FI L ED U.S. COURT OF A P P E A LS E LE V EN T H C IR C U IT J AN 16, 2008 THOMAS K. KAH

N CL ERK [DO N OT PUBLISH] IN THE UN ITED STATES COURT OF APPEALS FO R T HE EL EV EN TH CIRC UI T

____ ____ ____ ____ ____ ____ N o. 06- 1553 8

____ ____ ____ ____ ____ ____ D. C. Dock etNo. 0 5- 00 14 3- CR-T-2 4- MAP UNITED STAT ES OF AMERIC A, Pl ai nt iff -Ap pe ll ee, ve rs us MIC HAEL A. ROSIN, Defen da nt -Ap pe ll an t.

____ ____ ____ ____ ____ ____ Appeal f rom the United State s District Court fo r the Mi ddl e D istri ct

of F lor ida

____ ____ ____ ____ ____ ____ _ (J an ua ry16, 200 8) Be fo re BL A CK , H U L L and F A Y , Ci rc uit Jud ge s. PE R CU RIA M:2

Appe llant M ic ha el Ro sin , af orm er de rm at olo gis t, onc e ope rate d aluc rativ e derm atologypractice in Sara sota, Florida. In 2004, his lon g-tim e office m anager fi le d aqu i t am ac tio n, c ont en din g R osi n ha d de fr au de d th e gove rn m en t by pe rfo rm in g h un dr ed s o f un ne ces sa ry su rg eri es on eld erl y

Med ic are p at ie nt s. Fo llo w ing agov er

nm en t i nve sti ga tio n, Ro sinw as ind ic te d on35 c ount s of he al th care f ra ud i n vi olatio n of

18 U . S. C. § 13 47, and 3 5 c ount s of m ak ing f al se state m en ts i n ahe al th c ar e m atte r in v iol at ionof 18 U . S. C. § 10 35. F oll ow ing a 17- day j ur y tr ia l, Ro sinw as c onvi ct ed on a ll co unt s and s en te nc ed to 264 m onths’ inc ar ce ratio n, r es tit

uti on i n th e am ount

of $3, 697, 225. 38, and f

or fe iture in the am ou ntof $ 3,6 97 ,22 5.3 8. Ro sinappe al s hi s c onvi ct ionand s en te nc e on m yri ad gr ound s, c ont en din g his tr ia l w as ta int ed

by im pr ope r ev ide nc e, pr ej udi ci al c om m en ts b y the j udge and pr ose cu tor , and m isl ea din g j ur y ins tr uc tio ns. R osi n a lso c ha lle nge s th e subs tanti ve and p ro ce dur al r ea sona ble ne ss o f his se nte nc e an d th e le ga lity of the court’ s forfeiture order. H aving reviewed the r ecord, we find Rosin’s challenges to b e larg el y

w ith out f ound at ion . T he tr ia l i tse lf w as f undam en ta lly

f ai r, and R o s i n ’s s e n t e n c e w a s r e a s o n ab l e i na l l r e s p e c t s . T h e r e f o r e , w e a f f i rm.3 I. BACKGROUND From 1983 to 200 4, Rosin wa s the owner and sol e phy sician of a derm atologyclinic and laboratory in Sara sota, Florida. H e em ploy ed an office m an ag er an d l ab tec hn ic ia ns to ass is t h im in hi s cl in ic al work . Rosin was trained to perfor m a specialize d form

of derm atologi cal surgery ca lle d M ohs sur ge ry . T he pr oc ed ur e is d es ign ed

to m ini m iz e sc ar

ri ng d ur ing the rem ov al of c ert ai n t y

pe s o f sk in can cer, an d i s p erfo rm edin on e o r m or e st ag es . During eac h stage, the surgeon rem oves a thin lay er of skin and exam ines it und er a m ic ro sc ope , c he ck ing the bor de rs f or m al ign an cy

and m ap pin g th e loc at ionof any cancer . If a

doctor does no t see any

m alignancy , or determ ines he has rem oved the ou ter edge of the m alignancy , he stops cutting o r procee ds to anot her se ct ionof the ski n w he re the c an ce r is l oc at ed . T he goa l of sur ge ry is to r em ove all m alignant tis sue while m inim izing the rem oval of healthy tissue. T he surgery is often perform ed in onlyone or two stages, but som etim es requires f our or m ore sta ge s to e nsur e co m

ple te r em ova l of

the c an ce r. D ue to the ti m e an d e xpe rt ise the su rg ery req ui res , itis co st ly andno t ap pr op ria te forall pa ti en ts . App ro xi m at el y

95 % of R os in ’s pat ie nt s wer e el de rly Med ic are r eci pi en ts . The f ederal Me dicare program reim burses surgeon s for Mohs surgeries at a higher rate than it

r ei m bur se s f or oth er ty pe s of ski n c an ce r re m ova l. T he m or e sta ge s th e4

surgery requires, the higher the Medicaid reim bursem ent rate. From

Septem ber 1998 thr oughMay

200 5, Ro sinpe rf

orm ed 5, 980 ski n bi opsi es . O f the se , he reported that 99.43% re vealed cance r. D uring the sam e period, R osin b illed Me dic ar e fo r 4, 118 Moh s surg er ie s. H e pe rf orm ed f our sta ge s of sur ge ry in 98. 93% of

the se c as es . In Februar

y 2004 , C aroly

n Ferr ara, Rosin’s off

ice m anager, filed a quitam action, alleging Rosin had d efra uded the Governm ent by

filing false Medicar e cl ai m s and p er fo rm ing ne ed le ss s ur ge ri es . H er a lle ga tio ns l ed

to aninv es tig at ion an d, u lt im at el y , to th e fi li ng of c riminal ch arg es ag ai ns t Ro si n. A . T he T ria l A t tri al , the j ur

y he ar d te sti m ony

f ro m Ro sin , gov er

nm en t i nve sti ga tor s, charac ter w itnesses, num erous m edical experts, and a num ber of Rosin’ s form er em ploy ees and patients. T he testim ony of Rosin’ s form er e m

ploy ees re vealed that Rosin’s laboratory

wa s staffed by

poorly trained lab technicians who prepare d biop sy slides that were irregular and often unreadable. Form er e m ploy ees testified the y ha d a lte re d sl ide s onse ve ra l oc ca sio ns, in one c as e re pla ci ng s kinti ssu e w ith gum , and i n anothe r, w ithsty ro fo am . A cc or din g to the e m plo y ee s, Ro sin di ag no se d c an cer o n b ot h t he se sl id es .5

Rosin deni ed review ing sli des that contained foreign su bstances. I n ad dit ion , he c ha lle nge d th e cr ed ibi lity of his f orm er e m plo y ee s, e lic iti ng unc ontro ve rt ed

e vid en ce that se ve ra l, inc lud ing F er rara , ha d st ole n f

ro m him dur ing the c our se of

the ir e m plo ym en t, and s too d to be ne fi t f inanc ia lly f ro m the qu i t am law sui t. T he G ove rn m en t c al le d w itn es se s e m plo y ed by F lor ida ’ s M ed ic ar e re co rd s contractor to testify

regar ding the general m anner in which Medicare c laim s are pr oc es se d and t o sum

m ar iz e Ro sin ’ s bi lli ng p ra ct ic e. O ne of the se c ust odi an s, Julie Kear

n, testified that she had com piled data on all of Rosin’s Medicar e bil lin gs f or Mo hs s ur ge ri es pe rf

orm ed f ro m January 200 0 to D ec em

be r 2003 . T he c om pil ed da taw as giv ento K laus M ie sc ke , astatis tic ian f ro m the U niv er sity

of I lli noi s at C hic ag o w ithe xpe ri en ce in he al th c ar e fr au d in ve st ig at io ns . A t tri al , Mi es ck e te sti fi ed he use d th e da taK earn s ha d c om pil ed to se le ct a statis tic al ly

r an dom sam ple of 70 s ur gic al sli de s f

ro m w hic h he e xtr ap olate d lo ss fi n d i n g s . Th e 7 0 s l i d es Mi es ck e s el ec t edwe re p ro v i d edt o th e G o v ern m en t ’s m edical experts, Dr s. P earon L ang and Franklin Flowers, and to Rosin ’ s m edical ex pe rts forrev ie w.6

O ve r Ro sin ’ s ob

j ec tio n, the G ove rn m en t’ s e xpe rt s te sti fi ed a t tri al r eg ar din g their own surgical prac tices, r ates of cancer diagnosis, and the percentage of foursta ge Mo hs s ur ge ri es e ac h pe rf orm ed , in ad dit ionto of

fe ri ng t es tim ony

r eg ar din g th ei r r ev i ew o f R o s i n ’s s l i d es . Th re e d erm at o l o g y ex p er t s t es t i fi edo nRo s i n ’s be ha lf , statin g th at

som e of the sur gic al sli de s th ey

r ev ie w ed ha d r ev ea le d th e pr es en ce of

c an ce r. A lth oughthe e xpe rt s’ te sti m ony dif fe re d w ithr es pe ct

to w hic h sl ide s r ev ea le d e vid en ce of ski n c an ce r, a ll ag re ed

the sli de s w er e of su bs ta nd ardqu al it y

an d t ha t m an y

were u nr ead ab le . Pathologi st Deborah Bir

testified regar ding the m anner in which surgical sli de s are ty

pic al ly c re at ed , sta ine d, and r ea d. S he and L an g te sti fi ed that the poo r qua lit y of Ro sin ’ s surg ic al sli de s w as unr el at ed to the a ge of

the sli de s or

the m anne r in whic h th ey

ha d be ensto re d. T he de fe nse c ount er ed thi s te sti m ony

by arguing the sli des had been readable when they we re a ssem

bled and had deteriorated due to age, poor assem bly , or em

ploy ee sabotage. In addition to expert testim ony , the j ury heard fr om

nine characte r witnesses, who testified Rosin wa s an honest, charitable, and trustworthy father, do ct or , andco m

m un it y m em be r. Inc los ing arg um en t, the pr ose cu tor arg ue d R osi n’ s de fe nse w as not cr ed ibl e—

that whil e Ro sinc la im ed to be ac ar ing doc tor

be tr ay ed by his sta ff , he7

wa s in fact “ greedy ,” and interested onlyin m aking m oney from the Medicare pr ogr am , a s e vid en ce d by the m anne r in whic h he c ar ef ull y r ec or de d patie nts ’ financial inform ation, but m ade and retained little inform ation abou t their m edical histo ry and care . The prosec utor poin ted out in consist encies in Rosin’s def ense, an d c al le d up on j ur or s to ign or e the de fe nse ’ s “ atte m pts to co nf

use , ” ca lli ng Rosin’s theory

of the case “ m isleading” and “ unbelievabl e. ” Af ter being given Eleventh Circuit Patter n Jury Instructions, the j ury de li be rat edforon e an d aha lf d ay s b efo re co nv ic ti ng Ro si n o n a ll co un ts . B . Se nte nc ing Sentencing began Jun e 6, 2006 . Af ter tw o day s of testim ony , the c ourt or de re d th e he ar ing c ont inu ed unt il Jul y

6, 200 6. T he G ove rn m en t m ove d to re m an d R osi n to the c ust ody of the U nit ed

S ta te s M ar sha ls d

ur ing the r ec es s; the m oti on w as gr an te d. When sentencing resum ed on July6, 2006, Rosin’ s lawy er a sked the court to o rd er ac om pe te nc y e va luatio n, a lle gin g R osi n w as una ble to as sis t i n gathe ri ng m itigatin g evidence for the sentencing proceedings. T o show that a com petency he ari ng was re as on ab ly neces sa ry , Ros in cal le d Dr. Hym an Eis en st ei n, a ne ur opsy ch olo gis t and c lin ic al psy ch olo gis t who t es tif ie d f or f ive hours r eg ar din g8

t es t s h e h adp er fo rmedan di n t erv i ew s h e h adco n du ct edwi th Ro s i nan dRo s i n ’s f a mi l y. E i s e n s t e i nt e s t i f

i e dR o s i nw a s ani n t e l l i g e n tmanw h o s u f f e r e df r o m co gni tiv e de fi ci ts a s ar es ult of thr ee he ad

inj ur ie s, the f

ir st o f w hic h oc curr ed

in the 196 0s. A lth oughE ise nst ei n w as una ble to pr ovi de af

orm al dia gnos is w ith out fi rs t c ondu ct ing br ai n sc an s onRo sin , he te sti fi ed he c oul d no t “ ru le out

the poss ibility ” Rosin was suffe ring from dem entia as a r esult of brain injury . When as ke d ho wRo sin ’ s su spe ct ed de m en tia w oul d a ff

ec t hi s a bil ity to w ork w ith counsel, E isenstein h ad no answer e xcept to obs erve that Rosin appeared m ore in te res te d i n d is cu ss in g h is cri m in al co nv ic ti on th an in pre pa rin g fo r se nt en ci ng . Eisenstein also testified that Rosin appeared to suffe r fr om an obsessiv ecom pulsi ve disorder. A ccording to Eisenstein, this was the re ason Rosin had in si st edon pe rfo rm in g fo urst ag es of M oh s s ur ge ry foralm os t al l o f hi s p at ie nt s. O n th e ba sis of

thi s te sti m ony , c ouns el m ove d th e co urt t o st ay f urthe r se nte nc ing pr oc ee din gs and o rd er

af ull -s ca le c om

pe te nc y e va luatio n. T he j udge not ed

Ro sinha d be enart ic ulate on the stand d ur ing his j ur

y tr ia l, ap pe ar ed to unde rs tand the pr etri al , tr ia l, and e ar ly se nte nc ing pr oc ee din gs, and ha d no t c om

pla ine d a bout be ing una

ble to as sis t hi s c ouns el unt il the j udge or de re d hi m

r em an de d. T he j udge que sti one d E ise nst ei n’ s r el ianc e on t es ts9

adm ini ste re d by

oth er psy ch olo gis ts, and n ote d E ise nst ei n w as una ble to do any m or e than sp ec ulate about the pos sib ili ty

that R osi n m igh t

suf fe r som e de fi ci ts fr om br ai n in j ur ie s datin g ba ck

se ve ra l de ca de s. F ind ing no r ea sona ble c au se to believe Rosin was incom petent to participate in sentencing , the j udge denied Ro si n’s m ot io n fo r a fu ll co m pe te nc y ev al ua ti on an d h eari ng . Whe n se nte nc ing r es um ed , Ro sinr ai se d se ve ra l ob j ec tio ns t o th e pr obatio n of fi ce ’ s gu ide lin e ca lc ulatio n. F ir st, Ro sina sse rt ed the e nhanc em en ts f

or los s am ount and v ic tim s sh oul d be c al cu la te d w ithr ef er en ce onl y

to the pa tie nts w hose nam es w er e lis te d inthe ind ic tm en t. H e obj ec te d to inc lus ionof appr oxi m at el y 800 p atients (and the m edical claim s relating to tho se patients) on the groun d that ev ide nc e ab out

tho se pa tie nts and the ir

sur ge ri es ha d no t be enpr es en te d to the j ur y . I n a ddi tio n, Ro sina sse rt ed he sho uld

not be r equir ed

to re pay the Governm ent or be subjec t to sentence enhancem ents for any surgery with re spect to which any

expert opined that th e slide reveale d evidence of cance r or w as unr ea dable . T he dis tr ic t c ourt r ej ec te d R osi n’ s pr opos al , c re dit ing Ro sinonl y f or sur ge ri es f

or w hic h th e G ove rn m en t’ s e xpe rt , D r. F low er s, ha d f ound e vid en ce of cancer . A f t e r f i n d i n g R o s i nh a du s e ds o p h i s t i c a t e dme an s i nc arr yi n g o u th i s c r i me and had caused serious bo dily injury to several of his patients, the j udge calculatedTh e c ourt or de re d Ro sin

to p ay $3 ,6 41 ,2 47 .7 9 in

re sti tut ion

to M e dic are , $ 7, 11 1. 90 to 1 Aetna ( a private insuranc e compa ny ), and $48,865.69 to individual victims.

10 Ro sin ’ s of

fe nse le ve l a s 38 and h is c ri m ina l hi sto ry c at eg or y a s I , y ie ldi ng a gui de lin e im

pr iso nm en t r an ge of

235 to 293 m onths, w ithaf ine r an ge of

$25 , 000 to $ 250, 000 dol lars . ( T he 70 c ount s onw hic h R osi n w as c onvi ct ed c ar ri ed a cum ulativ e m ax im

um pe na lty of 700 y ears ’ im

pr iso nm en t and a

$17 . 5 m ill ion fi ne . ) T he j udge se nte nc ed Ro sinto 264 m onths’ inc ar ce ratio n, r es tit uti on i n th e am ount of $3, 697, 225. 38, and f

or fe iture in the a m ount

of $3, 697, 225. 38. 1 II. DISCUSS ION On ap pe al , Ros in rai se s s ev en ch al le ng es to hi s co nv ic ti on an d s en te nc e. H e co nte nds his tr ia l w as ta int ed be ca use ( 1) the pr ose cutor

intro duc ed

unf ai rl y pr ej udi ci al e vid en ce and arg um en t; (2 ) the tr ia l j udge int er ve ne d im pr ope rl y in the pr oc ee din gs; ( 3) im

pr ope r ev ide nc e w as a dm itt ed ; and ( 4) the j ur y w as m isl ed

by thr ee e rr one ous ins tr

uc tio ns. R osi n c ont en ds the se e rr or s, both a lon e an d cum ulatively , m erit re versal of his conviction . In addition , R osin challeng es (5 ) the dis tr ic t c ourt’ s f

ai lur e to h old

af ull c om pe te nc y he ar ing ; ( 6) the re as ona ble ne ss o f his w ith in- gui de lin e se nte nc e; and ( 7) the a m ount of his c ourtor de redfor fei tu re. W e ad dr es s ea ch in tu rn . A. Prosecutor ial Miscondu ct11

Fi rs t, Ro sinc ont en ds h e is e nti tle d to ane wtr ia l be ca use the G ove rn m en t en ga ge d inm isc ondu ct

thr ough out

his tr ia l. A lth oughm any of Ro sin ’ s c om

pla int s ar e ge ne ra liz ed , he appe ar s to c ha lle nge f our ty pe s of c ondu ct , c ont en din g th e Governm ent im

properly relied on evidence of his bad charac ter in violation of Fed. R. Evid. 404(a); m ade inflam m atory rem arks about him

and his coun sel dur ing c los ing arg um en t; vouc he d f or the pr ose cu tio n’ s c hie f inv es tig at or ; and m is rep res en te d t he tes ti m on y it s ex pe rt, Dr. Fl owe rs , wou ldbe off eri ng at t ria l. Rosin didnot raise contem poraneous ob

j ections to anyof the alleged m iscondu ct of w hic h he nowc om

pla ins ; the re fo re , “ re lie f is ava ila ble to re ct if

y onl y pla in er ro r that i s so obv iou s th at f ai lur e to c or

re ct it w oul d j eo pard iz e the f

ai rn es s and integrity of the trial. ” United States v. B ailey , 123 F. 3d 13 81, 1400 (11t h Cir. 1 9 9 7 ) ( ap p l yin g p l ai nerro r s t an d ar di nco n t ex to f c h al l en g es t o p ro s ec u t o r’s cl os in g a rg um en t). 1. Character evidence Ro sinc ont en ds the pr ose cu tor vio la te d F ed . R. E vid . 404 (a ) dur ing ope nin g an d c los ing arg um en ts. S pe ci fi ca lly , Ro sintake s is sue w iththe f oll ow ing co m m en ts m ad e dur ing ope nin g arg um en t: T he G ove rn m en t i s no t try ing to hol d th e D ef en dant a cc ount ab le f

or hone st m ist ak es . T he e vid en ce w ill sho wthat the D ef en dant w en t thr oughthe m oti ons to a

ppe ar that he c ar ed

about his pa tie nts , and t o12

ap pe ar that he w as e nga ge d inthe hon es t, e thi ca l and l eg al pr ac tic e of m edicine. Bu t wha t the e vid en ce w ill sho wis that wha t he r ea lly w as e nga ge d in w as asc he m e to d ef

ra ud the Me dic ar e sy ste m

by pe rf orm ing m ed ic al ly unj ust if ie d and i nva siv e sur ge ri es f or the sin gle pur

pose of m ak in g m on ey . Ro sina lso obj ec ts t o th e fo llo w ing arg um en t, m ad e dur ing c los ing : [T ] he e vid en ce in thi s c as e ha s pr es en te d tw o st ar kly dif fe re nt and ir re co nc ila ble pic tur es of

thi s D ef en dant. H e is e ith er

ac ar ing , de dic at ed phy sic ian w hose onl y

c onc er n is ade vot ed

int er es t i n th e w el fare of

his pa tie nts , or

he is a gr ee dy , dis hone st i ndi vid ua l who i s gui lty a s c harg ed

of the of fe nse in the sup er ce din g in dic tm en t.

. . . . T he f ir st and m ost

sa cr ed duty of am ed ic al doc tor , m em

be rs of the j ur y , is fi rs t t o do no h ar

m . A nd this phy sic ian w as m oti va te d by the sam e thi ng tha t m oti va te s e ve ry one w ho l ie s and who s te al s. T he de ta ils of the ir c ondu ct m ay dif fe r, but it c anbe e xpl ai ne d qu ite sim ply and i n on e w or d, gr ee d. Ro sinc ont en ds tha t by

poi nti ng t o c hara ct er

tr ai ts s uc h a s gr ee d, the pr ose cu tor in vi te d t he jury to jud ge hi s ch arac te r rat he r th an hi s ac ti on s. A lth oughRo sinha s f

ram ed his arg um en t a s ac ha lle nge to the a dm iss ibi lity o f c h ar a c t e r e v i d e n c e , h e i s n o tc h a l l e n g i n g an y evidence ; r athe r, he is ch al le ngi ng the pr opr ie ty

of the pr ose cu tor ’ s argu m en t . T he G ove rn m en t c onc ed es that the pr ose cu tor ’ s r em ar

ks w er e “ co lor fu l and p er ha ps f lam boy ant, ” but

is qui ck to po in t o utth atrhe to ric is no t i m pe rm is si bl e in th e co ur tro om . See U nited Sta tes v.13

Sm ith , 918 F . 2d 1 551, 156 1 ( 11th C ir . 199 0) . T he G ove rn m en t i nsi sts the pr ose cu tor ’ s r em ar

ks w er e fa ir

c om m en tary on the e vid en ce a dduc ed a t tri al , pa rti cu la rly with res pe ctto Ro si n’s h on es ty. Even assum ing th e prosecutor overstepped the bou nds of prosecuto rial pr opr ie ty , it

c annot be sa id tha t the pr ose cu tor ’ s st at em en ts c onst itute d pl ai n e rr or whe n “ vi ewedin th e co nt ex t o f th e rec or d a s a wh ol e.” Bailey , 12 3 F .3dat 1 40 0. E ve n un de r the le ss e xa ct ing standard appl ie d to r ev ie wof

pr es er ve d e rr or s, thi s Court will re verse a def

endant’ s convictio n on th e basis of prosecutorial m iscondu ct only

wher e the prosecutor’ s “ rem arks (1) w ere im proper and

( 2) prej udiced the defendant’ s subs tantive rights .” U nited Sta tes v . O ’K

ee fe , 461 F . 3d 1338 , 135 0 ( 11th C ir . 200 6) ( em pha sis a dde d) . Ade fe ndant’ s su bst an tiv e ri ght s ar e pr ej udi ci al ly

a ff ec te d on ly

w he n ar ea sona

ble pr oba bil ity ari se s th at , but

f or th e p ro se cu to r’s st at em en ts , th e o ut co m e o f th e tr ia l wo ul d h av e b een di ffer en t. Id . Inthi s c as e, the j ur

y he ar d e xte nsi ve te sti m ony f ro m w hic h it c oul d co nc lud e Ro sinw as gui lty of he al th c ar e fr au d. O ve r the c our se of a17- day tr ia l, any im pr ope r co m

m en ts w er e lim ite d to af ewse nte nc es in ope nin g and c los ing ar g u m en t . Th e ju ry wa s i n s tru ct edb ef o re i tb eg an d el i b er at i n g th at co u n s el ’s argum ents wer e not evidence and that the verdict shou ld be based on th e evidence14

al one . L ooki ng at the r ec or d a s aw hol e, the re is no r ea son to b el ie ve the pr ose cu tor ’ s c hara ct er iz at ionof the e vid en ce dur ing ope nin g or c los ing arg um en ts pr ej udi ci al ly

a ff ec te d th e tr ia l, m

uc h le ss o bvi ousl y

j eo pard iz ed

it s f ai rn es s and in te gr it y . 2. A lle ge dlyim prop er argum en t In addition to challenging the prosecutor’ s rem arks about Rosin ’ s charac ter, Ro sinc ha lle nge s r em ar

ks a lle ge dly

dir ec te d to w ar d hi s tr ia l c ouns el . D ur ing cl osi ng arg um en t, the pr ose cu tor a cc use d “ the de fe nse ” of “ ta lki ng o ut o f both sid es of the ir [ sic ] m outh. R ef

er ri ng c oll ec tiv el y

to Ro sinand h is c ouns el , the pr ose cu tor

arg ue d, “ T he y ’ re c au ght in the ir ow n w eb tr

y ing to expla in a ll of

the co n du ct th at o cc u rr edi nth e d ef en d an t ’s o ff

i ce , a n di ti s n o i s e b ec au s e i td o es n ’t m ak e se nse . ” F ina lly , dur ing his c los ing r eb utt al , the pr ose cu tor state d: I unde rs tand tha t i t i s di ff ic ult to be lie ve that a

phy sic ian, that a m ed ic al doc tor , w oul d do the thi ngs that this de fe ndant i s a cc use d of in the sup er ce din g in dic tm en t, but the re are in thi s w or ld, la die s and ge ntl em en , doc tor s who l ie and s te al , j ust a s th er e ar e law y er s who l ie an d st ea l, j ust

a s th er e ar e banke rs w ho l ie and s te al . T he re are pe opl e in this w or ld who l ie and s te al . Fo r re as ons that are not

e nti re ly c le ar , Ro sinis co nvi nc ed that, by m ak ing the se statem ents, the prosecutor intended to su ggest to th e j ury that defense counsel lied an d s to le .15

T his Co urt ha s he ld tha t i t i s im pr ope r to “ dis cr ed it de fe nse c ouns el in fr ont of the j ur y . . . and e ve n su

bse que nt j ur

y ins tr uc tio ns a im ed

a t r ec tif y ing thi s e rr or m ay not e nsur e that the se dis para gin g r em ar ks h av e not

a lr ea dy de pr ive d th e defendant of a fa ir trial. ” U nited Sta tes v . D e La V

ega , 913 F . 2d 8 61, 867 ( 11th Ci r. 199 0) ( ci tin g U

nited Sta tes v . M

cL ain , 82 3 F .2d14 57 , 14 62 (11 th Cir . 19 87 ), ov errul ed on o the r gr ound

s by U nited Sta tes v . L ane , 474 U . S. 438 , 106 S . Ct . 725 (1986)). D espite the seriousness of such an infraction, the C ourt has clarified that re ve rs al is onl y

w ar rante d w he n th e en tir e tr ia l i s so r ep le te w ithe rr or s th e de fen da ntwas d en ie d afai r tr ia l. U nited Sta tes v . Eck

hard t , 466 F . 3d 9 38, 947 (1 1t h C ir. 2 00 6) . A l th o u g h th e p r o s e c u t o r ’s r e mark s ab o u tth e w e a kn e s s o f R o s i n ’s c a s e c a me cl ose to cr oss ing the li ne of pr opr ie ty , the y

did not go o ve r the li ne . I n a tta ck ing inc onsi ste nc ie s inthe de fe nse ’ s th eo ry of the c as e, the pr ose cu tor

w as c om m en tin g fa ir ly on the e vid en ce a dduc ed a t tri al , and o n R osi n’ s c om pe tin g e xpl an at ion s f

or the ir re gul ar iti es in his la

bor at or y . A lth oughthe pr ose cu tor w oul d have be enw ise to m ak e the poi nt w ithle ss i nve ct ive , take n inc ont ex t, the r em ar ks w er e not cl earl y im pr op er an d c ert ai nl y

di d n otde ny Ros in a fai r tr ia l. W ithr eg ar d to the pr ose cu tor ’ s c om m en ts a bout doc tor s, law y er s, and bankers who “ steal and lie,” it is clear the prosecutor’ s com m ents wer e no m ore16

directed at Rosin’ s counsel th an at the prosecutor him self. T he Governm ent was m er el y sug ge sti ng t o th e j ur

y that su cc es sf

ul p eo ple som et im es c om m it cr im es . Tha t ar gu m en t was no t i m pr op er. 3. V ouc hin g Ro si n a rg ue s the pro se cu ti on im pr op erl y vo uc he d fo r wit ne ss Dian e New, the Governm ent’ s chief investigator. A lthou gh the argum ent is not enti rely clear , it appears to be this: In the course of investig ating Rosin ’ s crim e, Agent N ew si gn eda pr ob ab le cau se affi da vi t, upo n wh ic h asea rch warran t was is su ed . At trial, without ob

j ection from

the defense, the prosecutor adm itted the cover sheet fr om the se ar chw ar

rant, li sti ng e ac h of

the it em s th e ag en ts w er e au tho ri ze d to retrieve. O n that sheet was a notatio n that read, “ Af fidavit having been m ad e . . . by

S pe ci al A ge nt D iane C. N ew . ” Ro sinappe ar s to c ont en d th at , f ro m the not at ion , the j ur

y c oul d have inf

er re d am ag istrate ha d c re dit ed N ew ’ s a ff

idavit (o r el se th e warra ntwou ldno t h av e is su ed ), an d b y ex te ns io n, New’s cre di bi li ty. Ro sinarg ue s th at , by

a dm itt ing the c ove r she et int o e vid en ce , the pr ose cu tor “ se nt an unfair and constitut ionallyinappropriate m essage to the jur y of unparalleled and com pelling ‘ proof’ of R[osin] ’ s guilt with the very first w itness.” When review ing a defendant’ s vouchi ng claim , this Court exam ines whether (1 ) the pr ose cu tor

pla ce d th e pr es tig e of

the G ove rnm en t be hin d th e w itn es s by17

m ak ing e xpl ic it pe rs ona l a ssuranc es of the w itn es s’ s c re dib ili ty , or ( 2) the prosecutor im

plicitlyvouched for the witness’ s credibility by im ply ing th at e v i d e n c e n o tf

o rmal l y p r e s e n t e dt o th e ju ry s up p o rt s th e wi tn e s s ’s t e s t i mo n y. U nited Sta tes v . A ria s-Iz qui erdo , 44 9 F .3d11 68 , 11 77 -1 17 8 (1 1t h C ir. 2 00 6) .

“ T he pr ohi bit iona ga ins t vo uc hin g do es not f or bid pr ose cu tor s f

ro m arg uin g cr ed ibi lity

. . . it f or bid s arg uin g c re dib ili ty

ba se d onthe r ep utatio n of the governm ent office or

on evidence not before the j ury .” United States v. He rnan dez , 92 1 F .2d15 69 , 15 73 (11 th Cir . 19 91 ). O n se ve ra l oc ca sio ns d

ur ing tr ia l the pr ose cu tor m ad e pa ssi ng r ef

er en ce to th e f ac tth at a c o u rth adi s s u eda s ea rc h wa rr an tau th o ri zi n g a s ea rc h o f R o s i n ’s of fi ce . T he pr ose cu tor

did not c onne ct N ewto the iss uanc e of

that se ar chw ar

rant, or c om m en t onhe r cr ed ibi lity

in any w ay r el at ed to the w ar

rant. U nde r the se ci rc um stanc es , the intro duc tio n of the se ar chw ar

rant c ove r she et

did not a m ount to vo uc hi ng . Cf

. U nited Sta tes v . Ne wton , 44 F . 3d 9 13, 921 ( 11th C ir . 199 5) (prosecutor’ s statem ent bolst ering a key witness’ s testim ony

by asserting “ a j udge, state or f ed er al , is not

goi ng t o gi ve a. . . lawe nf or ce m en t of

fi ce r a se ar chw ar

rant to s earc h any

body ’ s ho use f

or no r ea son . . . , ” w hil e cl ose to the li ne , w as not im proper). T he prosecutor did no t vouch for the witness; therefore, no error w as m ad e.In his openingbrief, Rosin asser ted in passingthe Gover

nment had also made a 2 misleadingproff

er r eg ardingthe testimony of expert witness Klaus Miesc ke. The substance of th e ar gum e n t , w h i c hR o s i nd i d n o td e v e l o p i nh i s o p e n i n gb r i e f an d d i d n o tm e n t i o ni nh i s r e p l y, appea rs to relate to his claim that Miescke’ s testimony was inadmissible. (See Sec tion C.1, inf ra ) . T h e r e w a s n o d i s c r e p an c y b e tw e e nth e G o v e r n m e n t ’ s p r o f

f e r an d M i e s c k e ’ s t e s t i m o ny. 18 4. M isc hara cter iza tio n of

testi m ony A s af ina l c ha lle nge to the G ove rn m en t’ s c ondu ct at tri al , Ro sinc ont en ds the pr ose cu tio n m isr ep re se nte d th e ev ide nc e D r. F low er s w oul d pr es en t duri ng h is tr ia l t es tim ony . B ef

or e D r. F low er s w as pe rm itt ed to te sti fy a t tri al , the c ourt he ld 2 a co nf er en ce out sid e the pr es en ce of the j ur y . A t tha t c onf

er en ce , the pr ose cu tio n expla ine d F low er s w oul d te sti fy about his ow n de rm at olo gy

pr ac tic e, inc lud ing the rate s at whic h he dia gnos ed ski n c an ce r an d pe rf

orm ed f our sta ge s of Mo hs surgery . The prosec utor m ade the ar gum ent that Flower s’ proposed test im ony wa s not e xpe rt be ca use it w as gr ound ed

in the doc tor ’ s pe rs ona l e xpe ri en ce tr eatin g pa ti en ts . Ro sinr ai se d vi gor ous obj ec tio ns t o th e pr ose cu tio n’ s po sit ion , ins ist ing that, be ca use F low er s ha d no pe rs ona l kn ow le dge r eg ar din g R osi n’ s patie nts , his propos ed testim ony

had to be either expert or ir relevant. Rosin questi oned whether Flower s’ testim ony wa s adm issib le under D aube rt v . M erre ll D ow Pharm. , I nc. , 509 U. S. 579, 113 S. Ct. 2786 (1993), and challenged the legitim acy19

of pe rm itt ing F low er s to te sti fy about his ow n pr ac tic e fo r the pur pose of inv iti ng co m pa ris on be twee n R os in ’s andFlo wers ’ pr act ic es . U lti m at el y , how ev er , the j udge ha d th e fo llo w ing e xc hange w ithde fe nse co unse l: Co urt: A s I und er stand i t, Mr . K eh oe , y ou h av e no o bj ec tio n to

D r. F low er s qu al if

y ing a s an e xpe rt

w itn es s. Ke hoe: In all candor, no, Judge. I do believe that he is on e w hen

itco m es to th is pa rti cu la r are a . . . . Co urt: A ll ri ght . Whe n it c om es to his te sti m ony

and the se ar ea s th at m ay be sub j ec t t o qu es tio n by

the de fe nse , I ’ ll entertain a sidebar if

that’ s necessary . But, the Court w ill be gov er

ne d and—

by the c as e lawr equir ing the Co urt, a s gate ke ep er , to ba se it s de te rm inatio n on adm iss ibi lity

on the r el ev an ce and r el ia bil ity of the pr of fere d t es ti m on y . So, we’ll pro ceedon th atba si s. O n a ppe al , Ro sinarg ue s th e pr ose cu tor c om m itt ed m isc ondu ct

by arg uin g Flower s was a

treating phy sician who could testify as a f act w itness, rather than as the e xpe rt w itn es s he c le ar ly

w as . T ha t arg um en t i s m isg uid ed . T he pr ose cu tor m ad e anobv iou s le ga l e rr or w he n sh e ar gue d F low er s’ te sti m ony w as a dm iss ibl e as th atof afactwit ne ss , rat he r th an an ex pe rt. Cf . F ed . R. E vid . 602 ( “ Aw itn es s m ay not te sti fy to a m atte r unl es s . . . the w itn es s ha s pe rs ona l kn ow le dge of the m at te r.”). Howe ve r, a la wy er m ay be wron g wi th ou t co m

m it ti ng m is co nd uc t. A lth oughthe pr ose cu tor

e rr ed w he n sh e ar gue d F low er s w as not an e xpe rt , the re isFur thermore , the trial cour

t properly found (with Rosin’s conce ssion, no less) that 3 F low e rs was a qualifie d expert witness. 20 no evidence she intend ed to m islead the court. H er m istake did no t prej udice Ro sinin any

w ay , m uc h le ss c om

pr om ise the int eg ri ty

of the tr ia l. 3 B . I nte rv en tio n bytheD istric t C ourt Ro sinc ont en ds the tr ia l c ourt i m pr ope rl y de m onstrate d bi as a ga ins t hi m and le nt i ts w ei ght

to the G ove rn m en t’ s c as e by e nga gin g inr ep eate d qu es tio nin g of w itn es se s, c om

m en tin g onthe e vid en ce , and f re que ntl y int er ru pti ng d ef en se co unse l duri ng que sti oni ng. R osi n di d no t ob j ec t t o th e co urt’ s qu es tio ns d ur ing tri al ; t he refo re, we rev ie w forpl ai n e rro r on ly. Hanson v. W aller , 888 F . 2d 8 06, 813 (1 1thCi r. 198 9) ; Co ats & Clark , I nc . v . G ay , 755 F. 2d 15 06, 1511 (11t h Cir. 1985 ). Ade fe ndant i s de nie d ac onst itutio na lly f ai r tr ia l whe n aj udge str ay s f ro m ne ut ral it y , aba nd on in g h is pro pe r ro le an d a ss um in g t ha t o f an ad vo cat e. United Sta tes v . W

rig ht , 392 F . 3d 1 269, 127 4 ( 11th C ir . 200 4) ; se e als o Fe d. R. E vid . 614 , Advisory Com m ittee N ote. E ven when an obje ction to judicial conduct has b een pr es er ve d, in or de r to am ount

to re ve rs ibl e er

ro r, aj udge ’ s r em ar

ks m ust de m onstrate suc h pe rv as ive bia s and unf ai rn es s th at

the y pr ej udi ce one of

the pa rti es in th e cas e. United States v. V erbitskaya , 406 F. 3d 13 24, 1337 (11t h Cir.21

2005 ). Put another w ay , c omm ents m ade by the district court will cause r eversal onl y w he n th ey

“ ex ci te apr ej udi ce w hic h w oul d pr ec lud e a fa ir and d isp as sio na te consideration o f the evidence. ” B roug h v . I m pe ria l Ster lin g L td. , 297 F . 3d 1 172, 1181 (11th Cir. 2002) (internal quotation m arks om itted). I n determ ining whether the district court’ s com

m ents are pre

j udicial, the court of appeals “ m ust cons ider the record a s a w hole and no t m erely isolated rem arks.” I

d. at 1 18 1. While a defendant is entitled to an im partial j udge, it is also “ we ll settled that a f ed er al dis tr ic t j udge is not r el eg at ed to co m ple te sil en ce and i na ct iondur ing the course of cr im inal jury trial. ” W rig ht , 392 F . 3d at 12 74 ( 11th C ir . 200 4) (quot ing U

nited Sta tes v . Cox , 664 F. 2d 25 7, 259 (11th Cir. 1981)). It is axiom atic . . . “ [t] hat the trial j udge has a dutyto condu ct the trial care fu lly , pa tie ntl y , and i m part ia lly . H e m

ust be above e ve n th e ap pe aran ce o f be in g p art ia l t o t he pro se cu ti on .” On t he ot he r ha nd , a fe de ra l j udge is not

am er e m ode rator

of pr oc ee din gs. H e is a

c om m on lawj udge havin g th at

auth or ity his tor ic al ly

e xe rc ise d by

j udge s inthe com m on law process. He m ay com m ent on the evidence, m ay que sti on w itn es se s and e lic it fa ct s no t y et a dduc ed or c lari fy tho se pr es en te d, and m ay

m ai nta in the pa ce of

the tr ia l by

int er ru pti ng o r cu tti ng o ff

c ouns el a s am atte r of

dis cr et ion . W rig ht , 392 F . 3d at 12 74- 75 (quot ing Moore v. United States , 598 F . 2d 4 39, 442 (5 th Cir . 19 79 )). Ro sin ’ s arg um ents w ithr es pe ct to the dis tr ic t j udge are w hol ly w ith out m er it. I n hi s op en ing br ie f, Ro sinc at al ogue s anum be r of state m en ts and22

que sti ons by

the tr ia l c ourt he c ont en ds w er e im pr ope r. H av ing e xam ine d e ac h, w e can say

w ithc onf

ide nc e that i n e ac h in stanc e, the c ourt di d no m or e than a sk cl ar if y ing que sti ons, de te r co unse l f ro m e lic iti ng i rr el ev an t t es tim ony or te sti m ony that l ac ke d f

ound at ion , or

pr ev en t w itn es se s f

ro m giv ing e xte nde d te sti m ony on i rr el ev an tp o i n t s . Al th o u g h i ti s tru e t h e c o u rtd i dn o tqu es t i o nth e G o v ern m en t ’s w itn es se s inthe sam e w ay it que sti one d R osi n’ s, Ro sinha s no t po int ed to any co nduc t by

the G ove rn m en t tha t w oul d have w ar rante d in te rv en tio n by

the c ourt. C. Adm issio n of Evidence Inw ha t i s am ir

ro r im ag e to h is j udi ci al int er ve nti on c la im , Ro sinc ont en ds he w as de pr ive d of

af ai r tr ia l whe n th e dis tr ic t c ourt f ai le d to a ct sua sp onte to bar al l eg ed l y i n ad m i s s i b l e e v i d en ce , a n dre s tri ct edth e s co p e o f t es t i m o n y b y Ro s i n ’s ch ar ac te r w itn es se s. B y

sug ge sti ng the c ourt sh oul d have a ct ed sua spon te , Ro sin co nc ed es he did

not se ek to bar the e vid en ce he nowc ha lle nge s. Whe n a de fe ndant h as not

pr es er ve d an ob j ec tio n to an e vid en tiary

r uli ng, w e re vie wf

or pl ai n e rro r. U

nited Sta tes v . Sm ith , 45 9 F .3d12 76 , 12 96 (11 th Cir . 20 06 ). 1. M iescke’ s Testimony Ro sintake s is sue w iththe c ourt’ s f ai lur e to p re ve nt s ta tis tic ian K laus Miescke fr om

testify ing he had been retained by the Governm ent or that he had w orke d inthe pa st f

or the U nit ed

S ta te s A tto rn ey ’ s O ff

ic e on h ea lthc ar e fr au dBe fore sentenc ing, the Gover nment asked the ir expert, Dr. F lowers, to re view more 4 than 4,000 slides rec overe d from Rosin’s office . Consequently , the final loss figures we re ba sed on a univer se of slides that wa s larg er tha n Miescke’ s random sample. In it s b ri e f, the Go ve rnme nt i ne xplic a bly c onte nd s Mi e sc ke wa s n ot a n e xpe rt be c a us e 5 he did not rende r any

expert opinion. Although an e x pert is per mitted to render a

n opinion, Fed. 23 cas es . Ros in arg ue s t ha t b y st at in g h e h adbe en hi redto “ ex trapo la te lo ss fig ur es ,” Mi es ck e im

pli ed the 75 s ur gic al sli de s he r ev ie w ed w er e re pr es en ta tiv e of

the w hol e uni ve rs e of

sli de s f ro m w hic h th e random

sam ple s ha d be entake n ( m eanin g that in the cases not selected for re view, Rosin had perform ed unnecessary su rg eri es at t he same rate h e p erfo rm edth em wit h re sp ectto th e sa m

pl edsl id es ). A c c o r d i n g t o R o s i n , th e d i s tr i c tc o u rtp l a i n l y e rr e db y p e rmi t t i n g s u c h t e s t i mo n y. It is tr ue Mi es ck e inv ite d th e j ur y to inf er his sam ple w as ar el ia

ble m ic ro co sm

of Ro sin ’ s m ed ic al pr ac tic e. H ow ev er , it w as not e rr or to adm it the te sti m ony . Mi es ck e w as astatis tic ian w hose j ob i t w as to obt ai n ar ep re se ntativ e ra n d o m s amp l e o f R o s i n ’s Mo h s s u rg er i es . F ro m th at s amp l e, th e G o v ern m en t ’s m edical experts drewtheir conclusion s about th e perc entage of Rosin’ s surgical ca se s th at inv olv ed a ct ua l c an ce r, and f

ro m that sam ple the G ove rn m en t dr ewit s pr el im inary

los s f igure s. T he poi nt R osi n m iss es is that the re w as nothin g

4 im pr op er ab ou t M ie sc ke ’s tes ti m on y or t he in fere nc es to be dra wn fr om it . A t tri al , the de fe nse c onc ed ed that M ie sc ke w as an e xpe rt statis tic ian, qua lif ie d to pe rf

orm r an dom sam pli ng. T he pur

pose of statis tic al sam

pli ng i s to 5R. E vid . 7 03 , 7 04 , h e is n ot required to do so, and failure to offer an opinion does not neg ate a n expert’s status, see F e d. R. E vid . 7 02 . D ur ingthe Go ve rnme nt’ s p ro ff e r a nd duri nghis te sti mony , M ie sc ke dis c us se d h is s pe c ia lize d tr a ini ng , a s w e ll a s th e me tho do logy he e mpl oy s in selec ting r andom samples. His spec ialized knowledg e lay outside the province of the jury and rende red him an e x pert. 24 provide a m eans of determ ining the likeliho od that a large sam ple shares ch arac te ris ti cs of asm al le r sa m pl e. Se e, e.g ., L aure ns W al ke r & J ohn Mon ah an , Sam pli ng E vi de nc e at t

he Cr oss road

s , 80 S . Ca l. L . Re v. 969 , 973 -7 4 ( 2007 ) (denoting random

sam pling as “ a sin e qua non of scientific re search”) . Ther efore, it sur el y c am e as no s ur

pr ise to the j ur

y that the G ove rn m en t ha d r et ai ne d M ie sc ke fo r the pur

pose of obt ai nin g ar el ia

ble sam ple and u sin g th at

sam ple f or vari ous pur pose s, inc lud ing the c al cu la tio n of los s am ount s ( none of

w hic h M ie sc ke rev eal ed ) in a cas e whe re t he de fen da ntwas a ccu se d o f he al th care frau d. Ro sina sse rt s th e “ co urt ha d aduty to sua sp onte s tr i k e th e t e s t i mo n y, chastise the Governm ent . . . for its dising enuous repre sentation andgive a curativ e ins tr

uc tio n to the j ur

y . ” H e is m ist ak en . B ef

or e Mi es ck e te sti fi ed , the tr ia l j udge he ar d arg um en t f ro m both si de s r eg ar din g th e pe rm iss ibl e sc ope of Mi es ck e’ s te sti m ony . T he Co urt r ule d M ie sc ke c oul d no t r ep re se nt tha t hi s sam pli ng w as r ep re se ntativ e of the f ull br ea dthof

Ro sin ’ s m ed ic al pr ac tic e, but he ld M ie sc ke c oul d r ep re se nt tha t hi s sam pli ng w as r ep re se ntativ e of the da ta sam ple he ha d be enpr ovi de d. Mi es ck e’ s te sti m ony w as c onsi ste nt w iththe25

co urt’ s r uli ng, did not go b ey ond the bounds of his e xpe rt ise , and d id n ot unf ai rl y pr ejud ic e Ro si n i n a ny way . W ithr eg ar d to Mi es ck e’ s te sti m ony r eg ar din g hi s pa st a ff

ili at ionw iththe United States A ttorney ’ s Of fice, Rosin asserts that, by telling th e j ury

that he had worked on health care fra ud cases previously , Mie scke im plied Rosin had com m itted health care f

raud. Since that w as the crim e w ith which Rosin was ch ar ge d, it

c oul d hard ly

have sur pr ise d th e j ur

y to he ar the G ove rn m en t se le ct ed a st at is ti ci an fam il ia r wit h h eal th care frau d t o a na lyze dat a rel at in g t o R os in ’s cas e. Co nse que ntl y , Mi es ck e’ s te sti m ony on tha t po int

c oul d no t have pr ej udi ce d R osi n u n f a i r l y. 2. T es tim onyof F

low er s an d L ang N ex t, Ro sinc ont en ds the dis tr ic t c ourt e rr ed w he n it a llo w ed G ove rn m en t expe rt s F low er s and L an g to te sti fy about the ir ow n surg ic al pr ac tic es , inv iti ng the ju ry t o co n cl u d e R o s i n ’s p ra ct i ce wa s fr au du l en tb ec au s e t h e G o v ern m en t ’s experts diagnos ed cancer at m uch lower r ates and perform ed m any few er foursta ge Mo hs s ur ge ri es than di d R osi n. R osi n po int s to ahos t of r ea sons w hy

he be lie ve s it

w as im pr ope r to i nvi te ac om

pari son be tw ee n hi s pr ac tic e an d th e expe rt w itn es se s’ pr ac tic es : h e w as in pr ivate pr ac tic e w hil e the y w er e in academ ic clinics; he wa s a solo practitioner, while they we re not; his patients we re26

u n i fo rmly el d er l y, wh i l e t h ei r p at i en t s ’ ag es v ar i ed ; et c. Al th o u g h Ro s i n ’s cr iti que s w er e ex ce lle nt f odde r fo r cr oss -e xam inatio n, the y w en t t o th e w ei ght

of th e ev id en ce an d n otto it s ad m is si bi li ty. E vid en ce is re le vant whe n it ha s “ any te nde nc y to m ak e the e xis te nc e of any fa ct that i s of c onse que nc e to the de te rm inatio n of the a ct ionm or e or

le ss p ro bable than it would be withoutthe evidence.” Fed. R. Evid. 401. All r elevant evidence is adm issib le unless it is exclud ed under law. Fed. R. Evid. 402. The differe nces betwee n the rates at which the Governm ent’ s witnesses and Rosin di agnosed canc er and p er fo rm ed

m ult i- sta ge Mo hs s ur ge ry

did not pr ovi de c onc lus ive pr oof th atso m e o f Ro si n’s s ur ge rie s wer e m ed ic al ly unn eces sa ry an d fr au du le nt . Ne vertheless, if the testim ony of the expert w itnesses was believed, the star k differe nces betwe en their surgical procedures and outcom es and Rosin’s w ere pr obativ e on the que sti on whe the r Ro sinha d de fr au de d th e Me dic ar e pr ogr am by fil in g fa ls e cl ai m s. Rosin is righ t when he asserts the expert witnesses’ testim ony wa s pr ejud ic ia l, as all ev id en ce o f gu il t i s i nt en de d t o b e. It was no t, h owe ve r, unf air ly pr ejud ic ia l i n v io la ti on of t he rul es of e vi de nc e o r Ro si n’s ri gh ts un de r fed eral law. T he tr ia l c ourt di d no t e rr by f ai lin g to pr ev en t the e xpe rt s f ro m te sti fy ing about the ir m ed ic al pr ac tic es .27

3. F ailure to inf

orm jur y of w itn es ses’

e xp er t statu s Rosin cont ends it was re versible error for the court not to inform the j ury that M ie sc ke , Bi r, L an g, and F low er s w er e expe rt w itn es se s, and t o sp ec if

y the ir area s of expertise. Rosin cites no law for the proposition that courts m ust ins truct j ur ie s onthe sc ope of

an e xpe rt ’ s sp ec ia liz ed

kno w le dge , and w e can th ink of no reas on why th ey

sh ou ldbe requi redto do so . A t the c los e of

tr ia l, the j udge ins tr

uc te d th e j ur

y a s f oll ow s: N ow , w he n th e know le dge of ate ch nic al sub

j ec t m atte r m igh t be helpful to th e j ury , a

person having specialized training or experience in tha t t ec hni ca l f

ie ld i s pe rm itt ed

to state an op ini on c onc er nin g those technical m atters. Mer ely because such a w itness has exp ressed an opini on, however , does not m ean that y ou m ust accept that opi nio n. T he sam e as w ithany oth er w itn es s, it

is up t o y ou t o de ci de w he the r to r el y

upo n it . T he j udge e xe rc ise d hi s gate ke ep ing r es pons ibi lit ie s by r uli ng o n sp ec if

ic evidentiary

objec tions during th e trial, thereby preventing th e expert w itnesses from testify ing to m atters outside their relevant expertise. H aving do ne so, there w as no n ee d f

or him to spe ci fi ca lly

ide nti fy w hic h w itn es se s w er e “ expe rt ” an d w hic h w er e not . H e pr ope rl y ins tr uc te d th e j ur

y to w ei gh the f

ac ts the m se lve s, re ly ing on s pe ci al iz ed

kno w le dge or

te sti m ony

onl y w he n it w as he lpf

ul t o th ei r de li be rat io ns . 4. M itiga ting cha racter evidenceSee, e .g. , Testimony of Mr. Samuel Ur etsky , District Court Dkt. #156, at 74:17-75:23 6 (c ourt dir e c te d c ouns e l to “ mov e on ” a ft e r a sk ingc ha ra c te r w itn e ss e xten siv e qu e sti on s a bo ut h is milit ary service in the 1940s). 28 Ro sinc ont en ds the tr ia l c ourt pr ev en te d hi m f ro m f ull y pr es en tin g hi s defense by

lim iting his abilityto elicit backgroundtestim ony from his character w itn es se s, and b y

li m iti ng the sc ope of

tho se w itn es se s’ te sti m ony . T he tr an sc ri pt t e l l s ad i f f e r e n ts t o ry. Ro sinc al le d anum

be r of w itn es se s to te sti fy

that he w as hon es t, kin d, and ch ar ita ble . I n r es pons e to G ove rn m en t ob j ec tio ns, the tr ia l c ourt r

ule d: Aw itn es s m ay

be a ske d w ha t hi s op ini on i s of the tr uth fu lne ss o f the D ef en dant, and c anstate that, in his opi nio n, the D ef en dant i s atr

uth fu l person. T he other testim ony about charitable activities of the De fendant are [ s i c ] n o tr e l e v an t , an dI th i n kth e y s h o u l db e k e p tt o ami n i mu m. Although Rosin m ay

have wished to adm it m ore testim ony on the poi nt, the trial court properly

lim ited him

to presenting evid ence r elevant to the case. W ithr es pe ct

to Ro sin ’ s a lle ga tio n th at the c ourt c ur

ta ile d hi s a

bil ity to el ic it backgroundfac ts from

his witnesses, Rosin has not po inted to any im proper interruption s on the part of the trial court. When witness testim ony stray ed far af ie ld, the c ourt i nte rv en ed on s ev er al oc ca sio ns t o ke ep the c as e runni ng sm oothly . T he c ourt di d so in a m anne r that w as r es pe ct fu l and w el l w ith in i ts prerogative. 629

D . J uryI nstruc tio ns Rosin nextcontends th e j ury instruction s on reasonable dou bt, char acter ev ide nc e, and g ood fa ithm isl ed the j ur y and the re fo re ne ce ssi ta te ane wtr ia l. H is ar gum en t f

ai ls f or tw o r ea sons : F ir st, he him se lf pr opos ed the ins tr uc tio ns, and se co nd , th ey

were n oterro ne ou s. A s R osi n c onc ed es , the lawis cl ear that whe n aparty inv ite s an e rr or

by propos ing an ins truction he later challenges, or by aff irm atively

acce pting an ins tr uc tio n pr opos ed

by an op posi ng p ar

ty , thi s C ourt i s pr ec lud ed f ro m r ev ie w ing th e err oron ap pe al . U

nited Sta tes v . Silvestr i , 409 F. 3d 13 11, 1337 (11t h Cir. 2005 ). T ha t a lon e is r ea son fo r af fi rm ing the low er

c ourt’ s in str

uc tio n. I t i s no t the onlyrea son, however. Inr el ev an t part , the ins tr

uc tio n onr ea sona

ble doubt s ta te d: [W ] hil e the G ove rn m en t’ s burd enof pr oof is a str ic t or

he av y bur de n, it is n ot n ec es sary

that the D ef

en dant’ s gu ilt

be pr ove d be y ond al l poss ibl e doub t[ . ] [ I] t i s on ly r equir ed that the G ove rn m en t’ s pr oof ex cl ude any

r ea sona ble doubt c onc er

nin g th e D ef

en dant’ s gu ilt . Ro s i nco n t en d s th e u s e o f t h e p h ra s e “on l y re qu i re d ” min i m i ze dth e G o v ern m en t ’s burden of proof. Re ad in the context of the whole instructio n, howe ver, it is clear the phrase to which Rosin objects w as included in the instruction to help the jury unde rs tand the pr ose cu tio n’ s burd en . T he ins tr uc tio n e m pha siz es the G ove rn m en t30

be ar s a“ str ic t or

he av y ” bur de n. A t the sam e tim e, the ins tr uc tio n gu ar ds a ga ins t a re ad ing of

“ re as ona ble doubt” that w oul d r equir e the G ove rn m en t t o di spr ove a ll poss ibl e doub t— a bur de n hi ghe r than th e lawr equir es . T he ins tr uc tio n is ac curate , and i t w as not

e rr or f or the dis tr ic t c ourt t o c harg e the j ur y in the w or ds i t did . Si m ilarl y , Ro sin ’ s c ha lle nge to the ins tr uc tio n onc hara ct er

e vid en ce is w ith out m er it. T he c hara ct er

e vid en ce ins tr

uc tio n st at ed : N ow , the D ef

en dant h as of

fe re d e vid en ce of

the D ef en dant’ s tr ai ts o f ch arac te r an d s uc h e vi de nc e m ay gi ve ris e to a reas on ab le do ub t. Where a De fendant has offere d testim ony that the Def

endant is an hone st and truthf

ul p er son, the j ur

y sho uld c onsi de r that t es tim ony al ong w itha ll the oth er

e vid en ce in de ci din g w he the r the G ove rn m en t has proved bey ond a reasonable doub t that the Def endant comm itted the c ri m es c harg ed . The instruction m ade no m ention o f testim ony regar ding the defendant’ s charac ter fo r any tr ai t othe r than tr

uth fu lne ss. Ro sinc ont en ds the ins tr

uc tio n w as f

law ed be ca use it dir ec te d th e j ur

y to consider evidence of Rosin’ s “ truthfulness ,” but didnot inv ite the j ury to consid er ev ide nc e that R osi n w as a“ cari ng, c om pa ssi onate , kin d, and c hari ta ble ” pe rs on. Ro sinarg ue s th at

w ith out suc h an in str

uc tio n, the j ur

y “ lik el y dis re gard ed

a ll Ro sin ’ s othe r posi tiv e ch ar ac te r tr ai ts” in re ac hin g th ei r ve rd ic t. T his , he a sse rt s, wa s error.31

Rosin appears to believe his g eneral c haracte r for kind ness and charity wa s relevant because the prosecution charac terized him as a gre edy

doctor who wa s m or e in te res te d i n m ak in g m on ey fro m Med ic are t ha n i n c ari ng forhi s p at ie nt s. T ha t arg um en t be tr ay s am isunde rs tandi ng o f the r ole c hara ct er e vid en ce play ed

in the tr ia l. T he j ur

y w as not a ske d to de te rm ine w he the r Ro sinw as goo d ( hone st, kin d, e tc . ) or

ba d ( gr ee dy , c ru el , e tc . ): it w as a ske d to de te rm ine w he the r he de fr au de d th e Me dic ar e sy ste m by m ak ing f al se state m en ts and e nga gin g inhe al th care fra ud. Insofar as honestyis the oppo site of fra udul ent m isstatem ent, then Ro sin ’ s in te gr ity

in re que sti ng p ay

m en t f or ne ce ssary

sur ge ri es w as ale git im at e consideration. His genera l charac ter w as not. N othin g about th e char acter ins tr uc tio n w as inc or

re ct and the re is no r ea son to b el ie ve it m isl ed the j ur y in any way . Rosin’s c hallenge to the go od faith inst ruction is on ly slight ly m ore subs tantial. A s he point s out, and the Governm ent concedes, neither the parties no r th e d is tri ctco ur t t ai lo redth e p at te rn in st ru ct io n t o t he fact s o f hi s ca se . Sp eci fic al ly, Ro si n t ak es is su e wit h t he it al ic iz edpo rti on of t he in st ru ct io n b el ow: N ow , one w ho e xpr es se s an ho ne stl y he ld o pin ionor

an ho ne stl y fo rm ed be lie f is n ot c harg ea

ble w ithf ra udul en t i nte nt e ve n th oughthe opin ion is erroneous o r the belief m istaken. A nd sim ilarly , e vidence w hic h e sta

bli she s on ly

that a pe rs on m ad e a m ist ak e in j udgm en t or32

ane rr or in m an ag em en t or

w as c ar el es s do es not

e sta bli sh f ra udul en t int en t. On t he ot he r ha nd , an h onest b el ie f on thepar t of

thede fe ndan t that

a part ic ula r bu sin es s v en tur e wa s so und and would ulti m ately succeed w oul d no t i n and o f its el f co nst itute goo d f ai th a s th at

te rm is use d in th es e in st ru ct io ns if, in c arr yi ng o ut t he v en tur e the de fe ndant know ing ly

m ad e fa lse or

f ra udul en t r ep re se ntatio ns t o othe rs w iththe s p e c i f i c i n t e n tt o d e c e i v e th e m. (E m pha sis a dde d. ) Ro sinarg ue s th e fr au d w ithw hic h he w as c harg ed w as not re la te d to abus ine ss v en tur e; the re fo re , the r ef er en ce to unso und “ busi ne ss ve nt ur es ” sh ou ldha ve be en de le te d fr om th e in st ru ct io n. Pe rh ap s, but

not ne ce ssari ly . B ill ing Me dic ar e an d othe r he al th i nsur er s f or sur ge ri es is part

of the bus ine ss o f runni ng a m ed ic al c lin ic . U nde rs too d inthi s w ay , the ins tr

uc tio n is a cc ur at e. R osi n ha s no t su gge ste d any w ay the j ur y w oul d have be enm isl ea d init s de lib er at ion s by the im pr ope r ins tr

uc tio n, and n one is ap p ar e n t . Th e r e wa s n o e rr o r i np r o v i d i n g th i s i n s tr

u c t i o nt o th e ju ry. E . C um ula tiv e E

rro rs H av ing r ev ie w ed

the a lle ge d e rr or s of

the tr ia l j udge and p ro se cu tor indiv idually , the C ourt m ust also “ reviewthe prej udicial effec t of all . . . e rr or s, evaluated under both preserved and plain err or standards, in the aggregate. ” United States v. B aker , 432 F . 3d 1 189, 120 3 ( 11th C ir . 200 5) ; U nited Sta tes v. Blasco , 702 F. 2d 13 15, 1329 (11t h Cir. 1983 ) (“ A piece m eal re view of e ach33

inc ide nt d oe s no t e nd o ur inquir y . W e m ust c onsi de r the c um

ulativ e ef fe ct of the se inc ide nts and d et er

m ine w he the r, vie w ing the tr ia l a s aw hol e, appe llants rece iv eda fai r tr ia l as is th ei r du e u nd er o urCo ns ti tu ti on .”). Inthi s c as e, the re are no e rr or s to a ggr eg at e. H av ing c onc lud ed no subs tanti al e rr or s oc curr ed a t tri al , the re is no m or e to c onsi de r w ithr es pe ct to thi s cl ai m . Cf

. D elaw are v . V

an A rsd all , 475 U . S. 673 , 681 , 106 S . Ct . 143 1, 143 6 (1 986) ( “ [T ] he Co nst itutio n e nti tle s ac ri m ina l de fe ndant t o af ai r tr ia l, not

a perfec t one.”) . F . C om pe te nc y H ea rin g N ex t, Ro sinc ont en ds the dis tr ic t c ourt a buse d it s di sc re tio n by

f ai lin g to or de r a co m

pe te nc y e va luatio n and h old

a he ar ing on whe the r Ro sinw as able to as sis t hi s c ouns el in pr ep ar ing f or se nte nc ing due to br ai n in j ur ie s he ha d a lle ge dly in cu rredde cad es earl ie r. Se e U nited Sta tes v . Ni ck

el s , 324 F . 3d 1 250, 125 1- 52 (1 1thCi r. 200 3) ( ap pe llate c ourt r ev ie w s de nia l of m oti on f or de te rm inatio n of co m pe te nc y un de r 18 U.S.C. § 4 24 1 fo r ab us e o f di sc ret io n) . Inde te rm ini ng whe the r a de fe ndant i s c om pe te nt t o be se nte nc ed , the dis tr ic t c ourt m

ust loo k a t e vid en ce ind ic at ing “ a pr es en t i nabil ity to as sis t co un se l o r un de rs ta ndth e ch arg es ” ag ai ns t h im . M edina v . Sin gle tar

y , 59 F. 3d 1 095, 110 7 ( 11th C ir . 199 5) . F ed er al lawpr ovi de s:34

A t any ti m e af te r the c om

m en ce m en t of

apr ose cu tio n f

or an of fe nse an d pr ior to the se nte nc ing of

the de fe ndant, or

a t any ti m e af te r the co m m en ce m en t of

pr obatio n or

sup er vis ed r el ea se and p ri or

to the co m ple tio n of the se nte nc e, the de fe ndant o r the a tto rn ey f or the Governm ent m ay

file a m otion for a hearing to determ ine the m ental co m pe te nc y of the de fe ndant. T he c ourt sh al l gr an t the m oti on, or sha ll or de r suc h ahe ar ing on i ts o w n m oti on, if the re is re as ona

ble c au s e t o b e l i e v e th a tth e d e f e n d an tmay p r e s e n t l y b e s u f f e r i n g f r o m a m en ta l di se as e or

de fe ct r en de ri ng h im

m en ta lly inc om pe te nt t o th e ex te nt tha t he is una

ble to unde rs tand the na tur e an d c onse que nc es of the proceedings against him or to assist properly

in his defense. 18 U . S. C. § 42 41( a) . P ut anothe r w ay , “ [a ] dis tr ic t c ourt m ust c ondu ct a co m p et en cy h ea ri n g wh en th er e i s a ‘b o n a f i d e d o ub t ’ re g ar d i n g th e d ef en d an t ’s com petence. ” U

nited Sta tes v . R ahi m , 431 F . 3d 7 53, 759 ( 11th C ir . 200 5) ( ci tin g P ate v . R obi nson , 383 U. S. 375, 385, 86 S. C t. 836, 842 (1966)). Af ter hear ing five hou rs of testim ony from Rosin’s e xpert witness, D r. E ise nst ei n, the dis tr ic t c ourt c onc lud ed af ull blo w n c om

pe te nc y e va luatio n and he ar ing w as not

ne ed ed . A lth oughE ise nst ei n a sse rt ed Ro sinsuf

fe re d f ro m co gni tiv e de fi ci ts a s ar es ult of thr ee he ad

inj ur ie s, da tin g f

ro m the 196 0s thr ough the pr es en t, E ise nst ei n a cknow le dge d R osi n ha d a bove -ave ra ge int el lig en ce and wa s unable to say

how the alleged deficits af fecte d Rosin’s daily

life at a ll, m

uch le ss t o ade gr ee that w oul d in te rf er e w ithhis abil ity

to as sis t c ouns el . In deny ing th e m otion for a com petency evaluation, the district j udge no ted Ro sinha d be enart ic ulate on the stand d ur ing his j ur

y tr ia l, appe ar ed

to unde rs tand35

the pr etri al , tr ia l, and e ar ly se nte nc ing pr oc ee din gs, and h ad a t no ti m e pr ior

to his detention m ade any

com plaint abou t being un able to understand what was happenin g or assist coun sel in his d efense. T he j udge reasonably question ed Eisenstein’ s reliance on tests adm inistered by other psy cholog ists, and noted E ise nst ei n w as una

ble to do any

m or e than sp ec ulate about the pos sib ili ty

Ro sin m igh t su fferso m e d efi ci ts fro m bra in in juri es da ti ng ba cksev eral de cad es . Fi ndi ng n o r ea sona

ble c au se to be lie ve that R osi n w as inc om pe te nt t o part ic ipate in s en te nc ing , the j udge de nie d R osi n’ s m oti on f or a ddi tio na l br ai n im ag ing te sts an d asub se que nt c om

pe te nc y he ar ing . H is r

uli ng w as log ic al and w el l- ar tic ulate d, an d was no t an ab us e o f di sc ret io n. G . Se nte nc ing L as tly , Ro sinr ai se s c ha lle nge s to both th e dur at ionof his se nte nc e an d th e law fu lne ss o f the c ourt’ s f or fe iture or de r. H e co nte nds the dis tr ic t c ourt e rr ed in ca lc ulatin g hi s Guid el ine s se nte nc e an d inf ai lin g to vary

downw ar d f

ro m the guid eline range. In addition, Rosin contend s the court’ s forfeiture order violated hi s ri gh ts un de r th e Eig ht h a ndFif th Am en dm en ts . 1. Se nte nc e dura tio n Ch al le nge s to the dur at ionof ase nte nc e m ay

c om e in e ith er

of tw o f orm s: pr oc ed ur al or sub stanti ve . R osi n c ont en ds the c ourt e rr ed pr oc ed ur al ly w he n it36

ap pli ed im pr ope r se nte nc ing e nhanc em en ts, and e rr ed sub stanti ve ly

w he n it im po se d asen te nc e lo ng er t ha n n eed edto ach ie ve th e p ur po se s o f se nt en ci ng . a. G uid el ines c alc ula tio n Whe n r ev ie w ing adis tr ic t c ourt’ s se nte nc ing de ci sio n, thi s C ourt “ m ust f ir st ensure that the district court com m itted no si gnificant procedural err or, such as fa ili ng t o c al cu la te ( or

im pr ope rl y c al cu la tin g) the G uid el ine s r an ge , tr eatin g th e Guidelines as m andatory , [ or] failing to consi der the § 3553(a) fac tors . . . .” G all v. United States , — U . S. — , 128 S . Ct . 586 , 597 ( 2007 ). T his Co urt r ev ie w s a se nte nc ing c ourt’ s a

ppl ic at ionof

the S en te nc ing G uid el ine s de nov o. United Sta tes v . E

dm onds , 34 8 F .3d95 0, 9 52 -5 3 (1 1t h C ir. 2 00 3) . A cc or din g to Ro sin , the dis tr ic t c ourt m isc al cu la te d th e ap pli ca ble gui de lin e range in thr ee w ay s. F ir st, Ro sinc ont en ds, the dis tr ic t c ourt vi olate d United States v. Booker , 543 U. S. 220, 125 S. Ct. 738 (200 5), by enhancing his sentence based on e sti m at ion s of

the los s am ount

and the num

be r of vic tim s. T he j ur

y did not f ind these facts to be true bey ond a reasonable doub t; therefore , R osin con tends they were i m pr op erl y us edto en ha nc e th e se ve rit y of h is sen te nc e. T his Co urt e xpl ai ne d in United States v. R odrig uezthat “ the use of ex tr a- ve rd ic t e nhanc em en ts i n an a dvi sor y gui de lin es sy ste m

is not un co ns ti tu ti on al .” 398 F . 3d 1 291, 130 1 ( 2005 ) ; se e als o U nited Sta tes v . Ch au ,37

426 F. 3d 1 318, 132 3- 24 ( 11th C ir . 200 5) ( hol din g Booker doe s no t pr ohi bit dis tr ic t c ourt e nhanc em en t ba se d onf ac ts f ound by apr ep onde ranc e of

the ev ide nc e an d no t c harg ed in the ind ic tm en t, und er

an a dvi sor

y se nte nc ing sc he m e) . S o lo ng a s th e j udge vie w s th e G uid el ine s a s a dvi sor y and f ind s r el ev an t facts by a preponderance of

the evidence, he m ay

rely on facts not before the j ury to en ha nc e th e se nt en ce. U nited Sta tes v . D ougl

as , 489 F. 3d 11 17, 1129 (11t h Cir. 20 07 ). Thatis what happ en edhe re. Rely ing on the testim ony of D r. Flowe rs (the expert w itness who reviewe d the gr eate st num

be r of sli de s) , the c ourt c onc lud ed Ro sinc om

m itt ed f ra ud w ith re spe ct to m or e than 80 0 di ff

er en t vi ct im s, and the los se s a sso ci at ed w iththo se victim s exceeded $4 m illion . The c ourt’ s reliance on the extra- verdict enhanc em en ts w as pr ope r an d di d no t vi olate the Co nst itutio n. N ex t, Ro sinc ont en ds the c ourt e rr ed by e nhanc ing his se nte nc e ba se d onhis use of sop his tic at ed

m eans. Adis tr ic t c ourt’ s f ind ing that so phi sti cate d m eans we re used in the com

m issio n of a cr im e is a finding of fact w e re view f or clear erro r. U nited Sta tes v . B arak

at , 13 0 F .3d14 48 , 14 56 (11 th Cir . 19 97 ). The S entencing Guidelines prov ide for a tw o-level enhancem ent if an of fe nse inv olv es “ soph ist ic at ed m eans. ” U . S. S. G . § 2B 1. 1( b) (9 )( C) ( 2006 ). T he com m entary on that section s tates that soph isticated m eans are :38

es pe ci al ly c om ple x or e spe ci al ly

intri cate of

fe nse c ondu ct

pe rt ai nin g to the e xe cu tio n or

c onc ea lm en t of

an of fe nse . F or

e xam ple , in a te le m ar ke tin g sc he m e, loc at ing the m ai n of fi ce of the sc he m e in o ne j ur isd ic tio n bu t l oc at ing sol ic iti ng o pe ratio n inanothe r j ur isd ic tio n or din ar ily ind ic at es sop his tic at ed

m eans. C ondu ct

suc h a s hi din g as se ts o r tr an sa ct ion s, or

both, thr oughthe use of

f ic tit iou s e nti tie s, co rp or at e she lls , or

of fs hor e fi nanc ia l a cc ount s a lso or din ar ily ind ic at es sop his tic at ed

m eans. U. S. S. G. § 2B1.1(b)(9)( C) c m t. n. 8(B). T here is no requirem ent that each of a de fe ndant’ s in div idu al a ct ion s be sop his tic at ed in or de r to s uppo rt

im posi tio n of the enhancem ent; rather, it is sufficient if the totality of the schem e w as so ph is ti cat ed . Cf. United States v. F inck , 407 F . 3d 9 08, 915 ( 8thCi r. 200 5) (“ Re pe tit ive and c oor din at ed c ondu ct , tho ugh no o ne ste p is part ic ularl y com plicated, can be a sophis ticated schem e. ”). Rosin cont ends his schem e to defra ud Medicare w as not sop histicated because he perf

orm ed routine surgeries and did n ot use “ com plex tactics to cover up h is f ra ud. ” H ow ev er , the e vid en ce a dduc ed a t tri al r ev ea le d R osi n r ana laboratory

staffe d with poorly

trained technicians, direc ted his staff to discard surgical slides, and perform ed com plicated m

ultist age surgeries in a m anner de si gn edto m ax im iz e h is pro fit s wh il e ap pe ari ng fal se ly to t reatsk in can cer. Given those facts, the court did no t clear ly err in finding Rosin’s m eans we re

“ soph ist ic at ed ” w ith in the m eanin g of the e nhanc em en t.39

Th i rd l y, Ro s i nco n t en d s th er e w as n o ev i d en ce t o s up p o rtth e d i s tri ct co u rt ’s fi ndi ng tha t hi s patie nts ha d su ff er ed se ri ous bodi ly

inj ur y a s ar es ult

of his cr im ina l a ct ivi ty . S ec tio n 2B 1. 1( b) (1 2) of the U nit ed

S ta te s S en te nc ing G uid el ine s pr ovi de s atw o- le ve l e nhanc em en t f or c ri m es inv olv ing the “ co nsc iou s or r ec kle ss r isk

of de ath or se ri ous bodi ly

inj ur y . . . . ” S er iou s bo dil y

inj ur y is de fi ne d a s in

j ur y “ inv olv ing e xtr em e phy sic al pa in o r the pr otr ac te d im pa irm en t of a function of a bodilym em ber, organ, or m ental fac ulty ; or requiring m edical in te rv en ti on su ch as s ur ge ry , ho sp it al iz at io n, o r ph y si cal reh ab il it at io n.” U.S.S.G. § 1B1.1, c m

t. n. 1(L) (2006). Inarg uin g th er e w as no e vid en ce to j ust if y af ind ing of se ri ous bodi ly inj ur y , Ro sinm isr ep re se nts the f ac ts. A ft er

he ar ing f ro m num er ous pa tie nts during th e sentencing hearing, the j udge conclud ed that at least tw o had suffered se rio us ph y si cal in

juri es ab ov e an d b ey on d s ur ge ry as ares ul t o f Ro si n’s co nd uc t. The jud ge di d n oterr b y

en ha nc in g R os in ’s gu id el in e ran ge acco rd in gl y . b. F ailure to va ry If adis tr ic t c ourt’ s se nte nc ing de ci sio n is pr oc ed ur al ly sound, the appe llate court m ust “ consider the sub stantive reasonableness of the sentence im posed under an abuse-of-discretion standard.” G all , 128 S . Ct . a t 59 7. Whe n c ondu ct ing40

thi s r ev ie w , the c ourt m

ust take int o a cc ount

the tot al ity

of the c ir cum stanc es , in cl ud in g t he ex te ntof a ny vari an ce fr om th e g ui de li ne ran ge . Id

. Ro sinc ont en ds h is s en te nc e w as sub stanti ve ly unr ea sona

ble be ca use the dis tr ic t c ourt f

ai le d to vary

downw ar d onthe ba sis of his c hari ta

ble c ontri but ion s, his f am ily ’ s ne ed

f or sup port, his paym en t of

r es tit uti on i n f ull , and h is a lle ge dly dim ini she d m enta l c ap ac ity . I n bo th G all and Rita v. United States , 551 U . S. —, 127 S. Ct . 245 6 ( 2007 ), the S upr em e Co urt he ld tha t, in re vie w ing se nte nc es f or subs tanti ve r ea sona

ble ne ss unde r 18 U . S. C. § 35 53( a) , f ed er al appe llate c ourts m ay apply a presum ption of rea sonablen ess to dist rict court sentences im posed wit hi n t he gu id el in e ran ge . G all , 128 S . Ct . a t 59 1; R ita , 12 7 S . Ct. at24 63 . Although this Circuit has declined to ado pt such a presum ption , the C ourt has ac know le dge d th e ratio na le in R ita “ ca lls int o qu es tio n our re as ons fo r not affor ding a presum

ption of rea sonablen ess,” U nited Sta tes v . Ca m

pbe ll , 491 F . 3d 1306 , 131 4 n. 8 ( 11th C ir . 200 7) , and h as he ld tha t “ or din ar ily w e w oul d e xpe ct

a sentence w ithin the Guidelines range to be rea sonable.” United States v. T alley , 431 F.3d 784 , 788 (11th Cir. 2005). Inthi s c as e, the tr ia l j udge li ste ne d to m ult ipl e day s of

te sti m ony , he ar ing ev ide nc e fr om

e xpe rt s, f

orm er pa tie nts , and m em

be rs of the c om m uni ty about Rosin’s c haracte r, his actions, and the effe cts of his crim e. Rosin poin ts to oth er41

cases in which individu als convicted of Medicare fraud re ceived sentences lighter than hi s. T ha t f

ac t a lon e is n o r ea son fo r thi s c ourt t o va cate Ro sin ’ s se nte nc e: dif fe re nt d ef en dants of

te n r ec ei ve dif

fe re nt s en te nc es , a s th e fa ct s of e ac h c as e req ui re. Se e G all , 128 S . Ct . a t 59 8 ( “ It ha s be enuni fo rm

and c onst an t i n th e federa l j udicial tradition for the sentencing j udge to con sider every convicted person as an indiv idual and every case a s a unique stu dy

in the hum an failings that so m et im es m it ig at e, so m et im es m ag ni fy , th e cri m e an d t he pu ni sh m en t t o e ns ue .”). U nle ss a se nte nc e is g ro ssl y

dis pr opor

tio na te to the of

fe nse c om

m itt ed w e do n ot even consider the sentences im posed on other offenders who have comm itted si m il ar cr im es . U

nited Sta tes v . A ria s-Iz qui erdo , 449 F. 3d 11 68, 1186 (11t h Cir. 20 06 ). It is true Rosin rece ived a long sen tence; however , it is also true he w as fo un d g ui lt y

of c omm it ti ng ser io us cri m es th atex te nd edov er a p ro tra ct edpe rio d. H is c ri m es a ff

ec te d e lde rl y

pe rs ons, abuse d a

pos iti on o f tr

ust , and c ost

the Governm ent m illion s of dollars. A lthou gh Rosin point s to m itigatin g evidence, such as his charitable works and the needs of his wife and children, the district co urt f ound tho se f ac ts i nsuf fi ci en t t o j ust if

y ase nte nc e out sid e the gui de lin e range. Finding neith er m itigatin g nor aggravating circum stances in Rosin’s ca se,42

th e d i s tri ct co u rti m

p o s eda s en t en ce i nth e mid d l e o f t h e g u i d el i n e r an g e. We can no t s ay

he ab us edhi s d is cret io n b y do in g s o. 2. F orf ei tur e Ro sinr ai se s tw o di sti nc t c ha lle nge s to his f or fe iture or de r. F ir st, he contends that because the court ordere d full restitutio n, the forf eiture order is an ex ce ssi ve f

ine that vi olate s th e E igh th A m en dm en t. S ec ond, Ro sinc ha lle nge s th e $490 , 876. 11 d if

fe re nc e be tw ee n th e am ount of f or fe iture sou ght

in the ind ic tm en t and the am ountordered at sentencing as an im perm issib le m aterial var iance. a. E xc es siv e fin e When sentencing a defe ndant conv icted of a f ederal hea lth care off

ense, dis tr ic t c ourts are r equir ed to “ or de r the pe rs on t o f

or fe it pr ope rty , r ea l or

pe rs ona l, that c onst itute s or

is de ri ve d, dir ec tly

or ind ir ec tly , f

ro m gr oss pr oc ee ds tra ce ab le to the c om

m iss ionof

the of fe nse . ” 18 U . S. C. § 98 2( a) (7 ). R osi n do es not ch al le nge the c ourt’ s a

bil ity to or de r him

to pay f or fe iture , but

c ont en ds the am ount or de re d—$ 3, 697, 225. 38— is e xc es siv e, part ic ularl y in lig ht o f the f

ac t he m ad e fu ll re sti tut ionto the Me dic ar e pr ogr am . R osi n f ai le d to r ai se his obj ec tio n to th e tr ia l co ur t; th eref

or e, we rev ie w forpl ai n e rro r on ly. U nited Sta tes v . R aad , 40 6 F .3d13 22 , 13 23 (11 th Cir . 20 05 ).43

U nde r the E igh th A m en dm en t, af or fe iture is ex ce ssi ve “ if

it is gr oss ly disprop ortional to th e gravity of a def endant’ s offense. ” United States v. B aja ka jia n , 524 U . S. 321 , 334 , 118 S . Ct . 202 8, 203 6 ( 1998 ). B ec au se ex ce ssi ve ne ss “ is a

hig hly sub j ec tiv e j udgm en t, the c ourts s houl d be he sit an t t o subs titute their opin ion for that of [Congress] .” U nited Sta tes v . 817

N. E . 29t h Drive , 175 F . 3d 1 304, 130 9 ( 11th C ir . 199 9) ( ci tin g B aja ka jia n , 524 U . S. a t 33 4, 118 S. Ct . a t 20 37 ( “

j udgm en ts a

bout the a ppr opr ia te pun ish m en t f

or an of fe nse be lon g inthe f

ir st i nst an ce to the le gis la tur e” )) . I f the va lue of f or fe ite d pr ope rty is within the range of fines prescr ibed by Congress, a strong p resum ption arises th atth e fo rfei tu re i s co ns ti tu ti on al . 817 N.E. 29th Drive , 17 5 F .3dat 1 30 9. In this case, the m axim

um fine authorized by

statute was $250,000 for eac h cr im e Ro sinc om

m itt ed . 18 U . S. C. § 35 71( b) (3 ). H e w as c onvi ct ed on 7 0 c ount s, w hic h le d to am ax im

um f ine of $17 . 5 m ill iondol lars . A lth oughthe recom m ended guid eline fine w as substant ially less than that am ount($250,000), giv enthe f

ac t R osi n de fr au de d th e G ove rn m en t of m or e than $3 . 6 m ill ion , it is dif fi cu lt to s ay

af or fe iture tw ic e that am ount is unc onst itutio na l, part ic ularl y in lig ht o f the f

ac t tha t R osi n’ s ne t w orth e xc ee de d $1 1 m ill ion . Rosin cont ends the court sho uld have taken account of his restitution when se tti ng the a m ount

of his f or fe iture . Whil e supe rf

ic ia lly appe al ing , thi s arg um en t44

fai ls to acco un t fo r th e d iff eren t g oa ls ser ve d b y

res ti tu ti on an d fo rfei tu re. See U nited Sta tes v . L ea hy , 46 4 F .3d77 3, 7 93 n.8 (7t h C ir. 2 00 6) (“ Whi le we re co gni ze to the untra ine d e y e, thi s m igh t a ppe ar to be a‘ doub le dip , ’ r es tit uti on an d f or fe iture se rv e dif

fe re nt g oa ls . . . . ”) . T he goa l of r es tit uti on i s to co m pe ns at e v ic ti m s fo r th ei r lo ss es , se e, e.g ., 18 U . S. C. §§ 3 556, 366 3( a) (1 ) (authorizing restituti on to com pensate victim s of crim inal offenses), while the goal of for fei tu re i s t o p un is h, United States v. D icter , 198 F. 3d 12 84, 1289 (11t h Cir. 1999 ). T ha t a

de fe ndant m ay

ult im at el y

be or de re d to pay

in re sti tut ionand forfe iture m ore than he took is o f little consequence: [P ] ay ing r es tit

uti on p lus f

or fe iture a t w or st f

or ce s th e of

fe nde r to dis gor ge atot al a m ount

e qua l t o tw ic e the va lue of the pr oc ee ds o f the crim e. G iven the m any

tangible and in tangibl e costs of crim inal ac tiv ity , thi s is in no w ay dis pr opor

tio na te to the harm

inf lic te d up on go ve rn m en t an d s oc ie ty by th e o ffen se . U nited Sta tes v . V

ari ous Co m

put er s an d C om put er E qui pm en t , 82 F . 3d 5 82, 588 (3 d C ir. 1 99 6) (qu ot at io n m ark s an d b rack et s o m it te d) . Although Rosin’s f

orfeiture am ountwa s high , so w as the am ountby which he de fr au de d th e G ove rn m en t. T he f or fe iture or de r did

not vio la te the E xc es siv e Fi ne s C lause of

the E igh th A m en dm en t. b. V arian ce45

L as tly , Ro sinc ont en ds h is f or fe iture or de r w as inv al id b ec au se the re w as a m at er ia l vari an ce be tw ee n th e am ount sou ght in the ind ic tm en t and the a m ount the co urt or de re d hi m

to pay . A s an in iti al m atte r, w e que sti on whe the r the the or y of m aterial var iance even applies to forfeiture decisions, which im plicate a de fen da nt ’s rig htto be free fro m ex ces si ve pu ni sh m en t, see supra , r athe r than hi s rig htto no ti ce o f th e ch arg es ag ai ns t h im , U nited Sta tes v . R atl iff

-W hite , 493 F . 3d 812, 819 ( 7thCi r. 200 7) ( m at er ia l vari an ce im pli cate s de fe ndant’ s F if

th A m en dm en t r igh t t o be inf orm ed of na tur e an d c au se of

a cc usatio n a ga ins t hi m an d S ixth A m en dm en t r igh t t o in dic tm en t by gr an d j ur y ). T he c la im

that a m aterial var iance exists betwee n indi ctm ent and proof adduced at trial is a “ form of challenge to the sufficiency of the evidence, ” U

nited Sta tes v . J

en ki ns , 779 F . 2d 606, 616 ( 11th C ir . 198 6) . R osi n do es not poi nt t o pr ec ed en t i n th is C ir cu it or any other apply ing th e lawof m aterial var iance to a sentencing, f ine, or f orfeiture de ci si on , andou r in de pe nd en t s earc h h as rev eal edno ne . Ne vertheless, f

or the sake of ar gum ent, w e note “ [a] variance exists where the e vid en ce a t tri al pr ove s f ac ts dif fe re nt from those alleged in th e indictm ent, a s oppo sed to facts w hich, although not specifically m entioned in the indictm ent, are entirely consistent with its allegations.” U nited Sta tes v . G old , 743 F . 2d 8 00, 813 (11th Cir. 1984). “ The standard of r eview f or whether

there is a m aterial var iance46

be tw ee n th e al le ga tio ns i n th e ind ic tm en t and the f ac ts e sta bli she d a t tri al is tw of old : F ir st, w he the r a m at er ia l vari an ce did oc cur, and, se co nd, w he the r the defendant suffere d subs tantial prej udice as a re sult.” U nited Sta tes v . Ch astain , 198 F.3d 133 8, 1349 (11th Cir. 1999 ). Ro sinpoi nts out

that i n th e supe rc ed ing ind ic tm en t, the G ove rn m en t re que ste d f

or fe iture in the a m ount

of $3, 206, 349. 21. H ow ev er , a ft er the Governm ent’ s expert testified to a higher loss am ount , the c ourt ordered $3,697,225.38 in restitution—a differ ence of $490,876.11. T he differ ence be tw ee n th e am ount

li ste d inthe ind ic tm en t and the a m ount Ro sinw as or de re d to p ay d i f f e r e db y h a l f

ami l l i o nd o l l ar s , al ar g e s u m o f mo n e y, b u tana mo u n to n l y 15% gr eate r than th e am ount r eque ste d inthe ind ic tm en t. C onsi de re d inc ont ex t, itis do ub tfu l t he “ va ria nc e” co ul d b e co ns id ered“ su bs ta nt ia l.” Assum ing th e differ ence wa s significant enou gh to q ualify as a substantial vari at ionf

ro m the a m ount

sou ght in the ind ic tm en t, the ne xt que sti on w oul d be w he the r the dif

fe re nc e subs tanti al ly

pr ej udi ce d R osi n. T o sh owthat i t di d, Ro sin w oul d be r equir ed

to de m onstrate that “ the pr oof a t tri al dif

fe re d so gr eatly

f ro m the c harg es that [ he ] w as unf ai rl y sur pr ise d and w as una

ble to pr ep ar e ana de quate defense. ” United States v. A lred , 144 F . 3d 1 405, 141 5 ( 11th C ir . 199 8) . R osi n47

m akes no effort to explain how he w as prej udiced by the higher am ountproven at se nt en ci ng , anditis di ffi cu ltto see ho w he wo ul d h av e b een . T he c ourt’ s f

or fe iture or de r w as e qui va le nt t o th e am ount of m one y Ro sin ha d r ec ei ve d f

ro m Me dic ar e, pa tie nts , and p at ie nts ’ ins ur er s a s ar es ult of the fr au dul en t surg er ie s. R osi n’ s c ouns el ha d th e oppo rt uni ty to ar gue a t se nte nc ing that the c ourt ha d in cl ude d to o m any sur ge ri es in as se ssi ng the e xte nt o f the f ra ud, an d, in fa ct , he pr es en te d c om pe tin g e xpe rt

te sti m ony

on the poi nt. A lth oughthe co urt ul tim at el y

r ej ec te d R osi n’ s arg um en t, he c annot say he w as unf

ai rl y su rp ris edby the Gov ern m en t’s p os it io n a ndwas u nf ai rly preju di cedby it. T he re fo re , e ve n if

the re c oul d be am at er ia l vari an ce be tw ee n th e am ount sou ght in an indictm ent and the am ountordered f orfeited following conviction , R osin h as not sh own such a variance existed in thi s case. AFFIRMED.