230 F.3d 980 (7th Cir. 2000)
UNITED STATES OF AMERICA, Plaintiff-Appellee,v.ELENA S. DUNCAN, Defendant-Appellant.
No. 00-1346
In the  United States Court of Appeals  For the Seventh Circuit
Argued September 29, 2000Decided October 24, 2000

Appeal from the United States District Court  for the Northern District of Indiana, Hammond Division.  No. 98 CR 125--James T. Moody, Judge.[Copyrighted Material Omitted]
Before EASTERBROOK, RIPPLE and EVANS, Circuit Judges.
RIPPLE, Circuit Judge.


1
Elena Duncan was charged  by indictment with four counts of mail fraud in  violation of 18 U.S.C. sec. 1341. A jury found  Ms. Duncan guilty on all four counts, and she was  sentenced to 52 months' imprisonment. Ms. Duncan  now appeals her sentence. For the reasons set  forth in the following opinion, we affirm the  judgment of the district court.


2
* BACKGROUND


3
Ms. Duncan was convicted of a scheme to defraud  Medicare and Medicaid through her home health  care supply company, Home Care Connection  ("HCC"). Ms. Duncan billed the Medicare and  Medicaid programs for supplies that patients  never ordered, for supplies that patients never  received, and for supplies that were not ordered  or prescribed by a physician. This appeal focuses  on the sentencing phase of the proceedings and  Ms. Duncan's overbilling for "skin barriers." A  skin barrier is either a bandage or a form of  lotion or powder that serves the same purpose as  a bandage. The evidence submitted by the  Government at trial, which the jury was entitled  to accept, established that Ms. Duncan instructed  her employees to add skin barriers to all  patients' orders, whether or not the patients  requested them. The Government introduced  evidence through a registered nurse knowledgeable  about the Medicare/Medicaid coding system that  Medicare and Medicaid only reimburse skin barrier  purchases in cases of ostomies, iliostomies or  colostomies. Ms. Duncan introduced evidence from  the manufacturers of skin barriers that such  barriers are also appropriately used in cases of  urinary incontinence, osteopetrosis, arthritis,  muscular atrophy, varicose veins, diabetes,  asthma, decubitus ulcers and intestinal  obstruction.


4
After the jury found Ms. Duncan guilty of four  counts of mail fraud, the district court  conducted a sentencing hearing. The Government  introduced the testimony of Debra LaPosa, a  Medicaid fraud investigator, and Lynn Hemberger,  a special agent from the United States Department  of Health and Human Services, to establish the  amount of loss caused by Ms. Duncan's fraud.  LaPosa and Hemberger employed a three-step  process to calculate the amount HCC overbilled.  In the first step, the investigators calculated  the amount HCC received for supplies that were  never given to patients, for supplies that were  not necessary for a patient's medical condition  and for supplies that were never prescribed by a  physician. In the second step, the investigators  calculated the amount of money HCC received from  Medicare and Medicaid over and above the amounts  reflected in its delivery receipts. In the third  step, the investigators identified diagnoses for  which the use of skin barriers was not customary,  then calculated the amount of money HCC received  for dispensing skin barriers to treat these  diagnoses. LaPosa, who calculated the loss to  Medicaid, conducted the third step by hand after  reviewing each of the relevant files. Hemberger,  in contrast, calculated the loss to Medicare  under the third step using a computer.


5
Hemberger testified that, in order to prevent  double counting any particular overbilling, she  subtracted the total amount she calculated under  the first and second steps from the computer-  generated amount calculated under the third step.  She further testified that LaPosa did not have to  account for the possibility of double counting in  the same manner because she could avoid double  counting as she went through the files  individually by hand. Hemberger also deducted  about $9,500 from her total calculation based on  documents provided to her by Ms. Duncan that  indicated that certain supplies may have been  dispensed pursuant to physicians' orders.1  LaPosa's and Hemberger's calculations indicated  that the total loss to Medicare and Medicaid was  $358,272.88.


6
The Government also introduced the testimony of  Tiawana Blackwell at the sentencing hearing.  Blackwell was a former employee of Opportunity  Medical ("OM"), a health care supply company  started by Ms. Duncan after she stopped operating  HCC. Ms. Duncan had fired Blackwell after  Blackwell allegedly had stolen from OM. Blackwell  originally had been called by Ms. Duncan at the  guilt phase of the trial, but the district court  had ruled that her testimony was irrelevant  because it related to OM rather than to HCC. At  the sentencing hearing, at which she was a  government witness, Blackwell testified that,  after her trial and before her sentencing, Ms.  Duncan had used OM to commit Medicare and  Medicaid fraud in much the same way she had used  HCC to commit fraud. Blackwell gave investigators  the names of three patients whose accounts had  been used in OM's overbilling scheme. The  investigators confirmed that these patients, in  addition to others, had received supplies they  did not want or need. The investigators also  found forged physicians' orders in these  patients' files. Blackwell further testified that  Ms. Duncan had paid her $700 to testify falsely  at the trial that skin barriers were medically  necessary for all patients. Lastly, the  Government introduced evidence pertaining to one  of HCC's clients, Dolly Bollinger. The evidence  indicated that Ms. Duncan had removed supplies  from Bollinger's house after she learned that  Bollinger had been contacted by an investigator.


7
The district court accepted the Government's  calculation of the total amount of Ms. Duncan's  fraud as $358,272.88. In accordance with United  States Sentencing Guideline sec. 2F1.1, the court  arrived at a base offense level of 15. The court  added 2 levels because Ms. Duncan was a leader or  supervisor under sec. 3B1.1C. The court also  accepted as credible the evidence indicating that  Ms. Duncan had continued to engage in Medicare  and Medicaid fraud after her jury conviction,  that she falsified documents in her patient files  once the investigation had begun and that she  went to Bollinger's home to remove unnecessary  and excessive medical supplies after she learned  that Bollinger had been contacted by an  investigator. Based on this evidence, the court  increased Ms. Duncan's offense level by 2 points  for obstruction of justice. Lastly, the court  concluded that Ms. Duncan's criminal history  category of I did not reflect adequately the  seriousness of her crime or the likelihood that  she would repeat such conduct. The court stated  that Ms. Duncan's post-conviction fraud would  have resulted in at least one additional charge  of mail fraud, which would have increased her  criminal history category to III. The court  therefore granted the Government's request for an  upward departure and determined that Ms. Duncan  ought to be sentenced as having a criminal  history category of III and an offense level of  21.2 Based on this determination, the district  court sentenced Ms. Duncan to 52 months'  imprisonment.

II
DISCUSSION
A.

8
Ms. Duncan first asks that we decide whether the  Government's method for calculating the total  amount of the fraud, which the district court  accepted, overstates the total cost of HCC's  fraud. She submits that the third step of the  Government's methodology overstates the cost of  her fraud in two respects. She first contends  that LaPosa's calculation of the amount of the  Medicaid fraud impermissibly counted twice some  overbillings. She points out that LaPosa did not  take the same precautions to avoid double  counting as Hemberger did in calculating the loss  to Medicare. As a second attack on the amount of  loss determination, Ms. Duncan argues that LaPosa  and Hemberger improperly included in their  calculations billings for skin barriers that were  supported by physicians' orders.


9
In response, the Government first submits that  Ms. Duncan has waived her double-counting  argument because she did not raise it in the  district court. Alternatively, with respect to  Ms. Duncan's first argument, the Government  contends that, because LaPosa reviewed the files  by hand in performing her calculation, she was  able to detect and avoid any possible double  counting. With respect to Ms. Duncan's second  argument, the Government maintains that Ms.  Duncan failed to offer evidence that some of  HCC's billings for skin barriers were supported  by physicians' orders.


10
We review a district court's calculation of loss  pursuant to U.S.S.G. sec. 2F1.1(b)(1) for clear  error. See United States v. Gee, 226 F.3d 885, 899 (7th Cir. Sept. 11,  2000). The Guidelines do not require that the  district court compute the loss with precision;  the court need only make a reasonable estimate of  the loss based on the information available.  U.S.S.G. sec. 2F1.1, Application Note 9. When a  defendant appeals a district court's loss  calculation, she must show not only that the  calculation was inaccurate, but also that it was  "outside the realm of permissible computations."  United States v. Hassan, 211 F.3d 380, 383 (7th  Cir. 2000) (quoting United States v. Jackson, 25  F.3d 327, 330 (6th Cir. 1994)).

1.

11
The Government is correct that a specific  double-counting objection was never presented to  the district court. However, Ms. Duncan did  object to the Government's method of calculation  under the third step on the ground that each file  should have been reviewed individually. The  thrust of her objection was that, if the files  had been reviewed individually, some of the  billings would have been supported by physicians'  orders, thereby reducing the total cost of the  fraud. Had both investigators reviewed each file  individually, as Ms. Duncan argued they should  have, they presumably would have also uncovered  any instances of double counting. Although the  objection was not specifically addressed to the  issue of double counting, the district court was  certainly aware that Ms. Duncan objected to the  Government's calculation under the third step  because it was overinclusive. We shall,  therefore, turn to Ms. Duncan's specific  objections to the calculation accepted by the  district court.

2.

12
Upon examination of the record, we cannot say  that the district court erred in accepting  LaPosa's calculation of the Medicaid fraud  without adjusting it to account for double  counting, as Hemberger had done. The district  court had before it Hemberger's testimony that  LaPosa did not have to make the same adjustments  as Hemberger because, rather than rely on a  computer, LaPosa had gone through the files  individually. Although both parties expended a  marginal effort on producing a clear and precise  record, we think that the district court was  entitled to rely on this difference in  methodology to conclude that no double counting  had occurred with respect to the Medicaid  billings.

3.

13
We also see no basis for concluding that the  district court erred in its evaluation of the  possibility that some skin barrier billings were  considered fraudulent despite a physician's  authorization for their use. The Government  introduced evidence before the district court  that indicated that skin barriers were not  covered for many of the diagnoses for which Ms.  Duncan billed for them. The court also heard  testimony from HCC employees that Ms. Duncan had  told them to add skin barriers to patients'  orders, regardless of whether the patients needed  them. The only evidence Ms. Duncan offered in  rebuttal was literature from skin barrier  manufacturers indicating that skin barriers had a  wider usage than Medicare and Medicaid allowed.  The district court was permitted to credit the  testimony offered by the Government over the  information provided in the product literature.


14
We also note that Ms. Duncan turned over some  boxes of HCC's files to Hemberger and LaPosa and  requested that they inspect them for possible  deductions from their loss calculations.  Hemberger testified that she examined the files  and gave Ms. Duncan "every advantage" she could  when it came to physicians' orders that may have  supported HCC's reimbursement requests for skin  barriers. Sent. Tr. at 107. Indeed, the district  court concluded that Ms. Duncan failed to provide  the court with "a single instance where a skin  barrier included in the Government's calculation  was actually medically prescribed." Sent. Tr. at  191. We therefore conclude that the district  court did not clearly err in accepting the  Government's calculation of the total loss to the  Medicare and Medicaid programs.

B.

15
We now turn to Ms. Duncan's contention that the  district court erred in increasing her criminal  history category based on evidence that she had  engaged in further fraud during the period  between her conviction and her sentencing. The  district court added three points to Ms. Duncan's  criminal history category based on the  Government's evidence that she had continued to  defraud Medicare and Medicaid during this time.


16
Ms. Duncan notes that sec. 4A1.1(d) of the  Guidelines instructs a sentencing court to  increase a defendant's criminal history category  when the defendant commits an offense "while  under any criminal justice sentence." Section  4A1.1(e) of the Guidelines similarly instructs a  sentencing court to increase a defendant's  criminal history category if the defendant, inter  alia, offends again less than 2 years after her  release from prison. However, Ms. Duncan argues,  there is no similar increase provided for  defendants who have been tried for another  offense and not yet sentenced. She relies on our  decision in United States v. Connor, 950 F.2d  1267, 1276 (7th Cir. 1991), and contends that we  recognized there that Congress rationally has  determined that defendants who offend after  previously having been sentenced are more  dangerous than those who offend before they have  been sentenced. Ms. Duncan concludes that,  because she had not yet been sentenced at the  time she allegedly used OM to commit additional  fraud, she ought not be considered as dangerous  as other defendants who offend again after having  been sentenced.


17
The starting point of our analysis is U.S.S.G.  sec. 4A1.3. That section reads in pertinent part


18
If reliable information indicates that the  criminal history category does not adequately  reflect the seriousness of the defendant's past  criminal conduct or the likelihood that the  defendant will commit other crimes, the court may  consider imposing a sentence departing from the  otherwise applicable guideline range.


19
We review a district court's decision to depart  upwardly from the Guidelines under sec. 4A1.3  according to a three-part test.3 First, the  district court must state adequate grounds for  the departure; the adequacy of these grounds is  reviewed de novo. Second, the facts cited to  support the departure must actually exist in the  record; the standard of review under this step is  the clear error standard. Third, the degree of  the departure must be linked to the structure of  the Guidelines; the extent of the district  court's departure is reviewed deferentially.


20
We employed this three-part test and sanctioned  a sentencing court's decision to increase a  defendant's criminal history category when the  defendant has committed offenses similar to the  offense of conviction during the time between  conviction and sentencing in United States v.  Tai, 41 F.3d 1170, 1177 (7th Cir. 1994). In that  case, we held that a district court properly  added two levels to the defendant's criminal  history category when the defendant, convicted of  extortion, continued to extort victims from  prison prior to sentencing. We stated that, when  a defendant commits similar offenses after  conviction, it reflects the defendant's disregard  for the law and the likelihood that she will  commit further offenses in the future. See id.  When a district court upwardly departs on this  basis, it sufficiently links its departure to the  structure of the Guidelines when it analogizes  the post-conviction/pre-sentence conduct to a  prior sentence and increases the defendant's  criminal history category accordingly. See id. at  1176-77.


21
The district court's approach is in conformity  with our holding in Tai. As in Tai, Ms. Duncan  engaged in additional fraudulent conduct between  the time of her conviction and her sentencing.  The district court explicitly stated that, based  on this additional conduct, her initial criminal  history category did not reflect the seriousness  of her crime or the likelihood that she would  commit further crimes in the future. There is,  moreover, a factual basis for the district  court's determination in the record. Blackwell  testified that, subsequent to her conviction and  prior to her sentencing, Ms. Duncan continued to  defraud Medicare and Medicaid through her new  company, OM. Although Ms. Duncan argues that  Blackwell's testimony is an insufficient basis on  which to depart upwardly because Blackwell had  reason to lie under oath, the district court  found her to be a credible witness. Finally, the  district court did link the extent of its  departure to the Guidelines. It treated Ms.  Duncan's post-conviction/pre-sentence fraud as if  it had been a prior sentence and increased her  criminal history category accordingly, as  suggested by U.S.S.G. sec. 4A1.1A.


22
Ms. Duncan alternatively relies on U.S.S.G. sec.  4A1.2(a)(4). This section states in pertinent part


23
(4)  Where a defendant has been convicted of an  offense, but not yet sentenced, such conviction  shall be counted as if it constituted a prior  sentence under sec.4A1.1(c) if a sentence  resulting from that conviction otherwise would be  countable.


24
If this section were applicable, the district  court would have enhanced Ms. Duncan's criminal  history category by only one point. However, this  provision applies only when the intervening  criminal conduct has resulted in a conviction for  which the defendant has not yet been sentenced.  By its terms, therefore, this provision is not  applicable to Ms. Duncan's case because she had  not been convicted for the OM fraud. Therefore,  unlike the situation posited in this guideline,  it could not be reasonably anticipated that, in  due course, an additional sentence would be  imposed.4


25
In increasing Ms. Duncan's sentence, the  district court acted in conformity with the  Guidelines and our case law. We shall not disturb  its determination.

C.

26
We now examine whether the district court  clearly erred in adding two levels to Ms.  Duncan's base offense level for obstruction of  justice.


27
The district court determined that Ms. Duncan  had obstructed justice by offering to pay  Blackwell $700 to testify falsely that skin  barriers were medically necessary for all  patients, by producing false documents to  mitigate the loss to the victims of the fraud and  by removing medical supplies from Bollinger's  home to thwart an ongoing investigation. Ms.  Duncan argues that there was an insufficient  factual basis for each of the district court's  findings and that any allegedly false testimony  solicited from Blackwell was immaterial because  the district court ruled that Blackwell's trial  testimony was irrelevant. The Government responds  that the factual basis for the court's  conclusions is sufficient and that Blackwell's  false testimony was material because, if it had  been given at trial, it would have tended to  influence an issue under consideration.


28
A district court's finding that a defendant has  obstructed justice within the meaning of U.S.S.G.  sec. 3C1.1 is reviewed for clear error. See  United States v. Frazier, 213 F.3d 409, 416 (7th  Cir. 2000). The Guidelines explicitly state that  suborning or attempting to suborn perjury is a  form of obstruction for which the two-level  increase should be applied, see U.S.S.G. sec.  3C1.1, Application Note 4(b), as is producing  false or altered documents, see id. at  Application Note 4(c), and concealing evidence,  see id. at Application Note 4(d).


29
There is factual support in the record for each  of the district court's determinations regarding  the obstruction enhancement. Specifically,  Blackwell testified that Ms. Duncan offered her  $700 to testify falsely at trial. Despite Ms.  Duncan's arguments at trial that Blackwell was  inherently untrustworthy and had reason to lie,  the district court found her testimony credible.  Also, the Government produced evidence that there  were prescriptions in certain HCC patients' files  that physicians denied having written. Lastly,  the court heard evidence that Bollinger asked Ms.  Duncan to remove the excess medical supplies from  her home, but that Ms. Duncan failed to do so  until she learned that Bollinger had been  contacted by investigators who wanted to  videotape the excess supplies. Based on this  evidence, it is difficult to say that the  district court clearly erred in concluding that  Ms. Duncan suborned perjury from Blackwell,  falsified prescriptions in patient files and  tried to conceal evidence by removing supplies  from Bollinger's home.


30
As to Ms. Duncan's claim that Blackwell's  testimony was not material because the district  court ruled that it was irrelevant, the  Guidelines define "material" as "tend[ing] to  influence or affect the issue under  determination." U.S.S.G. sec. 3C1.1, Application  Note 6. All that is required for an obstruction  enhancement is that the suborned perjury could  affect, to some reasonable probability, the  outcome of the judicial process; the suborned  perjury does not have to succeed in affecting the  outcome. See United States v. Buckley, 192 F.3d  708, 710 (7th Cir. 1999), cert. denied, 68  U.S.L.W. 3725 (U.S. May 22, 2000) (No. 99-9189).  The testimony that Ms. Duncan asked Blackwell to  give certainly could have affected the outcome of  her trial. If Blackwell had testified that skin  barriers were medically necessary for all  patients, as Ms. Duncan had asked her to do, it  is possible that Ms. Duncan would not have been  held responsible for overbilling for skin  barriers.5 It is of no consequence that  Blackwell never actually testified falsely.  Obstruction of justice took place when Ms. Duncan  encouraged Blackwell to testify falsely in an  effort to improve her chances of acquittal.

Conclusion

31
The district court committed no reversible error  in the computation of Ms. Duncan's sentence.  Accordingly, the judgment of the district court  must be affirmed.

AFFIRMED


Notes:


1
 Ms. Duncan claims that this deduction was taken  to compensate for double counting that she thinks  occurred in the various steps of the  calculations. See Appellant's Br. at 5. However,  Hemberger's testimony at the sentencing hearing  indicates that this deduction was taken to give  Ms. Duncan the benefit of the doubt when  Hemberger found questionable physicians' orders  in HCC's files that purported to support HCC's  billings for medical supplies. See Sent. Tr. at  107.


2
 The district court also added 2 levels pursuant  to sec. 2F1.1 because the scheme involved more  than minimal planning and defrauded more than one  victim. This enhancement is not at issue in this  appeal.


3
 See United States v. Sarna, 28 F.3d 657, 661 (7th  Cir. 1994), quoted in United States v.  Archambault, 62 F.3d 995, 1000-01 (7th Cir.  1995).


4
 A situation of this sort confronted the court in  United States v. Connor, 950 F.2d 1267, 1276 (7th  Cir. 1991), the case upon which Ms. Duncan  relies. In Connor, the defendant had attempted to  escape while awaiting trial on federal charges.  He pleaded guilty to the escape charge and that  offense was grouped with the convictions  resulting from the other federal charges for  sentencing. Because the escape charge did not  result in any additional penalty under the  pertinent grouping formula, the district court  sought to increase the sentence through an upward  departure. This court reversed the resulting  enhancement on the ground that the Sentencing  Commission had provided for the situation when it  adopted the grouping formula that the district  court had employed. Thus, Connor involved a  situation in which the defendant's commission of  other criminal activity had already been factored  into the sentencing scheme and, therefore, could  not serve as the basis of another upward  departure.


5
 Blackwell was first called as a witness by the  defense during the guilt phase of the trial. The  district court ruled that her testimony about OM  was irrelevant because it involved activity not  charged in the indictment. The defense chose not  to ask her about the usages of skin barriers  despite her status as a registered nurse. Such an  inquiry would not have been irrelevant. Nor would  such a question have been irrelevant at  sentencing when the district court focused on the  amount of loss incurred by the Government. Thus,  had either the defense or the Government asked  her, in an appropriate context, about the use of  skin barriers, her answer would have been  relevant and could have possibly affected the  outcome of the proceeding.


