                                                          [DO NOT PUBLISH]


              IN THE UNITED STATES COURT OF APPEALS

                      FOR THE ELEVENTH CIRCUIT            FILED
                        ________________________ U.S. COURT OF APPEALS
                                                          ELEVENTH CIRCUIT
                              No. 08-10021                   MAY 4, 2009
                          Non-Argument Calendar            THOMAS K. KAHN
                                                               CLERK
                        ________________________

                    D. C. Docket No. 07-20271-CR-DMM

UNITED STATES OF AMERICA,


                                                                Plaintiff-Appellee,

                                   versus

RODOLFO AENLLE,

                                                          Defendant-Appellant.


                        ________________________

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

                                (May 4, 2009)

Before BLACK, BARKETT and WILSON, Circuit Judges.

PER CURIAM:

     Rodolfo Aenlle appeals his 84-month sentence imposed after a jury found
him guilty of (1) conspiring to defraud the United States, in violation of 18 U.S.C.

§ 371; (2) conspiring to commit health care fraud, in violation of 18 U.S.C. § 1349;

and (3) soliciting and receiving health care kickbacks, in violation of 42 U.S.C.

§ 1320a-7b(b)(1). Specifically, Aenlle challenges the loss amount that the district

court attributed to him.

       According to the indictment, Aenlle conspired with the owners of Unimed

Equipment & Supplies (“Unimed”) to submit false claims to Medicare for

medically unnecessary medications. In doing so, Aenlle obtained prescriptions for

Medicare beneficiaries, Unimed submitted claims to Medicare on behalf of those

beneficiaries, and Aenlle received kickbacks from the Medicare payments that

Unimed received. The district court sentenced Aenlle to 84 months’

imprisonment. In calculating his offense level, the district court increased his base

offense level by 16 based on the loss amount. See U.S. S ENTENCING G UIDELINES

M ANUAL § 2B1.1(b)(1)(I).1 While Aenlle’s conviction stemmed from his

submission of false prescriptions to Unimed through his own company, Direct

Nursing Associates, Inc. (“Direct Nursing”), in exchange for kickbacks, the district



       1
         If the greater of the value of a bribe or improper benefit to be conferred exceeds $5,000,
Guidelines § 2B4.1 requires the district court to increase the offense level as indicated by the
table in Guidelines § 2B1.1. U.S. SENTENCING GUIDELINES MANUAL § 2B4.1(b)(1). Section
2B1.1, in turn, provides for an increase of 16 levels when the loss amount is more than
$1,000,000.

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court found that Direct Nursing was involved in similar activity with Prestige

Pharmacy (“Prestige”) and that Direct Nursing directly submitted to Medicare false

claims for durable medical equipment. As such, the total loss amount associated

with Aenlle’s scheme amounted to $1,048,487, including: (1) $164,243, based on

prescriptions Aenlle and his co-conspirator Carlos Carrion delivered to Unimed

through Direct Nursing;2 (2) $58,010, based on prescriptions Aenlle and Carrion

delivered to Prestige through Direct Nursing; and (3) $826,234, based on claims

submitted by Direct Nursing directly to Medicare for medically unnecessary

equipment.3 Aenlle challenges only the attribution of the latter two amounts to

him, specifically the loss amounts relating to (1) Prestige and (2) Direct Nursing

claims for durable medical equipment from June 2003 to June 2006.

       On appeal, Aenlle argues that the district court erred in imposing his

sentence because its determination of the appropriate Guidelines offense level

involved speculation and went far beyond the facts that had been proven. He

maintains that the attribution to him of loss related to Prestige was based on

speculation, as no witness testified that Aenlle or Carrion gave any false

prescription to Prestige in return for a payment. According to Aenlle, the only

       2
        The parties agree that the intended loss amount as to Unimed of $164,243 should have
been $164,423. They also agree that this error is not relevant to Aenlle’s appeal.
       3
        Each of the three individual loss amounts reflect 80% of the actual amount billed to
Medicare in order to account for Medicare’s 20% co-pay requirement.

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“evidence” of his involvement with Prestige showed that some of the documents

seized from Prestige had the names Carlos and Rodolfo on them. Aenlle argues

that, even if there was sufficient evidence to support a finding that he was giving

false prescriptions to Prestige, there was no evidence that Prestige’s records were

accurate or that certain references to “Prestige Group 9” in those records referred

to him. Aenlle next contends that the attribution of loss relating to claims

submitted to Medicare by Direct Nursing for medical equipment also was based on

speculation as there was no evidence that every claim submitted by Direct Nursing

for equipment during Aenlle’s tenure with the company was false. In fact, Carrion

testified that he only saw that about 20 of Direct Nursing’s patients had equipment

that they did not seem to be using. As noted above, Aenlle contends that the only

loss that should have been attributed to him in determining the appropriate increase

in his offense level was the $164,243 (80% of $205,529) in loss from claims

submitted to Medicare by Unimed and another Pharmacy.

      We review a district court’s interpretation of the Guidelines de novo and its

factual findings for clear error. United States v. Masferrer, 514 F.3d 1158, 1164

(11th Cir. 2008) (citation omitted), cert. denied, 129 S. Ct. 996 (2009). In

particular, “[t]his court reviews for clear error a district court’s determination of

loss from fraud for sentencing purposes.” United States v. Liss, 265 F.3d 1220,



                                            4
1230 (11th Cir. 2001). “We cannot find clear error unless we are left with a

definite and firm conviction that a mistake has been committed.” United States v.

Crawford, 407 F.3d 1174, 1177 (11th Cir. 2005) (quotation marks and citation

omitted).

      Proper calculation of the Guidelines, and in particular a defendant’s offense

level, requires consideration of “all relevant conduct,” not merely charged conduct.

United States v. Hamaker, 455 F.3d 1316, 1336 (11th Cir. 2006). The government

must prove relevant conduct, such as the calculation of loss amount in a fraud case,

with “reliable and specific evidence.” United States v. Cabrera, 172 F.3d 1287,

1292 (11th Cir. 1999). A district court’s determination of relevant conduct is

governed by the preponderance of the evidence standard rather than the more

demanding standard of proof beyond a reasonable doubt. United States v. Hristov,

466 F.3d 949, 954 n.6 (11th Cir. 2006). Offense conduct is determined based on

relevant conduct, as provided in Guidelines § 1B1.3. Where, as here, Guidelines

§ 2B4.1 applies, relevant conduct includes “all acts and omissions . . . that were

part of the same course of conduct or common scheme or plan as the offense of

conviction.” U.S. S ENTENCING G UIDELINES M ANUAL § 1B1.3(a)(2) (cross-

referencing U.S. S ENTENCING G UIDELINES M ANUAL § 3D1.2(d)). According to the

commentary, offenses constitute a common scheme or plan for purposes of



                                           5
relevant conduct if they are “substantially connected to each other by at least one

common factor, such as common victims, common accomplices, common purpose,

or similar modus operandi.” U.S. S ENTENCING G UIDELINES M ANUAL § 1B1.3, cmt.

n.9(A) (emphasis added). “The court need only make a reasonable estimate of the

loss” based on the available information. U.S. S ENTENCING G UIDELINES M ANUAL

§ 2B1.1 cmt. n.3(C).

      As an initial matter, the Government asserts that all of Aenlle’s arguments

on appeal should be reviewed for plain error, apparently based on the fact that

Aenlle did not raise any objections after his sentence was imposed. However, “so

as long as a party states its objection to the sentence at some point during the

sentencing hearing, its failure to repeat the objection at the conclusion of the

imposition of sentence will not result in a waiver of that objection.” United States

v. Hoffer, 129 F.3d 1196, 1202 (11th Cir. 1997) (discussing United States v. Weir,

51 F.3d 1031, 1033 (11th Cir. 1995)). Aenlle adequately raised his objections that

there was insufficient evidence to hold him accountable for the losses relating to

Direct Nursing billing from June 2003 to June 2006 and the Prestige Pharmacy

kickbacks, even though he did not reiterate them after sentencing. See id. at 1203

(holding “that the government did not waive its objections to the district court's

departure decision and the resulting sentence by failing to reiterate these objections



                                           6
after the sentence was imposed”). Therefore, the more stringent plain error

standard of review does not apply.

      The Government also argues that Aenlle invited error for failing to object to

losses relating to Direct Nursing durable medical equipment claims that took place

between 2001 and 2003. Aenlle did not invite error because, at most, he failed to

object to that portion of the loss amount. Cf. United States v. Love, 449 F.3d 1154,

1157 (11th Cir. 2006) (per curiam) (noting that the “doctrine of invited error is

implicated when a party induces or invites the district court into making an error”)

(citation omitted). Aenlle objected that the Presentence Investigation Report

improperly included the billing of medical equipment by Direct Nursing between

June 2003 and June 2006 in its loss amount even though no trial evidence showed

that medical equipment billed during that time was medically unnecessary.

Because Aenlle did not object to the inclusion of fraudulent Direct Nursing durable

medical equipment claims from 2001 to 2003, he admitted the loss amounts for

that time period. See United States v. Shelton, 400 F.3d 1325, 1330 (11th Cir.

2005) (holding that factual findings set forth in the PSI not objected to by a

defendant are deemed admitted). In any event, Aenlle does not argue on appeal

that the DME claims from 2001 to 2003 were not fraudulent.

      Applying the clear error standard of review, we conclude that the district



                                           7
court did not clearly err by attributing the loss amounts related to durable medical

equipment claims from Direct Nursing and prescriptions claims from Prestige to

Aenlle. In United States v. Valladares, we addressed a defendant’s participation in

a scheme to defraud Medicare, where the defendant paid Medicare beneficiaries to

go to doctors, bribed doctors to obtain prescriptions for medically unnecessary

aerosol medication, and gave the prescriptions to pharmacies that would use them

to submit fraudulent Medicare claims. 544 F.3d 1257, 1261(11th Cir. 2008) (per

curiam). Although not included in the indictment, the government presented

evidence at trial that the defendant was independently submitting fraudulent

Medicare claims on behalf of her own company, which provided aerosol-related

medical equipment to Medicare beneficiaries. Id. We held that the district court

did not clearly err in finding that evidence of the defendant’s submission of

Medicare claims on behalf of her own company was relevant conduct as part of a

common plan or scheme because (1) the victim and purpose (i.e., to defraud

Medicare) of the pharmacy and equipment schemes were the same; (2) the two

schemes involved the same modus operandi of submitting fraudulent Medicare

claims; (3) both schemes used many of the same patients to bill Medicare; and

(4) the aerosol medication billed by the pharmacies was typically ingested through

the aerosol durable medical equipment billed by the defendant’s company, and



                                          8
Medicare only would reimburse aerosol medication taken through such equipment.

Id. at 1268. Likewise here, both the Direct Nursing evidence and the Prestige

evidence constituted “relevant conduct” to the claims for which Aenlle was

convicted insofar as (1) they involved the same victim (Medicare); (2) they shared

the same purpose of defrauding Medicare; (3) they involved the same modus

operandi of submitting fraudulent Medicare claims; and (4) they involved common

patients. See id. at 1258. In addition, as to the durable medical equipment claims

from Direct Nursing, Carrion testified that, when another person was in charge of

the company, they paid all of the patients and that none of the patients were

legitimate, which supports an inference that the prescription fraud kickback

scheme continued when Aenlle and Carrion assumed control in 2001.

      Because the district court did not clearly err in attributing loss amounts

relating to durable medical equipment claims from Direct Nursing and

prescriptions claims from Prestige to Aenlle, we affirm.

      AFFIRMED.




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