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`In the
`United States Court of Appeals
`For the Eleventh Circuit
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`____________________
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`Nos. 20-13091, 20-14377
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`____________________
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`UNITED STATES OF AMERICA,
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`versus
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`ELIZABETH PETERS YOUNG,
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` Plaintiff-Appellee,
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` Defendant- Appellant.
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`____________________
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`Appeals from the United States District Court
`for the Southern District of Florida
`D.C. Docket No. 0:19-cr-60157-RAR-1
`____________________
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` [PUBLISH]
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`In the
`United States Court of Appeals
`For the Eleventh Circuit
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`____________________
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`Nos. 20-13091, 20-14377
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`____________________
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`UNITED STATES OF AMERICA,
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`versus
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`ELIZABETH PETERS YOUNG,
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` Plaintiff-Appellee,
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` Defendant- Appellant.
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`____________________
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`Appeals from the United States District Court
`for the Southern District of Florida
`D.C. Docket No. 0:19-cr-60157-RAR-1
`____________________
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`Opinion of the Court
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`20-13091
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`Before JORDAN, ROSENBAUM, Circuit Judges, and MANASCO,* Dis-
`trict Judge.
`
`ROSENBAUM, Circuit Judge:
`
`Under the federal Anti-Kickback statute, it’s illegal to make
`or accept payments for referring business that a federal program
`will reimburse. Among other functions, this law helps ensure that
`medicine-related decision-makers do not make decisions for finan-
`cial-enrichment reasons but rather for the patient’s benefit.
`
`Here, a jury convicted Defendant Elizabeth Peters Young of
`conspiring to pay and receive kickbacks from federal reimburse-
`ments for medical creams and lotions that the pharmacies she
`worked with dispensed. As part of Young’s sentence, the district
`court ordered Young to make restitution in the amount of $1.5 mil-
`lion to the federal government, based on the amount of kickbacks
`Young received. The court also entered a forfeiture judgment
`against Young in that same amount because it represented the
`gross proceeds Young controlled during the conspiracy.
`
`Young now challenges her conspiracy conviction, the resti-
`tution order, and the forfeiture judgment. She asserts that insuffi-
`cient evidence supported her conspiracy conviction, that the gov-
`ernment did not meet its burden to support the restitution amount,
`
`
`* Honorable Anna M. Manasco, United States District Judge for the Northern
`District of Alabama, sitting by designation.
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`and that the district court erred in calculating the forfeiture
`amount.
`
`After careful review of the record and with the benefit of
`oral argument, we affirm Young’s conspiracy conviction. We also
`affirm the district court’s forfeiture judgment as consistent with
`controlling precedent. But we agree with Young that the district
`court erred in crafting the restitution order. Because the govern-
`ment did not establish that the amount of loss it experienced as a
`result of Young’s conduct equaled the total amount of kickbacks
`Young possessed during the conspiracy, we vacate the restitution
`order and remand for further proceedings consistent with this opin-
`ion.
`
`I.
`
`A.
`
`BACKGROUND
`
`Factual Background
`
`Young had a career marketing medical products to sur-
`geons. She often spent time in the operating room during surgery
`in case her surgeon clients needed assistance with the products she
`sold them, and she developed relationships with her clients.
`
`Around 2012, Young started her own distributorship, Young
`Surgical, LLC. Young Surgical initially sold devices related to spi-
`nal surgeries, as that was Young’s area of expertise.
`
`But in early 2015, Young decided to start marketing over-
`the-counter pain-relieving patches and creams to doctors who
`treated workers’ compensation patients. The patches went by the
`
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`brand name Terocin, and the creams went by the brand name Li-
`doPro. Terocin and LidoPro were expensive. So only a few
`healthcare programs, including the Federal Employees’ Compen-
`sation Act (“FECA”) program, administered by the Department of
`Labor’s Office of Workers’ Compensation Programs, would pay
`for them. Those programs applied an extremely high rate in reim-
`bursing the pharmacies that provided Terocin and LidoPro. For
`instance, a program paid one providing pharmacy $802 for Tero-
`cin, even though the product cost the pharmacy only $200, plus $16
`in shipping.
`
`Young decided that she would try to sell the patches and
`creams to Dr. Plas James, one of Young Surgical’s clients who
`owned and operated a practice in Georgia. So she approached Dr.
`James’s medical assistant and office manager, Desiree de la Cruz.1
`Young and de la Cruz had been friends for more than fifteen years.
`Over the years, Young had helped de la Cruz by buying her food
`and, on one occasion, even giving her a car. In February 2015,
`Young asked de la Cruz to tell Dr. James about Young’s new ven-
`ture selling Terocin and LidoPro.
`
`After meeting with de la Cruz, Young looked for a pharmacy
`that could provide Terocin and LidoPro. A Google search led her
`to a pharmacy in Pompano Beach, Florida, called Drugs4Less.
`
`
`1 At some point during the events in this case, de la Cruz’s name changed to
`Desiree Mitchell. To avoid confusion with co-conspirator Tim Mitchell, we
`refer to her throughout this opinion as Desiree de la Cruz.
`
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`Drugs4Less had a surplus of Terocin and LidoPro and had experi-
`enced trouble offloading them because of their expense.
`
`Young contacted the owner of Drugs4Less, Dr. Amir Serri,
`and they entered into a contract under which Young would receive
`a kickback of 50% of the net profits from the prescriptions she was
`able to direct to Drugs4Less. Drugs4Less then sent a few samples
`of Terocin and LidoPro to Dr. James, who agreed to use the prod-
`ucts with his patients.
`
`Around the same time, Young hired Tim Mitchell as a sales
`representative for Young Surgical. Mitchell and de la Cruz were
`living together then and later married. Before Young hired him,
`Mitchell had been a cashier and had held some positions as a sales
`representative, including for Aflac. But he had never worked in the
`healthcare industry.
`
`Young was not concerned about Mitchell’s lack of experi-
`ence, though. She hired him because of his relationship with de la
`Cruz, whom Young described as a “unicorn.” A “unicorn,” for
`these purposes, is someone who “worked in an office that had ac-
`cess to the doctor [and] had the ability to give everybody that came
`through a prescription,” which was “very, very rare” and “unique.”
`Whether or not it’s true that de la Cruz had the ability to “give”
`every patient a prescription for Terocin and LidoPro, the evidence
`showed that de la Cruz participated in securing prescriptions for
`Dr. James’s patients. For example, Young said de la Cruz “wr[ote]”
`“script[s],” and Young sent an email saying, “With all of [de la
`Cruz’s] refills today, we’re at nine thousand for the day.”
`
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`With Mitchell onboard as her sales representative and de la
`Cruz involved in processing prescriptions for Dr. James, Young im-
`plemented her kickback scheme. It worked like this: Dr. James
`saw patients in Georgia who sought treatment for injuries. He of-
`ten prescribed pain patches and creams to his patients. And Young
`made it easy for him to prescribe Terocin and LidoPro, between de
`la Cruz’s presence in Dr. James’s office and Young’s provision of
`preprinted prescription pads with the drug names Terocin and Li-
`doPro in large print and the generic form of the drugs in small print
`underneath.2
`When Dr. James prescribed Terocin or LidoPro to patients
`who were eligible for federal workers’ compensation, de la Cruz
`sent those prescriptions to be filled at the Drugs4Less pharmacy,
`even though it was located in Florida. Drugs4Less then filled the
`prescriptions, shipped the patches and creams for free to the pa-
`tients, and sent a bill to the FECA program in the Office of Work-
`ers’ Compensation Programs. That office reimbursed Drugs4Less
`at the extremely high rates Terocin and LidoPro supported, and
`Drugs4Less in turn sent half its profits to Young. Young then sent
`20% of her revenue to Mitchell for de la Cruz’s services.
`
`The co-conspirators focused on Terocin and LidoPro be-
`cause of their high reimbursement rates. In an email to her
`Drugs4Less contact, Young even called “adding [L]ido[P]ro” her
`
`
`2 The government does not assert that Dr. James was involved in Young’s
`scheme.
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`“best idea EVER.” And in response to an email from Drugs4Less
`asking about refills on Terocin patches, de la Cruz responded, “Re-
`fills for everyone!!!!!!!” But if federal programs denied prescriptions
`for Terocin or LidoPro, Dr. James’s office would not prescribe an
`alternative treatment, further highlighting that the scheme relied
`on the high rates Terocin and LidoPro supported.
`
`The scheme was a huge financial success. Just a few months
`into the venture, Young and Drugs4Less enjoyed their first month
`with over $100,000 in profits. By the end of August 2015, Young’s
`monthly share of the profits reached $134,952. In total, in the
`roughly sixteen months between March 2015 and July 2016, Young
`received $1,228,404 from Drugs4Less based on reimbursements
`from workers’ compensation programs, the vast majority of which
`came from the FECA program.
`
`Of this, Young sent Mitchell $338,255 as purported compen-
`sation for his work as a sales representative. In reality, though, as
`we’ve noted, these payments were kickbacks to de la Cruz for send-
`ing the prescriptions to Drugs4Less. Indeed, Mitchell testified at
`trial that he did no work at all in his position as a sales representa-
`tive for Young Surgical. He merely waited for the checks to come
`in each month as compensation for de la Cruz’s work securing the
`prescriptions.
`
`The arrangement continued through the summer of 2016.
`Around that time, Young took a few steps to try to limit the legal
`exposure from her scheme. First, Young had Mitchell sign a decla-
`ration stating that he didn’t try to influence Dr. James and that Dr.
`
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`James made all the medical decisions. Second, she sent Mitchell
`emails purporting to seek assurances that de la Cruz was not in a
`position of authority to award the referral of business (even though
`that was the reason Young hired Mitchell). Third, she arranged a
`training opportunity for Mitchell so he would appear to be a bona
`fide sales representative. And fourth, she asked Dr. Serri to hire
`Mitchell and herself as employees of Drugs4Less, which she hoped
`would shield her from liability under the Anti-Kickback Statute.
`
`But Dr. Serri refused to hire Young and Mitchell. So Young
`terminated the relationship with Drugs4Less and found employ-
`ment for herself and Mitchell at another pharmacy. Apparently un-
`able to find a cooperating pharmacy in Georgia, where the patients
`were located, or Florida, where Drugs4Less was, Young completed
`the Eleventh Circuit trifecta and went with Gateway Pharmaceuti-
`cals, a pharmacy in Birmingham, Alabama.
`
`Still, Young continued the same arrangement she had with
`Mitchell and de la Cruz, with only two differences. First, de la Cruz
`routed the Terocin and LidoPro prescriptions to Gateway instead
`of Drugs4Less. And second, because Mitchell was an employee of
`Gateway, Gateway paid him directly, so Young did not have to pay
`Mitchell anymore. From September 2016 through December
`2018, Gateway paid $298,756 to Young and $209,572 to Mitchell.
`
`All told, during the scheme, the FECA program reimbursed
`$1,863,649 to Drugs4Less and $1,092,919 to Gateway for Terocin
`and LidoPro prescriptions. Young received $1,527,160.75 in total
`
`
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`between the two pharmacies, and she passed $338,255 of that to
`Mitchell.
`
`B.
`
`Procedural History
`
`A federal grand jury returned an indictment against Young
`for her role in the kickback scheme. The Indictment charged
`Young with one count of conspiracy to pay and receive healthcare
`kickbacks in connection with the FECA program, in violation of 18
`U.S.C. § 371, 42 U.S.C. §§ 1320a-7b(b)(1)(A), and 1320a-7b(b)(2)(A);
`six counts of receiving healthcare kickbacks in connection with the
`FECA program, in violation of 42 U.S.C. § 1320a-7b(b)(1)(A); and
`four counts of paying healthcare kickbacks in connection with the
`FECA program, in violation of 42 U.S.C. § 1320a-7b(b)(2)(A).
`
`Young moved to transfer venue to the Northern District of
`Georgia, or alternatively, to dismiss based on improper venue. Af-
`ter a hearing, the district court denied Young’s motion with respect
`to the conspiracy count, the payment counts, and three of the re-
`ceipt counts, and the court dismissed the three remaining receipt
`counts.
`
`The surviving counts proceeded to a jury trial. The govern-
`ment called six witnesses, including Mitchell, as part of its case-in-
`chief.3 Mitchell testified that Young and de la Cruz enjoyed a
`
`
`3 For their roles in the conspiracy, Mitchell and de la Cruz both pled guilty to
`one count of conspiracy to receive healthcare kickbacks. Mitchell was sen-
`tenced to 60 months’ probation, including 12 months’ home detention, and he
`
`
`
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`longstanding close friendship. In 2015, Mitchell recounted, de la
`Cruz told Mitchell that Young had offered them an opportunity to
`make some money. So Mitchell and de la Cruz met with Young at
`a Chick-Fil-A, where Young explained that she wanted Mitchell to
`“focus on selling” LidoPro and Terocin to Dr. James, de la Cruz’s
`longtime employer. Mitchell noted that de la Cruz had a “[v]ery
`close” relationship with Dr. James.
`
`According to Mitchell, he had no knowledge of healthcare
`products, and Young provided no training or instruction. Although
`Mitchell tried to sell LidoPro and Terocin to a couple other doc-
`tors, Mitchell said, Young discouraged him from spending his time
`that way. And as for Dr. James, Mitchell never “pitch[ed]” him,
`marketed to him, presented to him on Terocin and LidoPro, or
`even provided him with samples. Instead, Mitchell testified, Young
`relied on de la Cruz’s “great relationship” with Dr. James. Young
`told Mitchell that “[e]very patient that comes through [Dr. James’s
`office] will get our patches and cream” because of de la Cruz.
`
`As Mitchell recounted his position with Young, de la Cruz
`did “all the work and [Mitchell] . . . ma[de] extremely good
`money.” But Young told Mitchell “not to do anything” in exchange
`for the money.
`
`
`was ordered to forfeit his illicit gains in the amount of $457,586 and pay that
`same amount in restitution. De la Cruz was sentenced to 12 months and 1
`day of imprisonment, and she was held jointly and severally liable for Mitch-
`ell’s restitution obligations.
`
`
`
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`Mitchell explained that de la Cruz was Dr. James’s back of-
`fice manager, so she was able to ensure that all his patients were
`prescribed LidoPro. According to Mitchell, it was de la Cruz who
`obtained the prescriptions for Terocin and LidoPro from Dr.
`James, de la Cruz who sent those prescriptions to the pharmacy,
`and de la Cruz who handled patient issues. Mitchell noted that en-
`suring that no patients complained was important because Young
`told him that “[i]f complaints got back to Dr. . . . James, he would
`have immediately shut down our operation.” Although, by his
`own testimony, Mitchell did “nothing,” he was paid “[a]round 450-
`something thousand dollars.” Mitchell opined that he received
`payment instead of de la Cruz to avoid having de la Cruz’s involve-
`ment raise “a red flag that would draw attention.”
`Mitchell also said that Young directed him to take steps to
`make the arrangement seem legitimate. For instance, he men-
`tioned that Young instructed him to start his own company solely
`for the purpose of depositing Young’s payments because “it looked
`better in regards to depositing those kind[s] of checks into a busi-
`ness account [as] opposed to a personal account.” Similarly, Mitch-
`ell recounted that Young told him to remove de la Cruz’s name
`from certain bank accounts. And when it came to payment, Mitch-
`ell testified that on several occasions before he opened the bank
`account in the name of his own company, Young split Mitchell’s
`payment into two or more checks, so no check totaled $10,000 or
`more. But after he opened his company’s bank account, Young
`paid him with checks well over $10,000.
`
`
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`For her part, Young also engaged in acts to falsely make her
`arrangement with Mitchell seem legitimate, Mitchell said. For ex-
`ample, after Mitchell and de la Cruz returned from their honey-
`moon, Young sent Mitchell an email that said, “Now that you and
`[de la Cruz] are married, I must assume that there is the potential
`of co-mingling your personal funds.” Yet for more than a year be-
`fore their marriage, Mitchell testified, Young knew that Mitchell
`and de la Cruz lived together, had given checks to de la Cruz for
`Mitchell, and was aware that Mitchell and de la Cruz had already
`been “co-mingling funds.” Still, Young’s email continued, “I must,
`with a reasonable amount of certainty, be sure that [de la Cruz] is
`not in a position of any authority to award the referral of business,”
`and then quoted the federal anti-kickback statute.
`
` Then, when Young started using Gateway instead of
`Drugs4Less to provide the products, Mitchell testified, he moved
`right along with Young. According to Mitchell, “My wife. Every-
`thing. The whole organization. Everything[]” moved to Gateway.
`Young also sent Mitchell a contract with Gateway to sign. Under
`the contract, Mitchell agreed to work as a marketing representative
`of Gateway.
`
`But in actuality, Mitchell continued to do nothing. And
`Cruz continued to refer Dr. James’s patients—this time to Gate-
`way.
`
`Mitchell also testified that he had pled guilty to conspiring
`to violate the anti-kickback law because he “was guilty.” According
`to Mitchell, he conspired with de la Cruz, Young, Drugs4Less, and
`
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`Gateway. Mitchell explained that he was testifying against Young
`in the hope of receiving a reduced sentence.
`
`Besides Mitchell, the government called Vanessa Hernan-
`dez, a pharmacy technician at Drugs4Less. Hernandez testified
`that Dr. Serri sought a way to unload his inventory of Terocin and
`LidoPro, that de la Cruz was Hernandez’s point of contact at Dr.
`James’s office, and that Hernandez kept Young updated on prob-
`lems with prescriptions. Those issues included instances like when
`the Office of Workers’ Compensation declined to reimburse a par-
`ticular order.
`
`And when Hernandez found the prescribing physician’s sig-
`nature illegible, she called de la Cruz for verification. On occasion,
`Hernandez continued, de la Cruz also phoned in prescriptions and
`approved refills on behalf of Dr. James.
`
`On another note, Hernandez explained that sometimes, an
`insurer declined to pay for a particular prescription, but it was pos-
`sible to receive coverage for an equivalent prescription. When the
`insurer denied payment for LidoPro and Terocin, though, Hernan-
`dez said, typically, no one sought an equivalent substitute.
`
`Young testified in her own defense. She claimed that all the
`payments she received from the pharmacies were legitimate pay-
`ments for marketing and customer referrals. She also testified that
`all payments she made to Mitchell were for his legitimate work as
`a sales representative. Young also called several other witnesses to
`testify on her behalf, including former supervisors and colleagues
`who had worked with her.
`
`
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`After a ten-day trial, the jury convicted Young on the con-
`spiracy count and the four counts related to paying kickbacks. The
`jury acquitted Young on the three remaining counts related to re-
`ceiving kickbacks.
`
`Young moved to set aside the verdict or conduct a new trial.
`But the district court denied her motion. The court sentenced
`Young to 57 months’ imprisonment and three years of supervised
`release.
`
`In connection with Young’s sentencing, the government
`moved for a preliminary criminal forfeiture order under 18 U.S.C.
`§ 982(a)(7). Under that provision, a court can order healthcare de-
`fendants to forfeit property “that constitutes or is derived, directly
`or indirectly, from gross proceeds traceable to the commission of
`the offense.” 18 U.S.C. § 982(a)(7). The government sought forfei-
`ture in the amount of $1,527,160.75, which represented the total
`amount Young received in kickbacks in exchange for referrals of
`Terocin and LidoPro to Drugs4Less and Gateway.
`
`Young opposed the motion on several grounds, three of
`which she continues to press on appeal: (1) any money that she
`transferred to co-conspirators should be excluded from the forfei-
`ture total under the Supreme Court’s decision in Honeycutt v. United
`States, 581 U.S. 443 (2017); (2) any money derived from private in-
`surers should be excluded; and (3) the total amount is an excessive
`fine in violation of the Eighth Amendment.
`
`After a hearing, the district court accepted the government’s
`proposed forfeiture amount. It found Young liable for the gross
`
`
`
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`proceeds of the conspiracy under Honeycutt and ordered forfeiture
`of the total amount deposited into her account—$1,527,160.75—
`no matter whether those funds came from government funds or
`private insurers.
`
`The district court also conducted a separate restitution hear-
`ing. The government sought restitution in the amount of
`$1,527,160.75—the same as the forfeiture amount. Young chal-
`lenged that proposed amount. She asserted that the government
`did not prove that any of the reimbursements she received were
`fraudulent and warranted restitution.
`
`The district court concluded that the value of the kickbacks
`could serve as the starting point to determine restitution. It also
`found that the government had sufficiently shown that Young’s
`scheme involved fraud and that Young had not offered evidence to
`establish that the patches and creams she provided were medically
`necessary. So the district court ordered restitution for the full
`amount of the kickbacks, $1,527,160.75.
`
`Young timely appealed the initial judgment and prison sen-
`tence. She also appealed the amended judgment, which included
`the forfeiture and restitution penalties. We consolidated Young’s
`appeals.
`
`II.
`
`STANDARDS OF REVIEW
`
`We review de novo a defendant’s challenge to the suffi-
`ciency of the evidence underlying her conviction. United States v.
`Dixon, 901 F.3d 1322, 1335 (11th Cir. 2018). In so doing, we “view
`
`
`
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`the evidence in the light most favorable to the government and
`draw all reasonable inferences and credibility choices in favor of the
`jury’s verdict.” Id. (citation omitted).
`
`As to a restitution order, we rely on three standards of re-
`view. First, we examine the legality of the restitution order de
`novo. United States v. Robertson, 493 F.3d 1322, 1330 (11th Cir.
`2007). After all, “[a] federal district court has no inherent authority
`to order restitution, and may do so only as explicitly empowered
`by statute.” United States v. Valladares, 544 F.3d 1257, 1269 (11th
`Cir. 2008) (quoting United States v. Dickerson, 370 F.3d 1330, 1335
`(11th Cir. 2004)). Second, we review the district court’s determi-
`nation of the restitution value of lost or destroyed property for
`abuse of discretion. Id. And third, we review the factual findings
`underlying the restitution order for clear error. Id.
`
`When assessing a forfeiture order, we review the district
`court’s findings of fact for clear error and its legal conclusions de
`novo. United States v. Goldstein, 989 F.3d 1178, 1202 (11th Cir.
`2021).
`
`III. DISCUSSION
`
`Our discussion proceeds in three parts. We first assess
`whether sufficient evidence supported Young’s conspiracy convic-
`tion. Then, we examine the district court’s restitution order and
`determine whether the court erred in measuring the government’s
`losses from Young’s scheme. Finally, we consider whether the dis-
`trict court erred in ordering Young to forfeit the full amount that
`
`
`
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`Drugs4Less and Gateway deposited into her account, given that
`she transferred some of that money to co-conspirators.
`A.
`Sufficient evidence supported Young’s convictions.
`
`Young asserts that insufficient evidence supported her con-
`spiracy conviction for two reasons. First, she argues that the gov-
`ernment failed to present enough evidence to support a conspiracy
`involving herself, the Mitchells, and Gateway that ran from August
`2016 to December 2018. Second, as to Drugs4Less and Gateway,
`Young contends that insufficient evidence established that de la
`Cruz or Mitchell served as a decisionmaker who could refer pre-
`scriptions to Drugs4Less or Gateway.
`
`We address her arguments in turn.
`1.
`The jury reasonably concluded that Gateway was involved
`in the conspiracy.
`
`Young argues first that the government failed to prove a
`conspiracy involving the Gateway pharmacy. She acknowledges
`that the government offered several pieces of evidence on this
`count: the Office of Worker’s Compensation Program’s billing
`data; bank records indicating payments from Gateway to Young
`and Mitchell; Mitchell’s testimony that “everything” moved from
`Drugs4Less to Gateway after Young stopped using Drugs4Less;
`and an email from Young to de la Cruz in which Young attached a
`Gateway prescription pad. Still, Young contends that no direct ev-
`idence supports her conviction.
`
`
`
`USCA11 Case: 20-13091 Document: 71-1 Date Filed: 07/22/2024 Page: 18 of 56
`
`18
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`Opinion of the Court
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`20-13091
`
`According to Young, the jury could draw only one permissi-
`ble inference from the evidence the government offered: Gateway
`received legitimate payments from the Office of Worker’s Com-
`pensation Programs and then paid Gateway’s legitimate employ-
`ees, Young and Mitchell, money that Young and Mitchell legiti-
`mately earned. Noting that the jury acquitted her on the receipt-
`of-kickbacks counts, Young reasons that the jury couldn’t have
`found that her role in the conspiracy continued once Gateway be-
`came involved because Young was no longer paying Mitchell at
`that time.
`
`We disagree. We’ve observed that “[b]ecause the crime of
`conspiracy is predominantly mental in composition, it is frequently
`necessary to resort to circumstantial evidence to prove its ele-
`ments.” United States v. Watkins, 42 F.4th 1278, 1285 (11th Cir.
`2022) (citation omitted). Indeed, we’ve noted that the government
`may rely entirely on circumstantial evidence to secure a conspiracy
`conviction. See United States v. White, 663 F.3d 1207, 1214 (11th Cir.
`2011) (“Because ‘conspiracies are secretive by nature, the existence
`of an agreement and [defendant’s] participation in the conspiracy
`may be proven entirely from circumstantial evidence.’”) (citation
`omitted). Here, the circumstantial evidence allowed the jury to
`permissibly conclude that Young was involved in a conspiracy with
`Gateway.
`
`First, the government presented Mitchell’s testimony that
`his arrangement with Young largely stayed the same after the core
`conspirators—Young, de la Cruz, and Mitchell—switched the
`
`
`
`USCA11 Case: 20-13091 Document: 71-1 Date Filed: 07/22/2024 Page: 19 of 56
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`
`Opinion of the Court
`
`19
`
`underlying pharmacy from Drugs4Less to Gateway. In other
`words, Mitchell continued to get paid to do essentially nothing,
`while de la Cruz arranged for the patients to receive prescriptions
`for Terocin and LidoPro and sent them to, now, Gateway. Second,
`the Office of Worker’s Compensation Programs’s financial records
`further support the conclusion that the Terocin and LidoPro pre-
`scription scheme worked in the same way before and after Gate-
`way’s involvement, with merely a change in which pharmacy filled
`the prescription. Third, more than twenty of Dr. James’s patients
`who had received medications from Drugs4Less began receiving
`shipments from Gateway. Fourth, the email from Young to de la
`Cruz included a Gateway prescription, which the jury reasonably
`could have understood to mean that Young and de la Cruz planned
`to continue their scheme in the same way it had operated with
`Drugs4Less. It makes no difference for purposes of the conspiracy
`count that Young no longer paid Mitchell directly because she still
`facilitated the kickback scheme with her co-conspirators.
`
`Based on the evidence, the jury reasonably could have de-
`termined that Young moved the kickback scheme to Gateway be-
`cause Drugs4Less declined to hire Mitchell and her as full-time em-
`ployees, so Young made the switch in an effort to maintain the
`scheme under the guise of legal protection. In short, sufficient ev-
`idence allowed the jury to reasonably conclude that the conspiracy
`continued, even though it ran through a different pharmacy. See
`United States v. Richardson, 532 F.3d 1279, 1286 (11th Cir. 2008) (“A
`conspiracy is presumed to continue until its objectives have been
`abandoned or accomplished.”).
`
`
`
`USCA11 Case: 20-13091 Document: 71-1 Date Filed: 07/22/2024 Page: 20 of 56
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`20
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`Opinion of the Court
`
`20-13091
`
`Young points to defense witnesses’ testimony to negate the
`government’s evidence about a continuing conspiracy with Gate-
`way. But at this stage, we must assume that the jury made all cred-
`ibility choices in the verdict’s favor. United States v. Estrada, 969
`F.3d 1245, 1266 (11th Cir. 2020). And the jury could have deter-
`mined that the defense witnesses were not credible. So we decline
`to consider their testimony when evaluating whether the govern-
`ment offered sufficient evidence to convict Young.
`2.
`The jury reasonably concluded that de la Cruz was a deci-
`sionmaker who could refer prescriptions.
`
`The Anti-Kickback Statute makes it unlawful to “knowingly
`and willfully offer[] or pay[] any remuneration (including any kick-
`back, bribe, or rebate) directly or indirectly, overtly or covertly, in
`cash or in kind to any person to induce such person . . . to refer an
`individual to a person for the furnishing or arranging for the fur-
`nishing of any item or service for which payment may be made in
`whole or in part under a Federal health care program[.]” 42 U.S.C.
`§ 1320a-7b(b)(2)(A). Young argues that de la Cruz was not a deci-
`sionmaker with authority to direct the patients’ prescriptions, so
`Young could not have paid de la Cruz “to induce [her] to refer” the
`patients for unlawful purposes.
`
`United States v. Vernon, 723 F.3d 1234 (11th Cir. 2013), fore-
`closes this argument. There, the defendant operated a specialty
`pharmacy, and he paid a “patient advocate” to direct her clients to
`fill their prescriptions at the defendant’s pharmacy. Id. at 1245.
`The patient advocate generally helped her clients by attending
`
`
`
`USCA11 Case: 20-13091 Document: 71-1 Date Filed: 07/22/2024 Page: 21 of 56
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`
`Opinion of the Court
`
`21
`
`medical appointments with them, helping with routine life tasks,
`and assisting in filling prescriptions. Id. After law enforcem
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