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20 the conduct criminal. To be clear, being at the crux of the criminality requires more than a causal relationship, such as “ ‘facilitation’ ” of the offense or being a but-for cause of its “success.”, (, concurring in judgment). Instead, with fraud or deceit crimes like the one in this case, the means of identification specifically must be used in a manner that is fraudulent or deceptive. Such fraud or deceit going to identity can often be succinctly summarized as going to “who” is involved.

Here, petitioner’s use of the patient’s name was not at the crux of what made the underlying overbilling fraudulent. The crux of the healthcare fraud was a misrepresentation about the qualifications of petitioner’s employee. The patient’s name was an ancillary feature of the billing method employed. The Sixth Circuit’s more colloquial formulation is a helpful guide, though like any rule of thumb it will have its limits. Here, however, it neatly captures the thrust of the analysis, as petitioner’s fraud was in misrepresenting how and when services were provided to a patient, not who received the services.