
ny on an issue in the case; and (2) that the witness was pecu‐
liarly in the other party’s power to produce.” Tavarez, 626
F.3d at 904–05; Wright, 722 F.3d at 1068–69. “A witness is pe‐
culiarly within a party’s power to produce if she either (1) is
physically available to only that party; or (2) has such a rela‐
tionship with one party as to effectively make her unavaila‐
ble to the opposing party, regardless of actual physical
availability.” Tavarez, 626 F.3d at 905. The second form of
unavailability thus encompasses both physical unavailability
and what has been termed “pragmatic unavailability.” Unit‐
ed States v. Villegas, 655 F.3d 662, 670 (7th Cir. 2011). George
argues that Hernal was unavailable because he cooperated
with the government in his case when he pled to the con‐
spiracy charge and the government dropped the obstruction
of justice enhancement. But George does not argue that Her‐
nal has an interest in the outcome of her case or otherwise
No. 17‐1714 15
was unavailable from a pragmatic standpoint. Hernal was
sentenced to 9 months’ imprisonment on January 29, 2015,
well before George’s trial in October 2015, and George
makes no argument that Hernal’s sentence could be impact‐
ed by George’s outcome. George relies instead on the evi‐
dence that Hernal cooperated with the government, but “a
witness’s status as a confidential informant does not neces‐
sarily give rise to a sufficient relationship with the govern‐
ment so as to render [him] unavailable to the defense.” Tava‐
rez, 626 F.3d at 905; Villegas, 655 F.3d at 670. Moreover, the
testimony that she claims Hernal would have provided at
best would have corroborated her claim that in March 2011
he told her that the arrangement was legal. But George
acknowledged that once she began receiving cash payments,
in at least November 2011, she was aware that the referrals
were unlawful, and therefore by her own admission she was
aware of the illegality when she accepted the payments in
2012. Accordingly, even if the missing witness instruction
had been appropriate, its omission here would have been
harmless error.
The judgment of the district court is AFFIRMED.