Before Smith, Clement, and Higginson, Circuit Judges. Stephen A. Higginson, Circuit Judge: This appeal arises from a scheme to defraud TRICARE, a federal health benefit plan. Following a jury trial, Sekhar Rao was acquitted of con- spiracy to commit health care fraud but was convicted of two counts of sub- stantive health care fraud based on two specific fraudulent claims. Rao raises three issues on appeal: (1) whether there was sufficient evidence to convict Rao on the substantive health care fraud counts; (2) whether the district court erred in excluding testimony regarding statements purportedly made to Rao by the scheme’s leader that he had vetted the scheme with an attor- ney; and (3) whether the district court erred in calculating the loss amount under the United States Sentencing Guidelines. Finding no reversible error, we AFFIRM Rao’s convictions and sentence. I A Erik Bugen and others devised a health care fraud scheme to order medically unnecessary toxicology and DNA cancer screening tests and to bill those tests to TRICARE, a federal health benefit plan for active duty and re- tired servicemembers and their families. As part of this scheme, Bugen started a shell company called ADAR Group, LLC (“ADAR Group”) to set up fraudulent testing sites for collecting urine and saliva samples, which would then be submitted for unnecessary toxicology and DNA testing, re- spectively. ADAR Group established a collection site in Killeen, Texas, near Fort Cavazos (then known as Fort Hood), to maximize reimbursements from TRICARE. The site did not contain any medical exam rooms and was run by an office manager with no medical training or experience. The facility would collect samples from as many as two hundred servicemembers and their spouses in a single day. At the direction of the office manager, the “pa- tients” filled out the patient portion of the testing requisition form; allowed the office manager to make copies of their military IDs, which listed their TRICARE numbers; and provided samples for testing. The office manager filled out the billing, diagnosis, and testing portions of the requisition forms. The “patients” then received a $50 Walmart gift card as payment. But ADAR Group needed a doctor to order the testing for the costs to be reimbursed by TRICARE. So, Bugen placed online job postings seeking remote contract physicians “to simply sign off on [ADAR Group's] Toxicol- ogy and DNA swabs for testing.” An example posting introduced at trial stated that ADAR Group “test[ed] [its] clients twice per week to insure [sic] they are staying sober” and that the physician would be “responsible for reviewing the Tox Results and DNA results for each client.” The posting listed the salary for the position as “$8,000.00/month.” Bugen testified that he consistently sought to deceive doctors, including Rao, about the nature of the ADAR Group scheme, including lying to them that the ADAR Group clinics “were outpatient facilities for soldiers that were struggling with drug addiction or alcoholism” and hiding from them that the “patients”—who were not receiving any substance abuse treatment—were given Walmart gift cards in exchange for providing samples. Rao responded to one of Bugen’s job postings and negotiated a con- tract with Bugen under which Rao would be given the title “Physician Con- sultant” and would be paid “$50 per billable analyzed toxicology sample or DNA sample.” Initially, Rao went to Bugen’s house once or twice per week to sign the pre-filled requisition forms by hand. Bugen testified that Rao did not review any patient medical information before signing the requisition forms. Instead, Bugen and Rao together reviewed only the sample and insur- ance card associated with each requisition form, after which Rao would sign as the provider. Sometimes, Rao would sign one or two hundred forms in a single visit to Bugen’s house. Bugen would submit the materials to the test- ing lab—primarily Cockerell Dermopathology—which then submitted the claims to TRICARE for reimbursement. According to Rao’s own hand-writ- ten records of tests he ordered during these meetings with Bugen, he signed orders for 692 urinalysis tests and 98 DNA tests between June 6 and June 27, 2015, and for 732 urinalysis tests and 138 DNA tests between July 1 and Au- gust 16, 2015.[1] As noted, the office manager had completed the diagnosis and testing codes on the requisition forms before Rao reviewed and signed them. The toxicology requisition forms almost always listed the same six diagnosis codes, which the forms indicated were “REQUIRED to indicate medical ne- cessity,” and ordered the same two “comprehensive panels” for the toxicol- ogy tests. According to expert trial testimony, these panels tested for multi- ple drugs that were no longer commonly used at the time the ADAR Group scheme was in operation. Eventually, Bugen and his co-conspirators became concerned that Rao was making too much money because of the pay structure Rao had nego- tiated. To limit Rao’s cut, Bugen decided to use a signature stamp, rather than having Rao continue signing by hand, so that Rao would not know the “full extent” of the number of requisition forms that ADAR Group was sub- mitting on his behalf. Bugen testified that he ordered a rubber stamp of Rao’s signature with Rao’s knowledge and consent.[2] According to Bugen, Rao knew that the stamp was being used by ADAR Group employees to sign req- uisition forms on Rao’s behalf, particularly given that Rao continued to re- ceive payment for tests, even after he stopped personally signing the forms by hand. One of the office managers testified that Bugen told her to keep the stamp safe because Rao had been reluctant before ultimately agreeing to or- der the stamp. She also testified, however, that Rao never asked that his stamp be returned to him. The two substantive counts in this case are based on two TRICARE claims, submitted on behalf of the same patient (“J.J.”), both listing Rao as the referring provider: (1) an October 13, 2015 submission for urinalysis tox- icology testing based on a principal diagnosis of alcohol abuse, uncompli- cated, billed to TRICARE for $2,584; and (2) an October 14, 2015 submis- sion for cancer-related DNA testing based on a principal diagnosis of malig- nant neoplasm of the prostate, billed to TRICARE for $31,626. J.J. was a repeat “patient.” All told, the Cockerell lab submitted claims to TRICARE for J.J. for thirty different care dates between June and November 2015, and Rao was J.J.’s referring provider for all but two of those care dates. Rao’s own handwritten records corroborated the early dates, memorializing that Rao ordered urinalysis for J.J. on six occasions between June 20 and July 24. Despite the diagnoses listed in the requisition forms, J.J. testified that he was neither abusing alcohol nor suffering from cancer. And despite Rao’s role as the referring provider, J.J. testified that he never met or spoke with Rao. Ultimately, the Cockerell lab billed $36,173,586 to TRICARE be- tween March 2, 2015, and March 18, 2016, and received $5,389,895 in reim- bursements for all of the claims in this period. In all, about thirty-five percent of the claims submitted to TRICARE listed Rao as the provider, totaling ap- proximately $13 million in costs billed to TRICARE. Between May 2015 and January 2016, Rao was paid approximately $55,000 through the ADAR Group scheme, all for tests that he submitted without meeting any patients, reviewing any of their medical history, or discussing the results. Eventually, the ADAR scheme came to light, and Rao agreed to meet with a special agent from the Department of Defense (“DoD”). The DoD agent testified that, when Rao was asked about his employment by ADAR Group, Rao described his position as “medical director” and explained that his role was to evaluate patients recovering from drug and alcohol abuse, to order lab tests in connection with that work, and to develop a testing protocol with the goal of avoiding fraud. The DoD agent also testified that Rao indi- cated that he had initially signed the requisition forms from home, but that ADAR Group eventually purchased a stamp with his signature. According to the DoD agent, Rao did not mention treating any patients or discussing their test results. B On September 25, 2019, a federal grand jury returned an indictment charging Rao and Parameswara with conspiracy to commit health care fraud in violation of 18 U.S.C. § 1349 (Count 1) and charging Rao alone with two counts of health care fraud, and aiding and abetting the same, in violation of 18 U.S.C. §§ 1347 and 2 (Counts 2 and 3), in connection with the claims sub- mitted to TRICARE for J.J.’s October 13 and 14 tests.[3] Rao pleaded not guilty to all three counts and exercised his right to a jury trial. The jury acquitted Rao on Count 1 (conspiracy to commit health care fraud) but found him guilty of the two counts of health care fraud in con- nection with J.J.’s October 13 and 14 tests (Counts 2 and 3). In advance of sentencing, Rao objected to numerous aspects of the Presentence Investiga- tion Report (“PSR”) prepared by the Probation Office, including the PSR’s loss calculation. The district court overruled Rao’s loss objection but ulti- mately varied downward from the 108-to-135-month range, sentencing Rao to 48 months of imprisonment, followed by three years of supervised release. Rao timely appealed, and we have jurisdiction over this appeal under 18 U.S.C. § 3742 and 28 U.S.C. § 1291. II Rao’s challenge to the sufficiency of the evidence to convict him on Counts 2 and 3 is limited to two narrow issues: whether the government presented sufficient evidence for the jury to conclude (1) that “Rao’s signa- ture or stamp caused the submission of the October 13 and 14 claims to TRI- CARE,” and (2) that “Rao authorized or knew of the use of his stamp to order lab work.”[4] A This court “review[s] preserved challenges to the sufficiency of the evidence de novo, but [is] highly deferential to the verdict.” United States v. Scott, 892 F.3d 791, 796 (5th Cir. 2018) (internal quotation marks and citation omitted). “[I]t is not the reviewing court’s role to ‘ask itself whether it be- lieves that the evidence at the trial established guilt beyond a reasonable doubt,’ but to ask, instead, ‘whether, after viewing the evidence in the light most favorable to the prosecution, any rational trier of fact could have found the essential elements of the crime beyond a reasonable doubt.’” Terry v. Hooper, 85 F.4th 750, 754 (5th Cir. 2023) (quoting Jackson v. Virginia, 443 U.S. 307, 318-19 (1979)), cert. denied, 144 S. Ct. 1074 (2024). However, “where the defendant asserts specific grounds for a specific element of a specific count in his motion for judgment of acquittal . . . , the defendant fails to preserve any other grounds.” United States v. Daniels, 930 F.3d 393, 402 (5th Cir. 2019) (cleaned up). In such circumstances, where a particular sufficiency argument is not preserved, the court instead analyzes
