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United States v. Kohli

United States Court of Appeals, Seventh Circuit

February 1, 2017

United States of America, Plaintiff-Appellee,
Naeem Mahmood Kohli, Defendant-Appellant.

          Argued September 9, 2016

         Appeal from the United States District Court for the Southern District of Illinois. No. 14-cr-40038 - J. Phil Gilbert, Judge.

          Before Posner, Manion, and Williams, Circuit Judges.

          Manion, Circuit Judge.

         Dr. Naeem Kohli, an Illinois physician who specialized in pain management, was convicted on multiple counts of prescribing narcotics without a legitimate medical purpose in violation of § 841(a) of the Controlled Substances Act. On appeal, he argues that the district court should have granted his motion for acquittal based on insufficient evidence. He also challenges the district court's jury instructions and several of its evidentiary rulings at trial.

         We conclude that the jury's verdict is supported by sufficient evidence and that the motion for acquittal was properly denied. We further hold that the district court's jury instructions provided a fair and accurate summary of the law, and that its challenged evidentiary rulings were not an abuse of discretion. We therefore affirm Dr. Kohli's conviction.

         I. BACKGROUND

         Dr. Naeem Kohli was a board-certified neurologist with extensive training in the treatment of chronic pain. He operated a private medical practice called the Kohli Neurology and Sleep Center located in Effingham, Illinois. Irregularities in the practice eventually caught the attention of federal officials, and in 2014 Dr. Kohli was indicted on three counts of healthcare fraud, two counts of money laundering, and ten counts of illegal dispensation of a controlled substance. During a fifteen-day trial, the jury learned about Dr. Kohli's prescribing practices from a variety of sources, including law enforcement and healthcare professionals, several expert witnesses, and Dr. Kohli's patients and their family members. Dr. Kohli also testified in his own defense.

         A. Expert Testimony of Dr. Parran

         Some of the most important testimony came from the government's expert witness Dr. Theodore Parran, an addiction specialist and internal medicine physician who has previously testified for the government in similar prosecutions. See, e.g., United States v. Chube II, 538 F.3d 693, 698 (7th Cir. 2008). Before trial, Dr. Parran reviewed Dr. Kohli's patient files for each of the patients who had received the allegedly unlawful prescriptions charged in the indictment. Dr. Parran did not dispute that these patients suffered from legitimate, painful medical conditions that might ordinarily warrant treatment with narcotics. As Dr. Parran explained to the jury, however, Dr. Kohli's files reflect that he prescribed narcotics to these patients under circumstances that were far from ordinary.

         The files showed, for example, that Dr. Kohli routinely prescribed addictive opioids to patients who had a history of drug addiction and who were known to be "multi-sourcing, " or simultaneously obtaining various prescriptions for controlled substances from multiple sources or providers. He also prescribed early refills, anywhere from a day to several weeks before the refills were due, to patients who repeatedly claimed that their narcotics medications had run out or were lost or stolen. These same patients often had irregular toxicology screens in which they tested negative for the drugs that Dr. Kohli had prescribed, but positive for other drugs (including illegal drugs and other controlled substances) that he did not prescribe. Dr. Kohli's office also received phone calls from the Veterans Administration and a certain patient's family members reporting that one of his patients was actively abusing drugs. Despite these troubling developments, Dr. Kohli continued to prescribe highly addictive Schedule II opioids, such as oxycodone and hydromorphone, on a regular basis.

         According to Dr. Parran, Dr. Kohli's prescriptions under these circumstances offered no medical benefit and were in some cases simply "inconceivable" from a clinical standpoint. Ultimately, based on his review of the relevant patient files, Dr. Parran concluded that the prescriptions identified in the indictment were inconsistent with the usual course of professional practice and had no legitimate medical purpose.

         B. Other Evidence regarding Dr. Kohli's Prescribing Practices

         Dr. Kohli's patients testified that he charged $350 per office visit to obtain a prescription for a controlled substance. Patients who did not have insurance, or who had insurance but were visiting early to obtain an early refill, paid the entire fee out of pocket. Dr. Kohli also traveled from his office once a month to see additional patients at Richland Memorial Hospital. The director of physician services at that hospital testified that she noticed Dr. Kohli's prescriptions for controlled substances were already filled out before he saw his patients there. She also observed that Dr. Kohli would see about 30 patients in 90 minutes.

         C. Cross-Examination and Impeachment of Dr. Kohli

         For four days, Dr. Kohli testified about his medical practice and insisted that he prescribed narcotics in a good-faith effort to help manage his patients' chronic pain. At one point, on direct examination, he also testified that no patient had ever died under his care: "Have you ever had a patient die under your care? No, sir." He reiterated the point the following day, again on direct examination. Faced with this unexpected claim, the government decided to investigate; it checked with the local coroner's office and found that a patient named Kenneth Kramer had died of an accidental overdose while under Dr. Kohli's care in 2006.

         In light of this new information, the government proceeded to impeach Dr. Kohli on cross-examination by questioning his earlier testimony that no patient had ever died under his care. When Dr. Kohli answered as before, the govern- merit asked him if he remembered his patient Kenneth Kramer. Dr. Kohli replied that he did not. The district court then stopped the government's line of questioning and ordered it to give opposing counsel the materials it had obtained from the coroner's office before the questioning could resume.

         After the defense reviewed the materials overnight, the government resumed its impeachment the next day by asking Dr. Kohli (over the defense's objection) if he remembered that a patient named Kenneth Kramer had died of an accidental overdose while under his care. Dr. Kohli responded that he did not know about Kramer's death until he received the materials from the government the day before.[1] The government did not introduce the materials from the coroner's office into evidence, but limited its impeachment to questioning Dr. Kohli on cross-examination and was bound by Dr. Kohli's answers by order of the district court.

         D. Jury Instructions and Verdict

         At the close of the evidence, Dr. Kohli moved for acquittal on grounds that the government had failed to present sufficient evidence to sustain a conviction. The district court denied the motion and submitted the case to the jury The court instructed the jury to render a conviction only if it found, beyond a reasonable doubt, that Dr. Kohli intentionally prescribed controlled substances outside the usual course of professional practice and without a legitimate medical purpose:

In order for you to find the Defendant guilty of a charge of causing the illegal dispensation of a Schedule II controlled substance, the Government must prove the following elements beyond a reasonable ...

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