FILED U.S. COURT OF AP P EALS E LEVEN T HC IRC U IT JULY 30, 2008 THOMAS K. KAH

N CLERK [ 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

________________________ N o. 07- 15707 N on -A rgum entC al endar

________________________ D. C . Do c k e tNo . 0 7 - 2 0 2 9 2 - C R - P AS U N I T E D S T A T E S O F A M E R I C A , P la in tif f - A p p e lle e , v ersu s A N A M A R I A P E R E Z , D e f e n d a n t- A p p e lla n t.

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_________________________ ( Ju l y 30, 2008) B efo re M A R C U S , W IL S O N an d F A Y , C i rcu i tJu d g es. P E R C U R I A M:2

A na M ar i a P er ez appeal s the 46 -m on th sent ence i m po se d aft ershe pl ed gui l ty t o one c ountof

c ons pi r a c y t o de f

r aud the U ni t e d S t a t e s , i n vi ol a t i on of 18 U . S . C . § 371; one c ountof c ons pi r a c y t o c om m i the a l th c a r e f r aud, i n vi ol a t i on of 1 8 U .S .C . § 1 3 4 9 ; a n d th r e e c o u n ts o f s o lic itin g a n d r e c e iv in g k ic kb a c k s , in v io la tio n o f

4 2 U .S .C . § 1 3 2 0 a - 7 b ( b ) ( 1 ) . P e r e z a r g u e s th a t th e d is tr ic t c o u rt c le a r ly e rr e d i n ap p l y i n g af

o u r - l e v e l l e a d e r s h i p - r o l e e n h a n c e m e n t , p u r s u a n tt o U. S . S . G. § 3 B 1. 1(a) . F or the re as on s di sc usse d b el ow , w e a ff i rm I. T he C ent er s f

or M edi care and M edi ca i d S ervi ce s r an a m edi ca l i nsurance p r o g r a m th a t c o v e r e d d u r ab le m e d ic a l e q u ip m e n t ( “D M E ” ) , s u c h a s p r o s th e tic l i m bs, brac es , w heel chai rs , ae rosol m edi ca t i on s, and o xygen con ce ntra t ors. U nd er thi s pr ogr a m , D M E s uppl i e r s c oul d s e e k r e i m bur s e m e ntf r om the gove rnm e ntf

or th e c o s t o f

D M E ite m s p r o v id e d to M e d ic a r e p a tie n ts . G e n e r a lly , ad o c to rw o u ld pres cr i be use of ace rt ai n D M E i t em by a pat i ent . If the pat i entw as a M edi care be ne f i c i a ry , the gove rnm e ntw oul d pa y as ubs t a nt i a l port i on of the c os tof

the D M E i t e m . T he pa t i e ntw oul d a s s i gn the r i ghtof pa y m e ntof

thi s r e i m bur s e m e nt t o the D M E s uppl i e r . T he D M E s uppl i e rthe n w oul d s ubm i tac l a i m t o the go vernm ent , i ncl ud i ng the M edi care benefi ci ary’ s nam e and M edi care i de nt i f i c a t i on num be r , the pr e s c r i bi ng doc t or ’ s na m e a nd M e di c a r e i de nt i f i c a t i on3

num be r , the na m e a nd M e di c a r e bi l l i ng num be rof the D M E i t e m pr e s c r i be d by the do ct or and p rovi ded b y the D M E supp l i er , and the dat e on w hi ch the D M E i t em w a s p r o v id e d b y th e D M E s u p p lie r . P e r e z ow ne d aD M E - s uppl y c om pa ny . T hr ough thi s c om pa ny , P e r e z s ought t o d efrau d th e M ed i care p ro g ram w i th reg ard t o aero so l m ed i cat i o n s. S p eci fi cal l y, s he e s t abl i s he d ar e l a t i ons hi p w i th c o- c ons pi r a t or s H e nry a nd K a r l aG onz a l e z , w ho ow ne d tw o pha rm a c i e s . H e nry G onz a l e z ga ve P e r e z al i s tof a e r os ol m e di c a t i ons thatcoul d b e “ bi l l ed” t o the M edi care prog ra m for r ei m bu rs em ent . P er ez re crui t ed doc t or s t o f

r audul e nt l y pr e s c r i be the s e a e r os ol m e di c a t i ons a nd m or e tha n 25 M edi care benefi ci ar i es t o p re t end t o n ee d these ae rosol m edi ca t i on s. P er ez ge ne r a l l y w oul d pa y the M e di c a r e be ne f i c i ar i e s appr oxi m a t e l y $150 pe rm onth f or u s e o f th e irn a m e s a n d M e d ic a r e id e n tif ic a tio n n u m b e r s . H e n ry a n d K a r la G onz a l e z the n w oul d s ubm i tc l a i m s f orthe s e f r audul e ntpr e s c r i pt i ons t o the M e di c a r e pr ogr a m . T he y w oul d gi ve P e r e z aki c kba c k of 50% of the r e i m bur s e m e ntm one y the y r e c e i ve d f ore a c h f r audul e ntc l a i m f

r om the g o v e rn m e n t. T h e p h a rm a c ie s o w n e d b y H e n ry a n d K a r laG o n z a le z u ltim a te ly r e c e i ve d at ot a l of

$204, 763 i n r e i m bur s e m e nt s f r om the gove rnm e ntf

or pr e s c r i pt i ons a rr a nge d by P e r e z , a nd P e r e z ul t i m a t e l y r e c e i ve d at ot a l of $102, 381 in k ic kb a c k s f

r o m H e n ry a n d K a r laG o n z a le z .4

H e n ry a n dK a r laG o n z a le z a ls o “w o rk e d w ith ” s e v e r a l o th e rD M E s u p p lie r s . T he pha rm a c i e s tha tthe y ow ne d ul t i m a t e l y r e c e i ve d at ot a l of appr oxi m a t e l y $14 m i l l i on i n r e i m bur s e m e nt s f r om the gove rnm e ntf

orpr e s c r i pt i ons a rr a nge d by a l l of the s e D M E s uppl i e r s . P e r e z w a s a w a r e of the s e othe rr e l a t i ons hi ps , a s s he s i gne d a

“ l og” tha ti nc l ude d the i rna m e s w he n r e tr i e vi ng he rki c kba c k pa y m e nt s f r om H e n ry a n d K a r laG o n z a le z . P e r e z a ls o s o u g h t to d e f r au d th e M e d ic a r e p r o g r a m w ith r e g ar d to re spi ra t ory e qu i pm ent , nam el y oxygen con ce ntra t ors. S peci fi ca l l y, she r ec rui t ed do ct ors t o fraud ul ent l y pre sc ri be the use of r es pi ra t ory e qu i pm entand M edi care b e n e f ic ia r ie s to p r e te n d to n e e d th e r e s p ir a to ry e q u ip m e n t. S h e th e n w o u ld s u b m it c l a i ms f o rth e s e f r au d u l e n tp r e s c r i p t i o n s t o th e M e d i c a r e p r o g r a m. Th e DM Es u p p ly c o m p a n y o w n e d b y P e r e z u ltim a te ly r e c e iv e d ato ta l o f $ 2 1 8 ,3 7 8 .9 6 in r e im b u r s e m e n ts f

r o m th e g o v e rn m e n t. B ef ore P er ez ’ s s ent enci ng , a probat i on offi ce r pre pare d a pres ent ence i nv es t i gat i on re po rt . T here i n, the prob at i on offi ce r r ec om m ended, i nt eral i a, that P er ez re ce i ve a f

ou r- l evel l ea ders hi p-rol e e nh ance m ent , pu rs uantt o § 3B 1. 1(a) , because s he w as an organi ze r or l ea der of acr i m i nal ac t i vi ty i nv ol vi ng fi ve or m ore part i ci pant s. T he prob at i on offi ce r not ed thatH enryG on za l ez re ce i ved a fourl evel l ea ders hi p-rol e e nh ance m ent , and K ar l a G on za l ez re ce i ved a three -l evel5

m a n a g e r ia l- r o le e n h a n c e m e n t. A t s e n te n c in g , P e r e z o b je c te d to r e c e iv in g ale a d e r s h ip - r o le e n h a n c e m e n t, a r g u in g th a t ath r e e - le v e l m a n a g e r ia l- r o le e n h a n c e m e n t w o u ld b e m o r e ap p r o p r ia te . S h e a s s e rte d th a t H e n ry a n d K a r laG o n z a le z w e r e th e o r g a n iz e r s o f th e c o n s p ir a c y . S he as se rt ed thatshe di d n ot“ control ” the M edi care benefi ci ar i es , as they w er e w i l l i ng pa rt i c i pant s a nd w e r e f r e e t o w ork w i th a nothe rD M E s uppl i e r , a nd di d not re crui tnece ss ar i l y a l l of the M edi care benefi ci ar i es i nv ol ved, as m any of them lik e ly “r e c ru ite d ” e a c h o th e r . T h e d is tr ic t c o u rt o v e rru le d P e r e z ’s le a d e r s h ip - r o le obj ec t i on . T he di stri ctcourtre as on ed thatP er ez re crui t ed m any M edi care benefi ci ar i es i nt o the ae rosol -f raud po rt i on of the conspi ra cyand o rgani ze d and ran th e r e s p ir a to ry - e q u ip m e n t- f r au d p o rtio n o f

th e c o n s p ir a c y e n tir e ly o n h e ro w n . II. W e r e vi e w adi s tr i c tc ourt ’ s appl i c a t i on of al e a de r s hi p- r ol e e nha nc e m e ntf or c le a re rr o r . U n ite d S ta te s v . R e n d o n , 3 5 4 F .3 d 1 3 2 0 , 1 3 3 1 ( 1 1 th C ir . 2 0 0 3 ) . P u rsu an tt o § 3 B 1 . 1 (a), a d i stri ctco u rtcan i n crease a d efen d an t ’ s b ase o ffen se le v e l b y f

o u r“[ i]f th e d e f e n d a n t w a s a n o r g a n iz e ro rle a d e ro f ac r im in a l a c tiv ity th a t in v o lv e d f

iv e o rm o r e p a rtic ip a n ts o rw a s o th e rw is e e x te n s iv e .” P u r s u a n t to th e c o m m e n ta ry to § 3 B 1 .1 ( a ) , th e f a c to r s th e d is tr ic t c o u rt s h o u ld c o n s id e rin de t e rm i ni ng w he the rade f e nda nthe l d al e a de r s hi p r ol e i n ac ons pi r a c y i nc l ude “ the6

e xe r c i s e of

de c i s i on m a ki ng author i ty , the na tur e of pa rt i c i pa t i on i n the c om m i s s i on of

the of f e ns e , the r e c rui tm e ntof a c c om pl i c e s , the c l a i m e d r i ghtt o a l a r ge rs ha r e of

the f rui t s of the c r i m e , the de gr e e of pa rt i c i pa t i on i n pl a nni ng or organi zi ng the offens e, the nature a nd sc op e of the i l l egal ac t i vi ty, and the degree of c ontr ol a nd author i ty e xe r c i s e d ove rothe r s . ” U . S . S . G . § 3B 1. 1, c om m e nt . ( n. 4) . A l s o, pur s ua ntt o the c om m e nt a ry , the r e c a n be m or e tha n one l e a de ror organi ze r i n a conspi ra cy . Id. L i kew i se , w e have hel d that“ [t ] he defendantdo es no thave t o b e the sol e l ea der or ki ng pi n o f the conspi ra cyi n o rdert o b e c on si dere d an organi ze r or l ea der w i thi n the m eani ng of the G ui del i nes. ” R endo n, 35 4 F . 3d at 1332. III. T h e d is tr ic t c o u rt d id n o t c le a r ly e rrin ap p ly in g ale a d e r s h ip - r o le enhancem ent . S ee R endo n, 35 4 F . 3d at13 31 . W i th regard t o the conspi ra cy i nvol vi ng a e r os ol - m e di c a t i on c l a i m s s ubm i tt e d by H e nry a nd K a r l aG onz a l e z , the r e c o r d d e m o n s tr a te s th a t P e r e z ’s p a rtic ip a tio n w ith in th e c o n s p ir a c y w a s in te g r a l, a s s he pr ovi de d the doc t or s a nd M e di c a r e be ne f i c i a r i e s w i l l i ng t o pa rt i c i pa t e . T he sc hem e w ou l d n othave w orked absenther c on tri bu t i on . A l so, the re cord de m ons tr a t e s tha tP e r e z c l a i m e d al a r ge rs ha r e of the f rui t s of the c r i m e tha n m a ny of i t s part i ci pant s, nam el y the M edi care benefi ci ar i es i nv ol ved. Indeed, P er ezPere z cl aimsthat sh ere c e ive d f ar f ewer f ruitsof thec rimetha

n H enr y and Ka rl a 1 Gonzalez becauseshe wa s obligated to shareher 50%with the Medica re benefic iaries. However, the g overnment pointed out at sentencingthat Henr y and Ka rla Gonzalez also had c os ts a sso c iate d withmaintainingthe ir ph arm ac ie s. We alsono tethat H enr y and Ka rl a Gonzalez rece ived 50% of thereimburse d money as a c ouple, while Pere z rece ived 50% alone. 7 c l a i m e d a n e qua l s ha r e of the pr of i t s a s the pl a y e rs he a dm i t s w a s a n or ga ni z e r , or K ar l a G on za l ez . 1 P u r s u a n t to th e c o m m e n ta ry to § 3 B 1 .1 , th e s e c h a r a c te r is tic s o f P e r e z ’s r o le a r e c ons i s t e ntw i th al e a de r s hi p- r ol e e nha nc e m e nt . S e e U . S . S . G . § 3B 1. 1, c om m e nt . ( n. 4) . W i th r e ga r d t o thi s c ons pi r a c y i nvol vi ng r e s pi r a t ory - e qui pm e nt c l a i m s s ubm i tt e d by P e r e z he r s e l f , the r e c or d de m ons tr a t e s tha tP e r e z r e c rui t e d the doc t or s a nd M e di c a r e be ne f i c i a r i e s , c l a i m e d the l a r ge s ts ha r e of the pr of i t s , a nd p l an n ed an d o rg an i zed th e o ffen se. P u rsu an tt o th e co m m en t ary t o § 3 B 1 . 1 , th ese c h a r a c te r is tic s o f

P e r e z ’s r o le a r e c o n s is te n t w ith ale a d e r s h ip - r o le e n h a n c e m e n t. S ee U . S . S . G . § 3 B 1. 1, com m ent . (n. 4). T he fa ctthatH enryG on za l ez al so pl ay ed ale a d e r s h ip r o le d o e s n o t a f f e c t th is c o n c lu s io n . S e e R e n d o n , 3 5 4 F .3 d a t 1 3 3 2 . T h u s , th e d is tr ic t c o u rt d id n o t c le a r ly e rrin ap p ly in g th e le a d e r s h ip - r o le e nha nc e m e nt . S e e i d. a t1331. AF F I RME D.