*

Honorable Thomas J. Meskill, Senior U.S. Circuit Judge for the Second Circuit, sitting by

designation. 

United States Court of Appeals.

Eleventh Circuit.

No. 94-5112.

UNITED STATES of America, Plaintiff-Appellee,

v.

Perla Martin DAVIS, Marta Morfa, Emilio Valdes, Elva R. Lamas, Defendants-Appellants.

July 2, 1997.

Appeals from the United States District Court for the Southern District of Florida. (No. 93-367-CRUU-B), Ursula Ungaro-Benages, Judge.

Before HATCHETT, Chief Judge, COX, Circuit Judge, and MESKILL*

, Senior Circuit Judge.

HATCHETT, Chief Judge:

Appellants Perla Martin Davis, Elva Lamas, Marta Morfa and Emilio Valdes, M.D., were

convicted in a complex Medicare fraud scheme. On appeal, appellants challenge their convictions

and sentences on a number of grounds, including insufficient evidence, erroneous jury instructions,

failure to charge the jury on an element of the offense, admission of uncharged criminal conduct

evidence, exclusion of expert psychological testimony, prejudicial prosecutorial comments, failure

to grant sentencing departures, and improper assessment of restitution. We affirm the restitution

orders assessed against appellants Davis, Lamas and Morfa, and the judgments and sentences that

the district court entered in all other respects.

BACKGROUND

In August of 1993, a grand jury returned a 23-count Medicare fraud indictment against the

appellants and eight other defendants. The indictment charged each of the twelve with conspiring,

in violation of 18 U.S.C. § 371, to (a) "defraud the United States by impeding, impairing and

obstructing the function of the Department of Health and Human Services in administering the

Medicare Program," and (b) commit offenses against the United States, including violations of the

False Claims Statute, 18 U.S.C. § 287, and the Anti-Kickback Statute, 42 U.S.C. § 1320a-7b (Count
 1

The indictment charged Davis in Counts 2, 3, 8 and 9; Morfa in Counts 10 and 14; Lamas

in Count 16; and Valdes in Counts 4, 7, 8 and 10. 

1). Counts 2-16 of the indictment charged various defendants, including appellants, with substantive

violations of the False Claims Act.1 Counts 17-23 included indictments for violations of 42 U.S.C.

§ 1320a-7b. The grand jury charged both Davis and Morfa with violating the Anti-Kickback

Statute: Davis in Count 19 and Morfa in Counts 21-23. The eight codefendants, including Frank

Morfa, Perla Morfa, Celia Morfa Martin, Mario Fonesca, Ana Conde, Luis Mateus, Sandra Mayorga

and Nora Vega, subsequently pleaded guilty, leaving appellants to proceed to trial.

The government alleged that the appellants and their co-defendants executed the Medicare

fraud scheme through the operation of sixteen related companies (the Morfa companies). Certain

members of the Morfa extended family, including appellants Davis, Lamas and Morfa, owned,

operated and worked for the businesses at different times during the course of the conspiracy. Over

a period of several years, the Morfa companies submitted false claims and billed Medicare for

medically unnecessary nutritional supplements and feeding supply kits, ostensibly for the purpose

of parenteral and enteral nutritional (PEN) therapy, the majority of which the intended patients never

received. Participants in the scheme included (1) recruiters, who solicited patients through whom

Medicare could be billed fraudulently without their knowledge; (2) physicians, such as Valdes, who

signed blank Certificates of Medical Necessity (CMNs) which authorized the issuance of PEN

therapy medical supplements and supply kits for the recruited patients, regardless of their medical

necessity and the patients' eligibility to receive such products; and (3) managers, who paid the

recruiters to locate Medicare-eligible participants, paid the physicians for signing false CMNs, and

ran the actual Medicare billing operation—completing the fraudulent CMNs, preparing falsified

Medicare claim forms and monthly summaries, and filing the documents with Medicare seeking

reimbursement.

On July 20, 1994, the United States District Court for the Southern District of Florida granted

judgments of acquittal on the false claims count against Lamas (Count 16), and one false claims

count against Morfa (Count 14). On August 1, 1994, the jury returned guilty verdicts on most of
 2

Lamas only received the guilty verdict on the conspiracy count following the district court's

dismissal of the substantive false claims charge. 

 3

We do not find appellants' arguments persuasive regarding the remaining issues raised in this

appeal, and, deciding that the district court did not commit reversible error, we dispose of them

without additional comment. See Eleventh Circuit Rule 36-1. 

the offenses charged in the indictment. Each appellant received a guilty verdict on Count 1, the

multiple-object conspiracy. In addition to the conviction on Count 1, Davis received guilty verdicts

on Counts 2, 3, 8 and 9, and an acquittal on Count 19; the jury declared Morfa guilty on Counts 10,

21, 22 and 23; and Valdes was found guilty on Counts 4, 7, 8 and 10.2 In October of 1994, the

district court sentenced Davis to forty-one months, Lamas to forty-six months and Morfa to forty-six

months of imprisonment. Pursuant to the information and recommendations found in the appellants'

Presentence Investigation Reports (PSR), the court ordered them to pay restitution jointly and

severally to the United States Department of Health and Human Resources (HHR) in installments

as the Bureau of Prisons instructed. The district court imposed the following restitution amounts:

$9,182,271.40 for Davis, $8,119,445.40 for Lamas and $8,119,445.00 for Morfa. Valdes received

a sentence of thirty months imprisonment; the court also ordered Valdes to pay $261,896.73 in

restitution.

ISSUE

The issue is whether the district court committed plain error in ordering appellants Davis,

Lamas and Morfa to pay restitution jointly and severally, without making the proper factual findings

regarding the amount of loss and appellants' respective abilities to pay.3

CONTENTIONS

The appellants argue that the district court (1) plainly erred in imposing restitution on them

for amounts greater than their specific contributions to the conspiracy; and (2) plainly erred in

failing to make the requisite factual findings regarding each appellant's ability to pay.

The government counters that the district court may attribute the total loss associated with

the conspiracy to a particular conspirator when imposing restitution. A defendant is liable for the

foreseeable acts of co-conspirators. While indigence is a consideration, it is, nonetheless, one of
 4

We acknowledge that Congress substantially amended sections 3663 and 3664 in 1996. See

Antiterrorism and Effective Death Penalty Act of 1996, Pub.L. No. 104-132, Title II, §§ 205(a),

206(a), 110 Stat. 1214, 1229-31, 1232-36 (Apr. 24, 1996), codified at 18 U.S.C.A. §§ 3663, 3664

(West Supp.1997). We need not apply the amended versions to these facts, however, because

the amendments are only effective "for sentencing proceedings in cases in which the defendant is

convicted on or after Apr. 24, 1996." 18 U.S.C.A. §§ 3663, 3664 note (West Supp.1997). All

future references to the VWPA within this opinion are to its pre-1996 amendment version. 

many factors and does not itself bar an order of restitution. Because the appellants did not dispute

the relevant facts at trial, the government contends that the district court was not required to make

explicit factual findings on the restitution issue.

DISCUSSION

In this appeal, appellants challenge the restitution order on two grounds: the district court

erred in determining the amount of loss attributable to each appellant for restitution purposes; and

the district court failed to make findings as to each appellant's ability to pay the restitution amount.

The Victim and Witness Protection Act of 1982 (VWPA), 18 U.S.C. §§ 3663-64, empowers the

district court to award restitution to victims. The VWPA enumerates those factors which a district

court must consider before imposing a restitution order. Section 3664(a) provides:

The court, in determining whether to order restitution under section 3663 of this title and the

amount of such restitution, shall consider the amount of the loss sustained by any victim as

a result of the offense, the financial resources of the defendant, the financial needs and

earning ability of the defendant and the defendant's dependents, and such other factors as the

court deems appropriate.

18 U.S.C. § 3664(a) (1994).4

 The court must award restitution "in accordance with sections 3663

and 3664." United States v. Twitty, 107 F.3d 1482, 1493 (11th Cir.1997) (quoting 18 U.S.C. §

3556).

 This court ordinarily reviews a district court's restitution order for abuse of discretion.

United States v. Remillong, 55 F.3d 572, 574 (11th Cir.1995). The court reviews the legality of the

restitution order de novo. United States v. Cobbs, 967 F.2d 1555, 1556 (11th Cir.1992). The

appellants admit, however, that they did not dispute the restitution order at sentencing. Moreover,

the appellants did not state any objections to their PSRs on the issue of restitution. A defendant's

failure to challenge a restitution order at sentencing constitutes a waiver of the objection. United

States v. Stinson, 97 F.3d 466, 468 n. 1 (11th Cir.1996), cert. denied, --- U.S. ----, 117 S.Ct. 1007,
136 L.Ed.2d 885 (1997). The appellants were obligated to preserve this issue for appeal, and their

silence in the face of that duty precludes us from addressing the merits of their contentions absent

a showing of manifest injustice. Effective appellate review is hindered when the asserted error has

not been brought to the district court's attention. Under these facts, therefore, we will review the

restitution orders for plain error. See United States v. Obasohan, 73 F.3d 309, 310-11 (11th

Cir.1996) (absent manifest injustice, this court will not entertain an appeal of a restitution order if

the defendant failed to raise an objection to the district court); see also Cobbs, 967 F.2d at 1557-58

(if plain error exists, this court may review the claim).

1. The Amount of Loss

 The appellants fail to show any error in the district court's measure of restitution assessed

on behalf of HHR. The appellants contend that the district court did not properly tailor the amount

of restitution to each appellant's specific conduct within the conspiracy. In Obasohan, this court

held that a district court may order a defendant to pay restitution for losses "which result from acts

done in furtherance of the conspiracy of which the defendant is convicted." 73 F.3d at 311. After

careful review of the record, we conclude that the district court did not commit error, plain or

otherwise, in calculating the amount of loss attributable to the appellants.

 A conspiracy is an ongoing criminal activity for which a participant remains culpable until

the conspiracy ends or the participant withdraws. Hyde v. United States, 225 U.S. 347, 369, 370,

32 S.Ct. 793, 56 L.Ed. 1114 (1912). "Congress intended restitution to be tied to the loss caused by

the offense of conviction." Hughey v. United States, 495 U.S. 411, 418, 110 S.Ct. 1979, 1983, 109

L.Ed.2d 408 (1990). Where the defendant is convicted of conspiracy to defraud, the district court

has "the authority to order restitution for the losses caused by the entire fraud scheme, not merely

for the losses caused by the specific acts of fraud proved by the government at trial." United States

v. Brothers, 955 F.2d 493, 497 (7th Cir.), cert. denied, 506 U.S. 847, 113 S.Ct. 142, 121 L.Ed.2d 94

(1992).

 Each appellant herein had a sufficiently substantial involvement in the fraud scheme to

warrant the restitution amount that the district court ordered. See United States v. Barnette, 10 F.3d
1553, 1556 (11th Cir.), cert. denied, 513 U.S. 816, 115 S.Ct. 74, 130 L.Ed.2d 28 (1994)(granting

restitution to the extent justice requires). Our conclusion follows the general proposition that a

defendant is liable for reasonably foreseeable acts of others committed in furtherance of the

conspiracy of which the defendant has been convicted. See, e.g., United States v. Ismond, 993 F.2d

1498, 1499 (11th Cir.1993). The appellants herein were thoroughly involved in this scheme to

defraud the Medicare system. Accordingly, the district court properly relied on the information

contained in the PSRs to render the appellants jointly and severally liable for the losses resulting

from the enterprise. The court did not plainly err in imposing restitution on each appellant based

on the acts of all those involved in the scheme for the period that the appellant was involved. See

United States v. Plumley, 993 F.2d 1140, 1142 (4th Cir.), cert. denied, 510 U.S. 903, 114 S.Ct. 279,

126 L.Ed.2d 230 (1993).

2. Ability to Pay

 The appellants also do not demonstrate that the district court failed to consider the

appellants' financial resources, such that the restitution order can be deemed manifestly unjust. The

statute requires that the district court "consider" the factors listed above prior to imposing restitution.

18 U.S.C. § 3664(a). This court has held that the district court must "evaluate the defendant's

financial condition and ability to pay before determining the restitution amount...." Remillong, 55

F.3d at 574 (citations omitted) (emphasis added).

 Neither the statute nor this court requires the district court to make specific factual findings.

Twitty, 107 F.3d at 1493 ("District courts are not obligated to make explicit factual findings of a

defendant's ability to pay restitution if the record provides an adequate basis for review."); see also

United States v. Hairston, 888 F.2d 1349, 1352-53 (11th Cir.1989). In order to warrant a reversal

of the restitution order, the challenging party must show that the "record is devoid of any evidence

that the defendant is able to satisfy the restitution order." Remillong, 55 F.3d at 574 (internal

quotation marks omitted). The appellant's burden is particularly acute under the plain error standard

of review.

 Under these facts, the record shows that the district court considered each appellant's ability
to pay prior to imposing restitution. The sentencing transcripts reveal that the district court noted

its reliance upon the information contained in each appellant's PSR. The PSRs assessed the

appellants' financial resources and capacities for future earnings. Each PSR recommended that the

appellant would be able to make monthly payments toward restitution. "A defendant who disputes

his ability to pay restitution bears the burden of demonstrating his financial resources by a

preponderance of the evidence." Twitty, 107 F.3d at 1494 n. 14; see also 18 U.S.C. § 3664(d)

(1994). A defendant's failure to present contrary evidence authorizes the district court to rely on the

information provided in the PSR. Twitty, 107 F.3d at 1494 n. 14.

Our prior decision in United States v. Page, 69 F.3d 482 (11th Cir.1995), does not compel

resentencing under the facts at issue. In Page, this court found plain error where the district court

did not provide the defendants with an opportunity to object to its findings of fact or conclusions of

law as required under United States v. Jones, 899 F.2d 1097, 1102 (11th Cir.), cert. denied, 498 U.S.

906, 111 S.Ct. 275, 112 L.Ed.2d 230 (1990), overruled on other grounds, 984 F.2d 1136 (11th

Cir.1993) (en banc ). Page, 69 F.3d at 492-93. Moreover, although the district court had adopted

wholesale the recommendations in the PSR, this was deemed insufficient because the district court

neglected to consider the defendants' objections. Page, 69 F.3d at 494. Furthermore, the record

demonstrated that the district court recognized one defendant's inability to pay the restitution

imposed. Page, 69 F.3d at 494. Our opinion in Page, therefore, stands only for the proposition that

"the wholesale adoption of the PSR at the commencement of the sentencing hearing, without more,

does not suffice to meet the court's obligation under 18 U.S.C. § 3664(a) and under Remillong to

consider a defendant's financial resources before imposing restitution." Page, 69 F.3d at 493-94.

The facts herein demonstrate that the district court sought input from the appellants. As in

Page, the district court acknowledged the information in the PSR and adopted its factual findings

regarding the appellants' abilities to pay restitution. Unlike Page, however, the court reviewed the

appellants' objections to the PSRs. The court then specifically asked each appellant and counsel

whether they objected to the court's findings of fact or the sentence imposed. No appellant took

exception to the restitution order. Where the PSR provides a detailed account of the "amount of the
loss sustained by the victim, the defendant's financial resources, and other factors enumerated in

Sections 3663-3664 as appropriate for the court to consider when imposing restitution[,] ... the

record provides an adequate basis for review of the restitution order[ ]." Twitty, 107 F.3d at 1493-

94. We cannot find plain error where the district court adopts a PSR supporting its restitution order,

provides the defendant with the chance to object, and considers any objections raised. While the

district court must explain its decision to reject any challenges to the restitution order, we can

impose no such burden where the defendant fails to avail himself of the opportunity to object.

Upon review of the record, we conclude that the district court did not plainly err in

determining appellants' restitution amounts. Even though the district court did not make any explicit

factual findings as to appellants' abilities to pay restitution, the record does reveal that the district

court considered appellants' abilities to pay as a factor. The district court gave each appellant an

opportunity to object to the restitution amount and encountered silence. The district court has only

the duty to consider the defendant's ability to pay; it does not have a duty to make a specific factual

finding. Twitty, 107 F.3d at 1493. Under these circumstances, the appellants have not shown that

the district court failed to honor that obligation. Accordingly, we affirm the district court's

restitution orders.

AFFIRMED.