FI LED U. S . COURT OF AP PE ALS E L E V E N T H C IR C U IT Febr uar y 21, 2008 T HOM AS K. KAHN CL E RK [ DO NO T P UB L I S H] I N THE UN I TE D STATE S C OU RT OF APPE ALS F O R T H E E L E V E N T H C IR C U IT

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_________________________ ( F e b r u ar y 21, 2008) B efo re T JO F L A T , B L A C K an d F A Y , C i rcu i tJu d g es. P E R C U R I A M:2

U do U do E kpo, J r . appe a l s hi s c onvi c t i on a nd 27- m onth s e nt e nc e f or11 c o u n ts o f h e a lth c a r e f

r a u d , in v io la tio n o f

1 8 U .S .C . § § 1 3 4 7 a n d 2 . F ir s t, a s to h is conv i ct i on , E kp o argues thatthere w as i nsuffi ci entevi dence t o sup po rta j ury in s tru c tio n o n d e lib e r a te ig n o r a n c e b e c a u s e th e e v id e n c e d e m o n s tr a te d th a t h e d id notbe l i e ve tha the w a s doi ng a ny thi ng w r ong, a nd tha the di d notl e a rn of the f r a udul e ntc l a i m s unt i l w e l l a f t e rthe y ha d be e n s ubm i tt e d. A c c or di ngl y , E kpo a s s e r ts th a t th e r e w a s n o e v id e n c e to s u g g e s t th a t h e d e lib e r a te ly a tte m p te d to a v o id th e tru th . S ec on d, as t o h i s s ent ence , E kp o argues thatthe di stri ctcourtcl ea rl y e rr ed by f i ndi ng tha the s houl d notr e c e i ve a ny c r e di ta ga i ns tthe c a l c ul a t e d l os s a m ount for the m ot ori ze d scoot er s, al so kn ow n as pow erop er at ed vehi cl es (“ P O V ”) , that he s ol d t o the M e di c a r e be ne f i c i a r i e s i n the tr a ns a c t i ons a ti s s ue , a s s e r t i ng tha tthe e v id e n c e s h o w s th a t h e d id n o t in te n d f o rM e d ic a r e to s u f

f e rac o m p le te lo s s . T hi r d, E kpo a r gue s tha tthe di s tr i c tc our te rr e d by appl y i ng a n e nha nc e m e ntf or obs truc t i on of

j us t i c e be c a us e i tr e l i e d on the j ury ’ s gui l ty ve r di c t , a nd di d not m a ke a n i nde pe nde ntf

a c tua l f i ndi ng tha the ha d c om m i tt e d pe r j ury . F our th, E kpo ar gu es thathi s s ent ence i s proce du ra l l y unrea sonabl e bec ause the di stri ctcourt i m prop er l y app l i ed a pres um pt i on i n favor of a se nt ence w i thi n the advi sory g u i d e l i n e r a n g e , f

a i l e d t o c o n s i d e rth e s e n t e n c i n g f a c t o r s e n u me r a t e d i n 1 8 U . S. C. § 3553( a ) , a nd f

a i l e d t o e xpl a i n i t s r e a s ons f ori m pos i ng as e nt e nc e w i thi n the3

g u id e lin e r a n g e . E kp o a ls o a r g u e s th a t h is s e n te n c e is s u b s ta n tiv e ly u n r e a s o n ab le be c a us e the c our tf

a i l e d t o c ons i de rthe § 3553( a ) f a c t or s s e pa r a t e l y a nd apa r tf r om the S ent enci ng G ui del i nes. L as t , E kp o argues that , by consi deri ng 24 addi t i on al a l l e ge dl y f

r a udul e nttr a ns a c t i ons notc ha r ge d i n the i ndi c tm e nt , orf ound by the j ury be y ond ar e a s onabl e doubt , the di s tr i c tc our ti nc r e a s e d hi s s e nt e nc e above the p erm i tt ed st atu t o ry m ax i m u m i n v i o l at i o n o f h i s S i x th A m en d m en tri g h t s. F orthe r e a s ons s e tf

or th m or e f

ul l y be l ow , w e a f

f i rm E kpo’ s s e nt e nc e a nd c onvi c t i on. E kp o o w n ed a b u sin es s, V & A S er v ices , d /b /a V & A M ed ical S u p p li es (“V & A ” ) , w h ic h h e e n r o lle d a s ad u r ab le m e d ic a l e q u ip m e n t ( “D M E ” ) s u p p lie rw ith M e d ic a r e . I n th e e n r o llm e n t ap p lic a tio n , E kp o a g r e e d th a t V & A w o u ld s u b m it truthf ul , a c c ur a t e , a nd c om pl e t e M e di c a r e c l a i m s , a nd f ur the ra gr e e d tha tthe c o m p a n y w o u ld b e r e s p o n s ib le f o ra ll c la im s s u b m itte d b y its e m p lo y e e s o ra g e n ts . E kp o a ls o p r o m is e d th a t V & A w o u ld r e s e a r c h a n d c o rr e c t c la im d is c r e p a n c ie s . M edi ca re i s autho ri ze d t o p ayfor m edi ca l l y nec es sa ryequi pm entsuch as po w er w h e e l c h a i r s a n d a c c e s s o r i e s th a ta r e p r o v i d e d t o b e n e f i c i a r i e s b y a u th o r i z e d D ME s u p p lie r s , s u c h a s V & A , w h o a r e e n r o lle d w ith M e d ic a r e . A n F B I i nv es t i gat i on re veal ed thatE kp o cause d fal se cl ai m s f or po w er w h eel ch ai rs t o b e su b m i tt ed t o M ed i care o n b eh al f o f 1 2 d i fferen tb en efi ci ari es, w hen, i n actual i ty, P O V s w er e provi ded t o tho se benefi ci ar i es i nst ea d. P O V s w er e4

as si gn ed a s peci fi c M edi ca re bi l l i ng code, and p ay m ent s f or tho se cl ai m s w er e l i m i t ed t o $ 1, 80 9. 43 . P ay m ent s f or po w erw heel chai rs , ho w ever , exce eded $4 , 00 0. 00 . In addi t i on t o the fa l se cl ai m s f or po w erw heel chai rs , E kp o al so caused f a ls e c la im s f

o rw h e e lc h a ira c c e s s o r ie s to b e s u b m itte d to M e d ic a r e in o r d e rto re cover other e xp ense s f or w hi ch he bel i eved V & A had n otprop er l y bee n r e i m bur s e d. M or e ove r , M e di c a r e m a de 24 a ddi t i ona l pa y m e nt s f orf r a udul e nt c l a i m s s ubm i tt e d by V & A , r e s ul t i ng i n at ot a l l os s a m ountof $164, 590. 43. I. A chal l enge t o a j ury i nstruct i on pres ent s aqu es t i on of l aw thatw e r evi ew d e n o v o . U n ite d S ta te s v . S to n e , 9 F .3 d 9 3 4 , 9 3 7 ( 1 1 th C ir . 1 9 9 3 ) . A d e lib e r a te i gn orance i nstruct i on i s notapprop ri at e w here the evi dence onl y poi nt s t o ei ther ac tual kn ow l edge or no kn ow l edge on the partof the defendant . S uch an i ns truc t i on “ i s appr opr i a t e onl y w he n the r e i s e vi de nc e i n the r e c or d s how i ng the defe nd antpu rposel y c on tri ved t o avo i d l ea rni ng the truth. ” I d. (quo t at i on om i tt ed). A n err on eous del i bera t e i gn orance i nstruct i on i s notre vers i bl e e rr or per s e, ho w ever . W hen a di stri ctcourtcom m i t s e rr or i n g i vi ng a del i bera t e i gn orance i nstruct i on because there i s i nsuffi ci entevi dence t o sup po rti t , the error c an no nethel es s be harm l es s dependi ng on the w ordi ng of the i nstruct i on . Id. at 9 3 7 - 3 8 . T h e e rr o ris h a rm le s s a s am a tte ro f la w w h e r e ( 1 ) “th e ju ry w a s c le a r ly i nstruct ed thata pre cond i t i on t o i t s app l i ca t i on of the del i bera t e i gn orance5

in s tru c tio n w a s p r o o f

b e y o n d ar e a s o n ab le d o u b t th a t [ th e d e f e n d a n t] d e lib e r a te ly ke pthi m s e l f

i gnor a nt , ” a nd ( 2) the e vi de nc e w a s s uf f i c i e ntt o s uppor tac onvi c t i on base d o n actual kn ow l edge, bu tno tnece ss ar i l y overw hel m i ng . S t on e, 9 F . 3d at 937- 39. T hi s i s be c a us e j ur i e s a r e pr e s um e d t o f ol l ow the j udge ’ s i ns truc t i ons . I d. a t 9 3 8 . H er e, the di stri ctcourtprop er l y i nstruct ed the j ury thati thad t o fi nd that E kp o w as del i bera t el y i gn orantbeyond a r ea sonabl e dou bt , and i ti s pre sum ed that the j ury f ol l ow e d the j udge ’ s i ns truc t i ons . S e e i d. a t938- 39. M or e ove r , the di s tr i c tc our ti ns truc t e d the j ury on a c tua l know l e dge , a nd the r e i s s uf f i c i e nt e v id e n c e to s u p p o r t ac o n v ic tio n b a s e d o n a c tu a l k n o w le d g e . A ttr i a l , E kpo de ni e d tha the ha d a ny know l e dge of M e di c a r e bi l l i ng pr oc e dur e s a nd s t a t e d tha thi s s on, I ni , w a s r e s pons i bl e f ors ubm i tt i ng a l l of V & A ’ s c l a i m s t o M e di c a r e e l e c tr oni c a l l y . H e a l s o i ndi c a t e d tha the di d not s u p e rv is e h is s o n ’s w o rk b e c a u s e h e la c k e d e x p e r tis e in M e d ic a r e b illin g a n d d id notknow a ny of

the bi l l i ng c ode s . E kpo de ni e d know l e dge of the f r a udul e nt c l a i ms s u b mi tt e d b y h i s s o n a n d i n s i s t e d th a th e d i d n o tl e a rn ab o u tth o s e c l a i ms u n t i l w el l aft er th e fact , w h en h e received n o t i ce th atso m e o f th e b en efi ci ari es’ M e d ic a r e s u m m a r ie s in d ic a te d th a t th e y w e r e b ille d f o rite m s th e y d id n o t r e c e iv e . I n c ontr a s t , B r i dge ttF l ournoy , af orm e rV & A e m pl oy e e , t e s t i f i e d tha ts he c o n f r o n te d E kp o ab o u t th e ite m s th a t w e r e b ille d to M e d ic a r e , b u t n o t d e liv e r e d to6

th e b e n e f i c i a r i e s , a n d i n d i c a t e d th a tEkp o s t a t e d th a th e w a s try i n g t o r e c o v e rs o me o f th e m o n e y h e h a d s p e n t o n p u r c h a s in g , d e liv e r in g , a n d s e rv ic in g aw h e e lc h a irto a part i cul arcust om er . F l ou rnoy’ s t es t i m on y w as corr ob orat ed by a r ec orded t e l e phone c onve r s a t i on s he ha d w i th E kpo, w ho a c know l e dge d tha tde l i ve r i ng a P O V to ab e n e f

ic ia ry , b u t b illin g M e d ic a r e f o rap o w e rw h e e lc h a irc o u ld “e a s ily g e t s o m e b o d y in to tr o u b le ,” a n d f u r th e ra d m itte d th a t “[ a ]ll [ h e ] h a d w a n te d w a s to f i nd a ny w he r e t o ge tm one y ba c k . . . . M one y tha t[ he ] ha d s pe nton [ the cust om er ’ s] chai r. ” M oreover, on cr oss- exam i nat i on , E kp o adm i tt ed thathe di re ct ed em pl oyee Im e I kp e t o p re pare ce rt i fi ca t es of m edi ca l nece ss i ty a nd del i veryt i cket s f or po w er w he e l c ha i r s r a the rtha n the P O V s tha tw e r e pr ovi de d t o the be ne f i c i a r i e s , a nd expres se d con ce rn thatIkpe had recorded thatthe benefi ci ar i es had rece i ved s c oot e r s on de l i ve ry t i c ke t s a nd othe rdoc um e nt s . E kpo a l s o a dm i tt e d tha the di re ct ed Ikpe t o i ncl ud e i t em s s uch as f oo tre st s a nd se atbel t s on the del i very t i cket s, even tho ug h h e knew thatP O V s di d n otcom e w i th such acce ss ori es . In addi t i on , E kp o ackno w l edged thatthere w er e r es ou rc es avai l abl e t o D M E supp l i er s t o a s s i s tthe m w i th M e di c a r e que s t i ons , buts t a t e d tha the di d nott a ke a dva nt a ge of th o s e r e s o u r c e s . W h en a d efen d an tch o o ses t o t est i fy, w e h av e h el d th at“ a st at em en tb y a de f e nda nt , i f

di s be l i e ve d by the j ury , m a y be c ons i de r e d a s s ubs t a nt i ve e vi de nc e of7

th e d e f e n d a n t's g u ilt. . . . T o b e m o r e s p e c if ic . . . w h e n ad e f

e n d a n t c h o o s e s to t e s t i f y , he runs the r i s k tha ti f di s be l i e ve d the j ury m i ghtc onc l ude the oppos i t e of hi s t e s t i m ony i s true . ” U ni t e d S t a t e s v. B r ow n, 53 F . 3d 312, 314 ( 11th C i r . 1995) (quo t at i on om i tt ed). B ec ause the fa ct s e st abl i shed attri al supp orta f i nd i ng that E kp o w as ei ther a ctual l y a w ar e of the fr audu l entcl ai m s thatw er e bei ng subm i tt ed t o M edi ca re , or, al t ernat i vel y, consci ou sl y a vo i ded l ea rni ng abou tM edi ca re rul es a nd r e gul a t i ons s o a s t o a voi d l e a rni ng aboutthos e c l a i m s , the di s tr i c tc our tdi d not c l e a r l y e rri n i ns truc t i ng the j ury on both the or i e s of a c tua l know l e dge a nd del i bera t e i gn orance. A cc ordi ng l y, w e a ff i rm as t o thi s i ss ue. II . U nde rU . S . S . G . § 2B 1. 1, the ba s e of f e ns e l e ve l f

orathe f tof f e ns e i nvol vi ng frau d o r d ecei ti s si x . W h ere th e resu l t i n g l o ss ex ceed s $ 5 , 0 0 0 , th e b ase o ffen se l ev el i n creases. U . S . S . G . § 2 B 1 . 1 (b )(1 ). A l o ss o f m o re th an $ 1 2 0 , 0 0 0 b u tl ess th an $ 2 0 0 , 0 0 0 ad d s 1 0 l ev el s. U . S . S . G . § 2 B 1 . 1 (b )(1 )(F ). In cal cu l at i n g l o ss a m ount s , “ l os s i s the gr e a t e rof a c tua l l os s ori nt e nde d l os s . ” U . S . S . G . § 2B 1. 1, com m ent . (n. 3(A )) . “ A ctual l oss” i s the re as on abl y f ores ee abl e pec un i ary harm re sul t i ng fr om the offens e, and “ i nt ended l oss” i s the pecuni ary harm thatw as i nt e nde d t o r e s ul tf

r om the of

f e ns e . U . S . S . G . § 2B 1. 1, c om m e nt . ( n. 3( A ) ( i ) a nd ( ii) ) . W e r e v ie w th e d is tr ic t c o u r t’s a m o u n t- o f - lo s s d e te rm in a tio n f

o rc le a re rr o r .8

U ni t e d S t a t e s v. C abr e r a , 172 F . 3d 1287, 1292 ( 11th C i r . 1999) . T he gove rnm e nt be a r s the bur de n of

e s t abl i s hi ng the a ttr i but abl e l os s by apr e ponde r a nc e of the e vi de nc e . S e e U ni t e d S t a t e s v. P ol a r , 369 F . 3d 1248, 1255 ( 11th C i r . 2004) (a d d re ss in g th e a p p li ca b il ity o f G u id elin es p ro v isio n s th at in cr ea se a d ef en d an t’ s of f e ns e l e ve l i n the c ont e xtof a n of f e ns e i nvol vi ng c ount e r f e i ti m m i gr a t i on s t a m ps ) . “ T he di s tr i c tc our t ’ s f a c tua l f i ndi ngs f orpurpos e s of

s e nt e nc i ng m a y be b a s e d o n , a m o n g o th e rth in g s , e v id e n c e h e a r d d u r in g tr ia l, u n d is p u te d s ta te m e n ts in the P S I , ore vi de nc e pr e s e nt e d dur i ng the s e nt e nc i ng he a r i ng. ” I d. “ T he s e n te n c in g g u id e lin e s r e c o g n iz e th a t o f te n th e a m o u n t o f

lo s s c a u s e d b y f

r a u d is di ff i cul tt o d et erm i ne ac cura t el y. T hu s, court s m ayre as on abl y e st i m at e that a m o u n t.” U n ite d S ta te s v . M ille r , 1 8 8 F .3 d 1 3 1 2 , 1 3 1 7 ( 1 1 th C ir . 1 9 9 9 ) . H ow e ve r , “ [ w ] hi l e e s t i m a t e s a r e pe rm i s s i bl e , c our t s m us tnots pe c ul a t e c onc e rni ng the e xi s t e nc e of

af a c tw hi c h w oul d pe rm i tam or e s e ve r e s e nt e nc e unde rthe g u id e lin e s .” U n ite d S ta te s v . S e p u lv e d a , 1 1 5 F .3 d 8 8 2 , 8 9 0 ( 1 1 th C ir . 1 9 9 7 ) . T he re cord i nd i ca t es thatE kp o d i d n otand d oes notno w di sput e that M e di c a r e a c tua l l y pa i d c l a i m s f orpow e rw he e l c ha i r s a nd a c c e s s or i e s t ot a l i ng $1 64 , 59 0. 43 . R ather, E kp o ass ert s thathe di d n oti nt end for M edi ca re t o suffe r a c o m p le te lo s s a s ar e s u lt o f h is f r a u d u le n t c o n d u c t a n d c o n te n d s th a t, a s ar e s u lt, th e c o u r t e rr e d b y f

a ilin g to r e d u c e th e lo s s a m o u n t b a s e d o n w h a t M e d ic a r e w o u ld ha ve pa i d f

orthe P O V s tha tw e r e a c tua l l ypr ovi de d t o the be ne f i c i a r i e s . T he9

appl i ca t i on no t es t o U . S . S . G . § 2 B 1. 1 p rovi de thatthe l oss a m ou nti s t o b e r educed by the am ou ntof m on eyor the fa i r m arketval ue of prop erty or s ervi ce s r endered tha ti s r e turne d t o the vi c t i m be f or e the of

f e ns e w a s de t e c t e d. U . S . S . G . § 2B 1. 1, com m ent . (n. 3(E )( i )) . B ec ause there i s no evi dence i n the re cord t o sho w that V & A r e tu rn e d a n y o f

th e mo n e y i tr e c e i v e d f r o m M e d i c a r e f

o ra n y o f th e c l a i ms ati ssu e, th e d i stri ctco u rtd i d n o tcl earl y err i n refu si n g t o ap p l y a cred i tt o th e l o ss a m ountf orthe va l ue of

the P O V s tha tw e r e di s tr i but e d. S i m i l a r l y , the r e i s no e v id e n c e in th e r e c o r d to s h o w th a t th e b e n e f ic ia r ie s w o u ld h a v e b e e n m e d ic a lly e l i gi bl e t o r e c e i ve P O V s . A l though the di s tr i c tc our tdi d note xpr e s s l y m e nt i on the t erm s “ ac tual ” a nd “ i nt ended” l oss i n o verrul i ng E kp o’ s obj ec t i on , i ti nd i ca t ed that i tco n si d ered th e d i fferen ce b etw een th e tw o am o u n t s an d fo u n d th atth e actu al l o ss w a s gr e a t e r . F ora l l the s e r e a s ons , the di s tr i c tc our tdi d notc l e a r l y e rrby f i ndi ng th a t E kp o w a s r e s p o n s ib le f o ralo s s a m o u n t o f

$ 1 6 4 ,5 9 0 .4 3 , a n d w e a f f irm a s to thi s i ss ue. II I. F o r a n o b stru ctio n o f ju stice e n h an ce m en t, w e r ev iew th e d istrict co u rt’s f in d in g s o f

f a c t f o rc le a re rr o ra n d th e ap p lic a tio n o f th e G u id e lin e s to th o s e f a c ts de no vo . U ni t ed S t at es v. M as se y, 44 3 F . 3d 81 4, 81 8 (11 th C i r. 20 06 ). “ F or a f a c tua l f i ndi ng t o be ‘ c l e a r l y e rr one ous , ’ thi s c our t , ‘ a f t e rr e vi e w i ng a l l of

the evi dence, m ustbe l ef

tw i th a defi ni t e a nd fi rm conv i ct i on thata m i st ake has been10

com m i tt ed. ’ ” U ni t ed S t at es v. R od ri gu ez -L op ez , 36 3 F . 3d 11 34 , 11 37 (11th C i r. 2004) ( c i t a t i on om i tt e d) . T he G ui de l i ne s pr ovi de f oratw o- l e ve l i nc r e a s e i n the o f f e n s e le v e l [ i]f ( A ) th e d e f

e n d a n t w illf

u lly o b s tru c te d o rim p e d e d , o ra tte m p te d to obs truc tori m pe de , the a dm i ni s tr a t i on of j us t i c e dur i ng the c our s e of the i nve s t i ga t i on, pr os e c ut i on, ors e nt e nc i ng of the i ns t a ntof

f e ns e of c onvi c t i on, a nd ( B ) the obs truc t i ve c onduc tr e l a t e d t o ( i ) the defe nd ant ’ s off

ense of conv i ct i on and any rel evantcond uct ; or (i i ) a c lo s e ly r e la te d o f

f e n s e . . . . U .S .S .G . § 3 C 1 .1 . P e r

ju ry is a m o n g th e e x a m p le s o f c o n d u c t w a rr a n tin g th is e n h a n c e m e n t. I d ., c o m m e n t. ( n .4 ( b ) ) . “P e r ju ry , f o rp u rp o s e s o f

ap p ly in g th is en h an cem en t , h as b een d efi n ed b y th e U n i t ed S t at es S u p rem e C o u rtas ‘ fal se t est i m o n y co n cern i n g a m at eri al m att er w i th th e w i l l fu l i n t en tt o p ro v i d e fal se t es t i m on y, ra ther than as are sul tof confusi on , m i st ake, or faul ty m em ory. ’ ” U ni t ed S t at es v. S i ng h, 29 1 F . 3d 75 6, 76 3 (11 th C i r. 20 02 ) ( qu ot i ng U ni t ed S t at es v . D u n n ig a n , 5 0 7 U .S . 8 7 , 9 4 , 1 1 3 S .C t. 1 1 1 1 , 1 2 2 L .E d .2 d 4 4 5 ( 1 9 9 3 ) ) . F oure l e m e nt s a r e r e qui r e d t o m a ke ape r j ury f i ndi ng: “ ( 1) the t e s t i m ony m us tbe unde roa th ora f f i rm a t i on; ( 2) the t e s t i m ony m us tbe f a l s e ; ( 3) the t e s t i m ony m us tbe m a t e r i a l ; a nd ( 4) the t e s t i m ony m us tbe gi ve n w i th the w i l l f ul i nt e ntt o pr ovi de f

a l s e t e s t i m ony a nd nota s ar e s ul tof am i s t a ke , c onf

us i on, or faul ty m em ory. ” S i ng h, 29 1 F . 3d 76 3 n . 4. W hi l e s peci fi c f i nd i ng s a s t o eac h i nst ance of a m at er i al l y f al se st at em entar e pre fe rabl e, w e c an af fi rm i f “ the di stri ct11

c our tm a ke s age ne r a l f

i ndi ng of obs truc t i on of

j us t i c e tha te nc om pa s s e s a l l of the f a c tu a l p r e d ic a te s o f

p e r ju ry .” U n ite d S ta te s v . V a lle jo , 2 9 7 F .3 d 1 1 5 4 , 1 1 6 8 ( 1 1 th C i r. 20 02 ) ( qu ot at i on om i tt ed). H e r e , the di s tr i c tc our tdi d notc l e a r l y e rri n appl y i ng the obs truc t i on enhancem ent . W e have s t at ed thatthe di stri ctcourtm aym ake ageneral obs truc t i on f

i ndi ng, a s he r e , w he r e i tuphe l d the obs truc t i on e nha nc e m e nt spec i fi ca l l y bec ause i tfoun d thatthere w er e s ta te m e n ts th a t w e r e w h o lly i rr ec on ci l abl e w i th the j ury ver di ct . S ee V al l ej o, 29 7 F . 3d at11 68 . T he courtw as m a ki ng af

i ndi ng tha tE kpo’ s t e s t i m ony c onc e rni ng hi s know l e dge of the f r a udul e ntc l a i m s f

orw he e l c ha i r s a nd a c c e s s or i e s c ons t i tut e d pe r j ury , by d e te rm in in g th a t it w a s irr e c o n c ilab le w ith th e ju ry v e r d ic t, s im ila rto th e c o u r t in V a lle jo , w h ic h f

o u n d th a t th e d e f

e n d a n t h a d p e r

ju r e d h im s e lf

b e c a u s e s ta te m e n ts thathe m ade w er e c on tra di ct ed by other w i tness es . A dd i t i on al l y, the other r e qui r e m e nt s of

pe r j ury w e r e m e t : E kpo m a de the s t a t e m e nt s a ttr i a l , unde roa th; the s t a t e m e nt s w e r e m a t e r i a l , a s the y appl i e d t o hi s know l e dge of the f r a udul e nt c l a i m s ; a nd the c our tc l e a r l y di d notbe l i e ve tha tthe s e s t a t e m e nt s w e r e the r e s ul tof co n fu sio n o r a fa u lty m em o ry . S ee S in g h , 2 9 1 F .3 d at 7 6 3 n .4 . M o re o v er , E kp o ’s te s tim o n y w a s d ir e c tly c o n tr a d ic te d b y F lo u rn o y , w h o s ta te d th a t h e d ir e c te d h e rto use the sa m e c od es for pow erw heel chai rs and P O V ’ s, prov i ded h erw i th p re pri nt ed C M N s t o sub m i tt o the benefi ci ar i es ’ do ct ors, and adm i tt ed thathe bi l l edUnited States v. Booker, 543 U.S. 220, 125 S.Ct. 738, 160 L .Ed.2d 621 (2005). 1 12 M edi ca re for a cc es sori es i n o rdert o rec ov erm on eythathe had l osti n the sa l e of a w he e l c ha i r . A c c or di ngl y , the di s tr i c tc our tdi d notc l e a r l y e rri n appl y i ng atw ol evel enhancem entt o E kp o’ s off ense l evel and w e a ff

i rm as t o thi s i ss ue. I V. W e r e vi e w the f

i na l s e nt e nc e i m pos e d by the di s tr i c tc our tf or r e a s o n ab le n e s s . U n ite d S ta te s v . W in in g e a r , 4 2 2 F .3 d 1 2 4 1 , 1 2 4 5 ( 1 1 th C ir . 2 0 0 5 ) . U nr e a s onabl e ne s s m a y be pr oc e dur a l , w he n the c our t ’ s pr oc e dur e doe s notf ol l ow B ooke r ’ s r e qui r e m e nt s , ors ubs t a nt i ve . S e e G a l l v. U ni t e d S t a t e s , N o. 06- 7949,

1 s lip o p . a t 1 2 ( U .S . D e c . 1 0 , 2 0 0 7 ) ; U n ite d S ta te s v . H u n t, 4 5 9 F .3 d 1 1 8 0 , 1 1 8 2 n .3 ( 11th C i r . 2006) . T he S upr e m e C our tha s e xpl a i ne d tha tas e nt e nc e m a y be pr oc e dur a l l y unr e a s onabl e i f the di s tr i c tc our ti m pr ope r l y c a l c ul a t e s the gui de l i ne i m pr i s onm e ntr a nge , tr e a t s the G ui de l i ne s a s m a nda t ory , f a i l s t o c ons i de rthe ap p r o p r ia te s ta tu to ry f

a c to r s , b a s e s th e s e n te n c e o n c le a r ly e rr o n e o u s f a c ts , o rf a ils t o adequ at el y e xp l ai n i t s r ea soni ng . G al l , N o. 06 -794 9, sl i p o p. at12 . T he C ou rt al so has e xp l ai ned thatthe subst ant i ve re as on abl enes s of ase nt ence i s r evi ew ed unde ra n abus e - of

- di s c r e t i on s t a nda r d. I d. I tha s s ugge s t e d tha tr e vi e w f or s ubs t a nt i ve r e a s onabl e ne s s unde rthi s s t a nda r d i nvol ve s i nqui r i ng w he the rthe f a c to r s in 1 8 U .S .C . § 3 5 5 3 ( a ) s u p p o r t th e s e n te n c e in q u e s tio n . I d . a t 1 7 . W h e n im p o s in g as e n te n c e , th e d is tr ic t c o u r t m u s t f ir s t c o rr e c tly c a lc u la te13

th e G u id e lin e s . U n ite dS ta te s v . T a lle y , 4 3 1 F .3 d 7 8 4 , 7 8 6 ( 1 1 th C ir . 2 0 0 5 ) . S ec on d, the di stri ctcourtm ustconsi der the fol l ow i ng fa ct ors t o d et erm i ne a re as on abl e s ent ence : ( 1) the na tur e a nd c i r c um s t a nc e s of the of f e ns e a nd the hi s t ory a nd ch aract eri st i cs o f th e d efen d an t ; (2 ) th e n eed t o refl ectth e seri o u sn ess o f th e o ffen se, t o p ro m o t e resp ectfo r th e l aw , an d t o p ro v i d e j u st p u n is h m e n t f

o rth e o f f e n s e ; ( 3 ) th e n e e d f

o rd e te rr e n c e ; ( 4 ) th e n e e d to prot ec tthe pu bl i c; (5) the need t o p rovi de the defendantw i th n ee ded e duc a t i ona l orvoc a t i ona l tr a i ni ng orm e di c a l c a r e ; ( 6) the ki nds of s e nt e nc e s a va i l abl e ; ( 7) the S e nt e nc i ng G ui de l i ne s r a nge ; ( 8) pe r t i ne nt p o lic y s ta te m e n ts o f

th e S e n te n c in g C o m m is s io n ; ( 9 ) th e n e e d to a voi d unw a nt e d s e nt e nc i ng di s pa r i t i e s ; a nd ( 10) the ne e d t o pr ovi de r e s titu tio n to v ic tim s . I d. ( c i t i ng 18 U . S . C . § 3553( a ) ) . W hi l e the di s tr i c tc our tm us tc ons i de rthe § 3553( a ) f

a c t or s , i ti s notr e qui r e d t o di s c us s e a c h f a c t or . I d. I ns t e a d, w e ha ve he l d tha ta n e xpl i c i ta c know l e dgm e nttha tthe di s tr i c tc our tha s c ons i de r e d the de f e nda nt ’ s a r gum e nt s a nd the § 3553( a ) f a c t or s w i l l s uf

f i c e . U ni t e d S t a t e s v. S c ott , 436 F . 3d 1324, 1329- 30 ( 11th C i r . 2005) ; s e e a l s o R i t av. U ni t e d S t a t e s , 551 U . S . __, 127 S . C t . 2456, 2469, 168 L . E d. 2d 203 ( 2007) ( hol di ng tha tthe d efen d an t ’ s sen t en ce w as reaso n ab l e w h en th e d i stri ctco u rtco n si d ered th e p art i es’ a r g u m e n ts a n d p r o v id e d ar e a s o n e d b a s is f o rits c h o ic e o f

s e n te n c e ) .

“ [T ] here i s ara ng e of r ea sonabl e s ent ence s f rom w hi ch the di stri ctcourtm ay c hoos e ” a nd the bur de n of e s t abl i s hi ng tha tthe s e nt e nc e i s unr e a s onabl e i n l i ghtof th e r e c o r d a n d th e § 3 5 5 3 ( a ) f a c to r s lie s w ith th e p a r ty c h a lle n g in g th e s e n te n c e .14

T a l l e y , 431 F . 3d a t788. W e ha ve he l d tha tas e nt e nc e w i thi n the gui de l i ne s r a nge i s nei ther per se re as on abl e, no r e nt i t l ed t o a pres um pt i on of re as on abl enes s. S ee id . a t 7 8 6 - 8 8 ; H u n t, 4 5 9 F .3 d a t 1 1 8 5 . H o w e v e r , th e S u p r e m e C o u r t h a s h e ld th a t, i n revi ew i ng se nt ence s f or re as on abl enes s und er18 U . S . C . § 3 55 3(a) , a f eder al appel l at e c ou rtm ayappl y apres um pt i on of re as on abl enes s t o a di stri ctcourt se nt ence i m po se d w i thi n the gu i del i ne ra ng e. R i t a, 55 1 U . S . at___, 12 7 S . C t . at 2462. N e ve r the l e s s , i tappe a r s tha t , e ve n i n l i ghtof R i t a , ourpr e vi ous hol di ngs re m ai n i nt ac t . U ni t ed S t at es v. C am pb el l , 49 1 F . 3d 13 06 , 13 13 n. 8 (11 th C i r. 20 07 ). W i th regard t o the procedural re as on abl enes s of E kp o’ s s ent ence , the di stri ct c our ti m pos e d apr oc e dur a l l y r e a s onabl e s e nt e nc e . S e e G a l l , N o. 06- 7949, s l i p op. a t12; H unt , 459 F . 3d a t1182 n. 3. T he di s tr i c tc our ta c know l e dge d i t s obl i ga t i on t o co n si d er th e ad v i so ry S en t en ci n g G u i d el i n es, al o n g w i th th e § 3 5 5 3 (a) factors, i n fas hi on i ng E kp o’ s s ent ence . S ee G al l , N o. 06 -794 9, sl i p o p. at12 . M oreover, the re cord dem on stra t es thatthe di stri ctcourtcorr ec t l y c al cul at ed the advi sory gu i del i ne ra ng e a nd consi dere d the se nt enci ng fa ct ors s etforth i n § 35 53 (a ), s pe c i f i c a l l y , the na tur e a nd s e r i ous ne s s of the of f e ns e , E kpo’ s pe r s ona l hi s t ory a nd c h a r a c t e r i s t i c s , a n d th e n e e d t o p r o v i d e Ekp o w i th me d i c a l c a r e . Se e i d . ; 1 8 U . S. C. § 3 5 5 3 ( a ) ( 1 ) a n d ( 5 ) . T h e d is tr ic t c o u r t f u rth e rc o n s id e r e d th e p a r tie s ’ a r g u m e n ts c onc e rni ng the s e nt e nc e t o be i m pos e d, a nd s uf f i c i e nt l y e xpl a i ne d i t s r e a s ons f or15

i m pos i ng the s e nt e nc e . G a l l , N o. 06- 7949, s l i p op. a t12. T o the e xt e ntE kpo a r gue s tha tthe di s tr i c tc our ti m pr ope r l y appl i e d a pr e s um pt i on of

r e a s onabl e ne s s ore f

f e c t i ve l y appl i e d tha tG ui de l i ne s i n a m an d at o ry fash i o n , w h en v i ew ed i n th e co n t ex to f th e sen t en ci n g p ro ceed i n g as a w ho l e, the di stri ctcourt ’ s s t at em ent s i nd i ca t e thati tun ders t oo d thatthe gu i del i nes w e r e a dvi s ory , a nd tha t , w hi l e i tha d di s c r e t i on t o de pa r t , i tdi d notf i nd tha tthe f a c t s of the c a s e j us t i f

i e d ade pa r tur e . A l though the di s tr i c tc our tm a y orm a y not ha ve c onf

us e d the c onc e ptof

adow nw a r d de pa r tur e pur s ua ntt o the S e nt e nc i ng G ui de l i ne s w i th the c onc e ptof adow nw a r d va r i a nc e pur s ua ntt o § 3553( a ) , a ny pos s i bl e e rr ora r i s i ng f

r om thi s c onf

us i on w a s ha rm l e s s be c aus e the r e i s no e v id e n c e to s h o w th a t E kp o s u f f e r e d p r e ju d ic e a s ar e s u lt. E kp o a ls o h a s n o t e s tab lis h e d th a t h is s e n te n c e is s u b s ta n tiv e ly u n r e a s o n ab le . S ee G all, N o . 0 6 -7 9 4 9 , sli p o p . at 1 2 ; H u n t, 4 5 9 F .3 d at 1 1 8 2 n .3 . E kp o ’s 2 7 - m o n th s e n te n c e w a s a t th e lo w - e n d o f th e a d v is o ry g u id e lin e r a n g e , a n d w e ll b e l o w th e s t a tu t o ry ma x i mu m s e n t e n c e o f 1 0 y e a r s ’ i mp r i s o n me n t . Se e 1 8 U . S. C. § 1347. T he r e c or d i ndi c a t e s tha tthe di s tr i c tc our tc ons i de r e d the na tur e a nd s e r io u s n e s s o f

th e in s ta n t o f

f e n s e , a lo n g w ith E kp o ’s la c k o f c r im in a l h is to ry , h is fa m i l y c i rc um st ance s, hi s a ge, and h i s hea l th, i n d et erm i ni ng thata G ui del i nes se nt ence w as approp ri at e. T here fore , the § 3 55 3(a) fa ct ors s up po rt ed the di stri ct c our t ’ s s e nt e nc e , a nd the di s tr i c tc our tdi d notabus e i t s di s c r e t i on. S e e G a l l , N o.16

06 -794 9, sl i p o p. at12 , 20 . T hu s, vi ew i ng the se nt enci ng proceedi ng as a w ho l e, E kp o’ s s ent ence i s r ea sonabl e, and w e a ff i rm as t o thi s i ss ue. V. B e c a us e E kpo f

a i l e d t o r a i s e ac ons t i tut i ona l c ha l l e nge t o hi s s e nt e nc e i n the di s tr i c tc our t , w e r e vi e w hi s c l a i m onl y f orpl a i n e rr or . S e e U ni t e d S t a t e s v. R o d r ig u e z , 3 9 8 F .3 d 1 2 9 1 , 1 2 9 8 ( 1 1 th C ir .) , c e r t. d e n ie d , 1 2 5 S .C t. 2 9 3 5 ( 2 0 0 5 ) . U nde rpl a i n e rr orr e vi e w , “ [ a ] n appe l l a t e c our tm a y notc orr e c ta n e rr orthe d e f e n d a n t f a ile d to r a is e in th e d is tr ic t c o u r t u n le s s th e r e is ( 1 ) e rr o r , ( 2 ) th a t is pl ai n, and (3) thataf

fe ct s s ub st ant i al ri gh t s. If al l three cond i t i on s a re m et , an ap p e lla te c o u r t m a y th e n e x e r c is e its d is c r e tio n to n o tic e af o r f e ite d e rr o r , b u t o n ly i f ( 4) the e rr ors e r i ous l y a f f e c t s the f a i rne s s , i nt e gr i ty , orpubl i c r e put a t i on of the j ud i ci al proceedi ng s. ” I d. (quo t at i on s a nd ci t at i on s om i tt ed). I n A ppr e ndi v. N e w J e r s e y , 530 U . S . 466, 120 S . C t . 2348, 147 L . E d. 2d 435 ( 2000) , the S upr e m e C our the l d tha t“ [ o] the rtha n the f a c tof apr i orc onvi c t i on, any f ac tthati ncre as es the penal ty f or a c ri m e bey on d the pres cr i bed st atut ory m axi m um m ustbe subm i tt ed t o a j ury, and p roved b ey on d a re as on abl e dou bt . ” 5 3 0 U .S . a t 4 9 0 , 1 2 0 S .C t. a t 2 3 6 2 - 6 3 . I n B o o k e r , th e S u p r e m e C o u r t e x te n d e d its A ppr e ndi l i ne of

c a s e s t o de c l a r e the m a nda t ory appl i c a t i on of the S e nt e nc i ng G ui del i nes t o b e uncon st i tut i on al , and reaf fi rm ed i t s hol di ng i n A pp re nd i that

“ [a ] ny fa ct(other than a pri or conv i ct i on ) w hi ch i s nec es sa ryt o sup po rta s ent ence17

exce edi ng the m axi m um autho ri ze d b y the fa ct s e st abl i shed by a pl eaof gu i l ty or a j ury ve r di c tm us tbe a dm i tt e d by the de f e nda ntorpr ove d t o aj ury be y ond a r e a s o n ab le d o u b t.” B o o k e r , 5 4 3 U .S . a t 2 3 2 - 3 3 , 2 4 4 , 1 2 5 S .C t. a t 7 4 9 - 5 0 , 7 5 6 . U nd erB oo ker, a di stri ctcourtm aycom m i tbo th con st i tut i on al and st atut ory error. U ni t ed S t at es v. M atheni a, 40 9 F . 3d 12 89 , 12 91 (11th C i r. 20 05 ). A B oo ker const i tut i on al error vi ol at es an i nd i vi du al ’ s S i xth A m endm entri gh tt o tri al by j ury w he r e aj udge e nha nc e s a n i ndi vi dua l ’ s s e nt e nc e ba s e d s ol e l y on j udi c i a l l y f ound f a c t s pur s ua ntt o am a nda t ory gui de l i ne s s y s t e m . U ni t e d S t a t e s v. P a z , 405 F . 3d 9 4 6 , 9 4 8 ( 1 1 th C ir . 2 0 0 5 ) . T h e r e is n o c o n s titu tio n a l e rr o rw h e r e as e n te n c e is e nha nc e d ba s e d on j udi c i a l f a c t - f i ndi ng be y ond the f

a c t s a dm i tt e d by the de f e nda nt o rf o u n d b y th e ju ry in an o n - m a n d a to ry s y s te m . R o d r ig u e z , 3 9 8 F .3 d a t 1 3 0 0 . B oo ker s t atut ory e rr or i s app l i ca t i on of the gu i del i nes a s m andat ory, ra ther than a dvi s ory . M a the ni a , 409 F . 3d a t1291. H e r e , no pl a i n e rr ore xi s t s i n thi s c a s e a s t o E kpo’ s S i xth A m e ndm e nt ar gu m entbecause the fi rs tpron g o f the pl ai n err or t es ti s notsa t i sf i ed. T he di stri ct c o u r t d id n o t c o m m it c o n s titu tio n a l o rs ta tu to ry e rr o ru n d e rB o o k e rb e c a u s e it se nt ence d E kp o u nd eran advi sorygu i del i nes s ys t em . R od ri gu ez , 39 8 F . 3d at 1300; M a the ni a , 409 F . 3d a t1291. T he r e w a s a l s o no e rr orunde rA ppr e ndi be c a us e the di s tr i c tc our tdi d nots e nt e nc e E kpo above the s t a tut ory m a xi m um of 1 0 y e a r s ’ im p r is o n m e n t, a s a u th o r iz e d b y 1 8 U .S .C . § 1 3 4 7 , f o rh e a lth c a r e f

r a u d .18

S ee B oo ker, 54 3 U . S . at24 4, 12 5 S . C t . at75 6. B ec ause there w as no B oo ker e rr or, th e r e is n o r e a s o n to r e a c h th e r e m a in in g th r e e p r o n g s o f th e p la in e rr o rte s t. M or e ove r , a s di s c us s e d above , E kpo ha s f a i l e d t o e s t abl i s h tha thi s s e nt e nc e of 27 m on ths’ i m pri sonm entw as un re as on abl e. A cc ordi ng l y, w e a ff i rm as t o thi s i ss ue. In l i gh tof the foregoi ng , E kp o’ s s ent ence and con vi ct i on ar e AF F I RME D.