## In the



# U n ited S ta tes Co urt o f Ap p ea ls

F o rth eS e v e n th C ir cu it
N o. 09

- 4088 U NI T ED S TATE SOF A MERI CA, P la intif f-A pp ellee, v. R OLA ND B O RRASI, D ef endant-Appellant.

A pp eal from the United S t ates Di strictC our t fo r the N o rthernDi stricto f Illino is, Eas tern Div isi on. No . 06 C R 916-2

—Wi ll iam J. H ibb ler , Judge .
A RGUED O CT OB ER 22, 2010

— D ECI DE D M AY 4, 2011

Befo re K ANN E , T INDER, an d H A MI L T ON, C ircu it Judges . K ANN E , Cir cu i tJudg e . R oland B orrasi, a m ed ical d octor, wa s c o nv i c t e d o fMed i c a r e fr a ud a ft e r h e a c c e pt e d a sa lar y fro m a h os p ita l in ex c h an ge for c on tin u ally r e fe r r i ngp a t i e nt s t o the f a c i l i t y, a v i o l a t i o n o f4 2 U. S
. C. § 13 20 a- 7b

. In thi s a p pea l, Bo r r as i a tt ac k s bo thhi s co nviction an d his sent en ce. W e find th at th e d istri ct cou rt did noter r by adm i tting m i nutes fro m hos pit alco m m i tte e m ee ting s to pr ove a tt en dan ce r ec o r ds whi l e ex cl udi ng2 N o. 09

- 4088 di sc us si o n o fr epo r ts t o whi chthe m inu tes r efer, a s th e l at te r c o ns ti tu te d i na dm i ss ibl e he ar sa y . Be ca us e the M edi car e fra ud st atute cr i m i nal i zes paym ents w hen i nduc ti o n o fr efer r al s i s amongthe pur po se s f o r the p aym en ts, w e also find that the d istri ct cou rt d id n ot err i n ins tr uct i ngthe j ur y . Acco r di ng l y, we affi r m hi s co nvic t io n. In ad d iti on, w e find that the d istri ct cou rt did noter r i n sent enci ng Borra si
. I t r eas onabl y e sti m ate d the l o s s a mou nti n de t e r mi ningh i s o ffe ns e l e v e l, i tp r o per l y a sse sse d a l ea d er sh i p enhancem ent t o hi s o ffense l eve l, and i t expresse d adequate r eas ons to sente nce Bo r r a s i t o a l o ng er term tha n hi s c o - de fe nd a nt
. Ac c o r din gly , w e a ffirm h is s en te n c e a s w ell.

I. B ACK GR OUN D Dr
. Bo r r a s i o w ne d Int e g r a t e d He a l th Ce nt e r s , S
. C. (“I nt egrated ”), a corpora te group o f he althc are p rovide rs i n Ro m eovill e, I l l i no i s. He wo r k ed pr i m ar i l y a t nur sing hom es a n d hos pit al s. Through thi s work, he b ecam e a cqua i nt ed wi thChi efExe cut i ve Offi ce r W en dy M amoo n, D irector o f O p erations M ah m ood Ba ig, and other offi cers and dir ecto rs ofRockCree k Cente r, L. P. , a l i censed inpati ent psy chi atr i c hos pit al in Lem ont, I l l i noi s. Rei m burse

m ents fro m the M edi car e federa l h ea lth ca re pro gr am const i tuted the vas t m aj or i ty ofpaym en ts r ecei ved by Rock Creek

. At so m e t i m e be twe en19 99 a nd 2 00 2, Bo r r as i, M amoo n, Bai g, a nd o th er s co ns pi r ed to pa y b r ibe s to Bo r r as i a nd o the r i ndi vi dual s atInt eg r at ed i n e xc ha ng e f o r a n inc r e a s ings t r e a m o fMed i car e pati ent r efer ra l s. Docto rs ZaferN o. 09

- 4088 3 Jaw ich, B ru c e R op er , an d A b h inSin gla , as w ell as p sy c h ologi st A gnes J onas, w er e am ong thos e em plo yed at Integr ate d at tha t tim e. Over that peri od, a sum o f$6 47, 204 i n potenti albr ibes w as pai d to Bo rra siand I ntegr ate d physi ci ans by Rock Creek

. I n 2001 al one, Borr as i refer re d approxi m ate l y 4 84 M edi car e pati ents to Rock Creek

. I n or der t o concea l thes e br ibes, B or ra siand other I ntegr ate d em plo yee s were pla ced on the Roc k Cre ek pay r o l l, g i ve n f al se t i tl es a nd f au x j o b des cr i pti o ns , a nd ask ed to subm it f al se ti m e s heets

. Bor ra si, f orexam ple , w as n am ed “S er vic e M ed ica l D ire c to r” an d w as alleg ed ly re quir ed to be avai l abl e a t a l l ti m es; Bai g l ate r tes ti fi ed th at Bo r r as i was no t ex pec te d to per f o r m an y of the du ti es l i ste d i n hi s j ob descri pti on. A c c or d ing t o m i nutes ofRockCree k’ s v ar i ous c om m i tte e m eet i ngs, B or ra si and som e Integr ate d ph ysi ci ans o ccasi onal l y a tte nd ed m eet i ngs a nd subm i tte d repor ts of t h eir work. But they att end ed o nl y a ve rysm al l per centag e o fthe actualm eet
i ng s, a nd mul ti pl e wi tn es se s te st i fied to r ar ely s ee i ng them i n the Rock Creekf aci l i ty for m eet i ngs o r othe r dut i es . J o na s, J awi ch, a nd Ro pere ac h t es ti fi ed th atthe I ntegr ate d ph ysi ci ans di d not perf or m thei r ass i gned adm i ni s t r a t i v e du t i e s , the i r r e po r t s a nd t i me s he e ts no twi th st an di ng . Baig te st i fi ed th athe , Bo r r as i, a nd M am oo n did notexpect the In teg ra ted physi ci ans t o perf or m any actualadm i ni str ati ve du ti es. I n ad d iti on, Rock C r eek p aid th e salary f or Int egrated ’s secret ary, as w ella s lease p aym en ts for on e of I nt egrated ’s offi ces. Thi s a rr angem ent p urpor tedl y g ave Rock Creek an ou tp at ien t c lin ic a t B or ra si’s bu ild in g a n d ce rt ain ly4 N o. 09

- 4088

su p p lem en te d B or ra si’s re n t . Fu rt h er , B aig w as p aid both to oversee th e ad m issi on an d stays of Int eg rated ’s re fer ra l s t o Rock Cre ek and al so to ensure the re fer re d pati ents w er e r etur ned to nursi ng h om es and f aci l i ti es tha tBo r r a s i c o ul d acces s a nd c o nt r o l

. T he s e me tho ds en ab led R oc k C re e k a n d B or ra si t o m ax im ize th eir M edi car e r ei m burse m ent c l ai m s. I n De ce m be r 2 00 6, a g ra nd j ur y r etur ne d a n indi ct m en t aga i nst Borr asi, M am oo n, and Bai g, charg i ng th em with one count o fco nspir acy to defr aud the U ni ted S tat es go ve rn m en t, in vio lat ion of 18 U .S.C . § 37 1, an d six counts each o fM edi car e- re l ate d briber y, i n vi ola ti on o f 42 U
. S. C. § 1 320a

- 7b et seq
. B aig p led gui l ty to al l se ven co unt s, b utM amoo n a nd Bo rrasi pr o ce ede d t o t r i al

. The thre e- w eektr i ali ncl ud ed tes ti m ony fro m Integr ate d a n d R o c kC r e e ke mp l o y e e s ; d o c u me n t a r ye v i d e n c e c o mpr i sing tim e sh ee ts , a tt en dan ce r ec o r ds fr o m meet i ng m i nutes, and M edi car e r ei m b u rs em ent c l ai m s; and re

c or d i ngs o fBor ra si ’ s co nver sat i ons w i th Integr ate d ph ysi ci ans r eco rded by Si ngl a, i nclud i ng o ne i n w hi ch Borr asiadm itte d to re fer ring pati ents i n exchange f or “fre e m oney ” fro m Rock Creek

. The j ury re turned ve rdi cts o fg ui l tyo n e ac h c o unta g ains t Bo r r as i a nd M amoo n. The di st r i ctc o ur t th enhel d a j o i nt, t wo- days en te nc i ng he aring for B orrasi and M am oon. Bot h d efend an ts w ere i n c r i m i na l hi st o r y c at eg o r y I
. Af te r c o ns i der i ngthe prese ntence re p or t ( PSR) and the parti es’ ar gum ents r eg ar di ngi nc r ea singthe o ffen se l ev elt o r efl ec t th e los s a m ou n t a n d en h an c in g t h e o ffen se lev el d u e t o th e ir l eader shi p ro les, the cour t ca l cul ate d Borr asi ’ s o ffenseN o. 09

- 4088 5 l ev ela t 28 ( y i el di nga r an g e o f7 8- 97months ’ i m pr i so nm ent) and M am oo n’s o ffense l eve l at26 ( yi el ding a ran ge of63

- 78 m ont h s’ i m pri sonm ent)
. The di str i ct c ourtthen he ar d the de fen dan ts ’ mit i g at i o n e vi den ce , i ncludi ng te st i m o ny r eg ar di ng a se ve r ely de bi l i ta tinga cc i den t M am oo n ’s s on h ad su ffer ed th at leftM am oo n a s h is sol e ca re gi ver . The co urt sente nc ed B or ra sito se venty
tw o m onths’ i m pri sonm ent a nd two y ear s’ superv i sed r el ea se . M amoo n was s en te nc ed to s i x months ’ i m pr i so nm ent, o ne ye aro fhom e co nfinem ent, and fi ve yea rs ’ supervi sed r el eas e. E ac h defendant w as re quir ed to pay $4 97, 20 4 i n r es ti tu ti o n. Borr asithen m ove d the di str i ct c ourtto rec onsider h i s s e n te n c e, ar gu in g t h at it sh ou ld be sign ifica n tly l o wert o co m po r t wi thM amoo n’ s. Af te r ho l di nga he ar i ng o n the matt er, the di st r i ctc o ur t d en ie d hi s m o ti o n, c o ncl ud i ng tha t the di spara te sente n c es w er e j usti fi ed by th e facts of th e case an d the ind iv id u a l d efend an ts’ cha ra c t e r i s t i c s . Bo r r a s i the n t i mel y a pp e a l e d.

II. A NA LYSIS Bo r r as i c ha l l en g es b o thhi s con vi ct i o n a nd hi s se nten ce in this ap p eal. H e fi rst argu es th a t tw o errors d u r i n gth e g u i l tp h a s e o fh i s t r i a l r e q u i r e a new tr i al

. He then ar gues that, ev en i fh is convi cti on s tands, we m ust r e ma n d f o r r e s e n t e n c i n g b e c a u s e o f th r e e e r r o r s dur i ng th e se nt en cingpha se . The g o ve r nm en t ar g ue s th atthe deci si ons about w hi ch Borr asico m pla i ns were not er ro neou s. W e w ill con sid er ea c h of B or ra si’s five iss u es in turn, beg i nning w i th the al l ege d i nfi rm i ti es i n hi s con vi cti o n.6 N o. 09

- 4088 A. Chal l e nges t o Convi ct i on A t the co ncl usi on o fhi s t ri al, Bor ra sim ove d fo r a new tr ial or , in t h e alt er n at ive , a j u d gm en t o f ac q u itt al, al l eging twel ve separ ate gro u nd s forr el i efthati ncl ud ed al l ege d evi denti ar y, pro cedural, and i nstructi onaler ro rs . On a p p ea l, he wis el y l i m i ts hi s a tta ck on hi s co nvi cti on to tw o a lleg at ion s o f err or . SeeEh rhartv. Se c’y of Health a nd H um a n S ervs. , 96 9 F
. 2d 534, 53 7 n. 2 ( 7th Ci r. 19 92) ( “[ I ] t be hoov es l i ti gants to choo se w i th car e a few se l ect i ssues f orr evi ew , pre fer abl y those notf or feit ed by wai ve r . ”)
. Hi s fi r sta l l eg at i o n o fe r r o r i nv olve s ane vi den

tiar y r ul i ng, a nd the s ec o nd f o cus es o n the g o ve r nm en t’s co m m en ta r y dur i ngc l o si nga r g um en ts r eg ar di ngthe sta tute he was char ged with viol ating. W e fi nd nei ther ar gum ent per suasi ve.

1. Exc l us i on of

He ars ay B or ra si firs t a rg u es th at th e d ist ric t c ou rterr on eo u sly i nter prete d and appli ed the Feder alRule s o fEvi dence w h en it p re ve n te d h im from u sin g c om m en ts in m eet i ng m i nu te s du ring hi s defense, despi te i ts ear l i er deci si on t o al l ow the go ver nm ent t o i ntro du ce the m i nutes i nto evi den c e a nd use them f ora differ ent purpos e. A ccor ding to Borr asi, thi s r uling prej ud i ced hi s ca se an d war r an ts r ev er sa l o fhi s co nv i cti o n. W e r ev i ew the d ist ri c t c ou rt ’s d ec isio n to ex c lu d e t h e e vid en c e o r lim it its use for an abu se of discretion, but w e r e v iew i ts interpreta ti on o fthe Rules deno vo . U ni t e d S t at e s v. Rogers , 58 7 F
. 3d 81 6, 8 19 ( 7th Ci r . 2 00 9)
. Ev eni fwe det er m i ne the evi denti ar y deci si on w as er ro neous, we w i l l notr eve rs eN o. 09

- 4088 7 i t i fthe j ury’ s ul ti m ate deci si on w as not i nfl uenced by th e e rro r. U ni t e d S t at e s v. O r os , 578 F.3d 7 0 3 , 7 0 7 (7th C ir. 2009 ). The m eet i ng m i nutes a t i ssue w er e t ake n duri ng Rock Creekco m m i tte e m eet i ngs. The f ace sheeto fea c h se t o f m i nut es l i st s at te nde es at th e m ee ting s. The gover nm e n t so ug ht to i nt rod uc e the m to sup p ort i ts ex p ert’s su mm a r y o fthe a t t e nd a nc e o fBo r r a s ia nd h i s Int egr ate d p hy sicians at R ock C reek m eetings
. Th is sum m ary p urp or te d to sh ow th at th ey d id n otp ar tic ip at e s u fficie n tly i n thei r ass i gned com m i tte es to j usti fy r ecei vi ng sa l ar i es fro m RockCree k forthei r re spect ive acti vi ti es. The go ver n m en t a n d B or ra si s tip u lat ed to t h e m in u te s’ a d m iss ib i l i t y, a nd Bo r r a s i n o w a r g ue s tha tthe s cop e o fthe s t i pu l a t i o n a g r e e me n tw a s n o tl i mi t e d t o s p e c i fi c c o n t e mpla ted uses o fthe evi dence. S o m e o f th e m i n u t e s c o n t a i n e d c o m m e n t s ab o u tc o mm i tte e r epor ts subm i tte d to Rock C re ek ’ s bo ar d ofdi re ctor s. Bor ra sisought t o i ntro du ce the m i nutes a s e xhibi ts so the j ury co uld cons ider th e inform ation in th ose re feren ced r epor ts, i ncl ud i ng the descr i pti ons ofm edi cal ser vi ces he and hi s e m ployees a l l ege dlyper f or m ed f or R oc k C re ek . H e b elie ve d th e s u b st an tiv e in for m at i o n in th e r epor ts

— pa r t i a l l y i nc o r po r a t e d b y the mi nu t es

— woul d r efut e th e g o ve r nm en t’ s as se r ti on tha t he a nd the oth er In tegrate d em p loyees did not h ave to p erform any workto r ecei ve a s al ar y fro m RockCree k. On the go ver nm ent’ s obj ecti on, the dis tr i ct c ourtr ule d the m i nutes’ subst anti ve descri pti ons ofthe re port s i nadm i ssibl e be c au se the s tat em ents w oul d consti tute8 N o. 09

- 4088

Fed eral Ru le ofE vidence 105 provides: “W hen evidence 1 whic h i s a dmi s s ib l e a s t o o n e p a r ty o r f o r o n e p u r p o s e but no t a dm i s s ibl e a s t o a noth e r pa r t y orf ora no the r pu r po s e i s a d- (co n tin u ed ...) hear say . I t di d al l ow B orra sito exam i ne RockCree k w i tness es abo ut wh ethertheyr ecei ved the re port s, an d Bo r r as i que st i o ne d M amoon abo utthe r epo r ts a nd com m itte e m eet i ngs a t l ength. N eve rthel ess , Bor ra si co nt en ds tha t th e ex cl us i o n was e r r o ne o us b ec au se the r epo r ts m et th e bus i ne ss - r ec o r ds ex ce pti o n to th e he ar sa y pr o hibi ti o n. F e de r a l Ru l e o fEv i de nc e 8 0 3 ( 6 ) e xc e pt s c e r t a i n “ r e c o r ds ofr e g ul a r l y c o nd uc t e d a c t i v i t y ” fr o m Ru l e 8 0 2 ’ s g e ne ra l ban o n the adm iss ion o fhear sayev i dence. Bor ra siar gues th at h os p it a l co m m itt ee m ee tin g m in u te s p lain ly fa ll w i thi n the s c o pe o fthe b us i ne s s r e c o r ds e xc e pt i on because theywere “r eco rd[ s]
. . . of acts , ev ents, co nd i ti ons, o pi ni o ns , o r di a g no s e s, m ade at o r n e a r the t i me . . . k e pt i n the cour se ofa regul ar l y c onducted busi ness acti vi ty” and b ec ause i t was RockCree k’ s r egul arprac ti ce t o tak e m i nu t e s o fb u s i n e s s me e t i n g s . F e d

. R
. E v i d

. 8 0 3 ( 6 )
. The di st r ict c o ur t ac ce pte d the pa r ti es ’ s ti pul at i o n tha t th e m i nu te s th emse l ve s woul d f al l wi th i n thi s ex ce pti o n. Bo r r as i no w co nt en ds th at, b ec au se the g o ve r nm en t d i d not l i m i t the uses to wh i ch the m i nutes c oul d be pu t upon the i r adm i ssi on, i t w aived any o pp or tuni ty to lat er lim it t h e e v id en tia ry u se s t o w h ich h e c ou ld ap p ly the m i nutes. To s up portt h i s br oad pre m i se, he c i tes Rul e 10 5, y ethe c i te s no c as e f o r hi s pr o positi o n tha t th e

1N o. 09

- 4088 9

(
. . . c on t i nu e d) 1 m itted , the cou rt, u p on requ est, sha ll restrict the ev id en ce to its p ro p er sco p e a n d in str u ct th e ju ry ac co rd in g ly .” Rule has s uch a precl usi ve effect at the m om ent o fadm i ssi o n. Inde ed, thi s ar g um en t i nv er ts the v ery s pi r i t o fthe Rul e. Rul e 105 is a ve hi cl e f o r the e nf o r ce m en t o fthe Fe d er al R u les of E vid en c e, bu t B or ra si’s at to rn ey w ou ld tu rn it i nto a t ra p

— se t upo n a dm i ss i o n o fe vi den ce a nd sprung l ate r i n tr i al

— to e ffec ti ve l y pr ev en t en f o r ce m en t ofthe Rules

. T h e m ee tin g m in u te s a lm os t c er ta in ly fell w ith inR u le 803( 6) , es peci al l y g i ven that

— despit e the i nvol vem ent of R o c k C r e e k o ffi c e r s i n th e fr a u d u l e n ts c h e me

— th e g o ve r nm e ntdi d n o tque s t i o n the r e l i ab i l i t y o fthe do c um ents. See Fe d. R. Evi d. 803( 6) ( excl ud i ng fro m the busi ness record s exc ep tion th ose record s w h ose “sou rce of inform ati on o r . . . m etho d orc i rcum sta nces ofpre parat i on ind icate lack of tru stw ort h in ess”). B orrasi, how ever, c h al l enges the excl usi on of the re port s re fer enced in the m i n utes and any co m m ents i n the m i nutes r egar ding the s ubstance o ftho se re port s. Those re port s a n d a n y s t a t e me n t s th e r e fr o m a r e h e a r s a y, a s e a c h c o mpr i se s st at ement s wri tt en by phy si ci an s no t tes ti fy i ng be f o r e th e co ur t th at Bo r r as i wi sh ed to i nt r o duce f o r the tr u th of th e m at te rs as se rt ed

. See Fed

. R. Evid

. 801(c). The go ver nm ent a rg ues

— and Borr asidoes notr efute

— that Borr asin eve r l ai d any addit i onalf oundati on f o r the a dm i ss i o n o f th es e r epo r ts o r th e m i nut es ’ s ubs ta nti ve disc ussi on o f t h em . That a l one j usti fi es the di str i ct10 N o. 09

- 4088

cour t’ s deci si on t o barthe j ury’ s re c eip t o fthe re port s, as co ur ts may no t per m i t th e i nt r o duct i o n o fhe ar say co ntained w i thi n hear sayunl ess each l aye r i s p ro perl y a dm i tted under a n excepti on t o Rule 802. F ed

. R. Evi d. 805. Speci fi cal ly, “ statem ents m ade bythi rd part i es i n an othe rwis e a dm i ssibl e business re cor d cannot pr oper l y b e adm i tte d fo r thei r tr uth unle ss they c an b e s how n i nd epe nd e nt l y t o f a l l wi thin a r e c o g ni z e d he a r s ay e xc e pti on. ” U nited Sta tes v. C hrist, 513 F.3d 7 62, 769 ( 7th Cir. 20 08) ( q uot i ng Woods v. Ci ty of Chi cago , 23 4 F
. 3d 979, 98 6 ( 7th Ci r . 2 00 0) )
. Borras i b r o adl y c o nc l ude s th atthe m i nutes ar e not “doubl e hear say ” because the m i nutes did notco ntain state m ents ofo utsi ders to Rock Creek, butr athe r s ta tement s o fr epo r ts b y Int eg r at ed phy si ci an s wi th pr i v i l e g e s a t Ro c k Cr e e k

. Bu t he do es not

— an d coul d not

— ar gue that the r epor ts w er e them selv es tr ustw or thy b usi ness re cor ds f allin g w i thi n Rule 80 3( 6) o r an y o th e r e x c e p t i o n . Ac c o r d i n g l y, th e s t a t e me n t s c o ntained i n the re port s, as wellas any quotati ons fro m orspeci fi c r efer en ces to them i n the m i nutes, co nsti tuted i nadm i ssibl e hea rs ay. The dis tr i ct c ourtdi d n ot er ro neousl y inter pret Rules 80 2 a nd 80 3( 6)
. I t pr oper l y a l l owed Bor ra sito ar gue that ce rt ai n re port s w er e m ade and then t endered du ring the m eet i ngs, and i t al l owed hi m to use the adm i tted m i nutes in an at tem pt to pro ve thos e argum ents. Bu t the co urt did notabuse i ts d isc re tio n i n re fusi ng to ad m it a n y s u b st an tiv e d es c r i p tio n s o f th e re p or ts in the m i nutes o r the r epor ts them sel ves. H ad w e fo u n d th e e x c lu sio n err on eo u s, w e w ou ld never thel ess have f ound itto co nsti tute harm les s e rr orN o. 09

- 4088 11 be ca use it coul d no t ha ve ha d a s ubs ta nt i ala nd inj u riou s e ffec t o n t h e o u tc om e o f th e t ria l. Se eO r os , 57 8 F.3 d at70 9. B or ra s i a rg u es th at h e w as p rej u d ice d in h is d efens e beca us e he w as barred from show ing the j ury th at h e a n d oth er Int eg ra te d p h ys icia n s e ar n ed th eir salaries. Y e t B orrasi w as able to exp ou nd on th is theory o fde fen se thr o ug ho ut hi s cr o ss - ex ami na ti o ns , hi s ca se - i nch ief, and h is closing argu m en ts. E ven i f th e cou rt al l owed Bor ra sito in tr oduce the m i nutes’ speci fi c di scussi ons of the r epor ts purporting to sho w the I ntegr ate d physi ci ans’ work, i t i s hi ghl y unl i kel y that the ev i dence w oul d have o ff setthe ove rw hel m i ng ev i dence that B or ra si an d th e oth er p h ys icia n s w er e be in g p a i d in signifi can t p art for th eir referral s instea d of th e ir services
. Bai g t est i fi ed that he pai d ki ckba cks to Borr as i; J aw i ch te sti fi ed that he d i d m i ni m aladm i ni str ati ve wo r kf o r R o c kCr e e ka nd tha th i s c o nt r a c t ’ s j o b de s c r i pti o n was no t ac cur at e; and th e j ur y he ar d r ec o r ded co nver sat i ons i n w hi ch Borr asi d es c ribed the “fre e m oney ” I nt eg r at ed recei ve d f o r the i r r efer r al s. Acco r di ng l y, “ an y er r o r th e d i st r i ctc o ur t co m m i tt ed was ha r m l es s an d a r eve rs ali s no t warr anted. ” Id. at71 0.

2. Int e rpre t at i on of

42 U
. S. C. § 1320 a- 7b Borr asi ’ s s eco nd chal l enge to hi s co nvi ction t u rns on the inter preta ti on o fthe cri m i nalst atute he was char ged wi th v i o l a t i nga nd c o ns pi ri ng t o v i o l a t e . Be c a us e me di cal ser vi ces f orthe pati ents Borr asir efer re d to Rock Creek w er e pai d fo r by M edi car e, hi s r efer ra l s a nd con d u ct w er e s ubjec t t o cer tain sta tutory r est ri cti ons. Bor ra siwas12 N o. 09

- 4088 charg ed, f orexam ple , w ith vi ol ating o ne st atute des i g ne d t o h e l p c o mba th e a l th c a r e fr a ud : [ W ] hoeve r knowingl y a nd wil l fully s ol i ci ts or re cei ves any r em unerat i on ( i ncl ud i ng anyki ckba ck, b r ibe , o r reb ate)
. . . i n r etur n fo r r efer r i ng an i nd i vi du alto a person forthe furni shi ng o r ar ra ngi ng f orthe furni shi ng of any i tem orse rv i ce for w h ich p ay m en t m ay be m ad e i n w h ole or in p ar t u n d er a Fe d er al h ea lth ca re p ro gr am . . . sh all be gu il t y of a fel ony and up on con viction th ereof, shal l be fi ned not m or e than $25 , 000 ori m pri sone d f o r no t m o r e th anfi ve y ea r s, o r b o th

. 42 U
. S. C. § 1 320a

- 7b(b) ( 1)
. The go ver nm ent theor i zed that Borr asiand the othe r I ntegr ate d ph ysi ci ans r eceiv ed paym ents

— i n the gui se ofsa l aries

— fro m RockCree k f orthei r re fer ra l s o fM edi car e pati ents. Borr asipoint s out, however, thatthe sta tute exem pts som e be havi orfro m i ts cove rage. I t doe s no t cr i m i nal i ze “a ny amo u n tp a i d b y a n e mpl o y e r t o a n e mpl o y e e ( who has a bo na fi de em plo ym ent r el ati onshi p w i th such em plo yer ) f orem plo ym ent in the provi si on o fco vered i te m s o r s er vi ce s. ” 42 U. S
. C
. § 1 32 0a

- 7b ( b) ( 3)
. S ei zing t h is lan gu age, Borrasi argues that the p rosecu tion p rejudi ci al l y mis st at ed th e l aw i n its c l o singa r g um en t by sugge sting tha t i t di d not m at teri fany port i on o f Rock C re ek ’ s paym ents to hi m o r othe r I ntegr ate d ph ysi ci an s was purs ua ntt o l eg i ti m at e empl o y m en t r el at i o nshi ps beca use the st atute wa s v i ol ate d i fany port i on o f the pay m ents w as f orpati ent r efer ra l s. H e con te n d s that th e g ov er n m en t’s arg u m en t t o th e jur y n u l l i f ied h isN o. 09

- 4088 13 th eory of d efense and that the d istri ct cou rt did not cure th e m i sc o nduc t by st r i k i ng th e ar g um en t an d by givin g ana dequa te c ur at i ve i ns truct i o n. B ecau se B orrasi’ s ch all e n g e t o the d istri ct cou rt’s j ury i nstr ucti ons necess ar i l y i m pli cate s a questi on o fl aw

— th e sco pe o f§ 1320 a- 7b(b) ( 3) ’ s e xem pti on

— we r ev i ew the dist ri ct c ourt ’ s instr ucti ons deno vo . U ni t e d S t at e s v. D iSantis , 56 5 F
. 3d 35 4, 35 9 (7 th Ci r. 20 09)
. W e a l so re vi ew deno vo wh ethera parti cul ari nstr ucti on was appropri ate as a m at te r of law

. U nited Sta tes v. Ta nn er, 628 F. 3d 890, 904 ( 7th Ci r. 20 10)
. W e wil l affi rm Borras i ’ s co nvi cti on i fthe j ury i nstr ucti ons f ai rl y a nd acc u ra tel y s um m ar i zed th e l aw, a nd we wi l l r ev er se o nl y i fthe i ns truct i o ns m i sl ed the j u ry a n d prej ud i ced hi s defense. U nited Sta tes v. Q uin tero , 618 F.3d 746 , 753 (7th C ir. 2010). Bo r r as i ur g es us t o a do pt a “ p ri m ar y mot i va ti o n” do ct rine , unde r whi chthe t r i ero ff ac t woul d de te r m i ne th e defen dan ts ’ i nt en t i n a ny g i ve n case an d fi nd th em no t g ui l tyi fthe pr i m ar y mot i va ti o n b eh i nd the re m unerat i on was to co m pensate f orbo na fide se rv i ces pr o vi ded. U nd erthe pr i m ar y mot i va ti o n do ct r i ne , the dist ri ct c ourt ’ s instr ucti ons i n thi s ca se w oul d have be en both i na ccu rate as to th e law and i na d eq ua te to cu re an y pr ej udi ce fr o m the g o ve r nm en t’ s st at ement s dur i ng i t s c l o s i nga r g ume nt s . He c o nt e nd s tha ts uc h a c o ns tr ucti on i s nec ess ar y b oth to av oid the possibi l i ty ofco nvi ction base d on inn ocen t or de m in im is co nd uct and al so to give effect to th e rule of lenity i n th e face of statu t o ry am bi gui ty. Pe rsu a s iv e au th ority w eighs h eavily against B orrasi’ s pr o po sa l

. He r el i es o n Un i t e d S t at e s v . B a yS t a t eA m-14 N o. 09

- 4088 bulancea n d Hosp. Rental Se rv. , Inc. , 874 F.2d 20 (1st C ir. 1 9 8 9 ) , wh e r e the F i r s tCi r c ui ta ffi r med the a pp e l l ants’ co nv i ct i o ns a fte r “ th e di st r i ctc o ur t i ns truct ed th atthe defe nd ants coul d o nl y be f ound guil ty i fth e p aym ents w er e m ade pri m ar i l y a s [ re fer ra l ] i nd ucem ents. ” Id. at30
. Bu t co ntra ry to hi s a l l ega ti on, ther e doe s no t a pp earto be a ci rcui t s pli t r ega rdi ng t h e a pp ro pri ate i nter preta
tio n of § 1 32 0a -7b (b ). Th e F irs t C i r c u it d id n otd ec id e in B a y St a te“whether the g ove rnm ent m ust s how thatsuch pa y men t s we r e ma de p r i mari l y ors o l e l y wi th a c o r r up t i ntent. ” Id. Rather, i t hel d that the di str i c t cour t’ s instr ucti on a t l eas t “ com port [ ed] w i th c on gr ess i onali ntent. ” Id. Each ci rcui t t o actual l y r each the i ssue has rej ecte d the pr i m ar y m oti vati on theor y Bor ra siadvoca tes
. See U nited Sta tes v. G reber, 76 0 F
. 2d 68 , 7 1 ( 3d Ci r . 1 98 5) ( “T he te xt r efer s t o ‘ any r em unerat i on. ’ That incl ud es not on ly su m s f or whi chno a ctua l s er vi ce was pe r f o r m ed but al so thos e a m ounts f orwh i ch so m e pr ofess i onalti m e was ex p en d ed .”); U nite d S ta tes v. D avis , 13 2 F
. 3d 1092 , 10 94 ( 5th Ci r. 19 98) ( hol ding th at § 1 320a

- 7b(b) ( 2) i s v i ol ate d w heneverthe benefi ts extended w er e par tially t o i nd uce p at ien t re fer ra ls); U nite d State s v. Kats , 87 1 F. 2d 105, 10 8 ( 9th Ci r. 1 989) ( “[ T]he M edi car e fra ud st atute i s v i ol ate d if‘one pu rp ose of the p aym en t w as to ind uc e futu re re ferra ls.’ ” ( quo ting G reber, 760 F.2d at69 )); U nited Sta tes v. M cC la tch ey, 2 1 7F
. 3 d 8 2 3 , 8 35 ( 10 th C i r . 2 0 0 0 ) ( “ [ A] perso n w ho o ffer s o r pays r em u nera ti on t o anothe r per so n v i o l at es the Acts o l o ng a s o ne pur po se o fthe offe r or p ay m e n t is to ind u c e M ed ica re or M ed ica id p atient referr als. ”). W e fi nd the r ea so ni ngo fthe Thi r d, F i fth, N i nth, a nd T en th Circu its co n v incing, and w e d ecline B orrasi’ sN o. 09

- 4088 15 i nv i ta ti o n t o c r ea te a c ircui t spl i t. Nothingi n the M edi ca r e fr au d s ta tu te i m pl i es tha t o nl y the pr im ary m ot ivat i on o fr em unerat i on i s t o be c onsi dered in as se ss in g B or ra si’s co n d u c t. W e joinou r sis te r c irc u its in hol ding that i fpart o f t he paym ent c om pensated past r efer r al s o r i nduc ed futur e r efer r al s, tha t po r ti o n o fthe p aym en t viol ates 42 U
. S. C
. § 1320a-7b (b)( 1). T h e d ist ric t c ou rt ’s i n st ru c tio n s c om p or te d w ith th is co m m o n- se ns e ho l di ng . The i ns truct i o n trac k ed th e l a n gu ag e o f § 13 20 a-7b (b )(1) , com b in in g it w ith a d efin iti on o fr em unera tion. To c onvi ct Bor ra si, the i nstr ucti on r e qu i r e d th e j ur y t o fi nd

—b ey on d a re as on ab le d oubt

— that s o me a mo un t was pa i d n o tp u r s u a n tt o a b o n a fi d e e mp loy m en t re lat ion sh ip . Th e t ria l co u rtd id n oterr in i nstr ucti ng the j ury, and the gov ernm ent’ s com m en ts du ring i ts cl osing ar gum ents did n ot enti tl e Bor ra sito a cura t i v e i ns t r uc t i o n. Be c a us e a tl e a s tp a r to fthe p aym en ts to Borr asiwas “i ntended to i nd uce” hi m to r efer pati ents to Rock Creek, “the st atute w as vi ol ate d, eve n i fthe paym ents w er e a l so i ntended to com pensate f orpro fess i onalse rv i ces. ” G reber, 76 0 F
. 2d at 72.

B. Chal l e nges t o S e nt e nc i ng Borr asial so at ta cks hi s s entence , ar gui ng tha t three er r o r s r equi r e us t o r emand f o r r es en te nc i ng . F i r st, he a l l e g e s the di s t r i c tc o ur tdi d n o tma k e a de qu a t e fi nd i ngs as to hi s offense l eve l bas ed upon the v al ue he re cei ved fr o m hi s Ro ckCr ee ka ct i vi ti es . Sec o nd, he c o nt en ds th e di st r i ctc o ur t er r ed byi nc r ea singhi s o ffen se lev eldue to h is pu rpor ted l eader shi p ro l e in the cri m i nalsche m e.16 N o. 09

- 4088 Fi nal l y, he a sse rt s tha t th e g re at dispar i ty between hi s s ente n c e a nd thato fhi s co - defe nd ant warr ants r es en te nc i ng . W e a re unpe r su ade d b y hi s th r ee c o nt en ti ons and w i l l affi rm hi s s entence
.
1. S uf f i ci e ncy of

Lo s s Cal cu l at i on Borr asiar gues that the di str i ct c ou rt di d not m ake fi nd i ng s as t o the l o ss a m o unts uffi ci en t to de te r m i ne th e appr o p r i at e l ev elo fhi s o ffen se . S pec i fi ca l l y, he c o nte n d s t h at t h e d ist ric t c ou rtsh ou ld h av e g ive n h im m o r e th anthe $ 15 0, 00 0 cr edi t i t g av e hi m for t he v alue ofthe a c tu al s er vi ces he per f or m ed f orRockCree k. A cco r di ngt o Bo r r as i, the di st r i ctc o ur t’ s findi ng s l ac k ed th e r equi si te s pec i fi ci tyt o de ny hi m a g r ea te r di sc o unt ba se d upon hi s o bj ec ti o ns t o the PS R. The g o ve r nm en t ar gue s th ata ny c r edi t was i na ppr o pr i at e and th at th e los s a m ou n t s h ou ld h av e b ee n t h e fu ll am ou n t list ed in th e PS R. B ased on B orrasi’ s crim inal cond uc t, th e d istri ct cou rt ass ess ed hi s base offense l eve l at 8 under U. S. S. G. § 2 B4. 1, B r ib e r y i n Pr o c u r e me n to fB a n kL o a n a n d O th e r C o mm er ci alBr ibe r y . That se ct i o n r equi r es a ug m en tingthe ba se o ffen se l ev el ac co r di ng to § 2B1
. 1, co ns i der i ng the v a l ue o fb e ne fi t s r e c e i v e d thr o ugh the c r i me. U. S
. S
. G. § 2 B4. 1( b) ( 1)
. A fterco nsi derin g th e PS R and argum ents from both B orrasi an d th e govern m en t, th e d istr ic t c ou rt deter m i ned that Borr asiaccepted bribes tot al i ng $6 47, 204, a s um thati nc lu d ed the adm i ni str ati ve sal ar i es of Borr asiand hi s Integr ate d gro up , the value of the l eas e Rock Creek pai d for Borr asi, and a port i on ofBai g’ s s al ar y.N o. 09

- 4088 17 Borr asidi d not obj ect to th at cal cul ati on, but ra ther ar gu ed that he sho uld have r ecei ved a si gni fi cant c re d it aga i nst that am ount base d o n the 24- hour on- cal l se rv i ces hi s t eam r endered, thei r m em ber shi p and part i ci pati on i n Rock Creekco m m ittees, and var i ous a dm i ni str ati ve ser vi ces they provi ded to RockCree k. The di st r i ctc o ur t no te d tha t th e $6 47, 20 4 l o ss a m o unt cor re sponded to a 14- l eve l i ncre ase . I t then f ou n d that Borr asi had per f or m ed som e val uabl e ser vi ces for Rock Cr ee k, b utno ted thati t was di ffi cul t to meas ur e th e ex ac t va l ue o ftha t be ne fi t. The di st r i ctc o ur t red uce d the l oss am ount by$1 50, 000 to “co m pensa te f orthe eff or ts o fthe v arious in di vi dual s whi chdi d i n f ac t be ne fi t th e p atient s at[ Ro ckCr ee k ] , a nd s o m e adj us tmentf o r the avai l abi l i ty 24 hours a day ofcer tain m edic alper sonnel to b e a t the b e c k a nd c a l l f o r the r e s i de nt s o f[ Rock Creek ]
. ” ( Se nt. Tr. 52
. ) Thi s r ed u c tio n did notchange th e o ffen se lev el, s ee U
. S. S. G. § 2 B1. 1, but did r educe the r est i tuti on r equi re d ofBor ra sito $4 97, 204. The l oss am ount ca l cul ate d b y the di str i ct c ourtf or s e n te nc i n gi s a f a c t u a l d e t e r mi n a t i o n, o n e wh i c h we re vie w for c lea r er ro r. U nite d State s v. A li, 619 F. 3d 713, 72 0 ( 7th Ci r. 20 10)
. W e wil l uphol d the di str i ct c ourt ’ s l oss calcu lation un less w e a r e left w ith a d efi nite an d firm c o n vic tio n th at th e d ist ric t c ou rtm ad e a m ist ak e. U nited Sta tes v . Salem , 5 97F
. 3d 87 7, 8 84 ( 7th Ci r . 2 01 0)
. Our d e f e r e n c e w ill no t e x c u se anab se n c e o f find in gs alt o ge th er , i d. at88 6, but a co urt’ s fi nd i ngs ne ed onl y b e a re as on ab le e st im at e o f th e los s, U ni t e d S t at e s v. Chr i s t i ans on , 586 F. 3d 532, 53 7 ( 7th Ci r. 20 09)
. Bor ra si ’ s b urden of18 N o. 09

- 4088 pr o o fo n a ppea l r equi r es hi m t o de m o ns tr at e th atthe dist ri ct c ourt ’ s dete rm i nati on was inaccurat e a n d o utsid e t h e re alm of p er m iss ible co m p u ta tio n s. Id. Borr asiar gues that he m ust be r ese ntenced bec ause the di str i ct c ourt ’ s dete rm i nati on o fhow m u c h to r educe th e l o ss a m o unt

—ba se d o n the f air m arke t va l ue o fthe se rv i ces he r endered

— w as not suffi ci entl y deta i l ed to const i tute a r eas onabl e e sti m ate bas ed on the ev id ence. H e as se r ts tha t t he di st r i ctc o ur t di d no t i den ti fy the f o r mul a o r me tho do l o g y i tu s e d a nd thu s di d n o tp r o v i de the par ti cul ar i ty re quir ed f orse ntenci ng dete rm i nati ons. W e di sa g r ee wi thBo r r as i ’ s co nt en ti o n. The g o ve r nm ent pr ove d the l oss val ue to be $647, 204. B or ra sidi d not ob j ec t t o that am ount, and he bo re the burden ofpro vi di ng“ su bs ta nt i at ed ev i den ce . . . to c o unt erthe g o ve r nm ent’ s e xpli ci t proo f ofl oss . ” U ni t e d S t at e s v. Gor don , 49 5 F.3 d 42 7, 43 2 (7 th C ir. 20 07 ). H e n ee d ed to co n vin c in gly refute th e govern m en t’s proof w ith his ow n, but there w as no t est i m ony as to the v al ue o fthe on- cal l se rv i ces, and ther e was m uch evi dence sho w i ng tha t the al l ege d ad m inist rative services w ere non ex tan t or de m inim is
. See U nited Sta tes v. Sensm eier, 36 1 F
. 3d 98 2, 98 9 (7th C ir. 2004 ) (“ [W ]hi l e we acknow l edge that the bur den i s o n th e g ov er n m en t t o p ro ve loss , t h e d efe n d an ts ’ w h olly un su bsta nt iated s tatem en ts are not enou gh to un d erm i ne , no r ev en ques ti o n, the c o ur t’ s ac ce pta nc e o fthe gov er nm ent’ s pro ofo fl oss. ”)
. W er e we to gi ve effect to each o fBorras i ’ s v ague val uati ons, i n f act, the cre dit s for se rv ices r endered would have exc e e de d the t ota l l oss proven bythe gov er nm ent. U l ti m ate l y, Bor ra sihas notN o. 09

- 4088 19

m et his he avy bu rd en of p roving th at th e d is t r ic t cou rt’s d e t er m in at ion w as “o u ts id e t h e re alm of p er m iss ible c o mput a t i o ns . ” U ni t e d S t at e s v. Pe t e rs on- Knox , 47 1 F
. 3d 816, 822 (7th C ir. 2006) ( quo ting U n i t e d S ta tes v. Lo pez , 222 F.3d 428, 437 (7th Cir. 2000)). T h e gover nm ent a rgues

— a n d fr o m th e c o l d r e c o r d we ar e in c l i ned to agr ee

— that “i fanythi ng, the dist ri ct cour t was o verly genero us i n cr edi ti ng Bor ra siwith $150 , 000” bec ause th e s er vi ces he al l ege dlyr endered w er e e ith er illu so ry or v alu ele ss . (A p p elle e’s B r. at36 -37 .) The dis tr i ct c ourtga ve Borr asithe benefi t o fthe doubt b y c re d itin g h is a lleg ed se rv ice s in an y a m ou n t, an d it is th e d ist r i ctc o ur t’ s l ac ko fs pec i fi ci tyi n do i ngs o tha t he now at tack s. Grante d, the di stric t co urt coul d have be en m or e s p ec ific in d isc u ss in g h ow it ca lcu lat ed t h e cr ed it aga i nst the l oss am ount g ener ate d by Bor ra si ’ s cr i m i nal acti vi ti es. But w e hav e pr evi ousl y found such est i m ati on re aso nabl e t o deter m in e the l oss am ount f orse ntenci ng, no tabl y i n a fr au d c as e i n w hi chf ac tu alc o m pl ex i ti es abo ut th e e x ist en c e an d v alu e of m ed ica l se rv ice s a b ou n d ed

. See U nite d State s v. Vivit, 214 F.3d 908 , 914-16 (7th C ir. 2000 ). Give n the com ple xi ti es ofthi s M edi care fra ud cas e, as w el l as the l ack ofev i dence to es tabl i sh the exi ste nce a n d v a l u e o fa n y l e g i t i ma t e l y r e n d e r e d s er vi ce s , we fin d th e d ist ric t c ou rt ’s e st im at e o f th e a m ou n t t o c re d it B orrasi r eason able. T he distric t c ou rt did not clearly err w he n it det erm ined the loss value a t tribute d to Borrasi’s cri m e.20 N o. 09

- 4088 2. Appl i ca t i on of

Le ade rs hip Enhan ce m e nt Bo rra si next ar gues that the di str i ct c ourtwas not j usti fi ed in asses si ng a f our- l eve l l eader shi p enhancem en t ag ains t hi m whi l e as se ss i ngo nly a two- l ev ele nha nc e men ta g a i ns tMamo o n. T he di s t r i c tc o ur ti nc r e a s ed Borr asi ’ s o ffense l eve l under U.S

. S. G. § 3 B1. 1( a) after fi nd i ng tha t he w as an o rg ani zero r l eadero fIntegr ate d and Rock Cre ek’ s cr i m i nalact i vi ti es. Bor ra siar gues that th e co ur t di d no t co ns i derthe a ppr o pr i at e enha nc ement fac tor s on the re cor d. H e al so ar gues that he w as on ly a m i d dl eman be twe enthe Int eg r at ed phy si ci an s an d th e Ro ckCr ee khi er ar ch y

— a hi er ar chy that incl ud ed M am oo n, w h o B or ra si v en om ou sly as se rt s s h ou ld have bor ne the br unt ofany l eader shi p enhancem ent. W e r ev i ew the di st r i ctc o ur t’ s f ac tu alf i ndi ngr eg ar di ng th e four-l evel enh an cem en t for clear error, and Borras i’ s ar gum ents do not l eave us with a “ fi rm and defi nite conv ict i on that a n er ro r has be en m ade. ” Ta nn er, 62 8 F
. 3d at 907
. The c o ur t ex pl i ci tly a do pte d the PS R’ s as se ss m en t ofthe l eader shi p enhancem ent. The PSR e xam i ned seve n fac to rs rele va n t in d et er m in in g B or ra si’s role in t h is c rim in al s c h em e, see U nited S ta tes v . Cu rb , 626 F. 3d 921, 92 4- 25 (7th Cir

. 20 10) , and concl ud ed that each s up port ed the e nhancem ent in thi s ca se. Of parti cu lar not e, Bor ra si acti vel y r ecr uit ed physi ci ans into hi s s chem e, co ntro l led th e I nt eg r at ed phy si ci an s, s o l i di fi ed an d e xpa nde d the r el at i o ns hi p b etween I nt eg r at ed an d Ro ckCr ee k, a nd est abl i shed Bai g’ s r ol e in Rock Creek ’ s a dm i ssi ons departm en t t o f a c ilita te th e s c h em e. See U nited Sta tes v. Ho use, 110 F. 3d 1281 , 12 84 ( 7t h Ci r. 19 97) ( affi rm i ng o rg ani zerN o. 09

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an d l ea dere nha nc ementwher e th e appe l l an t was the co m m o n c o nne ct i o n b etwee n the c r i m i na l s, wher e he “br ought

. . . p eo ple to gether, bo th i nd i vi du al l y a nd as a g r o up, t o fur th erthe b us i ne ss of the co ns pi r ac i es , ” an d w he re he h ad sub stan tial d ecision-m aking au th ority)
. A l though the di str i ct c ourtas se ss ed onl y a two- l eve l enhancem ent t o M am oo n, RockCree k’s C EO , heractual r o l e i n the fr au dul en t sc he m e was l es s ex ten si ve a nd funda m en ta l tha n Bo r rasi ’ s. W e co nc l ude tha t th e dist ri ct c ourtdi d not cl ear l y e rri n ass ess i ng a f our- l eve l enhancem ent t o Borr asibas ed on hi s r ol e in the offense.

3. Se nte ncing D is crepancy Borr asifi nal l y a rgu es that hi s s entence was unreasonab l e be cause i t was m uch l onge r than thati m posed o n hi s co - defen dan t. W e r ev i ew th e di st r i ct court’s s en tenci ng pro cedures, i ncl ud i ng its co nsi derat i on o fthe 18 U .S.C . § 35 53 (a) fa c to rs , deno vo . U nited Sta tes v. P ulley, 60 1 F .3d 66 0, 66 4 (7 th C ir. 20 10 ). I f th e c o u r t p ro p er ly ap p li ed those proc ed ure s, w e review t h e sen ten ce’s su b st an tiv e re as on ab len es s fo r an ab u se of d isc re tio n . Id. W he n d eterm in ing the ap p rop riate sente nc e for a g i ve n defen dan t, th e di st r i ct co ur t sh o ul d co ns i der “the ne ed to a vo i d unwar r an te d s en te nc e di spa r i ti es a m o ng defen dan ts with si m i l arr ec o r ds who ha ve b ee n fo und g ui l tyo fs i m i l arc o nduc t. ” 18 U. S
. C. § 3 55 3( a) ( 6)
. The dist ri ct c ou rt found that the guidel i nes r ange w as re asonab l e a nd f ai r f or Bor ra si, but gave hi m a m i ni m al dow nw ar d adj ustm ent a ccoun ti ng f orhi s m edi cal22 N o. 09

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ser vi ce t o und er - ser ved gr oup s; i t ul ti m ate l y s entence d hi m to 72 m on th s’ i ncarc er ati on. By co ntra st, the dist ri ct co ur t f o und Mam oo n’ s ca se t o b e o ut si de th e he ar tl an d ofthe sta tute, f ound her t o be th e c rit ical car egi verf or her prof ou n d ly disabl ed so n, and f ound the gui del i nes r a ng e t o b e c o ns i de r ab l y l o ng e r tha n ne c e s sar y t o pr ev en t M amoo n from r e- o ffen di ng ; i t ul ti m at ely s en te nc ed he r t o 6 months ’ i nc ar ce r at i o n. In de ny i ng Borr asi ’ s m oti on t o rec onsi der hi s s entence bas ed on th i s di s pa r i t y, the di s t r i c t c o ur t e xp l a i ne d tha t the di scre pancy i n sent enci ng was not onl y j ustifi ed but dem anded bythei r re specti ve acti ons and ci rcum sta nces. Borr asi n ow ar gues that a pl ai n appli cati on o f § 3 553( a) ( 6) m andates vacature ofhi s s entence i n l i ght o f M amoo n’ s, whi chhe c o m pl ains w as mar k edly l en i en t com pared to hi s o w n. W e di sag re e be cause § 3 553(a )(6) all ow s for w a rran teddi spari ti es am ong co- defe nd ants’ se n te n c es . P ulley, 601 F.3d at 668

. H ere, th e d istri ct cou rt m ade i nd i vi du al, part i cul ar i zed se ntenci ng dete rm i nati o ns ba se d o n th e § 35 53 ( a) f ac to r s as to Bo rrasi a nd M amoo n dur i ngb o ththe se nt en cinghe ar i nga nd the h ea rin g on B or ra si’s m ot ion for re c on sid er at ion . I t fol l o wed the a ppr o pr i at e pr o ce dur es a nd c o ns i der ed th e avo i dance ofdi spari ty i n arriv ing a t i ts sente nces. W e fi nd tha t th e di st r i ctc o ur t pr o per l y c al cul at ed th e g u i d e l i n e s r a n g e i n B o r r a s i ’ s c a s e a n d th a tth e b e l o wgu id elin es se n te n c e it im p os ed is re as on ab le. Se ei d. at66 8 ( “[ I ]f t h e d i str i ct c ourtpro vi des an a dequ ate st ate m ent o f r ea so ns , c ons i st en t wi th§ 3 55 3( a) , f o r b el i ev i ngtha t th e sente nce i s a pp ro pri ate , a n d i t i s withi n the Gu i del i nes r an g e, we pr es um e th e se nt en ce i s su bs ta nt i ve l y r easo n-N o. 09

- 4088 23 ab le.” ). A c c or d in gly , th e d is t r i c t c ou rtd id n oterr in se n te n c in g B or ra si.

III. C ON CLU SI ON The dist ri ct courterr ed i n nei theri ts evi denti ar y r ulings nori ts j ury i nstr ucti ons, so we A FFIRM t he district cou rt’s j u d gm en t o f co n vic tio n . Th e d ist ric t c ou rtrea s on ab ly estim ated the am o u nt of loss in d eterm ining B orrasi’ s o ffen se l ev el, pr o p erlye nha nc ed th e o ffen se l ev eldue to hi s l ea der sh i p r o l e, a nd c o r r ectl y co ns i der ed an d rej ecte d his di sparate sente nci ng ar gum ent. A ccor dingl y, w e A FFIRM the s e nt e nc e i mpo s e d.

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