Court Opinion

ID: 58517
Source: CourtListenerOpinion
Date Created: 2010-04-26 02:43:55+00
Date Added: 2024-06-11T14:58:39.973301
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             IN THE UNITED STATES COURT OF APPEALS

                     FOR THE ELEVENTH CIRCUIT           FILED
                      ________________________ U.S. COURT OF APPEALS
                                                         ELEVENTH CIRCUIT
                                                            JAN 16, 2008
                             No. 06-15538
                                                          THOMAS K. KAHN
                       ________________________
                                                              CLERK

                 D. C. Docket No. 05-00143-CR-T-24-MAP

UNITED STATES OF AMERICA,

                                                           Plaintiff-Appellee,

                                  versus

MICHAEL A. ROSIN,

                                                        Defendant-Appellant.

                       ________________________

                Appeal from the United States District Court
                    for the Middle District of Florida
                     _________________________

                            (January 16, 2008)

Before BLACK, HULL and FAY, Circuit Judges.

PER CURIAM:
      Appellant Michael Rosin, a former dermatologist, once operated a lucrative

dermatology practice in Sarasota, Florida. In 2004, his long-time office manager

filed a qui tam action, contending Rosin had defrauded the government by

performing hundreds of unnecessary surgeries on elderly Medicare patients.

Following a government investigation, Rosin was indicted on 35 counts of health

care fraud in violation of 18 U.S.C. § 1347, and 35 counts of making false

statements in a health care matter in violation of 18 U.S.C. § 1035. Following a

17-day jury trial, Rosin was convicted on all counts and sentenced to 264 months’

incarceration, restitution in the amount of $3,697,225.38, and forfeiture in the

amount of $3,697,225.38.

      Rosin appeals his conviction and sentence on myriad grounds, contending

his trial was tainted by improper evidence, prejudicial comments by the judge and

prosecutor, and misleading jury instructions. Rosin also challenges the

substantive and procedural reasonableness of his sentence and the legality of the

court’s forfeiture order. Having reviewed the record, we find Rosin’s challenges

to be largely without foundation. The trial itself was fundamentally fair, and

Rosin’s sentence was reasonable in all respects. Therefore, we affirm.

                                          2
                                 I. BACKGROUND

      From 1983 to 2004, Rosin was the owner and sole physician of a

dermatology clinic and laboratory in Sarasota, Florida. He employed an office

manager and lab technicians to assist him in his clinical work.

      Rosin was trained to perform a specialized form of dermatological surgery

called Mohs surgery. The procedure is designed to minimize scarring during the

removal of certain types of skin cancer, and is performed in one or more stages.

During each stage, the surgeon removes a thin layer of skin and examines it under

a microscope, checking the borders for malignancy and mapping the location of

any cancer. If a doctor does not see any malignancy, or determines he has

removed the outer edge of the malignancy, he stops cutting or proceeds to another

section of the skin where the cancer is located. The goal of surgery is to remove

all malignant tissue while minimizing the removal of healthy tissue. The surgery

is often performed in only one or two stages, but sometimes requires four or more

stages to ensure complete removal of the cancer. Due to the time and expertise the

surgery requires, it is costly and not appropriate for all patients.

      Approximately 95% of Rosin’s patients were elderly Medicare recipients.

The federal Medicare program reimburses surgeons for Mohs surgeries at a higher

rate than it reimburses for other types of skin cancer removal. The more stages the

                                           3
surgery requires, the higher the Medicaid reimbursement rate. From September

1998 through May 2005, Rosin performed 5,980 skin biopsies. Of these, he

reported that 99.43% revealed cancer. During the same period, Rosin billed

Medicare for 4,118 Mohs surgeries. He performed four stages of surgery in

98.93% of these cases.

      In February 2004, Carolyn Ferrara, Rosin’s office manager, filed a qui tam

action, alleging Rosin had defrauded the Government by filing false Medicare

claims and performing needless surgeries. Her allegations led to an investigation

and, ultimately, to the filing of criminal charges against Rosin.

A. The Trial

      At trial, the jury heard testimony from Rosin, government investigators,

character witnesses, numerous medical experts, and a number of Rosin’s former

employees and patients. The testimony of Rosin’s former employees revealed that

Rosin’s laboratory was staffed by poorly trained lab technicians who prepared

biopsy slides that were irregular and often unreadable. Former employees testified

they had altered slides on several occasions, in one case replacing skin tissue with

gum, and in another, with styrofoam. According to the employees, Rosin

diagnosed cancer on both these slides.

                                          4
      Rosin denied reviewing slides that contained foreign substances. In

addition, he challenged the credibility of his former employees, eliciting

uncontroverted evidence that several, including Ferrara, had stolen from him

during the course of their employment, and stood to benefit financially from the

qui tam lawsuit.

      The Government called witnesses employed by Florida’s Medicare records

contractor to testify regarding the general manner in which Medicare claims are

processed and to summarize Rosin’s billing practice. One of these custodians,

Julie Kearn, testified that she had compiled data on all of Rosin’s Medicare

billings for Mohs surgeries performed from January 2000 to December 2003.

       The compiled data was given to Klaus Miescke, a statistician from the

University of Illinois at Chicago with experience in health care fraud

investigations.

      At trial, Miescke testified he used the data Kearns had compiled to select a

statistically random sample of 70 surgical slides from which he extrapolated loss

findings. The 70 slides Miescke selected were provided to the Government’s

medical experts, Drs. Pearon Lang and Franklin Flowers, and to Rosin’s medical

experts for review.

                                         5
      Over Rosin’s objection, the Government’s experts testified at trial regarding

their own surgical practices, rates of cancer diagnosis, and the percentage of four-

stage Mohs surgeries each performed, in addition to offering testimony regarding

their review of Rosin’s slides. Three dermatology experts testified on Rosin’s

behalf, stating that some of the surgical slides they reviewed had revealed the

presence of cancer. Although the experts’ testimony differed with respect to

which slides revealed evidence of skin cancer, all agreed the slides were of

substandard quality and that many were unreadable.

      Pathologist Deborah Bir testified regarding the manner in which surgical

slides are typically created, stained, and read. She and Lang testified that the poor

quality of Rosin’s surgical slides was unrelated to the age of the slides or the

manner in which they had been stored. The defense countered this testimony by

arguing the slides had been readable when they were assembled and had

deteriorated due to age, poor assembly, or employee sabotage.

      In addition to expert testimony, the jury heard from nine character

witnesses, who testified Rosin was an honest, charitable, and trustworthy father,

doctor, and community member.

      In closing argument, the prosecutor argued Rosin’s defense was not

credible—that while Rosin claimed to be a caring doctor betrayed by his staff, he

                                          6
was in fact “greedy,” and interested only in making money from the Medicare

program, as evidenced by the manner in which he carefully recorded patients’

financial information, but made and retained little information about their medical

history and care. The prosecutor pointed out inconsistencies in Rosin’s defense,

and called upon jurors to ignore the defense’s “attempts to confuse,” calling

Rosin’s theory of the case “misleading” and “unbelievable.”

      After being given Eleventh Circuit Pattern Jury Instructions, the jury

deliberated for one and a half days before convicting Rosin on all counts.

B. Sentencing

      Sentencing began June 6, 2006. After two days of testimony, the court

ordered the hearing continued until July 6, 2006. The Government moved to

remand Rosin to the custody of the United States Marshals during the recess; the

motion was granted.

      When sentencing resumed on July 6, 2006, Rosin’s lawyer asked the court

to order a competency evaluation, alleging Rosin was unable to assist in gathering

mitigating evidence for the sentencing proceedings. To show that a competency

hearing was reasonably necessary, Rosin called Dr. Hyman Eisenstein, a

neuropsychologist and clinical psychologist who testified for five hours regarding

                                         7
tests he had performed and interviews he had conducted with Rosin and Rosin’s

family.

      Eisenstein testified Rosin was an intelligent man who suffered from

cognitive deficits as a result of three head injuries, the first of which occurred in

the 1960s. Although Eisenstein was unable to provide a formal diagnosis without

first conducting brain scans on Rosin, he testified he could not “rule out the

possibility” Rosin was suffering from dementia as a result of brain injury. When

asked how Rosin’s suspected dementia would affect his ability to work with

counsel, Eisenstein had no answer except to observe that Rosin appeared more

interested in discussing his criminal conviction than in preparing for sentencing.

      Eisenstein also testified that Rosin appeared to suffer from an obsessive-

compulsive disorder. According to Eisenstein, this was the reason Rosin had

insisted on performing four stages of Mohs surgery for almost all of his patients.

On the basis of this testimony, counsel moved the court to stay further sentencing

proceedings and order a full-scale competency evaluation.

      The judge noted Rosin had been articulate on the stand during his jury trial,

appeared to understand the pretrial, trial, and early sentencing proceedings, and

had not complained about being unable to assist his counsel until the judge

ordered him remanded. The judge questioned Eisenstein’s reliance on tests

                                           8
administered by other psychologists, and noted Eisenstein was unable to do any

more than speculate about the possibility that Rosin might suffer some deficits

from brain injuries dating back several decades. Finding no reasonable cause to

believe Rosin was incompetent to participate in sentencing, the judge denied

Rosin’s motion for a full competency evaluation and hearing.

      When sentencing resumed, Rosin raised several objections to the probation

office’s guideline calculation. First, Rosin asserted the enhancements for loss

amount and victims should be calculated with reference only to the patients whose

names were listed in the indictment. He objected to inclusion of approximately

800 patients (and the medical claims relating to those patients) on the ground that

evidence about those patients and their surgeries had not been presented to the

jury. In addition, Rosin asserted he should not be required to repay the

Government or be subject to sentence enhancements for any surgery with respect

to which any expert opined that the slide revealed evidence of cancer or was

unreadable. The district court rejected Rosin’s proposal, crediting Rosin only for

surgeries for which the Government’s expert, Dr. Flowers, had found evidence of

cancer.

      After finding Rosin had used sophisticated means in carrying out his crime

and had caused serious bodily injury to several of his patients, the judge calculated

                                          9
Rosin’s offense level as 38 and his criminal history category as I, yielding a

guideline imprisonment range of 235 to 293 months, with a fine range of $25,000

to $250,000 dollars. (The 70 counts on which Rosin was convicted carried a

cumulative maximum penalty of 700 years’ imprisonment and a $17.5 million

fine.) The judge sentenced Rosin to 264 months’ incarceration, restitution in the

amount of $3,697,225.38,1 and forfeiture in the amount of $3,697,225.38.

                                     II. DISCUSSION

       On appeal, Rosin raises seven challenges to his conviction and sentence.

He contends his trial was tainted because (1) the prosecutor introduced unfairly

prejudicial evidence and argument; (2) the trial judge intervened improperly in the

proceedings; (3) improper evidence was admitted; and (4) the jury was misled by

three erroneous instructions. Rosin contends these errors, both alone and

cumulatively, merit reversal of his conviction. In addition, Rosin challenges

(5) the district court’s failure to hold a full competency hearing; (6) the

reasonableness of his within-guideline sentence; and (7) the amount of his court-

ordered forfeiture. We address each in turn.

A. Prosecutorial Misconduct

       1
         The court ordered Rosin to pay $3,641,247.79 in restitution to Medicare, $7,111.90 to
Aetna (a private insurance company), and $48,865.69 to individual victims.

                                              10
      First, Rosin contends he is entitled to a new trial because the Government

engaged in misconduct throughout his trial. Although many of Rosin’s complaints

are generalized, he appears to challenge four types of conduct, contending the

Government improperly relied on evidence of his bad character in violation of

Fed. R. Evid. 404(a); made inflammatory remarks about him and his counsel

during closing argument; vouched for the prosecution’s chief investigator; and

misrepresented the testimony its expert, Dr. Flowers, would be offering at trial.

Rosin did not raise contemporaneous objections to any of the alleged misconduct

of which he now complains; therefore, “relief is available to rectify only plain

error that is so obvious that failure to correct it would jeopardize the fairness and

integrity of the trial.” United States v. Bailey, 123 F.3d 1381, 1400 (11th Cir.

1997) (applying plain error standard in context of challenges to prosecutor’s

closing argument).

      1. Character evidence

      Rosin contends the prosecutor violated Fed. R. Evid. 404(a) during opening

and closing arguments. Specifically, Rosin takes issue with the following

comments made during opening argument:

      The Government is not trying to hold the Defendant accountable for
      honest mistakes. The evidence will show that the Defendant went
      through the motions to appear that he cared about his patients, and to

                                          11
      appear that he was engaged in the honest, ethical and legal practice of
      medicine.

      But what the evidence will show is that what he really was engaged in
      was a scheme to defraud the Medicare system by performing
      medically unjustified and invasive surgeries for the single purpose of
      making money.

Rosin also objects to the following argument, made during closing:

      [T]he evidence in this case has presented two starkly different and
      irreconcilable pictures of this Defendant. He is either a caring,
      dedicated physician whose only concern is a devoted interest in the
      welfare of his patients, or he is a greedy, dishonest individual who is
      guilty as charged of the offense in the superceding indictment.

      ....

      The first and most sacred duty of a medical doctor, members of the
      jury, is first to do no harm. And this physician was motivated by the
      same thing that motivates everyone who lies and who steals. The
      details of their conduct may differ, but it can be explained quite
      simply and in one word, greed.

Rosin contends that by pointing to character traits such as greed, the prosecutor

invited the jury to judge his character rather than his actions.

      Although Rosin has framed his argument as a challenge to the admissibility

of character evidence, he is not challenging any evidence; rather, he is challenging

the propriety of the prosecutor’s argument. The Government concedes that the

prosecutor’s remarks were “colorful and perhaps flamboyant,” but is quick to

point out that rhetoric is not impermissible in the courtroom. See United States v.

                                          12
Smith, 918 F.2d 1551, 1561 (11th Cir. 1990). The Government insists the

prosecutor’s remarks were fair commentary on the evidence adduced at trial,

particularly with respect to Rosin’s honesty.

      Even assuming the prosecutor overstepped the bounds of prosecutorial

propriety, it cannot be said that the prosecutor’s statements constituted plain error

when “viewed in the context of the record as a whole.” Bailey, 123 F.3d at 1400.

Even under the less exacting standard applied to review of preserved errors, this

Court will reverse a defendant’s conviction on the basis of prosecutorial

misconduct only where the prosecutor’s “remarks (1) were improper and (2)

prejudiced the defendant’s substantive rights.” United States v. O’Keefe, 461 F.3d

1338, 1350 (11th Cir. 2006) (emphasis added). A defendant’s substantive rights

are prejudicially affected only when a reasonable probability arises that, but for

the prosecutor’s statements, the outcome of the trial would have been different.

Id.

      In this case, the jury heard extensive testimony from which it could

conclude Rosin was guilty of health care fraud. Over the course of a 17-day trial,

any improper comments were limited to a few sentences in opening and closing

argument. The jury was instructed before it began deliberating that counsel’s

arguments were not evidence and that the verdict should be based on the evidence

                                          13
alone. Looking at the record as a whole, there is no reason to believe the

prosecutor’s characterization of the evidence during opening or closing arguments

prejudicially affected the trial, much less obviously jeopardized its fairness and

integrity.

       2. Allegedly improper argument

       In addition to challenging the prosecutor’s remarks about Rosin’s character,

Rosin challenges remarks allegedly directed toward his trial counsel. During

closing argument, the prosecutor accused “the defense” of “talking out of both

sides of their [sic] mouth. Referring collectively to Rosin and his counsel, the

prosecutor argued, “They’re caught in their own web trying to explain all of the

conduct that occurred in the defendant’s office, and it is noise because it doesn’t

make sense.” Finally, during his closing rebuttal, the prosecutor stated:

       I understand that it is difficult to believe that a physician, that a
       medical doctor, would do the things that this defendant is accused of
       in the superceding indictment, but there are in this world, ladies and
       gentlemen, doctors who lie and steal, just as there are lawyers who lie
       and steal, just as there are bankers who lie and steal. There are people
       in this world who lie and steal.

For reasons that are not entirely clear, Rosin is convinced that, by making these

statements, the prosecutor intended to suggest to the jury that defense counsel lied

and stole.

                                         14
      This Court has held that it is improper to “discredit defense counsel in front

of the jury . . . and even subsequent jury instructions aimed at rectifying this error

may not ensure that these disparaging remarks have not already deprived the

defendant of a fair trial.” United States v. De La Vega, 913 F.2d 861, 867 (11th

Cir. 1990) (citing United States v. McLain, 823 F.2d 1457, 1462 (11th Cir. 1987),

overruled on other grounds by United States v. Lane, 474 U.S. 438, 106 S. Ct. 725

(1986)). Despite the seriousness of such an infraction, the Court has clarified that

reversal is only warranted when the entire trial is so replete with errors the

defendant was denied a fair trial. United States v. Eckhardt, 466 F.3d 938, 947

(11th Cir. 2006).

      Although the prosecutor’s remarks about the weakness of Rosin’s case came

close to crossing the line of propriety, they did not go over the line. In attacking

inconsistencies in the defense’s theory of the case, the prosecutor was commenting

fairly on the evidence adduced at trial, and on Rosin’s competing explanations for

the irregularities in his laboratory. Although the prosecutor would have been wise

to make the point with less invective, taken in context, the remarks were not

clearly improper and certainly did not deny Rosin a fair trial.

      With regard to the prosecutor’s comments about doctors, lawyers, and

bankers who “steal and lie,” it is clear the prosecutor’s comments were no more

                                          15
directed at Rosin’s counsel than at the prosecutor himself. The Government was

merely suggesting to the jury that successful people sometimes commit crimes.

That argument was not improper.

      3. Vouching

      Rosin argues the prosecution improperly vouched for witness Diane New,

the Government’s chief investigator. Although the argument is not entirely clear,

it appears to be this: In the course of investigating Rosin’s crime, Agent New

signed a probable cause affidavit, upon which a search warrant was issued. At

trial, without objection from the defense, the prosecutor admitted the cover sheet

from the search warrant, listing each of the items the agents were authorized to

retrieve. On that sheet was a notation that read, “Affidavit having been

made . . . by Special Agent Diane C. New.” Rosin appears to contend that, from

the notation, the jury could have inferred a magistrate had credited New’s affidavit

(or else the warrant would not have issued), and by extension, New’s credibility.

Rosin argues that, by admitting the cover sheet into evidence, the prosecutor “sent

an unfair and constitutionally inappropriate message to the jury of unparalleled

and compelling ‘proof’ of R[osin]’s guilt with the very first witness.”

      When reviewing a defendant’s vouching claim, this Court examines whether

(1) the prosecutor placed the prestige of the Government behind the witness by

                                         16
making explicit personal assurances of the witness’s credibility, or (2) the

prosecutor implicitly vouched for the witness’s credibility by implying that

evidence not formally presented to the jury supports the witness’s testimony.

United States v. Arias-Izquierdo, 449 F.3d 1168, 1177-1178 (11th Cir. 2006).

“The prohibition against vouching does not forbid prosecutors from arguing

credibility . . . it forbids arguing credibility based on the reputation of the

government office or on evidence not before the jury.” United States v.

Hernandez, 921 F.2d 1569, 1573 (11th Cir. 1991).

        On several occasions during trial the prosecutor made passing reference to

the fact that a court had issued a search warrant authorizing a search of Rosin’s

office. The prosecutor did not connect New to the issuance of that search warrant,

or comment on her credibility in any way related to the warrant. Under these

circumstances, the introduction of the search warrant cover sheet did not amount

to vouching. Cf. United States v. Newton, 44 F.3d 913, 921 (11th Cir. 1995)

(prosecutor’s statement bolstering a key witness’s testimony by asserting “a judge,

state or federal, is not going to give a . . . law enforcement officer a search warrant

to search anybody’s house for no reason . . . ,” while close to the line, was not

improper). The prosecutor did not vouch for the witness; therefore, no error was

made.

                                           17
       4. Mischaracterization of testimony

       As a final challenge to the Government’s conduct at trial, Rosin contends

the prosecution misrepresented the evidence Dr. Flowers would present during his

trial testimony.2 Before Dr. Flowers was permitted to testify at trial, the court held

a conference outside the presence of the jury. At that conference, the prosecution

explained Flowers would testify about his own dermatology practice, including the

rates at which he diagnosed skin cancer and performed four stages of Mohs

surgery. The prosecutor made the argument that Flowers’ proposed testimony was

not expert because it was grounded in the doctor’s personal experience treating

patients.

       Rosin raised vigorous objections to the prosecution’s position, insisting

that, because Flowers had no personal knowledge regarding Rosin’s patients, his

proposed testimony had to be either expert or irrelevant. Rosin questioned

whether Flowers’ testimony was admissible under Daubert v. Merrell Dow

Pharm., Inc., 509 U.S. 579, 113 S. Ct. 2786 (1993), and challenged the legitimacy

       2
          In his opening brief, Rosin asserted in passing the Government had also made a
misleading proffer regarding the testimony of expert witness Klaus Miescke. The substance of
the argument, which Rosin did not develop in his opening brief and did not mention in his reply,
appears to relate to his claim that Miescke’s testimony was inadmissible. (See Section C.1,
infra). There was no discrepancy between the Government’s proffer and Miescke’s testimony.

                                               18
of permitting Flowers to testify about his own practice for the purpose of inviting

comparison between Rosin’s and Flowers’ practices.

      Ultimately, however, the judge had the following exchange with defense

counsel:

       Court:      As I understand it, Mr. Kehoe, you have no objection to
                   Dr. Flowers qualifying as an expert witness.

      Kehoe:       In all candor, no, Judge. I do believe that he is one when
                   it comes to this particular area . . . .

      Court:       All right. When it comes to his testimony and these
                   areas that may be subject to question by the defense, I’ll
                   entertain a sidebar if that’s necessary. But, the Court
                   will be governed and—by the case law requiring the
                   Court, as gate keeper, to base its determination on
                   admissibility on the relevance and reliability of the
                   proffered testimony. So, we’ll proceed on that basis.

      On appeal, Rosin argues the prosecutor committed misconduct by arguing

Flowers was a treating physician who could testify as a fact witness, rather than as

the expert witness he clearly was. That argument is misguided. The prosecutor

made an obvious legal error when she argued Flowers’ testimony was admissible

as that of a fact witness, rather than an expert. Cf. Fed. R. Evid. 602 (“A witness

may not testify to a matter unless . . . the witness has personal knowledge of the

matter.”). However, a lawyer may be wrong without committing misconduct.

Although the prosecutor erred when she argued Flowers was not an expert, there is

                                         19
no evidence she intended to mislead the court. Her mistake did not prejudice

Rosin in any way, much less compromise the integrity of the trial.3

B. Intervention by the District Court

       Rosin contends the trial court improperly demonstrated bias against him and

lent its weight to the Government’s case by engaging in repeated questioning of

witnesses, commenting on the evidence, and frequently interrupting defense

counsel during questioning. Rosin did not object to the court’s questions during

trial; therefore, we review for plain error only. Hanson v. Waller, 888 F.2d 806,

813 (11th Cir. 1989); Coats & Clark, Inc. v. Gay, 755 F.2d 1506, 1511 (11th Cir.

1985).

       A defendant is denied a constitutionally fair trial when a judge strays from

neutrality, abandoning his proper role and assuming that of an advocate. United

States v. Wright, 392 F.3d 1269, 1274 (11th Cir. 2004); see also Fed. R. Evid. 614,

Advisory Committee Note. Even when an objection to judicial conduct has been

preserved, in order to amount to reversible error, a judge’s remarks must

demonstrate such pervasive bias and unfairness that they prejudice one of the

parties in the case. United States v. Verbitskaya, 406 F.3d 1324, 1337 (11th Cir.

       3
         Furthermore, the trial court properly found (with Rosin’s concession, no less) that
Flowers was a qualified expert witness.

                                               20
2005). Put another way, comments made by the district court will cause reversal

only when they “excite a prejudice which would preclude a fair and dispassionate

consideration of the evidence.” Brough v. Imperial Sterling Ltd., 297 F.3d 1172,

1181 (11th Cir. 2002) (internal quotation marks omitted). In determining whether

the district court’s comments are prejudicial, the court of appeals “must consider

the record as a whole and not merely isolated remarks.” Id. at 1181.

      While a defendant is entitled to an impartial judge, it is also “well settled

that a federal district judge is not relegated to complete silence and inaction during

the course of criminal jury trial.” Wright, 392 F.3d at 1274 (11th Cir. 2004)

(quoting United States v. Cox, 664 F.2d 257, 259 (11th Cir. 1981)).

      It is axiomatic . . . “[t]hat the trial judge has a duty to conduct the trial
      carefully, patiently, and impartially. He must be above even the
      appearance of being partial to the prosecution.” On the other hand, a
      federal judge is not a mere moderator of proceedings. He is a common
      law judge having that authority historically exercised by judges in the
      common law process. He may comment on the evidence, may
      question witnesses and elicit facts not yet adduced or clarify those
      presented, and may maintain the pace of the trial by interrupting or
      cutting off counsel as a matter of discretion.

Wright, 392 F.3d at 1274-75 (quoting Moore v. United States, 598 F.2d 439, 442

(5th Cir. 1979)).

       Rosin’s arguments with respect to the district judge are wholly without

merit. In his opening brief, Rosin catalogues a number of statements and

                                           21
questions by the trial court he contends were improper. Having examined each,

we can say with confidence that in each instance, the court did no more than ask

clarifying questions, deter counsel from eliciting irrelevant testimony or testimony

that lacked foundation, or prevent witnesses from giving extended testimony on

irrelevant points. Although it is true the court did not question the Government’s

witnesses in the same way it questioned Rosin’s, Rosin has not pointed to any

conduct by the Government that would have warranted intervention by the court.

C. Admission of Evidence

      In what is a mirror image to his judicial intervention claim, Rosin contends

he was deprived of a fair trial when the district court failed to act sua sponte to bar

allegedly inadmissible evidence, and restricted the scope of testimony by Rosin’s

character witnesses. By suggesting the court should have acted sua sponte, Rosin

concedes he did not seek to bar the evidence he now challenges. When a

defendant has not preserved an objection to an evidentiary ruling, we review for

plain error. United States v. Smith, 459 F.3d 1276, 1296 (11th Cir. 2006).

      1. Miescke’s Testimony

      Rosin takes issue with the court’s failure to prevent statistician Klaus

Miescke from testifying he had been retained by the Government or that he had

worked in the past for the United States Attorney’s Office on health care fraud

                                          22
cases. Rosin argues that by stating he had been hired to “extrapolate loss figures,”

Miescke implied the 75 surgical slides he reviewed were representative of the

whole universe of slides from which the random samples had been taken (meaning

that in the cases not selected for review, Rosin had performed unnecessary

surgeries at the same rate he performed them with respect to the sampled slides).

According to Rosin, the district court plainly erred by permitting such testimony.

       It is true Miescke invited the jury to infer his sample was a reliable

microcosm of Rosin’s medical practice. However, it was not error to admit the

testimony. Miescke was a statistician whose job it was to obtain a representative

random sample of Rosin’s Mohs surgeries. From that sample, the Government’s

medical experts drew their conclusions about the percentage of Rosin’s surgical

cases that involved actual cancer, and from that sample the Government drew its

preliminary loss figures.4 The point Rosin misses is that there was nothing

improper about Miescke’s testimony or the inferences to be drawn from it.

       At trial, the defense conceded that Miescke was an expert statistician,

qualified to perform random sampling.5 The purpose of statistical sampling is to

       4
         Before sentencing, the Government asked their expert, Dr. Flowers, to review more
than 4,000 slides recovered from Rosin’s office. Consequently, the final loss figures were based
on a universe of slides that was larger than Miescke’s random sample.
       5
         In its brief, the Government inexplicably contends Miescke was not an expert because
he did not render any expert opinion. Although an expert is permitted to render an opinion, Fed.

                                               23
provide a means of determining the likelihood that a large sample shares

characteristics of a smaller sample. See, e.g., Laurens Walker & John Monahan,

Sampling Evidence at the Crossroads, 80 S. Cal. L. Rev. 969, 973-74 (2007)

(denoting random sampling as “a sine qua non of scientific research”). Therefore,

it surely came as no surprise to the jury that the Government had retained Miescke

for the purpose of obtaining a reliable sample and using that sample for various

purposes, including the calculation of loss amounts (none of which Miescke

revealed) in a case where the defendant was accused of health care fraud.

       Rosin asserts the “court had a duty to sua sponte strike the testimony,

chastise the Government . . . for its disingenuous representation and give a

curative instruction to the jury.” He is mistaken. Before Miescke testified, the

trial judge heard argument from both sides regarding the permissible scope of

Miescke’s testimony. The Court ruled Miescke could not represent that his

sampling was representative of the full breadth of Rosin’s medical practice, but

held Miescke could represent that his sampling was representative of the data

sample he had been provided. Miescke’s testimony was consistent with the

R. Evid. 703, 704, he is not required to do so, and failure to offer an opinion does not negate an
expert’s status, see Fed. R. Evid. 702. During the Government’s proffer and during his
testimony, Miescke discussed his specialized training, as well as the methodology he employs in
selecting random samples. His specialized knowledge lay outside the province of the jury and
rendered him an expert.

                                                24
court’s ruling, did not go beyond the bounds of his expertise, and did not unfairly

prejudice Rosin in any way.

      With regard to Miescke’s testimony regarding his past affiliation with the

United States Attorney’s Office, Rosin asserts that, by telling the jury that he had

worked on health care fraud cases previously, Miescke implied Rosin had

committed health care fraud. Since that was the crime with which Rosin was

charged, it could hardly have surprised the jury to hear the Government selected a

statistician familiar with health care fraud to analyze data relating to Rosin’s case.

Consequently, Miescke’s testimony on that point could not have prejudiced Rosin

unfairly.

      2. Testimony of Flowers and Lang

      Next, Rosin contends the district court erred when it allowed Government

experts Flowers and Lang to testify about their own surgical practices, inviting the

jury to conclude Rosin’s practice was fraudulent because the Government’s

experts diagnosed cancer at much lower rates and performed many fewer four-

stage Mohs surgeries than did Rosin. Rosin points to a host of reasons why he

believes it was improper to invite a comparison between his practice and the

expert witnesses’ practices: he was in private practice while they were in

academic clinics; he was a solo practitioner, while they were not; his patients were

                                          25
uniformly elderly, while their patients’ ages varied; etc. Although Rosin’s

critiques were excellent fodder for cross-examination, they went to the weight of

the evidence and not to its admissibility.

      Evidence is relevant when it has “any tendency to make the existence of any

fact that is of consequence to the determination of the action more or less probable

than it would be without the evidence.” Fed. R. Evid. 401. All relevant evidence

is admissible unless it is excluded under law. Fed. R. Evid. 402. The differences

between the rates at which the Government’s witnesses and Rosin diagnosed

cancer and performed multi-stage Mohs surgery did not provide conclusive proof

that some of Rosin’s surgeries were medically unnecessary and fraudulent.

Nevertheless, if the testimony of the expert witnesses was believed, the stark

differences between their surgical procedures and outcomes and Rosin’s were

probative on the question whether Rosin had defrauded the Medicare program by

filing false claims.

      Rosin is right when he asserts the expert witnesses’ testimony was

prejudicial, as all evidence of guilt is intended to be. It was not, however, unfairly

prejudicial in violation of the rules of evidence or Rosin’s rights under federal law.

The trial court did not err by failing to prevent the experts from testifying about

their medical practices.

                                             26
      3. Failure to inform jury of witnesses’ expert status

      Rosin contends it was reversible error for the court not to inform the jury

that Miescke, Bir, Lang, and Flowers were expert witnesses, and to specify their

areas of expertise. Rosin cites no law for the proposition that courts must instruct

juries on the scope of an expert’s specialized knowledge, and we can think of no

reason why they should be required to do so.

      At the close of trial, the judge instructed the jury as follows:

      Now, when the knowledge of a technical subject matter might be
      helpful to the jury, a person having specialized training or experience
      in that technical field is permitted to state an opinion concerning
      those technical matters. Merely because such a witness has expressed
      an opinion, however, does not mean that you must accept that
      opinion. The same as with any other witness, it is up to you to decide
      whether to rely upon it.

The judge exercised his gatekeeping responsibilities by ruling on specific

evidentiary objections during the trial, thereby preventing the expert witnesses

from testifying to matters outside their relevant expertise. Having done so, there

was no need for him to specifically identify which witnesses were “expert” and

which were not. He properly instructed the jury to weigh the facts themselves,

relying on specialized knowledge or testimony only when it was helpful to their

deliberations.

      4. Mitigating character evidence

                                          27
       Rosin contends the trial court prevented him from fully presenting his

defense by limiting his ability to elicit background testimony from his character

witnesses, and by limiting the scope of those witnesses’ testimony. The transcript

tells a different story.

       Rosin called a number of witnesses to testify that he was honest, kind, and

charitable. In response to Government objections, the trial court ruled:

       A witness may be asked what his opinion is of the truthfulness of the
       Defendant, and can state that, in his opinion, the Defendant is a truthful
       person. The other testimony about charitable activities of the Defendant are
       [sic] not relevant, and I think they should be kept to a minimum.

Although Rosin may have wished to admit more testimony on the point, the trial

court properly limited him to presenting evidence relevant to the case.

       With respect to Rosin’s allegation that the court curtailed his ability to elicit

background facts from his witnesses, Rosin has not pointed to any improper

interruptions on the part of the trial court. When witness testimony strayed far

afield, the court intervened on several occasions to keep the case running

smoothly. The court did so in a manner that was respectful and well within its

prerogative.6

       6
          See, e.g., Testimony of Mr. Samuel Uretsky, District Court Dkt. #156, at 74:17-75:23
(court directed counsel to “move on” after asking character witness extensive questions about his
military service in the 1940s).

                                               28
D. Jury Instructions

      Rosin next contends the jury instructions on reasonable doubt, character

evidence, and good faith misled the jury and therefore necessitate a new trial. His

argument fails for two reasons: First, he himself proposed the instructions, and

second, they were not erroneous.

      As Rosin concedes, the law is clear that when a party invites an error by

proposing an instruction he later challenges, or by affirmatively accepting an

instruction proposed by an opposing party, this Court is precluded from reviewing

the error on appeal. United States v. Silvestri, 409 F.3d 1311, 1337 (11th Cir.

2005). That alone is reason for affirming the lower court’s instruction. It is not

the only reason, however.

      In relevant part, the instruction on reasonable doubt stated:

      [W]hile the Government’s burden of proof is a strict or heavy burden,
      it is not necessary that the Defendant’s guilt be proved beyond all
      possible doubt[.] [I]t is only required that the Government’s proof
      exclude any reasonable doubt concerning the Defendant’s guilt.

Rosin contends the use of the phrase “only required” minimized the Government’s

burden of proof. Read in the context of the whole instruction, however, it is clear

the phrase to which Rosin objects was included in the instruction to help the jury

understand the prosecution’s burden. The instruction emphasizes the Government

                                         29
bears a “strict or heavy” burden. At the same time, the instruction guards against a

reading of “reasonable doubt” that would require the Government to disprove all

possible doubt—a burden higher than the law requires. The instruction is

accurate, and it was not error for the district court to charge the jury in the words it

did.

       Similarly, Rosin’s challenge to the instruction on character evidence is

without merit. The character evidence instruction stated:

       Now, the Defendant has offered evidence of the Defendant’s traits of
       character and such evidence may give rise to a reasonable doubt.
       Where a Defendant has offered testimony that the Defendant is an
       honest and truthful person, the jury should consider that testimony
       along with all the other evidence in deciding whether the Government
       has proved beyond a reasonable doubt that the Defendant committed
       the crimes charged.

The instruction made no mention of testimony regarding the defendant’s character

for any trait other than truthfulness.

       Rosin contends the instruction was flawed because it directed the jury to

consider evidence of Rosin’s “truthfulness,” but did not invite the jury to consider

evidence that Rosin was a “caring, compassionate, kind, and charitable” person.

Rosin argues that without such an instruction, the jury “likely disregarded all

Rosin’s other positive character traits” in reaching their verdict. This, he asserts,

was error.

                                           30
       Rosin appears to believe his general character for kindness and charity was

relevant because the prosecution characterized him as a greedy doctor who was

more interested in making money from Medicare than in caring for his patients.

That argument betrays a misunderstanding of the role character evidence played in

the trial. The jury was not asked to determine whether Rosin was good (honest,

kind, etc.) or bad (greedy, cruel, etc.): it was asked to determine whether he

defrauded the Medicare system by making false statements and engaging in health

care fraud. Insofar as honesty is the opposite of fraudulent misstatement, then

Rosin’s integrity in requesting payment for necessary surgeries was a legitimate

consideration. His general character was not. Nothing about the character

instruction was incorrect and there is no reason to believe it misled the jury in any

way.

       Rosin’s challenge to the good faith instruction is only slightly more

substantial. As he points out, and the Government concedes, neither the parties

nor the district court tailored the pattern instruction to the facts of his case.

Specifically, Rosin takes issue with the italicized portion of the instruction below:

       Now, one who expresses an honestly held opinion or an honestly
       formed belief is not chargeable with fraudulent intent even though the
       opinion is erroneous or the belief mistaken. And similarly, evidence
       which establishes only that a person made a mistake in judgment or

                                           31
      an error in management or was careless does not establish fraudulent
      intent.

      On the other hand, an honest belief on the part of the defendant that a
      particular business venture was sound and would ultimately succeed
      would not in and of itself constitute good faith as that term is used in
      these instructions if, in carrying out the venture the defendant
      knowingly made false or fraudulent representations to others with the
      specific intent to deceive them.

(Emphasis added.) Rosin argues the fraud with which he was charged was not

related to a business venture; therefore, the reference to unsound “business

ventures” should have been deleted from the instruction.

      Perhaps, but not necessarily. Billing Medicare and other health insurers for

surgeries is part of the business of running a medical clinic. Understood in this

way, the instruction is accurate. Rosin has not suggested any way the jury would

have been mislead in its deliberations by the improper instruction, and none is

apparent. There was no error in providing this instruction to the jury.

E. Cumulative Errors

      Having reviewed the alleged errors of the trial judge and prosecutor

individually, the Court must also “review the prejudicial effect of all . . . errors,

evaluated under both preserved and plain error standards, in the aggregate.”

United States v. Baker, 432 F.3d 1189, 1203 (11th Cir. 2005); United States v.

Blasco, 702 F.2d 1315, 1329 (11th Cir. 1983) (“A piecemeal review of each

                                           32
incident does not end our inquiry. We must consider the cumulative effect of

these incidents and determine whether, viewing the trial as a whole, appellants

received a fair trial as is their due under our Constitution.”).

      In this case, there are no errors to aggregate. Having concluded no

substantial errors occurred at trial, there is no more to consider with respect to this

claim. Cf. Delaware v. Van Arsdall, 475 U.S. 673, 681, 106 S. Ct. 1431, 1436

(1986) (“[T]he Constitution entitles a criminal defendant to a fair trial, not a

perfect one.”).

F. Competency Hearing

      Next, Rosin contends the district court abused its discretion by failing to

order a competency evaluation and hold a hearing on whether Rosin was able to

assist his counsel in preparing for sentencing due to brain injuries he had allegedly

incurred decades earlier. See United States v. Nickels, 324 F.3d 1250, 1251-52

(11th Cir. 2003) (appellate court reviews denial of motion for determination of

competency under 18 U.S.C. § 4241 for abuse of discretion).

      In determining whether a defendant is competent to be sentenced, the

district court must look at evidence indicating “a present inability to assist

counsel or understand the charges” against him. Medina v. Singletary, 59

F.3d 1095, 1107 (11th Cir. 1995). Federal law provides:

                                           33
      At any time after the commencement of a prosecution for an offense
      and prior to the sentencing of the defendant, or at any time after the
      commencement of probation or supervised release and prior to the
      completion of the sentence, the defendant or the attorney for the
      Government may file a motion for a hearing to determine the mental
      competency of the defendant. The court shall grant the motion, or
      shall order such a hearing on its own motion, if there is reasonable
      cause to believe that the defendant may presently be suffering from a
      mental disease or defect rendering him mentally incompetent to the
      extent that he is unable to understand the nature and consequences of
      the proceedings against him or to assist properly in his defense.

18 U.S.C. § 4241(a). Put another way, “[a] district court must conduct a

competency hearing when there is a ‘bona fide doubt’ regarding the defendant’s

competence.” United States v. Rahim, 431 F.3d 753, 759 (11th Cir. 2005) (citing

Pate v. Robinson, 383 U.S. 375, 385, 86 S. Ct. 836, 842 (1966)).

      After hearing five hours of testimony from Rosin’s expert witness, Dr.

Eisenstein, the district court concluded a full blown competency evaluation and

hearing was not needed. Although Eisenstein asserted Rosin suffered from

cognitive deficits as a result of three head injuries, dating from the 1960s through

the present, Eisenstein acknowledged Rosin had above-average intelligence and

was unable to say how the alleged deficits affected Rosin’s daily life at all, much

less to a degree that would interfere with his ability to assist counsel.

      In denying the motion for a competency evaluation, the district judge noted

Rosin had been articulate on the stand during his jury trial, appeared to understand

                                          34
the pretrial, trial, and early sentencing proceedings, and had at no time prior to his

detention made any complaint about being unable to understand what was

happening or assist counsel in his defense. The judge reasonably questioned

Eisenstein’s reliance on tests administered by other psychologists, and noted

Eisenstein was unable to do any more than speculate about the possibility Rosin

might suffer some deficits from brain injuries dating back several decades.

Finding no reasonable cause to believe that Rosin was incompetent to participate

in sentencing, the judge denied Rosin’s motion for additional brain imaging tests

and a subsequent competency hearing. His ruling was logical and well-articulated,

and was not an abuse of discretion.

G. Sentencing

      Lastly, Rosin raises challenges to both the duration of his sentence and the

lawfulness of the court’s forfeiture order. He contends the district court erred in

calculating his Guidelines sentence and in failing to vary downward from the

guideline range. In addition, Rosin contends the court’s forfeiture order violated

his rights under the Eighth and Fifth Amendments.

      1. Sentence duration

      Challenges to the duration of a sentence may come in either of two forms:

procedural or substantive. Rosin contends the court erred procedurally when it

                                          35
applied improper sentencing enhancements, and erred substantively when it

imposed a sentence longer than needed to achieve the purposes of sentencing.

             a. Guidelines calculation

      When reviewing a district court’s sentencing decision, this Court “must first

ensure that the district court committed no significant procedural error, such as

failing to calculate (or improperly calculating) the Guidelines range, treating the

Guidelines as mandatory, [or] failing to consider the § 3553(a) factors . . . .” Gall

v. United States, — U.S. — , 128 S. Ct. 586, 597 (2007). This Court reviews a

sentencing court’s application of the Sentencing Guidelines de novo. United

States v. Edmonds, 348 F.3d 950, 952-53 (11th Cir. 2003).

      According to Rosin, the district court miscalculated the applicable guideline

range in three ways. First, Rosin contends, the district court violated United States

v. Booker, 543 U.S. 220, 125 S. Ct. 738 (2005), by enhancing his sentence based

on estimations of the loss amount and the number of victims. The jury did not find

these facts to be true beyond a reasonable doubt; therefore, Rosin contends they

were improperly used to enhance the severity of his sentence.

      This Court explained in United States v. Rodriguez that “the use of

extra-verdict enhancements in an advisory guidelines system is not

unconstitutional.” 398 F.3d 1291, 1301 (2005); see also United States v. Chau,

                                          36
426 F.3d 1318, 1323-24 (11th Cir. 2005) (holding Booker does not prohibit

district court enhancement based on facts found by a preponderance of the

evidence and not charged in the indictment, under an advisory sentencing

scheme). So long as the judge views the Guidelines as advisory and finds relevant

facts by a preponderance of the evidence, he may rely on facts not before the jury

to enhance the sentence. United States v. Douglas, 489 F.3d 1117, 1129 (11th Cir.

2007). That is what happened here.

      Relying on the testimony of Dr. Flowers (the expert witness who reviewed

the greatest number of slides), the court concluded Rosin committed fraud with

respect to more than 800 different victims, and the losses associated with those

victims exceeded $4 million. The court’s reliance on the extra-verdict

enhancements was proper and did not violate the Constitution.

      Next, Rosin contends the court erred by enhancing his sentence based on his

use of sophisticated means. A district court’s finding that sophisticated means

were used in the commission of a crime is a finding of fact we review for clear

error. United States v. Barakat, 130 F.3d 1448, 1456 (11th Cir. 1997).

      The Sentencing Guidelines provide for a two-level enhancement if an

offense involves “sophisticated means.” U.S.S.G. § 2B1.1(b)(9)(C) (2006). The

commentary on that section states that sophisticated means are:

                                        37
      especially complex or especially intricate offense conduct pertaining
      to the execution or concealment of an offense. For example, in a
      telemarketing scheme, locating the main office of the scheme in one
      jurisdiction but locating soliciting operation in another jurisdiction
      ordinarily indicates sophisticated means. Conduct such as hiding
      assets or transactions, or both, through the use of fictitious entities,
      corporate shells, or offshore financial accounts also ordinarily
      indicates sophisticated means.

U.S.S.G. § 2B1.1(b)(9)(C) cmt. n. 8(B). There is no requirement that each of a

defendant’s individual actions be sophisticated in order to support imposition of

the enhancement; rather, it is sufficient if the totality of the scheme was

sophisticated. Cf. United States v. Finck, 407 F.3d 908, 915 (8th Cir. 2005)

(“Repetitive and coordinated conduct, though no one step is particularly

complicated, can be a sophisticated scheme.”).

      Rosin contends his scheme to defraud Medicare was not sophisticated

because he performed routine surgeries and did not use “complex tactics to cover

up his fraud.” However, the evidence adduced at trial revealed Rosin ran a

laboratory staffed with poorly trained technicians, directed his staff to discard

surgical slides, and performed complicated multistage surgeries in a manner

designed to maximize his profits while appearing falsely to treat skin cancer.

Given those facts, the court did not clearly err in finding Rosin’s means were

“sophisticated” within the meaning of the enhancement.

                                          38
      Thirdly, Rosin contends there was no evidence to support the district court’s

finding that his patients had suffered serious bodily injury as a result of his

criminal activity. Section 2B1.1(b)(12) of the United States Sentencing

Guidelines provides a two-level enhancement for crimes involving the “conscious

or reckless risk of death or serious bodily injury . . . .” Serious bodily injury is

defined as injury “involving extreme physical pain or the protracted impairment of

a function of a bodily member, organ, or mental faculty; or requiring medical

intervention such as surgery, hospitalization, or physical rehabilitation.” U.S.S.G.

§ 1B1.1, cmt. n.1(L)(2006).

      In arguing there was no evidence to justify a finding of serious bodily

injury, Rosin misrepresents the facts. After hearing from numerous patients

during the sentencing hearing, the judge concluded that at least two had suffered

serious physical injuries above and beyond surgery as a result of Rosin’s conduct.

The judge did not err by enhancing Rosin’s guideline range accordingly.

             b. Failure to vary

      If a district court’s sentencing decision is procedurally sound, the appellate

court must “consider the substantive reasonableness of the sentence imposed

under an abuse-of-discretion standard.” Gall, 128 S. Ct. at 597. When conducting

                                           39
this review, the court must take into account the totality of the circumstances,

including the extent of any variance from the guideline range. Id.

      Rosin contends his sentence was substantively unreasonable because the

district court failed to vary downward on the basis of his charitable contributions,

his family’s need for support, his payment of restitution in full, and his allegedly

diminished mental capacity. In both Gall and Rita v. United States, 551 U.S. —,

127 S. Ct. 2456 (2007), the Supreme Court held that, in reviewing sentences for

substantive reasonableness under 18 U.S.C. § 3553(a), federal appellate courts

may apply a presumption of reasonableness to district court sentences imposed

within the guideline range. Gall, 128 S. Ct. at 591; Rita, 127 S. Ct. at 2463.

Although this Circuit has declined to adopt such a presumption, the Court has

acknowledged the rationale in Rita “calls into question our reasons for not

affording a presumption of reasonableness,” United States v. Campbell, 491 F.3d

1306, 1314 n. 8 (11th Cir. 2007), and has held that “ordinarily we would expect a

sentence within the Guidelines range to be reasonable.” United States v. Talley,

431 F.3d 784, 788 (11th Cir. 2005).

      In this case, the trial judge listened to multiple days of testimony, hearing

evidence from experts, former patients, and members of the community about

Rosin’s character, his actions, and the effects of his crime. Rosin points to other

                                          40
cases in which individuals convicted of Medicare fraud received sentences lighter

than his. That fact alone is no reason for this court to vacate Rosin’s sentence:

different defendants often receive different sentences, as the facts of each case

require. See Gall, 128 S. Ct. at 598 (“It has been uniform and constant in the

federal judicial tradition for the sentencing judge to consider every convicted

person as an individual and every case as a unique study in the human failings that

sometimes mitigate, sometimes magnify, the crime and the punishment to ensue.”).

Unless a sentence is grossly disproportionate to the offense committed we do not

even consider the sentences imposed on other offenders who have committed

similar crimes. United States v. Arias-Izquierdo, 449 F.3d 1168, 1186 (11th Cir.

2006).

      It is true Rosin received a long sentence; however, it is also true he was

found guilty of committing serious crimes that extended over a protracted period.

His crimes affected elderly persons, abused a position of trust, and cost the

Government millions of dollars. Although Rosin points to mitigating evidence,

such as his charitable works and the needs of his wife and children, the district

court found those facts insufficient to justify a sentence outside the guideline

range. Finding neither mitigating nor aggravating circumstances in Rosin’s case,

                                          41
the district court imposed a sentence in the middle of the guideline range. We

cannot say he abused his discretion by doing so.

      2. Forfeiture

      Rosin raises two distinct challenges to his forfeiture order. First, he

contends that because the court ordered full restitution, the forfeiture order is an

excessive fine that violates the Eighth Amendment. Second, Rosin challenges the

$490,876.11 difference between the amount of forfeiture sought in the indictment

and the amount ordered at sentencing as an impermissible material variance.

             a. Excessive fine

      When sentencing a defendant convicted of a federal health care offense,

district courts are required to “order the person to forfeit property, real or personal,

that constitutes or is derived, directly or indirectly, from gross proceeds traceable

to the commission of the offense.” 18 U.S.C. § 982(a)(7). Rosin does not

challenge the court’s ability to order him to pay forfeiture, but contends the

amount ordered—$3,697,225.38—is excessive, particularly in light of the fact he

made full restitution to the Medicare program. Rosin failed to raise his objection

to the trial court; therefore, we review for plain error only. United States v. Raad,

406 F.3d 1322, 1323 (11th Cir. 2005).

                                          42
      Under the Eighth Amendment, a forfeiture is excessive “if it is grossly

disproportional to the gravity of a defendant’s offense.” United States v.

Bajakajian, 524 U.S. 321, 334, 118 S. Ct. 2028, 2036 (1998). Because

excessiveness “is a highly subjective judgment, the courts should be hesitant to

substitute their opinion for that of [Congress].” United States v. 817 N.E. 29th

Drive, 175 F.3d 1304, 1309 (11th Cir. 1999) (citing Bajakajian, 524 U.S. at 334,

118 S. Ct. at 2037 (“judgments about the appropriate punishment for an offense

belong in the first instance to the legislature”)). If the value of forfeited property

is within the range of fines prescribed by Congress, a strong presumption arises

that the forfeiture is constitutional. 817 N.E. 29th Drive, 175 F.3d at 1309.

      In this case, the maximum fine authorized by statute was $250,000 for each

crime Rosin committed. 18 U.S.C. § 3571(b)(3). He was convicted on 70 counts,

which led to a maximum fine of $17.5 million dollars. Although the

recommended guideline fine was substantially less than that amount ($250,000),

given the fact Rosin defrauded the Government of more than $3.6 million, it is

difficult to say a forfeiture twice that amount is unconstitutional, particularly in

light of the fact that Rosin’s net worth exceeded $11 million.

      Rosin contends the court should have taken account of his restitution when

setting the amount of his forfeiture. While superficially appealing, this argument

                                          43
fails to account for the different goals served by restitution and forfeiture. See

United States v. Leahy, 464 F.3d 773, 793 n.8 (7th Cir. 2006) (“While we

recognize to the untrained eye, this might appear to be a ‘double dip,’ restitution

and forfeiture serve different goals . . . .”). The goal of restitution is to

compensate victims for their losses, see, e.g., 18 U.S.C. §§ 3556, 3663(a)(1)

(authorizing restitution to compensate victims of criminal offenses), while the goal

of forfeiture is to punish, United States v. Dicter, 198 F.3d 1284, 1289 (11th Cir.

1999). That a defendant may ultimately be ordered to pay in restitution and

forfeiture more than he took is of little consequence:

      [P]aying restitution plus forfeiture at worst forces the offender to
      disgorge a total amount equal to twice the value of the proceeds of the
      crime. Given the many tangible and intangible costs of criminal
      activity, this is in no way disproportionate to the harm inflicted upon
      government and society by the offense.

United States v. Various Computers and Computer Equipment, 82 F.3d 582, 588

(3d Cir. 1996) (quotation marks and brackets omitted).

      Although Rosin’s forfeiture amount was high, so was the amount by which

he defrauded the Government. The forfeiture order did not violate the Excessive

Fines Clause of the Eighth Amendment.

             b. Variance

                                            44
      Lastly, Rosin contends his forfeiture order was invalid because there was a

material variance between the amount sought in the indictment and the amount the

court ordered him to pay. As an initial matter, we question whether the theory of

material variance even applies to forfeiture decisions, which implicate a

defendant’s right to be free from excessive punishment, see supra, rather than his

right to notice of the charges against him, United States v. Ratliff-White, 493 F.3d

812, 819 (7th Cir. 2007) (material variance implicates defendant’s Fifth

Amendment right to be informed of nature and cause of accusation against him

and Sixth Amendment right to indictment by grand jury). The claim that a

material variance exists between indictment and proof adduced at trial is a “form

of challenge to the sufficiency of the evidence,” United States v. Jenkins, 779 F.2d

606, 616 (11th Cir. 1986). Rosin does not point to precedent in this Circuit or any

other applying the law of material variance to a sentencing, fine, or forfeiture

decision, and our independent search has revealed none.

      Nevertheless, for the sake of argument, we note “[a] variance exists where

the evidence at trial proves facts different from those alleged in the indictment, as

opposed to facts which, although not specifically mentioned in the indictment, are

entirely consistent with its allegations.” United States v. Gold, 743 F.2d 800, 813

(11th Cir. 1984). “The standard of review for whether there is a material variance

                                          45
between the allegations in the indictment and the facts established at trial is

twofold: First, whether a material variance did occur, and, second, whether the

defendant suffered substantial prejudice as a result.” United States v. Chastain,

198 F.3d 1338, 1349 (11th Cir. 1999).

      Rosin points out that in the superceding indictment, the Government

requested forfeiture in the amount of $3,206,349.21. However, after the

Government’s expert testified to a higher loss amount, the court ordered

$3,697,225.38 in restitution—a difference of $490,876.11. The difference

between the amount listed in the indictment and the amount Rosin was ordered to

pay differed by half a million dollars, a large sum of money, but an amount only

15% greater than the amount requested in the indictment. Considered in context,

it is doubtful the “variance” could be considered “substantial.”

      Assuming the difference was significant enough to qualify as a substantial

variation from the amount sought in the indictment, the next question would be

whether the difference substantially prejudiced Rosin. To show that it did, Rosin

would be required to demonstrate that “the proof at trial differed so greatly from

the charges that [he] was unfairly surprised and was unable to prepare an adequate

defense.” United States v. Alred, 144 F.3d 1405, 1415 (11th Cir. 1998). Rosin

                                          46
makes no effort to explain how he was prejudiced by the higher amount proven at

sentencing, and it is difficult to see how he would have been.

      The court’s forfeiture order was equivalent to the amount of money Rosin

had received from Medicare, patients, and patients’ insurers as a result of the

fraudulent surgeries. Rosin’s counsel had the opportunity to argue at sentencing

that the court had included too many surgeries in assessing the extent of the fraud,

and, in fact, he presented competing expert testimony on the point. Although the

court ultimately rejected Rosin’s argument, he cannot say he was unfairly

surprised by the Government’s position and was unfairly prejudiced by it.

Therefore, even if there could be a material variance between the amount sought in

an indictment and the amount ordered forfeited following conviction, Rosin has

not shown such a variance existed in this case.

      AFFIRMED.

                                         47