Court Opinion

ID: 9894394
Source: CourtListenerOpinion
Date Created: 2023-11-01 18:00:54.304309+00
Date Added: 2024-06-11T09:08:49.811519
License: Public Domain

USCA11 Case: 22-12677     Document: 30-1       Date Filed: 11/01/2023   Page: 1 of 15

                                                      [DO NOT PUBLISH]
                                      In the
                 United States Court of Appeals
                          For the Eleventh Circuit

                            ____________________

                                    No. 22-12677
                            Non-Argument Calendar
                            ____________________

        UNITED STATES OF AMERICA,
                                                         Plaintiﬀ-Appellee,
        versus
        CARIE LYN BEETLE,
        a.k.a. Carie Lyn Douglas,

                                                      Defendant-Appellant.

                            ____________________

                  Appeal from the United States District Court
                      for the Southern District of Florida
                    D.C. Docket No. 9:19-cr-80234-KAM-1
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        2                      Opinion of the Court                22-12677

                             ____________________

        Before ROSENBAUM, GRANT and HULL, Circuit Judges
        PER CURIAM:
               After a jury trial, Carie Beetle appeals her total sentence of
        60 months’ imprisonment for conspiracy to commit health care
        and wire fraud, in violation of 18 U.S.C. § 1349, and money
        laundering, in violation of 18 U.S.C. §§ 1957 and 2. On appeal,
        Beetle argues the district court erred: (1) in applying a 22-level
        increase in her offense level under U.S.S.G. § 2B1.1(b)(1) based on
        the amount of loss; and (2) in awarding $17,242,910.95 in
        restitution. After review, we affirm Beetle’s sentence and the
        restitution amount.
                               I. BACKGROUND
        A.    Offense Conduct
               Beetle’s convictions arose out of fraud associated with a
        substance abuse treatment center and a sober home in Florida
        owned and managed by Beetle and Eric Snyder. Beetle and Snyder
        conspired to defraud insurance companies by submitting claims for
        urinalysis and treatment that was either medically unnecessary or
        not provided.
              At trial, the government presented evidence, including
        testimony from Snyder, that patients submitted to drug testing
        several times per week even though the drug tests were not
        reviewed by a doctor or used to guide patients’ treatment. Beetle
        and Snyder also had employees and patients forge patients’
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        22-12677               Opinion of the Court                        3

        signatures on sign-in sheets, backdate forms, and create fraudulent
        documents to make it appear as though patients attended therapy
        sessions or submitted to drug testing when they did not. And they
        paid kickbacks and bribes to individuals with private insurance who
        agreed to reside at the sober homes, attend therapy sessions, and
        submit to regular testing for purposes of billing the individuals’
        insurance plans.
               Employees lacking the necessary licenses conducted the
        therapy sessions. Patients skipped therapy and tested positive
        without consequences. Patients signed each other in for therapy
        sessions and then did not attend. Doctors did not review drug tests
        or reviewed them only after ordering another drug test.
              A forensic accountant testified that Beetle and her co-
        conspirators submitted insurance claims totaling $49,503,037.12
        and were paid $17,242,910.95.
        B.    Presentence Investigation Report
               Beetle’s presentencing investigation report (“PSI”) stated
        that Beetle and Snyder submitted claims of approximately
        $58,209,385 for substance abuse treatment and received
        $20,209,691 in reimbursements from insurance companies. The
        PSI recommended a total offense level of 39 consisting of: (1) a base
        offense level of seven, pursuant to U.S.S.G. § 2B1.1(a)(1); (2) a 22-
        level increase for an “intended loss amount of $58,209,385,”
        pursuant to the table in § 2B1.1(b)(1); (3) a two-level increase for
        the number of victims, pursuant to § 2B1.1(b)(2)(A)(i); (4) a two-
        level increase for sophisticated means, pursuant to
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        4                      Opinion of the Court                22-12677

        § 2B1.1(b)(10)(C); (5) a two-level increase for vulnerable victims,
        pursuant to § 3A1.1(b)(1); and (6) a four-level increase for her role
        as a leader, pursuant to § 3B1.1(b)(1).
                While the table in § 2B1.1(b)(1) uses the term “loss,” the
        commentary explains that the loss amount is “the greater of actual
        loss or intended loss.” U.S.S.G. § 2B1.1 cmt. n.3(A). And “intended
        loss” is defined as “the pecuniary harm that the defendant
        purposely sought to inflict . . . .” Id. § 2B1.1 cmt. n.3(A)(ii).
               With Beetle’s total offense level of 39 and her criminal
        history category of I, the PSI recommended: (1) an advisory
        guidelines range of 262 to 327 months’ imprisonment; and (2) a
        restitution amount of $17,242,910.95.
               Beetle objected to the PSI’s factual statement that she and
        Snyder submitted approximately $58,209,385 in insurance claims
        and received $20,209,691 in insurance payments. Beetle contended
        that she and Snyder submitted approximately $10,801,140 in claims
        and received $3,974,151, during the nine months she was “present”
        on a day-to-day basis, and that amount should be her relevant
        conduct. Beetle also contended that some urinalysis was
        legitimate, some therapy took place, and the government
        identified only $39,064 in payments for unattended group therapy
        sessions.
              Beetle also objected to the 22-level increase based on loss
        amount. Beetle disputed the PSI’s “intended loss amount” of
        $58,209,385. Beetle contended she should be held responsible for
        only “the amount of urine testing that was paid through August
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        22-12677              Opinion of the Court                       5

        2013, minus a percentage for the urinalysis testing that was
        arguably medically necessary.” Beetle requested a loss amount of
        $4,756,444, which was the amount actually paid for drug testing
        during that time, with adjustments for properly billed urinalysis
        and improperly billed group therapy. She also pointed out that
        Snyder and another co-conspirator were held accountable for only
        the amount insurance companies actually paid and that it was
        “only just that Ms. Beetle’s relevant conduct be determined
        similarly.”
               The government argued that the loss amount should reflect
        the entire amount billed up to December 2014, which was around
        $49.5 million. Although in August 2013, Beetle transferred her
        ownership interests in the businesses to Snyder, Beetle maintained
        a financial interest in them through December 2014.
        C.    Sentencing
              At Beetle’s July 29, 2022 sentencing hearing, the district
        court stated that the jury found Beetle participated in the
        conspiracy through December 2014 and that facts up to that time
        were “relevant for and should remain in the presentence report.”
               Beetle reiterated her argument that her loss amount should
        reflect only what the insurance companies actually paid. She also
        argued the amount should be reduced because (1) some patients
        attended group therapy and (2) one third of the urinalysis (or once
        per week) “would be a proper amount” and could be considered
        medically necessary. Beetle read from shift notes indicating that
        Snyder sometimes spoke with patients after a positive drug test.
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        6                      Opinion of the Court                22-12677

              During the hearing, the district court discussed Application
        Note 3(F) to § 2B1.1, which sets forth “Special Rules” about loss
        determination. The district court focused on subsection (viii),
        which applies to “Federal Health Care Offenses Involving
        Government Health Care Programs,” and provides that “the
        aggregate dollar amount of fraudulent bills submitted to the
        Government health care program shall constitute prima facie
        evidence of the amount of the intended loss . . . if not rebutted.”
        U.S.S.G. § 2B1.1 cmt. n. 3(F)(viii) (emphasis added).
                The district court pointed out that this “guideline
        commentary says . . . the presumptive loss amount is the amount
        billed, not the amount paid” and that it was the defendant’s burden
        “to show that the amount billed is inappropriate.” The district
        court asked why Beetle was relying on the amount paid. Beetle
        responded that her co-conspirators were sentenced based on the
        amount paid, and it was wrong to punish her for going to trial. The
        district court stated that her co-conspirators’ guidelines
        calculations were based on negotiated loss amounts in their plea
        agreements. The district court explained that it was required first
        to calculate Beetle’s advisory guidelines range before it could
        consider whether to vary downward based on how she was treated
        compared to other defendants.
               Beetle also argued that insurance companies routinely pay
        less than the full amount billed. Beetle stressed that trial evidence
        showed the total amount billed for urinalysis was $19 million, but
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        22-12677               Opinion of the Court                         7

        the total amount paid was only $4,756,044, and for most of that
        time, “Beetle wasn’t even there.”
               The government argued that Beetle should be held
        accountable for the entire billed amount up to December 2014,
        which trial evidence showed was $49.5 million for both urinalysis
        and therapy sessions. The government pointed out that the
        urinalysis tests were tainted because they were procured through
        kickbacks and that the $19 million billed for urinalysis did not
        account for the evidence of hundreds of unattended therapy
        sessions billed to the insurance companies.
               After consulting Application Note 3(F)(viii) in the
        commentary to U.S.S.G. § 2B1.1, the district court found that the
        government presented sufficient evidence of the intended loss and
        that Beetle failed to sufficiently rebut that evidence. Beetle pointed
        out that the commentary in Application Note 3(F)(viii) was for
        government programs and Beetle’s offense conduct related to
        private insurance companies. The district court determined that
        Application Note 3(F)(viii) still provided guidance that was
        applicable in Beetle’s case, overruled her objection, and adopted
        the loss amount in the PSI. The district court stated that it would
        take Beetle’s arguments about the loss amount into account in
        considering a variance.
                The district court sustained Beetle’s objection to the two-
        level increase for the number of victims, lowering the total offense
        level to 37. The district court confirmed with the prosecutor that
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        8                       Opinion of the Court                  22-12677

        the $49.5 million dollar loss amount was based on six victim
        insurance companies Beetle agreed were proven.
                The district court calculated a total offense level of 37, which
        with a criminal history category I, resulted in an advisory
        guidelines range of 210 to 262 months. The district court then
        heard the parties’ arguments. The government agreed that a
        downward variance was warranted and asked for a sentence
        between 72 and 80 months. Upon inquiry from the district court,
        Beetle’s counsel said, and the government agreed, that the range
        would have been 57 to 71 months had the court sustained Beetle’s
        objections and adopted her proposed loss amount. Beetle asked for
        “a little less” than that range.
               As to restitution, Beetle reiterated that it should reflect the
        amount of loss actually caused by her own conduct and limited to
        the amount paid for only medically unnecessary urinalysis, which
        was $4,756,444. After confirming that the $17,242,910.95 in the PSI
        was based on the amount insurance providers paid for both
        urinalysis and therapy from the conspiracy’s inception to
        December 2014, when Beetle left the conspiracy, the district court
        overruled Beetle’s objection and adopted that amount as
        restitution “for the reasons essentially that [it] overruled” Beetle’s
        offense level objections.
              The district court explained that a downward variance was
        warranted by the 18 U.S.C. § 3553 sentencing factors and imposed
        a 60-month sentence for her health care and wire fraud conspiracy
        conviction and a concurrent 22-month sentence for her money
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        22-12677               Opinion of the Court                         9

        laundering conviction, for a total sentence of 60 months. The
        district court ordered $17,242,910.95 in restitution, to be paid joint
        and several with her co-conspirators.
                               II. LOSS AMOUNT
        A.    General Principles
               Section 2B1.1 applies to theft and fraud offenses. 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 Beetle’s case, for
        instance, the base offense level was increased by 22 levels because
        the district court found that the loss amount was more than $25
        million but less than $65 million. See id. § 2B1.1(b)(1)(L).
                 Although the government must support its loss calculation
        with specific, reliable evidence, the Guidelines do not require a
        precise determination of loss. United States v. Barrington, 648 F.3d
        1178, 1197 (11th Cir. 2011). The district court need make only a
        reasonable estimate of the loss based on the available information.
        Id.; see also U.S.S.G. § 2B1.1 cmt. n.3(C).
               Section 2B1.1 itself does not define the term “loss.” Rather,
        as noted earlier, the commentary to § 2B1.1 “explains that the ‘loss’
        is the greater of the actual or intended loss.” United States v.
        Verdeza, 69 F.4th 780, 793 (11th Cir. 2023); U.S.S.G. § 2B1.1 cmt.
        n.3(A). Further, actual loss is defined as “reasonably foreseeable
        pecuniary harm,” and intended loss is defined as “pecuniary harm
        that the defendant purposely sought to inflict.” U.S.S.G. § 2B1.1
        cmt. n.3(A)(i)-(ii).
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        10                     Opinion of the Court                  22-12677

        B.     New Issue on Appeal
               On appeal, Beetle argues that the term “loss” in U.S.S.G.
        § 2B1.1(b)(1) unambiguously refers to only actual loss when it is
        given its plain and ordinary meaning. Therefore, Beetle contends,
        the district court erred in considering and deferring to the
        Sentencing Commission’s definition of “loss” in the commentary
        to include both actual loss and intended loss. To make her
        argument, Beetle relies on this Court’s recent en banc decision in
        United States v. Dupree, 57 F.4th 1269 (11th Cir. 2023) (en banc),
        issued while her appeal was pending.
               In Dupree, this Court “overruled our precedent” holding that
        commentary to the Guidelines was binding unless it was plainly
        erroneous or inconsistent with the guideline itself, a federal statute,
        or the Constitution. Verdeza, 69 F.4th at 793-94. Dupree concluded
        that, after Kisor v. Wilkie, 588 U.S.—, 139 S. Ct. 2400, (2019),
        sentencing courts should defer to guidelines commentary only
        when, after first exhausting all the traditional tools of construction,
        the regulation is “genuinely ambiguous.” Dupree, 57 F.4th at 1274-
        75; Verdeza, 69 F.4th at 794. Applying this new rule in Dupree, the
        Court held that U.S.S.G. § 4B1.2, the career offender guideline,
        unambiguously excluded inchoate offenses, and therefore the
        commentary including inchoate offenses within the definition of
        “controlled substance offense” was not binding and was entitled to
        no deference. Dupree, 57 F.4th at 1277-79.
              The problem for Beetle is that in the district court she never
        claimed the term “loss” in the guidelines provision was plain and
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        22-12677                   Opinion of the Court                       11

        unambiguous, and she did not challenge the definition of “loss” as
        including both actual and intended loss in the guidelines
        commentary. Rather, she claimed the intended loss amount
        should be calculated based on the amount billed versus the amount
        paid. Thus, we review Beetle’s new legal issue for plain error.
        United States v. Rogers, 989 F.3d 1255, 1261-63 (11th Cir. 2021). To
        be plain, an error must have been specifically and directly resolved
        by the explicit language of a statute, rule, or on point precedent
        from the Supreme Court or this Court. United States v. Sanchez, 940
        F.3d 526, 537 (11th Cir. 2019). 1
               Our Court in Verdeza already held that Dupree “did not
        specifically and directly resolve the question of whether § 2B1.1’s
        definition of loss is ambiguous,” and thus Dupree cannot establish
        plain error. 69 F.4th at 794 (quotation marks omitted).
        Accordingly, under our precedent, Beetle cannot show the district
        court plainly erred by deferring to the definition of loss in the
        guidelines commentary.
        C.      Preserved Error Review
               Beetle makes two additional claims as to loss amount that
        arguably are subject to preserved error review. We ordinarily
        review a district court’s determination of the loss amount for clear
        error. United States v. Cavallo, 790 F.3d 1202, 1232 (11th Cir. 2015).
        A guideline calculation error requires remand unless it was

        1 Beetle does not dispute that plain error review applies.
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        12                     Opinion of the Court                  22-12677

        harmless, that is, it did not affect the sentence imposed. United
        States v. Mathews, 874 F.3d 698, 710 (11th Cir. 2017).
                Beetle argues that the correct intended loss amount was
        only $49,503,037.12, which the government conceded at
        sentencing, rather than the $58,209,385 stated in the PSI. On
        appeal, the government agrees that the intended loss amount
        should have been the $49 million figure. But this error had no
        effect on the calculation of Beetle’s total offense level or her
        advisory guidelines range. Under § 2B1.1(b)(1)’s loss amount table,
        either intended loss amount would have resulted in the same 22-
        level increase in Beetle’s offense level. See U.S.S.G. § 2B1.1(b)(1)(L)
        (providing for a 22-level increase if the loss involved more than $25
        million but less than $65 million).
               Beetle also contends the district court improperly relied on
        Application Note 3(F)(viii) in the commentary, which applies only
        to government health care programs and not to private insurance
        companies. See U.S.S.G. § 2B1.1 cmt. n.3(F)(viii) (stating that the
        aggregate dollar amount of fraudulent bills submitted to a
        government health care program constitutes prima facie evidence
        of the amount of intended loss unless rebutted). But at sentencing
        the district court did not apply Application Note 3(F)(viii). Indeed,
        it acknowledged Beetle’s point that the commentary was not
        applicable to her offense, and merely found it provided some
        “guidance” on the issue of whether the intended loss amount for
        Beetle’s conspiracy should include the total amount billed to the
        private insurance companies or some lesser amount, as Beetle had
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        22-12677                   Opinion of the Court                                13

        argued. We cannot say the district court’s reference to Application
        Note 3(F)(viii) was reversible error, especially given that the
        applicable commentary, Application Note 3(A), also instructed the
        district court to use the intended loss amount. 2
                                   III. RESTITUTION
               A defendant convicted of fraud must pay restitution to the
        victims of her offense. 18 U.S.C. § 3663A(a)(1), (c)(1)(A)(ii). A
        restitution award must be based on the amount of actual losses the
        victim suffered as a result of the defendant’s conduct. United States
        v. Huff, 609 F.3d 1240, 1247-48 (11th Cir. 2010). The government
        bears the burden of proving the victims’ loss amount by a
        preponderance of the evidence. 18 U.S.C. § 3664(e). The
        government need not “calculate the victim’s actual loss with laser-
        like precision, but may instead provide a reasonable estimate of
        that amount.” United States v. Martin, 803 F.3d 581, 595 (11th Cir.
        2015) (quotation marks omitted).
               In cases of healthcare fraud, restitution amounts must be
        offset by the value of medically necessary goods and services that
        were actually provided. United States v. Bane, 720 F.3d 818, 828
        (11th Cir. 2013). The defendant bears the burden of proving the
        value of medically necessary goods or services should be deducted
        from the restitution amount. Id. at 829 n.10. That burden includes
        showing “that the services [she] provided were medically

        2 Because Beetle failed to show reversible error as to the district court’s use of

        intended loss, we do not address her arguments regarding the proper
        determination of the actual loss attributable to her.
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        14                      Opinion of the Court                   22-12677

        necessary.” United States v. Moss, 34 F.4th 1176, 1193 (11th Cir.
        2022).
                We review de novo the legality of a restitution order and the
        factual findings supporting it for clear error. Id. at 1192. “We will
        find a clear error if, after reviewing all the evidence, we are left with
        the definite and firm conviction that a mistake has been
        committed.” Id. (quotation marks omitted).
               Here, Beetle failed to show the district court’s restitution
        amount of $17,242,910.95 was clear error. First, the district court
        based restitution on the amount actually paid by the insurance
        companies, not, as Beetle argues, on the intended loss. Beetle does
        not dispute that the victim insurers paid $17,242,910 for drug
        testing and therapy billed by her sober home and treatment center
        during the conspiracy period. The government carried its burden
        to prove the victim insurers’ actual losses of $17,242,910.95. See
        Huff, 609 F.3d at 1247-48; Martin, 803 F.3d at 595.
               Second, Beetle failed to prove the value of any medically
        necessary services that reduced the restitution award. See Bane, 720
        F.3d at 829 n.10. The district court considered and rejected her
        argument that the urinalysis and therapy were medically necessary,
        and that determination is supported by the evidence. Any
        treatment provided at the sober home and treatment center was
        procured through kickbacks and prescribed by bribed doctors.
        While shift notes showed that employees sometimes looked at
        urinalysis results and occasionally spoke with a patient, the notes
        did not show that any medical professional used those results in
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        22-12677              Opinion of the Court                      15

        determining a treatment course. And trial evidence established
        that even if some patients attended therapy sessions, they were not
        conducted by qualified professionals. See Moss, 34 F.4th at 1193
        (affirming the district court’s restitution amount where the
        defendant failed to prove visits to patients were medically
        necessary).
                               IV. CONCLUSION
              For the foregoing reasons, we affirm Beetle’s 60-month
        sentence and the award of restitution in the amount of
        $17,242,910.95.
              AFFIRMED.