[DO NOT PUBLISH]

In the

United States Court of Appeals

For the Eleventh Circuit

____________________

No. 22-12837

Non-Argument Calendar

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UNITED STATES OF AMERICA, 

Plaintiff-Appellee,

versus

ARMANDO VALDES, 

Defendant-Appellant.

____________________

Appeal from the United States District Court

for the Southern District of Florida

D.C. Docket No. 1:21-cr-20590-KMW-1

____________________

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Before WILSON, LUCK, and HULL, Circuit Judges.

PER CURIAM:

After pleading guilty, Armando Valdes appeals his 60-month 

sentence for health care fraud, in violation of 18 U.S.C. § 1347. 

Valdes’s conviction and sentence arise out of his scheme to submit 

millions of dollars in fraudulent medical claims to United 

Healthcare and Blue Cross Blue Shield for intravenous infusions of 

Infliximab, an expensive immunosuppressive drug. These 

infusions, purportedly given to patients at Valdes’s medical clinic, 

Gasiel Medical Services (“Gasiel”), were either not provided or 

were medically unnecessary. 

On appeal, Valdes argues that the district court erred by:

(1) applying a 22-level increase in his offense level under U.S.S.G. 

§ 2B1.1(b)(1) because the loss amount exceeded $25 million; 

(2) applying a two-level increase under U.S.S.G. § 2B1.1(b)(10)(C) 

for using sophisticated means; (3) applying a two-level increase 

under U.S.S.G. § 3B1.3 for abusing a position of trust or using a 

special skill; and (4) ordering the forfeiture of his primary residence 

as substitute property. After review, we affirm Valdes’s sentence.

I. LOSS AMOUNT

Under U.S.S.G. § 2B1.1(b)(1), a defendant’s offense level 

increases with the amount of “loss” caused by the offense. In 

Valdes’s case, his base offense level was increased by 22 levels 

because the district court found that the loss amount was $38 

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million, and thus more than $25 million, as provided in 

§ 2B1.1(b)(1)(L). 

A. U.S.S.G. § 2B1.1(b)(1)

Section 2B1.1(b)(1)(L) provides that a defendant’s base 

offense level is increased by 22 levels if the loss from the fraud 

offense was more than $25 million but less than $65 million. 

U.S.S.G. § 2B1.1(b)(1)(L),(M). The commentary to § 2B1.1 defines

loss as the greater of either the actual loss, which is the “reasonably 

foreseeable pecuniary harm that resulted,” or the intended loss, 

which is the “pecuniary harm that the defendant purposely sought 

to inflict.” Id. § 2B1.1 cmt. n.3(A)(i)-(ii). Intended loss includes 

harm “that would have been impossible or unlikely to occur.” Id.

§ 2B1.1 cmt. n.3(A)(ii). Insurance fraud, in which the claim 

exceeded the insured value, is cited as an example of impossible or 

unlikely harm. Id. 

The Guidelines do not require a precise determination of 

loss. United States v. Barrington, 648 F.3d 1178, 1197 (11th Cir. 2011). 

Instead, the district court need make only a reasonable estimate 

based on the available information. Id.; see also U.S.S.G. 

§ 2B1.1 cmt. n.3(C). 

While the government has the burden to prove the loss 

amount with specific, reliable evidence, the district court may 

make its factual findings as to the loss amount based on, among 

other things, evidence presented at trial or sentencing or on the 

undisputed statements in the presentence investigation report 

(“PSI”). United States v. Moran, 778 F.3d 942, 973 (11th Cir. 2015). 

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We review a district court’s loss determination for clear error. 

Barrington, 648 F.3d at 1197. 

B. Analysis

Here, Valdes has not shown the district court’s loss amount 

of $38 million was clear error. In his factual proffer and at his plea 

hearing, Valdes admitted that through Gasiel, he submitted 

approximately $33 million in fraudulent claims to United 

Healthcare and approximately $5 million in fraudulent claims to 

Blue Cross Blue Shield. Because there is a strong presumption that 

those statements are true, United States v. Medlock, 12 F.3d 185, 187 

(11th Cir. 1994), the district court could rely on them in 

determining the loss amount. 

Valdes contends some of the $33 million submitted to 

United Healthcare was attributable to duplicate claims and 

therefore should not have been included in the intended loss

amount.1 Valdes also claims the intended loss amount “was the 

30% contracted payment” under United Healthcare’s pricing 

payment agreement. There are several problems with Valdes’s 

arguments.

First, for purposes of the loss amount under § 2B1.1, the 

intended loss includes unlikely amounts of pecuniary harm, such 

1 Valdes has never disputed that the intended loss amount was the appropriate 

measure of loss in his case or argued that the definition of loss in the Guidelines 

commentary should not apply. He has merely argued that duplicate claims 

should not be part of the intended loss because he did not intend them to be 

paid. 

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as claims that exceed the insured value. U.S.S.G. § 2B1.1 cmt. 

n.3(A)(ii); United States v. Moss, 34 F.4th 1176, 1191-92 (11th Cir. 

2022) (affirming district court’s use of the amount billed, rather 

than the amount the defendant expected to be reimbursed, even 

though it was unlikely the defendant would be paid the full billed 

amount). Thus, even if United Healthcare was unlikely to 

reimburse Valdes for the entire amount billed or for duplicate 

claims, those claims were nonetheless properly included in the 

intended loss amount. 

Second, at the sentencing hearing, Valdes’s own fraud 

analyst testified that, even accounting for duplicate claims, the total 

loss amount was above $25 million, the threshold for the 22-level 

increase in Valdes’s offense level. Further, Valdes did not present 

any testimony or evidence at sentencing to support his assertion 

that he intended United Healthcare to reimburse him only 30% of 

the billed amount.2 See Moss, 34 F.4th at 1192 (affirming where the 

defendant did not point to any evidence, such as revenue 

projections based on the actual reimbursable amount, showing he 

intended to obtain less than the amount billed). Accordingly, 

Valdes has not shown clear error in the district court’s 

determination of the loss amount or its application of the 22-level 

increase in Valdes’s offense level under § 2B1.1(b)(1).

2 Valdes himself did not testify. Valdes’s expert testified about the duplicate 

billing but not about an agreement with United Healthcare to reimburse only 

30% of the amount billed. 

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II. SOPHISTICATED MEANS ENHANCEMENT

Valdes also challenges the district court’s application of a

sophisticated means enhancement under U.S.S.G. § 2B1.1. Valdes 

argues that his offense involved the largely repetitive act of billing 

for a service that was not provided and was easily detectable. 

A. U.S.S.G. § 2B1.1(b)(10)(C)

If a defendant’s fraud offense involved sophisticated means, 

his offense level is increased by two levels. U.S.S.G. 

§ 2B1.1(b)(10)(C). The commentary defines “sophisticated means” 

as “especially complex or especially intricate offense conduct 

pertaining to the execution or concealment of an offense.” Id.

§ 2B1.1 cmt. n.9(B). Hiding assets or transactions using fictitious 

entities or corporate shells ordinarily indicates sophisticated 

means. Id. 

Whether conduct is sophisticated is based on the conduct as 

a whole, not on the individual steps. Barrington, 648 F.3d at 1199. 

Repetitive and coordinated conduct can be a sophisticated scheme 

even when no one step is particularly complicated. Id. When a 

large amount of money is stolen gradually and the fraud is not 

discovered over a long period, the length of time for which the 

conduct is not detected can reflect the sophistication of the scheme. 

United States v. Feaster, 798 F.3d 1374, 1381 (11th Cir. 2015).

In addressing a sophisticated means enhancement, we 

review a district court’s factual findings for clear error and its 

application of the guideline provision to those facts de novo. See

United States v. Humber, 255 F.3d 1308, 1311 (11th Cir. 2001). 

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B. Analysis

Here, we find no error in the district court’s application of 

the two-level sophisticated means enhancement.

Based on his factual proffer and undisputed facts in the PSI, 

Valdes operated an elaborate, years-long scheme to defraud 

insurance companies for expensive Infliximab infusions, obtaining 

over $7 million as a result. The large amount of money defrauded 

and the six-year period the scheme went undetected support a 

finding of sophisticated means. See Feaster, 798 F.3d at 1381. The 

fact that Gasiel was a real medical clinic that provided other, 

legitimate medical services to real patients, including primary care 

services and other intravenous infusions, made the fraud scheme 

involving Infliximab infusions more difficult to detect. 

Contrary to Valdes’s claims, his fraudulent billing was not 

simple, repetitive conduct. To be paid for the fraudulent Infliximab 

infusions and related services, Valdes had to submit itemized claim 

forms to the insurance companies that required various 

information, including descriptions of the services provided and 

billing codes. These claim forms had to be prepared in compliance 

with applicable laws and regulations, including certifying that the 

billed services were medically necessary and actually provided. 

This is the kind of repetitive, yet complex, conduct that qualifies as 

sophisticated means. See Barrington, 648 F.3d at 1199.

Moreover, Valdes, the beneficial owner and operator of 

Gasiel, took steps to conceal his ownership of Gasiel and his 

involvement in the fraud. At the sentencing hearing, FBI Special 

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Agent Zachary Mandell testified that Valdes was not listed in 

Gasiel’s corporate records despite being the actual owner and 

operator. Valdes hid behind two licensed doctors, Hilario Isaba 

and Ramon Santiago, who claimed no ownership interest in Gasiel

and did not prescribe Infliximab. Valdes, who had medical training 

in Cuba, held himself out to patients as a doctor, but Isaba and 

Santiago were identified as the referring providers for all $38 

million in false claims.3 In addition, Isaba was listed as Gasiel’s 

registered agent and president. Valdes’s false paper trail initially 

worked, as Isaba was the original target of Special Agent Mandell’s 

investigation. 

In light of these facts, the district court properly applied a 

two-level sophisticated means enhancement.

III. ABUSE-OF-TRUST ENHANCEMENT

Valdes also argues that the district court’s application of 

U.S.S.G. § 3B1.3’s abuse-of-trust enhancement was unwarranted. 

A. U.S.S.G. § 3B1.3

If a defendant abused a position of public or private trust, or 

used a special skill, in a manner that significantly facilitated the 

3 On appeal, Valdes argues that he never held himself out as a doctor at the 

clinic. However, Valdes did not object to that factual statement in paragraph 

13 of the PSI, so it is deemed admitted for sentencing purposes. See United 

States v. Wade, 458 F.3d 1273, 1277 (11th Cir. 2006). Special Agent Mandell 

also testified that many of the clinic patients he interviewed referred to Valdes 

as “Dr. Armando” and that Valdes dispensed pills to patients and sometimes 

reviewed charts and test results with patients. 

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commission or concealment of the fraud offense, the sentencing 

court increases his offense level by two levels. U.S.S.G. § 3B1.3. A 

special skill is one not possessed by members of the general public 

and usually requires substantial education, training, or 

licensing. Id. § 3B1.3 cmt. n.4. Being a doctor is a type of special 

skill. Id.

The district court applied the two-level enhancement 

because: (1) Valdes engaged in activities consistent with what a 

doctor would do and (2) the clinic’s patients thought he was a 

doctor. 

B. Analysis

On appeal, the parties vigorously dispute whether Valdes—

who trained as a doctor in Cuba but was not licensed in the United 

States—occupied, and abused, a position of trust vis-à-vis the clinic 

patients. 

We need not answer that question, however, because the 

enhancement also applies if Valdes used a special skill to facilitate 

the commission of the fraud scheme. The undisputed facts show 

Valdes used his skills as a trained doctor, whether licensed or not,

to facilitate his fraud by submitting false medical claims. Given that 

Valdes used a special skill in the commission of his offense, the 

district court properly applied § 3B1.3’s two-level enhancement.

IV. FORFEITURE OF VALDES’S RESIDENCE

Valdes argues the district court erred by ordering the 

forfeiture of his home as substitute property. Valdes admits that as 

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part of his plea agreement, he agreed to forfeit his primary 

residence as substitute property. Valdes claims, however, that this 

agreement was not voluntary because the district court failed to 

advise him that his home was a substitute forfeiture asset during 

the plea colloquy, in violation of Federal Rule of Criminal 

Procedure 11. 

A. General Principles

A district court must order a defendant guilty of a federal 

health care offense to forfeit property derived, directly or 

indirectly, from the commission of the offense. 18 U.S.C. 

§ 982(a)(7). Further, the district court is required to order the 

forfeiture of other property of the defendant, i.e., substitute 

property, if any property derived from the commission of the 

offense cannot be forfeited as a result of the defendant’s actions. 21 

U.S.C. § 853(p).

As to Valdes’s guilty plea, a district court must ensure that a 

defendant’s guilty plea is knowing and voluntary. United States v.

Sosa, 782 F.3d 630, 636 (11th Cir. 2015). To that end, the district 

court accepting a guilty plea must comply with Rule 11 and, in 

particular, address the three core concerns by ensuring that (1) the 

guilty plea is free from coercion, (2) the defendant understands the 

nature of the charges, and (3) the defendant understands the 

consequences of his plea. Fed. R. Crim. P. 11(b); United States v. 

Utsick, 45 F.4th 1325, 1337-38 (11th Cir. 2022). 

To comply with the third core concern, “Rule 11(b)(1) 

provides a list of rights and other relevant matters about which the 

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court is required to inform the defendant prior to accepting a guilty 

plea, including . . . the possibility of forfeiture.” United States v. 

Moriarty, 429 F.3d 1012, 1019 (11th Cir. 2005) (emphasis added); 

Fed. R. Crim. P. 11(b)(1)(J) (requiring the district court to inform 

the defendant of “any applicable forfeiture” and determine that the 

defendant understands it). 

B. Guilty Plea

The record shows that the forfeiture allegations in Valdes’s 

indictment and the plea agreement he signed both expressly 

identified Valdes’s primary residence by address as being substitute 

property potentially subject to forfeiture. 

Then, at his plea hearing, Valdes confirmed to the district 

court that he had read, thoroughly reviewed with his lawyer, and 

understood the indictment and plea agreement, both of which 

were translated into Spanish. The district court also reviewed the 

forfeiture provision in Valdes’s plea agreement, and explained,

among other things, that Valdes “not only agree[d] to give up 

property that was directly derived from this crime,” but also “to 

give up what is known as substitute assets.” Valdes responded that 

he understood the forfeiture provision. 

C. Plain Error Review

The day before sentencing, the government filed a motion 

for a preliminary order of forfeiture that, among other things, 

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forfeited Valdes’s primary residence as substitute property.4 Valdes 

did not oppose the motion or object to the proposed forfeiture of 

his residence before or during his sentencing. 

In fact, Valdes did not raise any issue about the forfeiture of 

his home until after his sentencing, at a status conference at which

Valdes’s trial attorney was permitted to withdraw. Valdes also did 

not object to the adequacy of his guilty plea proceedings or move 

to withdraw his guilty plea, despite being given the opportunity to 

do so with his newly appointed counsel. 

As such, Valdes agrees that our review of his forfeiture issue 

is for plain error only. See United States v. Monroe, 353 F.3d 1346, 

1349 (11th Cir. 2003); see also Sosa, 782 F.3d at 636 & n.2 (concluding 

the defendants’ “post-sentencing filings did not timely preserve”

the issue of whether they knowingly and voluntarily agreed to the 

forfeiture provisions in their plea agreements). 

Under plain error review, (1) there must be error; (2) that is 

plain; (3) that affects the defendant’s substantial rights; and (4) that 

seriously affects the fairness, integrity, or public reputation of 

judicial proceedings. Monroe, 353 F.3d at 1349. When neither the 

Supreme Court nor this Court has resolved an issue, there can be 

no plain error. Sosa, 782 F.3d at 637. We may review the whole 

4 The government’s motion for a preliminary forfeiture order sought 

forfeiture of Valdes’s primary residence as substitute property because the 

government was unable to locate all of the directly forfeitable property. 

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record when determining whether acceptance of a plea was plain 

error. United States v. Vonn, 535 U.S. 55, 59, 74 (2002). 

D. Analysis

Here, we strongly presume Valdes’s statements made 

during the plea colloquy are true. See Medlock, 12 F.3d at 187. In 

these statements, Valdes acknowledged he had read and 

understood his indictment and plea agreement. 

Valdes has not explained how he could have read and 

thoroughly reviewed the indictment and plea agreement with his 

attorney without understanding that the substitute property 

potentially subject to forfeiture was his primary residence. Indeed, 

his primary residence was the only substitute property specifically 

identified in the documents. And the indictment spelled out that 

under certain circumstances caused by Valdes, the government 

was “entitled to the forfeiture of the substitute property.” 

If that’s not enough, at sentencing Valdes’s attorney stressed 

in mitigation that Valdes had agreed to forfeit “five properties”—

his primary residence was one of the five real properties listed in 

the plea agreement—and that Valdes would be homeless after his 

release from prison. There are no indications in the record that 

Valdes disagreed with his attorney’s statements, corroborating that 

Valdes had agreed to forfeit his primary residence. The record as a 

whole reflects that Valdes understood that his primary residence 

was the substitute property that could be subject to forfeiture.

Valdes points out that during the plea colloquy, the district 

court did not specifically mention his home, define “substitute 

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property,” or explain the legal ramifications of having his home 

listed as substitute property. Valdes does not cite any binding 

precedent from this Court or the Supreme Court requiring such a 

detailed discussion of the forfeiture provision to satisfy the 

requirements of Rule 11. In the absence of such precedent, the 

district court’s failure to discuss the substitute property in more 

detail cannot be plain error. See Sosa, 782 F.3d at 637.

Because Valdes has shown no plain error in the district 

court’s accepting his guilty plea as to the forfeiture allegations, he 

has not shown the district court erred in ordering the forfeiture of 

his primary residence as substitute property.

AFFIRMED

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