Opinion ID: 77689
Heading Depth: 2
Heading Rank: 2

Heading: Calculating the Loss

Text: 47 Because we vacate Medina's conviction on all counts, we need not address the sentencing issues on her appeal. However, since we affirm some of the convictions as to Guerra and Canepa, we address one sentencing issue. 48 Canepa argues, and Guerra adopts her argument, that the district court erred when it held that the entire amount Medicare paid out to United and Ocean from the time period in the indictment, January 2000 through April 2003, was fraudulent and thus, could be included in the loss amount at sentencing. 10 The government counters that the district court did not err, arguing that there was evidence that the vast majority of patients were paid illegal kickbacks, and therefore, any claim submitted on their behalf was fraudulent. Thus, any money Medicare paid out on those claims is attributable to the loss amount. 49 Although the Sentencing Guidelines are now used in an advisory manner, as per United States v. Booker, 543 U.S. 220, 125 S.Ct. 738, 160 L.Ed.2d 621 (2005), the district court must still correctly calculate the sentencing range prescribed by the guidelines. United States v. Crawford, 407 F.3d 1174, 1178 (11th Cir.2005). A district court's determination regarding the amount of loss for sentencing purposes is reviewed for clear error. United States v. Nostari-Shamloo, 255 F.3d 1290, 1291 (11th Cir.2001); United States v. Cabrera, 172 F.3d 1287, 1292 (11th Cir.1999). See also U.S.S.G. § 2B1.1, comment (n.3(C)) (stating that because [t]he sentencing judge is in a unique position to assess the evidence and estimate the loss based upon that evidence . . . the court's loss determination is entitled to appropriate deference) (citing 18 U.S.C. § 3742(e) and (f)). 11 In calculating the loss amount, loss is the greater of actual loss or intended loss. 12 U.S.S.G. § 2B1.1, comment (n.3(A)). 50 The district court needs only to make a reasonable estimate of the loss amount. U.S.S.G. § 2B1.1(b)(1)(D), comment (n.3(C)). A reasonable estimate of the loss amount is appropriate because often the amount of loss caused by fraud is difficult to determine accurately. United States v. Miller, 188 F.3d 1312, 1317 (11th Cir.1999). But [w]hile estimates are permissible, courts must not speculate concerning the existence of a fact which would permit a more severe sentence under the guidelines. United States v. Sepulveda, 115 F.3d 882, 890 (11th Cir.1997) ( citing United States v. Wilson, 993 F.2d 214, 218 (11th Cir.1993)). The amount of loss must be proven by a preponderance of the evidence, and the burden must be satisfied with reliable and specific evidence. Id. (internal quotes omitted). 51 The government cites United States v. Cruz-Natal, 150 Fed.Appx. 961 (11th Cir. Oct.11, 2005), to argue that the district court did not err in its loss calculation. Cruz-Natal, an unpublished opinion, is distinct from the instant case in that there was no argument that the total amount the defendant attempted to recover from Medicare was fraudulent. That case held simply that the district court did not clearly err in finding that the intended loss was the appropriate means by which to calculate loss, because it was greater than the actual loss. Id. at 964. It did not hold that, as a general matter, the total amount of all claims submitted to Medicare is an appropriate loss calculation in Medicare fraud cases. 52 In the instant case, the district court made no factual findings as to the amount of loss. When Canepa objected to the loss amount, rather than enumerating what reliable and specific evidence it used to calculate the loss amount, the district court stated With regard to the loss amounts for which each of the defendants is to be held accountable those are my findings. I am overruling the objections as to the amount each defendant is to be held responsible for. Without further information from the district court, we cannot determine what factual basis was used to reach the conclusion that every claim submitted to Medicare constituted loss. Indeed, upon our review of the record, there is not sufficient evidence that any of the prescriptions were not medically necessary, or were not delivered to the patients. 53 As to Guerra, the total amount billed to Medicare on the health care fraud claims that we affirm is only $11,820. We find these claims fraudulent not because they were based on illegitimate prescriptions, but because the patients or doctors received kickbacks after Guerra certified to Medicare that she would not pay such remunerations. There was no evidence presented that these claims were not medically necessary. Even though Tanya Moore testified that Medicare would not pay a claim if they knew parties were receiving kickbacks, this is not sufficient to establish a loss to Medicare. Moore testified that Medicare pays out a fixed amount for every type of claim. Therefore, evidence that shows that United and Ocean paid kickbacks from a fixed level of profits is not sufficient to show actual or intended loss to Medicare. As to Canepa, since we vacate her convictions on all counts of health care fraud, she cannot be held responsible for any loss resulting from Guerra's fraud. 54 Therefore, we hold that the district court clearly erred when it did not make specific factual findings upon which to base the loss amounts attributable to each individual defendant.