United States v. Amir Bajoghli ( 2015 )


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  •                               PUBLISHED
    UNITED STATES COURT OF APPEALS
    FOR THE FOURTH CIRCUIT
    No. 14-4798
    UNITED STATES OF AMERICA,
    Plaintiff - Appellant.
    v.
    AMIR A. BAJOGHLI,
    Defendant - Appellee.
    Appeal from the United States District Court for the Eastern
    District of Virginia, at Alexandria. Gerald Bruce Lee, District
    Judge. (1:14-cr-00278-GBL-1)
    Argued:   March 25, 2015                       Decided:   May 11, 2015
    Before NIEMEYER and FLOYD, Circuit Judges, and HAMILTON, Senior
    Circuit Judge.
    Reversed and remanded by published opinion. Judge Niemeyer
    wrote the opinion, in which Judge Floyd and Senior Judge
    Hamilton joined.
    ARGUED: Paul Nathanson, OFFICE OF THE UNITED STATES ATTORNEY,
    Alexandria, Virginia, for Appellant.   Peter Hugh White, SCHULTE
    ROTH & ZABEL LLP, Washington, D.C., for Appellee.      ON BRIEF:
    Dana J. Boente, United States Attorney, Matthew Burke, Assistant
    United States Attorney, Katherine L. Wong, Assistant United
    States   Attorney,  OFFICE  OF   THE  UNITED   STATES   ATTORNEY,
    Alexandria, Virginia, for Appellant.   Joe Robert Caldwell, Jr.,
    BAKER BOTTS LLP, Washington, D.C.; Kirk Ogrosky, Murad Hussain,
    ARNOLD & PORTER LLP, Washington, D.C., for Appellee.
    2
    NIEMEYER, Circuit Judge:
    Dr.    Amir     Bajoghli,      a    board-certified         dermatologist,           was
    indicted for executing a “scheme or artifice to defraud” when
    billing public and private healthcare benefit programs during
    the period from January 2009 through August 2012, in violation
    of 
    18 U.S.C. § 1347
    , and for related offenses.                          The indictment
    set forth, in 53 of its 60 counts, particular “executions” of
    the fraudulent scheme.
    On September 30, 2014, several weeks before the scheduled
    trial    date   of      October 22,      2014,      Bajoghli    filed      a    motion     to
    strike as unduly prejudicial certain financial details alleged
    in Paragraph 50 of the indictment; on October 13, he filed a
    motion in limine to exclude evidence of post-scheme conduct that
    the government intended to introduce to show his consciousness
    of guilt; and on October 20, he filed a motion in limine to
    exclude all evidence of the scheme that was not directly related
    to one of the 53 specifically charged executions.                          The district
    court    granted     all    three   motions,         the    latter   two       on   the   day
    before the trial was scheduled to begin.                       On the same day, the
    government      filed      this   interlocutory            appeal,   pursuant        to    
    18 U.S.C. § 3731
    , challenging the rulings.
    Because       we    conclude       that       the   district    court’s        rulings
    unduly    restricted       the    latitude         reasonably    necessary          for   the
    government to carry its burden of proof, we reverse and remand.
    3
    I
    Bajoghli is the owner of the Skin and Laser Surgery Center,
    a medical practice that operates from three offices in Virginia
    and    one    in     Washington,         D.C.,       and     that     specializes          in   skin
    diseases      and     the       performance       of       Mohs      micrographic          surgery.
    According       to       the     indictment,          Mohs       surgery     is        a    “highly
    lucrative,” “specialized surgical technique for the removal of
    skin cancer from healthy skin” that is “generally performed on
    sensitive areas of the body, such as the head and neck, where
    preservation         of    healthy       tissue       and       cosmetic     appearance            are
    particularly important.”
    On    August       12,    2014,    the    grand       jury     returned     a       60-count
    indictment against Bajoghli, charging: 53 counts of healthcare
    fraud, in violation of 
    18 U.S.C. § 1347
    ; 6 counts of aggravated
    identity      theft       committed       in     connection          with    the       scheme       to
    defraud,      in     violation      of    18     U.S.C.         § 1028A;    and    1       count    of
    obstruction of justice, in violation of 
    18 U.S.C. § 1512
    (c)(2).
    The    indictment         alleged        that    over       a    three-and-one-half             year
    period --       from      January    2009       through         August     2012    --      Bajoghli
    “knowingly and willfully execute[d] . . . a scheme and artifice
    to    defraud      and    to    obtain,     by       means      of   materially        false       and
    fraudulent pretenses, . . . money owned by and under the custody
    and control of health care benefit programs, in connection with
    4
    the   delivery        of    health    care    benefits,       items,       and   services.”
    More particularly, seventeen counts alleged executions of the
    scheme in which Bajoghli routinely diagnosed patients with skin
    cancer, even though they did not, in fact, have cancer, and then
    performed       the    medically         unnecessary     Mohs       surgery      on    benign
    tissue.     Fifteen          counts      alleged    executions       of    the   scheme    in
    which    Bajoghli          directed      “unlicensed     and     unqualified          medical
    assistants”       to       perform    wound       closures     on    the    Mohs      surgery
    patients and then billed the healthcare benefit programs as if
    he personally had performed or supervised the closures, thereby
    claiming    more           money    than     he    was   entitled          to    under    the
    reimbursement schedule.                Ten counts alleged executions of the
    scheme in which Bajoghli billed for services that he claimed he
    had personally performed when, in fact, they had been performed
    by    non-doctors,           again       allowing      him     to      claim     a     higher
    reimbursement than he would have been allowed to claim had he
    disclosed    that       non-doctors        had     performed     the      services.       And
    eleven    counts       alleged       executions     in   which      Bajoghli       submitted
    bills    “for    preparing         and     analyzing     [skin      pathology]        slides”
    when, in fact, he had personally performed neither service, but
    instead had hired outside contractors to perform the services at
    a cost far below the amount he claimed from the programs.
    Bajoghli         filed       three     pretrial        motions       to    limit    the
    government’s evidence against him at trial:                            the September 30
    5
    motion to strike allegations of certain financial details from
    Paragraph 50 of the indictment; the October 13 motion in limine
    to exclude evidence of post-scheme conduct, which the government
    planned to introduce to show consciousness of guilt; and the
    October 20 motion in limine to exclude any evidence that was not
    directly     related      to    one   of   the   53    executions    specifically
    charged in the indictment.
    In the September 30 motion, Bajoghli sought to strike from
    Paragraph 50 the allegation that he “regularly billed the health
    care benefit programs $300 to $450 per slide.”                       Paragraph 50
    alleged in full:
    The defendant fraudulently submitted claims to
    patients’ health care benefit programs for preparing
    the permanent section slides and analyzing those
    slides, when he actually performed neither service.
    The defendant regularly billed the health care benefit
    programs $300 to $450 per slide, when he had paid the
    Ohio company and the dermatopathologist a total of
    approximately $15 per slide for actually rendering the
    services.
    (Emphasis added).         Because healthcare benefit programs reimburse
    physicians     at   a     predetermined        rate,    Bajoghli    claimed   that
    evidence of what he billed would be unfairly prejudicial because
    those amounts did not represent what he actually expected to
    receive    from     the        programs.       The     district    court   granted
    Bajoghli’s motion and, in doing so, also excluded, sua sponte,
    any evidence of “the fees or payments Defendant allegedly made
    to outside sources to perform” these services -- that is, the
    6
    $15 per slide paid to outside contractors.                   The court stated
    that    the    government     could    introduce   evidence    to   prove   that
    Bajoghli “would have been paid less (or not at all) had the
    claims not been materially false,” but that it could not state
    the specific dollar amounts.
    In     the   October   13     motion,   Bajoghli    sought   to   exclude
    evidence of actions that he had taken after the charged scheme
    had ended, which the government planned to introduce at trial to
    show his consciousness of guilt.                The government intended to
    show that after Bajoghli was interviewed by law enforcement,
    (1) he immediately stopped sending pathology slides to outside
    contractors; (2) he stopped performing Mohs surgery without a
    supporting biopsy; and (3) he deleted scheduling data for past
    wound       repairs   that    were     performed   by     medical   assistants.
    Bajoghli argued that this evidence was irrelevant; that it was
    evidence of subsequent remedial measures, which is barred by
    Federal Rule of Evidence 407; and that, if admitted at trial, it
    would be unfairly prejudicial, in violation of Federal Rule of
    Evidence 403.         The district court did not rule on this motion
    until it ruled on the October 20 motion.
    In     the   October   20     motion,   Bajoghli    sought   to   exclude
    “volumes of irrelevant, uncharged misconduct” evidence, as he
    characterized it, that related to his fraudulent conduct during
    the three-and-one-half year period of the scheme but that was
    7
    not directly tied to any of the 53 charged executions.                                         He
    argued that because this evidence was not directly relevant to
    any    of    the        53    charged      counts,        it     was    therefore       improper
    “[p]ropensity evidence” offered only to show the defendant’s bad
    character, in violation of Federal Rule of Evidence 404(b).                                   He
    also argued that by waiting until so close to the date of trial
    to give him notice of its intent to introduce this evidence, the
    government        failed       to     comply    with       the       notice    requirement     of
    Federal Rule of Evidence 404(b)(2).
    On October 21, the day before the scheduled trial date, the
    district court issued an order granting both the October 13 and
    October      20    motions.           In   doing     so,       the    court    ruled,   without
    explanation,         that       “[a]ll     testimony           is . . .       limited   to    the
    53 charges         in    the     indictment,”          thus      excluding         evidence    of
    Bajoghli’s uncharged conduct.                   And in excluding evidence of the
    defendant’s post-scheme conduct, it gave as reasons that the
    government had not provided adequate notice of its intent to
    introduce         this       “prior    ‘bad     act’      evidence,”          as   required    by
    Federal Rule of Evidence 404(b)(2), and, in any event, that the
    evidence would be excluded under Federal Rule of Evidence 403,
    as    “the    probative          value     of      [the        post-scheme]        evidence   is
    substantially outweighed by the danger of unfair prejudice.”
    The     government         filed     this      interlocutory            appeal,   seeking
    review of the district court’s pretrial evidentiary rulings.
    8
    II
    The government first challenges the district court’s ruling
    limiting       “[a]ll    testimony . . .         to     the     53     charges         of     the
    indictment” and thus excluding evidence of Bajoghli’s uncharged
    conduct in furtherance of the scheme during the three-and-one-
    half    year    period.      It    notes   that       this     ruling       is   especially
    debilitating       because        Bajoghli’s         criminal        intent       is        hotly
    contested in this case, and it therefore contends that it needs
    to     rebut    the     defense     that   the        charged        transactions            were
    “isolated      mistakes”     by    demonstrating        that     it    did       not    merely
    “cherry pick” aberrant transactions.                    As it argues, it must be
    able     to     prove     the     entire        scheme,       including          Bajoghli’s
    intentional and willful conduct in executing it.                         Such a burden,
    it maintains, requires that it be allowed to introduce evidence
    that, although perhaps not directly related to any of the 53
    executions      charged,     is     nonetheless        relevant        to    proving         the
    scheme itself.          The government warns that if it were not able to
    offer evidence of uncharged executions in proving the scheme, it
    would have to charge hundreds, if not thousands, of counts in
    every large-scale healthcare-fraud case, such as this one.
    Bajoghli       maintains     that     the      district        court       correctly
    concluded that the evidence at trial must relate to one of the
    specifically      charged       executions      of    the     fraudulent         scheme       and
    that “evidence of an uncharged fraudulent scheme should not be
    9
    admitted.”       He asserts that the government’s brief paints with
    too broad a brush, ignoring the 53 specific and discrete charges
    it brought under § 1347.              As he argues, “the evidence at trial
    must relate to a specific allegation of fraud that the jury will
    have to consider.”            Because, as he contends, any evidence of
    uncharged     conduct       would    be    only   “loosely       relevant”      to    the
    charged      executions,      the     evidence    should     be     excluded         under
    Rule 403      as     unfairly       prejudicial      and     under        Rule 404(b),
    including Rule 404(b)(2)’s notice requirement, as “other acts”
    evidence.
    The   scope    of    relevant      evidence   at    trial    is,    of   course,
    dictated by the indictment.               In this case, however, Bajoghli’s
    position reveals a misunderstanding of the nature of the charges
    in the indictment and the scope of proof that is relevant.
    Section     1347    punishes    “[w]hoever     knowingly      and    willfully
    executes . . . a scheme . . . to defraud any health care benefit
    program”      when    delivering       healthcare     services.            
    18 U.S.C. § 1347
    (a)(1) (emphasis added).              A “scheme to defraud” is thus an
    element of the offense.             See United States v. McLean, 
    715 F.3d 129
    ,   137-38      (4th    Cir.   2013)    (“To   sustain    a     conviction        under
    
    18 U.S.C. § 1347
    , the government [is] required to prove beyond a
    reasonable doubt that [the defendant] knowingly and willfully
    executed a scheme to defraud insurers by billing for medically
    unnecessary procedures” (emphasis added)).                   While fraud can be
    10
    committed    simply     by    engaging       in    an   isolated        transaction,     a
    scheme to defraud requires a plot, plan, or arrangement that is
    executed     by    a   fraudulent         transaction.            See     Black’s     Law
    Dictionary    1546     (10th       ed.    2014)    (defining      “scheme”       as   “[a]
    systemic plan; a connected or orderly arrangement”; or “[a]n
    artful plot or plan, [usually] to deceive others”).
    In    this    case,     the    scheme       alleged   in     the    indictment    is
    described as encompassing four types of conduct, beginning in
    January 2009 and continuing through August 2012.                          And although
    the indictment charged only 53 “executions” of the scheme in
    53 separate       counts,     it     also    alleged       that     each       particular
    execution    was    “part    of     the   scheme     and   artifice       to    defraud.”
    Thus, the indictment charged that “for the purpose of executing
    the aforementioned scheme and artifice,” described earlier to
    have lasted from January 2009 through August 2012, the defendant
    engaged in the particularly described fraudulent transactions.
    (Emphasis added).          Because a scheme is an element of a § 1347
    offense and because the specifically alleged three-and-one-half
    year scheme is made part of each execution, evidence of the
    entire scheme is relevant to proving each particular execution.
    It is important to recognize that just as all the overt
    acts of a conspiracy need not be charged in an indictment, see
    United States v. Janati, 
    374 F.3d 263
    , 270 (4th Cir. 2004) (“It
    is well established that when seeking to prove a conspiracy, the
    11
    government is permitted to present evidence of acts committed in
    furtherance       of   the   conspiracy        even    though     they    are    not    all
    specifically described in the indictment”), all executions of a
    scheme likewise need not be charged, see United States v. Pless,
    
    79 F.3d 1217
    , 1220 (D.C. Cir. 1996) (“That the government chose
    to charge as the execution of the scheme only the three deposits
    in National [Bank] does not reduce the boundaries of the scheme,
    which the statute requires the government to prove. . . . [I]t
    is not necessary for the government to charge every single act
    of execution of the scheme in order to prove the whole scheme”).
    Nonetheless, evidence of transactions and conduct not charged is
    relevant to proving the existence of and the boundaries of the
    conspiracy       or    scheme.        See    Janati,    
    374 F.3d at 275
          (“[T]he
    government has the right and the burden to prove in its case-in-
    chief   a    conspiracy      broader         than    the     individual      overt     acts
    alleged     [and]      therefore       the    district        court   must      give   the
    government       a    reasonable      opportunity       to    carry   this      burden”);
    Pless, 
    79 F.3d at 1220
     (“[T]he government is [not] artificially
    limited     to   presenting      to    the    jury     only    that   portion     of    the
    scheme that directly related to [the charged executions]”).                               A
    scheme and a conspiracy thus are, for these purposes, similar
    concepts.        See United States v. Lothian, 
    976 F.2d 1257
    , 1262
    (9th Cir. 1992) (“Because an essential element of these offenses
    is a fraudulent scheme, mail and wire fraud are treated like
    12
    conspiracy in several respects”); United States v. Read, 
    658 F.2d 1225
    ,   1239    (7th        Cir.    1981)      (“A   scheme     to   defraud   and
    conspiracy      embrace    analogous,            but   not     identical,    concepts”);
    United States v. O’Connor, 
    580 F.2d 38
    , 41-42 (2d Cir. 1978)
    (equating “a continuing scheme” with a conspiracy); SEC v. Nat’l
    Bankers Life Ins. Co., 
    324 F. Supp. 189
    , 195 (N.D. Tex. 1971)
    (describing “the possibility of reading ‘scheme’ as synonymous
    with    a   conspiracy”        in    a     federal       securities     statute).      We
    therefore conclude that when the government charges a defendant
    under § 1347 with a scheme to defraud and elects to charge only
    some of the executions of that scheme, its election does not
    limit    its    proof     to    only       the    charged       executions.      It    may
    introduce other evidence of uncharged executions to prove the
    scheme.
    To be sure, a district court still retains broad-ranging
    discretion      to   manage      trials       and      limit    proof    that   is,    for
    instance, overly duplicative.                    But, as we noted in Janati, its
    discretion must be balanced by the need to give the government
    adequate latitude to prove its case, especially in a large and
    complex     healthcare-fraud          case       where    the    defendant’s    criminal
    intent is placed at issue.                 See 
    374 F.3d at 273-74
    .           We conclude
    that, in this case, the district court abused its discretion in
    failing to give the government sufficient latitude to carry its
    burden of proof.
    13
    In addition, it follows that because evidence of conduct
    not   charged     in   a   specific    execution     may   be   relevant     to   the
    nature and scope of a scheme charged under § 1347, such evidence
    is intrinsic to the “scheme” element, and Rule 404(b) therefore
    does not, as Bajoghli argues, regulate it as “other bad acts”
    evidence.    See Unites States v. Grimmond, 
    137 F.3d 823
    , 832 (4th
    Cir. 1998) (“[W]hen ‘other crimes, wrongs, or acts’ evidence is
    relevant to establishing an element of the offense, Rule 404(b)
    is not even implicated”).
    In   sum,   we   conclude       that   the   district     court   abused    its
    discretion in limiting the government’s proof to that which is
    directly relevant to one or more of the 53 executions charged in
    the indictment, without taking into account the relevance of
    uncharged    conduct       to   the    alleged     overarching     scheme.        The
    government has the burden of proving a scheme to defraud and
    Bajoghli’s knowing and willful conduct in executing the scheme.
    And to that end, it must be allowed to offer evidence probative
    of these elements, even if that evidence is not directly related
    to one of the 53 executions.
    III
    The government next challenges the district court’s ruling
    to exclude evidence of the defendant’s post-scheme conduct.                       It
    seeks to introduce evidence (1) that “after being interviewed by
    14
    law        enforcement,           [Bajoghli]          immediately       stopped        sending
    pathology         slides”     to    outside      contractors;        (2) that       after    his
    interview,         “the       defendant      stopped         performing       Mohs     surgery
    without       a        biopsy”;     and    (3) that       the    defendant       “delet[ed]
    scheduling data for the past wound repairs that were performed
    by    medical       assistants.”           The    district      court    considered         this
    evidence          to     be   “prior       ‘bad       act’    evidence”       governed        by
    Rule 404(b) and excluded it on the ground that the government
    had not provided Bajoghli with adequate notice, as required by
    Rule 404(b)(2). ∗ Moreover, the court excluded this evidence under
    Rule 403, concluding that its probative value was “substantially
    outweighed by the danger of unfair prejudice . . . , confusing
    the    jury . . . ,           and    waste       of     judicial      resources.”           The
    government         argues     that    the    district        court    erred    in     applying
    Rule 404(b) because the evidence is intrinsic to the charged
    crimes; that is, it “bear[s] directly on the defendant’s intent
    as    to     the       charged     fraud    (not      some    other     crime)       and    [is]
    ∗
    Even if Rule 404(b) were to apply, it is difficult to
    understand how the government had not provided adequate notice
    to Bajoghli. Bajoghli’s motion to exclude evidence of his post-
    scheme conduct admitted as much, stating, “The government has
    indicated that they plan to introduce evidence of changes in
    procedures and practices in [his] offices after he became aware
    that he was under criminal investigation, presumably to
    demonstrate that the prior practices were illegal.”    Moreover,
    in his motion to exclude this evidence, Bajoghli did not raise a
    lack of notice as a ground for exclusion.
    15
    inextricably intertwined with how he committed the fraud and his
    efforts to conceal it once he learned [of the] investigation.”
    Bajoghli       contends       that    Rule 404(b)         does    apply       to    this
    evidence because, as he argued with respect to the evidence of
    his uncharged conduct, it would not be “tied to any one of the
    53 narrowly defined executions of healthcare fraud” and thus
    would       not   be       “intrinsic”         to        the   charged    offenses.            More
    particularly, he contends that “evidence of remedial measures,”
    as    a    matter     of    law,    “cannot         be     ‘intrinsic’     to     any    of    [the
    charged] offenses” because the remedial measures all occurred
    after the period of time noted in the indictment as encompassing
    the alleged fraudulent scheme.                           In addition, he contends that
    its       admission       would    be    unfairly          prejudicial     under        Rule 403,
    parroting the district court’s conclusion.
    Again, we agree with the government.                           As the government
    points out, it intends to offer evidence of Bajoghli’s post-
    scheme conduct to prove his knowledge and intent to defraud, as
    is    required       by    § 1347.        For       instance,     that     Bajoghli      stopped
    sending pathology slides to outside contractors after he learned
    he was under investigation, but before federal agents had even
    become aware of this practice -- as the government represents --
    would      tend     to     prove    Bajoghli’s            fraudulent     intent    and       guilty
    knowledge with respect to this aspect of the scheme.                                Similarly,
    the government notes that Bajoghli “intends to challenge [the
    16
    charge     of    fraudulent      Mohs    surgeries]          by    asserting      that    he
    exercised        reasonable      medical        judgment      in        performing     Mohs
    surgeries and that any errors were the product of innocent . . .
    mistakes.”       Thus, it reasons, evidence that Bajoghli stopped his
    practice of performing Mohs surgeries without first reviewing
    biopsies once he learned of the investigation would tend to show
    that he knew the accepted standard of care for diagnosing skin
    cancer     and    had    deliberately      chosen       to    disregard       it.        And
    finally, as the government notes, evidence that Bajoghli deleted
    scheduling data from his computers -- data that revealed who had
    actually    performed         wound-repair       procedures        --    would    tend    to
    refute his claim that this aspect of the fraud resulted from
    honest     billing       mistakes.         Cf.     McLean,         715    F.3d    at     139
    (concluding that evidence that the defendant “attempted to shred
    patient files subpoenaed” by the government was probative that
    the defendant knew he “had something to hide”).                            The proffered
    evidence therefore would be probative to prove knowledge and
    intent,     which       are   elements     of     the   crimes          charged   in     the
    indictment.        And because Rule 404(b) does not apply to conduct
    that is intrinsic to the charged crime, the district court erred
    in applying the rule to this evidence.                        See United States v.
    Basham, 
    561 F.3d 302
    , 326 (4th Cir. 2009) (“The Rule 404(b)
    inquiry . . . applies only to evidence of other acts that are
    17
    ‘extrinsic to the one charged’” (quoting United States v. Chin,
    
    83 F.3d 83
    , 87 (4th Cir. 1996))).
    Bajoghli       nonetheless        argues      that    his    post-scheme      conduct
    cannot    be    intrinsic       to    the     charged    offenses         because    it    took
    place after the end of the period of activity charged in the
    indictment.          But it simply does not follow that conduct that
    takes place after the end of the period of activity charged in
    the    indictment      is     --    as   a    matter    of    law    --    subject    to    the
    requirements of Rule 404(b).                  In fact, our case law demonstrates
    that simply because a defendant’s conduct takes place outside
    the time frame of the activities charged in the indictment does
    not,    as     Bajoghli       argues,        automatically         render    that    conduct
    extrinsic       to    the     charged        offense    and    therefore       subject      to
    Rule 404(b).          See United States v. Kennedy, 
    32 F.3d 876
    , 885
    (4th Cir. 1994) (“The basic flaw in [the defendant’s] argument
    is that . . . [it] erroneously assumes that all evidence falling
    outside      the     charged       conspiracy       period    necessarily      involves       a
    separate,       unrelated          offense     subject        to    the     strictures      of
    [Rule 404(b)].          It is well-established, however, that the mere
    fact that the evidence involved activities occurring before the
    charged      time     frame    of    the     conspiracy       does    not    automatically
    transform       that        evidence         into    ‘other        crimes’     evidence”).
    Instead, conduct that takes place outside the time frame of the
    charged offense can avoid having to comply with the requirements
    18
    of    Rule 404(b)       where         it       is,    inter        alia,     “relevant       to
    establishing an element of the offense.”                             Grimmond, 
    137 F.3d at 831-32
    .       And, as we concluded above, Bajoghli’s post-scheme
    conduct is relevant to proving his fraudulent intent and guilty
    knowledge.
    The   district      court’s         additional       ruling    --     that    Rule 403
    requires exclusion of the evidence because its probative value
    is substantially outweighed by the danger of unfair prejudice
    and    other     concerns       --    reflects        a    misunderstanding          of     what
    constitutes       unfair      prejudice           under     Rule 403.         Once     it     is
    recognized that evidence is probative of an element of the crime
    charged, “the balance under Rule 403 should be struck in favor
    of    admissibility,          and      evidence           should     be     excluded        only
    sparingly.”         United States v. Aramony, 
    88 F.3d 1369
    , 1378 (4th
    Cir. 1996); see also United States v. Siegel, 
    536 F.3d 306
    , 319-
    20    (4th   Cir.    2008).          And    in    this     context,       unfair    prejudice
    “speaks to the capacity of some concededly relevant evidence to
    lure the factfinder into declaring guilt on a ground different
    from proof specific to the offense charged.”                              Basham, 
    561 F.3d at 327
     (emphasis added) (quoting Old Chief v. United States,
    
    519 U.S. 172
    , 180 (1997)) (internal quotation marks omitted).
    Neither      Bajoghli     nor    the       district        court    has    identified        any
    ground    that    would    support         a     finding    of     guilt    different       from
    proof that is specific to the offense charged.
    19
    Because       the   district       court     misapplied         Rule 404(b)        and
    Rule 403     in      excluding     evidence       of      Bajoghli’s       post-scheme
    conduct, it abused its discretion.
    V
    Finally,      the   government      challenges         the     district     court’s
    ruling to exclude evidence that, despite receiving between $100
    and $130 per slide from healthcare benefit programs based on his
    claim that he both prepared and analyzed his patients’ pathology
    slides himself, Bajoghli paid outside contractors only $15 per
    slide   to    perform    those     tasks.      The     government       contends    that
    evidence     of   financial      gain   “is     critical      in    a   fraud    case    to
    establish a defendant’s intent to defraud.”                        It argues that the
    arrangement       between   Bajoghli      and     the     outside       contractors      is
    “part and parcel of proving this aspect of the fraud” and that
    “an essential part of this arrangement was the amount that the
    defendant     paid    them.”       According         to   the   government,        “[t]he
    substantial       disparity    between      the      amount     that    the     defendant
    received, and what he paid” can only “underscore[] [Bajoghli’s]
    motive for this intentional deception.”
    Bajoghli contends that evidence of what he paid the outside
    contractors is irrelevant, and thus he urges us to affirm the
    district court’s ruling to exclude it.                     According to Bajoghli,
    “this case is about billing and whether or not the billing was
    20
    false.”      Because “[a]ny amounts paid to outside contractors were
    not part of the alleged misrepresentations in bills submitted to
    insurers,” those amounts, he argues, “were not material to the
    charged      offenses       of        executing           healthcare          fraud       schemes     by
    submitting false claims.”
    We agree with the government.                            Because a violation of the
    healthcare fraud statute requires knowing and willful conduct,
    see    
    18 U.S.C. § 1347
    (a),              the     government             must     establish
    Bajoghli’s intent to defraud.                       United States v. Godwin, 
    272 F.3d 659
    , 666 (4th Cir. 2001).                       And evidence of financial gain is
    particularly         probative            in    a     fraud       case        to    establish       the
    defendant’s      intent         to    defraud.            See,        e.g.,    United      States     v.
    Beverly,      284    F.    App’x       36,      40    (4th       Cir.    2008)      (per     curiam);
    accord      United    States         v.    Davis,         
    490 F.3d 541
    ,       549    (6th     Cir.
    2007); United States v. Dearing, 
    504 F.3d 897
    , 901 (9th Cir.
    2007) (endorsing the Sixth Circuit’s declaration in Davis that
    evidence of profits can serve as indirect proof of one’s intent
    to defraud); United States v. Wheeler, 
    889 F. Supp. 2d 64
    , 68
    (D.D.C. 2012) (“In a § 1347 [healthcare-fraud] case, ‘intent [to
    defraud] can be inferred . . . from profits’” (quoting Dearing,
    
    504 F.3d at 901
    )).
    Moreover,          the        district         court’s          ruling       allowing         the
    government to introduce evidence that the defendant “would have
    been    paid    less       (or       not       at    all)       had     the    claims       not     been
    21
    materially   false”   simply   does    not   allow    the   government   to
    present its case with sufficient detail and narrative.            Cf. Old
    Chief, 
    519 U.S. at 183
     (recognizing “the offering party’s need
    for evidentiary richness and narrative integrity in presenting a
    case”).
    We conclude, accordingly, that the district court abused
    its discretion in excluding this evidence.
    REVERSED AND REMANDED
    22