United States v. Vivit, Salvador A. ( 2000 )


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  • In the
    United States Court of Appeals
    For the Seventh Circuit
    No. 99-3773
    United States of America,
    Plaintiff-Appellee,
    v.
    Salvador A. Vivit,
    Defendant-Appellant.
    Appeal from the United States District Court
    for the Northern District of Illinois, Eastern Division.
    No. 98 CR 157 01--James B. Zagel, Judge.
    Argued April 10, 2000--Decided June 6, 2000
    Before Easterbrook, Kanne and Rovner, Circuit Judges.
    Kanne, Circuit Judge. A jury found Salvador
    Vivit, a medical doctor, guilty of sixteen counts
    of mail fraud based on a scheme in which he and
    his patients submitted false claims to insurance
    companies that grossly overstated the amount of
    care he had provided. The district court
    sentenced Vivit to seventy-two months
    imprisonment for these offenses. On appeal, Vivit
    does not contest the convictions, but he claims
    that the district court committed numerous errors
    in determining the appropriate sentence. Finding
    no errors in Vivit’s sentence, we affirm the
    decision of the district court.
    I.   History
    Salvador Vivit operated the Family Medical
    Center, a one-doctor clinic located in Elmwood
    Park, Illinois. At the Family Medical Center,
    Vivit employed only two other individuals,
    Estrella Del Moral, who worked as a receptionist,
    did filing and sometimes provided physical
    therapy to Vivit’s patients, and Adriano "Andy"
    Apostol, his partner, who processed and filed
    insurance claims for Vivit.
    Vivit and Apostol had founded the clinic
    together in 1993, with Apostol providing about
    $7,000 in start-up money and equipment. However,
    because Vivit was the only licensed doctor, he
    ran the clinic as a sole practitioner. Vivit
    recruited patients and performed medical
    treatment, while Apostol processed and filed
    insurance claims for him and used the office as
    a base for other shady business ventures. In
    September 1994, Vivit and Apostol had a
    disagreement. Apostol then quit and removed many
    items from the clinic, including the clinic’s
    computer, a television, a chair and 134 boxes of
    patient files documenting the clinic’s accident
    victims. These patient files were given by
    Apostol to the Elmwood Park Police department,
    who investigated and eventually arrested Vivit.
    Shortly after removing this equipment from the
    clinic, Apostol departed for the Philippines,
    where he remains.
    Between 1993 and 1996, Vivit involved as many
    as 130 patients in a complicated scheme to
    defraud insurance companies by charging for
    services that he did not provide. Vivit engaged
    in five principal types of fraudulent conduct:
    (1) billing insurers for patient visits that did
    not occur; (2) billing for physical therapy that
    was not performed; (3) creating false medical
    records and reports to submit to insurance
    companies; (4) allowing his unlicensed assistant,
    Del Moral, to perform physical therapy without
    Vivit’s supervision while he charged for therapy
    performed by a licensed therapist; (5) ordering
    unnecessary allergy tests for patients with no
    allergy symptoms.
    Based on the information in Vivit’s files
    obtained from Apostol, interviews conducted with
    Vivit’s patients and claims filed by Vivit or his
    patients to their insurers, the government
    obtained enough evidence to secure a four-count
    indictment in July 1998. In December 1998, a new
    grand jury returned a seventeen-count superseding
    indictment charging Vivit with devising and
    executing a scheme to defraud. The indictment
    alleged that Vivit engaged in fraudulent use of
    the mails on seventeen separate instances between
    1993 and 1996, and the final count of the
    indictment claimed that one check was mailed in
    furtherance of the conspiracy as late as August
    6, 1996. On June 29, 1999, the district court
    conducted a jury trial to consider the charges
    against Vivit.
    At trial, the government produced the testimony
    of twenty-six former Vivit patients and entered
    into evidence false bills and medical reports
    created for forty-nine patients. Each of the
    testifying patients had in some way been involved
    in Vivit’s scheme to defraud their insurers.
    Some, including Roy, Myla and Lauro Sansano,
    merely filled out false attendance sheets at
    Vivit’s request. However, the Sansanos testified
    that they back-dated many of the signatures to
    conceal a considerable lapse of time between when
    the accident from which they claimed injuries
    occurred and their initial visit to Vivit,
    belying Vivit’s claim that the attendance sheets
    were used to make future appointments. In
    addition, Roy Sansano testified that they visited
    Vivit because a friend told him that to receive
    a favorable insurance settlement, they should see
    Vivit, a doctor who would produce false medical
    documentation to support their claim.
    Other patients testified about more extensive
    fraudulent conduct. For example, Veronica
    Leighton testified that she received $53,000 as
    a result of filing a false disability insurance
    claim. Leighton, who pleaded guilty to tax
    evasion and mail fraud for her crimes, first
    submitted a false medical bill to her insurer
    based, in part, on twenty-nine fictitious visits
    to Vivit’s clinic for which Vivit created a
    record. Leighton decided that she also should
    seek disability benefits, and she testified that
    Vivit told her how to prepare a fraudulent claim
    for her disability insurer. In conjunction with
    this fraud, Vivit filled out a certificate of
    disability swearing that in his medical opinion
    Leighton was disabled.
    Many other patients testified that, in addition
    to overbilling by creating a false attendance
    record, Vivit exaggerated the amount of treatment
    that he performed. Vivit’s records showed that he
    had performed ultrasound therapy on numerous
    patients in 1993, but the government produced the
    supplier of Vivit’s ultrasound machine, who
    testified that the machine was not delivered
    until the spring of 1994. In addition, Vivit’s
    files show that he performed an examination and
    two follow-up examinations on Sharlon Silvestre,
    but Silvestre testified that Vivit never examined
    him. Vivit also included a diagnosis of whiplash
    and migraines in his medical record, but
    Silvestre testified that he did not have
    headaches and that Vivit never informed him that
    he suffered from whiplash. Vivit’s files also
    show that he performed therapy on Jennifer
    Cailles’s back and neck. Cailles, who was sixteen
    at the time when she was treated by Vivit,
    testified that this therapy was never performed.
    In addition, many other patients added testimony
    to the record similar to that offered by
    Silvestre and Cailles.
    Other patients testified that Vivit failed to
    provide adequate medical services in the course
    of his care. Avelina De La Rosa testified that
    she had extremely high blood pressure following
    an automobile accident, but Vivit failed to test
    her blood pressure during the course of his
    diagnostic examination. Melandro Lubguban
    testified that he visited Vivit in pain following
    an automobile accident, but Vivit failed to
    examine him at all. Phina Garcia testified that
    she was covered with bruises when she visited
    Vivit, but Vivit did not examine her and instead
    approved hydro collator treatments for her, a
    treatment plan that medical experts advised
    against.
    Del Moral also testified for the government,
    stating that she had performed "microphone"
    (ultrasound) therapy, hydro collator therapy and
    electrical muscle stimulation therapy on numerous
    patients without Vivit’s supervision. She
    testified that the unsupervised therapy occurred
    largely because Vivit arrived at the clinic in
    the afternoon, and Del Moral performed one or two
    therapy sessions each morning. Although she
    lacked a license to perform physical therapy, she
    claimed that Vivit had trained her and that she
    was taking courses on therapy. Del Moral also
    testified that Vivit told her to make his
    patients falsify attendance sheets to inflate the
    amount of therapy they supposedly received. Del
    Moral testified that Vivit prepared patient
    bills, sometimes with the aid of Apostol, and
    gave them to her to file and mail.
    The government also presented the testimony of
    two experts, Drs. Daniel Samo and Gregory
    Mulford. Both doctors testified that the therapy
    that Vivit prescribed would be useless without an
    additional prescription of a course of exercise.
    They also testified that Vivit’s failure to
    examine patients constituted a "hideous"
    dereliction of duty and that the prescription of
    hydro collator or electrical muscle stimulation
    therapy to patients with bruising was
    contraindicated. Finally, the doctors provided
    expert analysis about the amount which Vivit’s
    fraudulent claims of treatment cost various
    insurers. Both experts testified that because all
    the treatment prescribed by Vivit was
    unnecessary, the entire amount of his bills
    should be considered fraudulent.
    On the basis of this evidence, the jury
    returned a guilty verdict against Vivit on
    sixteen of the seventeen counts of the
    indictment. The district court sentenced Vivit in
    October 1999. Because it found that the
    convictions all involved substantially the same
    harm, the court chose to group all the
    convictions, pursuant to United States Sentencing
    Guidelines sec. 3D1.2. The total offense level of
    the combined counts started at level six as
    directed by sec. 2F1.1(a), but the court
    increased the total offense level to thirteen
    because it found that the government had proved
    that, in aggregate, Vivit had defrauded insurers
    of between $120,000 and $200,000.
    The government originally argued that Vivit had
    defrauded insurers of $265,618.80, of which about
    $60,000 should have been removed for legitimate
    pain and suffering of Vivit’s patients. However,
    Vivit argued that the actual loss was much less
    because of the medical services that he provided.
    The parties argued extensively over the
    computation of loss, and the government, in
    support of its position, presented the court with
    a "Vivit loss chart" that listed all the costs
    associated with fraudulent billing by Vivit. This
    chart showed that Vivit had submitted bills
    containing fraudulent information valued at about
    $149,000, to which insurers paid out nearly
    $130,000, but the chart did not subtract the
    value of legitimate medical services performed by
    Vivit. The court found this chart persuasive and
    eventually attached the chart to its ultimate
    judgment. After listening to the parties’
    extended discussion on the calculation of amount
    of loss, the court concluded, "I think it is
    quite clear from the papers before me and from
    the trial and from the testimony, that a loss of
    at least $100,000 was proved. I am inclined to
    believe that more than $200,000 was proved, but
    relying on what I believe is most appropriate for
    this case, and that which cannot be questioned,
    I find that we have to add seven points rather
    than eight to the total offense level."
    From a total offense level of thirteen, the
    court ultimately enhanced Vivit’s total offense
    level to twenty-seven. The court initially raised
    the total offense level two levels pursuant to
    sec. 2F1.1(b)(6)(A) because the court found that
    Vivit’s treatment recklessly placed his patients
    at serious risk of bodily injury. The court
    explained that "what [Vivit]’s position in this
    court is ’you know, I really didn’t do very much.
    I used the most conservative treatment.’ . . .
    But the fact of the matter is that the most
    conservative treatment is not always best. . . .
    [H]e was, given his medical examination
    practices, a very lucky man that he did not miss
    something more serious, and for all we know maybe
    he did."
    The court enhanced four levels pursuant to sec.
    3B1.1(a) for Vivit’s role as an organizer or
    leader, basing its decision that Vivit led five
    other participants on the facts set out in the
    Pre-Sentencing Investigation and Report ("PSR"),
    and two additional levels because Vivit abused
    his position of trust relative to insurers,
    pursuant to sec. 3B1.3. In relation to the latter
    enhancement, the court noted that it enhanced
    Vivit’s sentence not because of his use of a
    special skill, which the court felt would
    constitute double-counting in relation to its
    vulnerable victim enhancement, but because "it is
    fair to say that he counted upon that the
    insurance companies would extend trust to him,
    and certainly after a period of time doing this
    it is quite clear that he understood that they
    did trust him; so that he did abuse his trust
    relative to the insurance companies."
    In addition, the court enhanced Vivit’s sentence
    by two levels pursuant to sec. 3A1.1(b) because
    many of his patients constituted vulnerable
    victims and an additional two levels according to
    sec. 3B1.4 for using minors to commit an offense.
    Finally, the court enhanced two more levels
    because Vivit’s scheme intended to defraud more
    than one victim, pursuant to sec. 2F1.1(b)(2).
    Adding all these enhancements, Vivit’s total
    offense level reached twenty-seven. Because
    Vivit’s criminal history category was I, this
    total offense level created a sentencing range of
    70 to 87 months. The district court sentenced
    Vivit to 72 months imprisonment, followed by
    three years supervised release. Vivit also was
    ordered to pay $149,877 in restitution.
    II.    Analysis
    On appeal, Vivit challenges his sentence on
    five grounds. First, Vivit claims that the
    district court erred in calculating the loss
    amount caused by his scheme. Second, Vivit finds
    error in the court’s determination that he used
    minors in his scheme and in its application of
    this enhancement in light of potential ex post
    facto concerns. Third, Vivit claims that the
    court erred in determining that his treatment
    recklessly subjected his patients to a risk of
    serious bodily injury. Fourth, Vivit challenges
    the district court’s attribution of a leadership
    role to him for his conduct in the scheme. Fifth,
    Vivit challenges the district court’s enhancement
    to his sentence for abuse of a "position of
    trust" in relation to the insurance companies
    that he defrauded.
    A.    Calculation of Loss
    At sentencing, the government and the probation
    office provided a "loss assessment" for the harm
    caused by Vivit as totalling $265,618.80.
    However, the district court found that the
    government was able to prove a loss of only
    $120,000 to $200,000. On this basis, the court
    enhanced Vivit’s sentence seven levels, pursuant
    to United States Sentencing Guidelines sec.
    2F1.1(b)(1)(H). On appeal, Vivit claims that the
    district court erred in its calculation of loss
    because the court failed to subtract the value of
    the legitimate medical services rendered from the
    loss incurred by the insurance companies and
    because the court’s calculation of loss included
    evidence of fraud of which there was no testimony
    at trial or sentencing. The definition of loss is
    a question of law, reviewed de novo. See United
    States v. Holiusa, 
    13 F.3d 1043
    , 1045 (7th Cir.
    1994). The amount of loss calculated by the
    district court is a finding of fact, which we
    review for clear error. See United States v.
    Craig, 
    178 F.3d 891
    , 899 (7th Cir. 1999). We find
    clear error only when we are "left with the
    definite and firm conviction that a mistake has
    been made." United States v. Strache, 
    202 F.3d 980
    , 984-85 (7th Cir. 2000) (citation omitted).
    Guidelines sec. 2F1.1(b)(1) directs sentencing
    courts to increase the defendant’s total offense
    level according to the total amount of loss
    created by a defendant’s actions, if that loss
    exceeds $2,000. U.S.S.G. sec. 2F1.1(b)(1).
    Application note 8 to sec. 2F1.1 indicates that
    the valuation of loss for the purposes of sec.
    2F1.1 will be determined in the same fashion as
    for sec. 2B1.1 (theft). U.S.S.G. sec. 2F1.1
    application note 8. Application note 2 to sec.
    2B1.1 defines loss as "the value of property
    taken, damaged, or destroyed." U.S.S.G. sec.
    2B1.1 application note 2. However, application
    note 8(a) to sec. 2F1.1 provides that when a
    fraud is committed by misrepresenting the value
    of an item that has some value, courts should
    value the loss at the amount by which the item
    was overvalued, that is, the difference between
    the represented value and the actual value.
    U.S.S.G. sec. 2F1.1 application note 8(a).
    The valuation of loss "need not be determined
    with precision. The court need only make a
    reasonable estimate of the loss, given the
    available information." U.S.S.G. sec. 2F1.1
    application note 9. Guidelines sec. 2F1.1(b)(1)
    provides that courts should enhance the
    defendant’s total offense level by at least eight
    points if a loss greater than $200,000 is proved,
    by only seven points if the total loss lies
    between $120,000 and $200,000, and by six or less
    points when the loss is less than $120,000.
    U.S.S.G. sec. 2F1.1(b)(1)(A)-(I). At sentencing,
    the parties engaged in an extended discussion
    about the proper valuation of loss to attribute
    to Vivit’s scheme, in which the government
    claimed a loss valuation of greater than $200,000
    and Vivit claimed a loss of less than $120,000.
    At the close of this discussion, the district
    court determined that "I think it is quite clear
    from the papers before me and from the trial and
    from the testimony, that a loss of at least
    $100,000 was proved. I am inclined to believe
    that more than $200,000 was proved, but relying
    on what I believe is most appropriate for this
    case, and that which cannot be questioned, I find
    that we have to add seven points rather than
    eight to the total offense level."
    The parties disagree whether any of Vivit’s
    services should be netted against the bills that
    he provided to insurers for his services. Vivit
    notes that we measure the amount of net detriment
    to the victim in calculating the amount of loss,
    rather than the total amount of money
    transferred. See United States v. Mount, 
    966 F.2d 262
    , 265 (7th Cir. 1992). However, the government
    contends that none of the services performed by
    Vivit was medically necessary, and the great
    majority of the services billed were not even
    performed, making those services performed the
    type of action made only to give the appearance
    of legitimacy. In support of its contention, the
    government cites the case law of another circuit
    which provides that "if the ’value’ to the victim
    is merely a part of the fraudulent scheme, the
    defendant is not entitled to a credit." United
    States v. Sayakhom, 
    186 F.3d 928
    , 947 (9th Cir.
    1999). However, the court in Sayakhom also noted
    that "in calculating loss, the district court
    should give credit for any legitimate services
    rendered to the victims." 
    Id. at 946.
    Application note 8(a) to sec. 2F1.1 reminds
    courts that in frauds where the item
    misrepresented has some value, the value of this
    item should be netted against the price offered
    to determine the amount of loss. While we have
    traditionally applied this netting theory in the
    fraudulent sale of goods, see United States v.
    Schneider, 
    930 F.2d 555
    , 558 (7th Cir. 1991), we
    have also applied this theory to the fraudulent
    misrepresentation of other items of value, when
    some value has actually been transferred. See
    United States v. Jackson, 
    95 F.3d 500
    , 505-06
    (7th Cir. 1996). Despite the government’s
    contention that the overwhelming majority of
    Vivit’s billing was based on unperformed or
    unnecessary services, the evidence presented
    demonstrates that Vivit did perform some
    legitimate medical services. For this reason, we
    calculate the amount of loss suffered by the
    insurers by netting the total costs submitted by
    Vivit, minus the legitimate medical services that
    he provided.
    However, we find no evidence in the record for
    Vivit’s main contention on appeal, that the
    district court failed to perform this cost-
    netting in calculating the amount of loss caused
    by Vivit’s fraud. The government urged the court
    to adopt an amount of loss that the government
    conservatively placed at greater than $200,000,
    based on the $265,000 paid out by insurers less
    the legitimate claims of Vivit’s patients. The
    court felt that a loss greater than $200,000 had
    probably been proved but decided to sentence
    Vivit conservatively, finding that the government
    had not clearly established a loss of $200,000.
    As a benchmark, the court used the "Vivit loss
    chart," which calculated Vivit’s fraudulent
    billing at approximately $150,000, of which
    insurers paid nearly $130,000. The court seems to
    have determined that the Vivit loss chart
    accurately reflected the amount of loss
    established by the government for the purpose of
    determining the sec. 2K1.1(b)(1) enhancement.
    Unsatisfied by the court’s decision, Vivit
    claims that the Vivit loss chart lacks any basis
    in fact, because the chart fails to net out the
    legitimate services provided by Vivit. However,
    Vivit fails to recognize that the chart was
    composed only of those bills in which fraudulent
    information was submitted. In addition to showing
    the total amount of loss, the chart shows the
    ratio of legitimate services provided to
    fraudulent services claimed, by showing for each
    bill what fraudulent activity Vivit had
    performed. The chart provides data on which to
    determine the amount of loss claimed, because it
    provides a basis from which to discount the value
    of legitimate services provided by Vivit from the
    fraudulent billing that he submitted. In
    addition, the court was provided with evidence
    about the amount Vivit charged for the
    performance of legitimate services.
    Armed with an accurate cost of fraudulent
    services provided by Vivit and the ratio of
    fraudulent to legitimate services provided, as
    well as the rates that Vivit charged, we find
    that the district court made a reasonable
    approximation of the loss given the factual
    complexity of Vivit’s scheme. Because the amount
    of loss need not be calculated with precision and
    because we believe that the loss chart and other
    facts in the record relied on by the district
    court to formulate a loss calculation support the
    amount of loss found by the district court, we
    find no clear error in the calculation of loss
    made by the district court.
    Vivit also argues that the district court’s
    calculation of loss must be overturned because it
    is based on testimony of witnesses who did not
    testify at trial or at sentencing. While we
    appreciate that the government bears the burden
    of proof in demonstrating the amount of loss, see
    United States v. Bahhur, 
    200 F.3d 917
    , 924 (6th
    Cir. 2000), the sentencing court is not bound by
    the Federal Rules of Evidence at sentencing and
    "may take any information into account in passing
    sentence so long as it has sufficient indicia of
    reliability to support its probable accuracy."
    United States v. Carmack, 
    100 F.3d 1271
    , 1276
    (7th Cir. 1996). The information on which the
    district court based its loss calculation had
    been presented into evidence at trial without
    objection before the court considered it, and
    given the cumulative and reinforcing nature of
    this evidence, we find no clear error in
    determining that this evidence was supported by
    sufficient indicia of reliability in support of
    its accuracy, a finding that Vivit does not
    dispute. Additional testimony at sentencing is
    unnecessary to support a finding of reliability.
    See United States v. Morrison, 
    207 F.3d 962
    , 968
    (7th Cir. 2000). "A court can consider whatever
    evidence is before it in arriving at the amount
    of loss." United States v. Brown, 
    136 F.3d 1176
    ,
    1184 (7th Cir. 1998). Therefore, we find no clear
    error in the district court’s reliance on
    evidence in the record that was not supported by
    witness testimony in its calculation of loss
    amount.
    B.   Use of Minors
    Next, Vivit contends that the district court
    committed error in increasing his total offense
    level by two points for using minors in the
    commission of his offenses, pursuant to U.S.S.G.
    sec. 3B1.4. Vivit argues that the court committed
    error in finding that minors had in fact
    participated in Vivit’s scheme. Vivit also argues
    that because all the fraudulent mailings
    involving minors were completed before the
    enactment of sec. 3B1.4, enhancement under this
    Guidelines section violates the Ex Post Facto
    Clause of the Constitution. We review de novo the
    district court’s interpretation of sec. 3B1.4,
    see United States v. Brack, 
    188 F.3d 748
    , 765
    (7th Cir. 1999), and the question whether the Ex
    Post Facto Clause was violated by the enhancement
    pursuant to sec. 3B1.4.
    1.   Ex Post Facto Clause
    Guidelines sec. 3B1.4, the "use of minors"
    enhancement, was enacted with an effective date
    November 1, 1995. U.S.S.G. sec. 3B1.4 historical
    note. Vivit admits that he filed false records
    for many minor patients, but he asserts that this
    conduct all occurred before November 1, 1995, and
    that application of the sec. 3B1.4 enhancement
    violates the Ex Post Facto Clause of the United
    States Constitution, U.S. Const. Art. I, sec. 9,
    because that clause generally prohibits the
    retroactive application of the Sentencing
    Guidelines if it results in a more onerous
    penalty. See United States v. Shorter, 
    54 F.3d 1248
    , 1261 (7th Cir. 1995).
    The one-book rule, the policy statement guiding
    the use of multiple guidelines, found in
    Guidelines sec. 1B1.11(b)(1), provides that
    "[t]he court shall use the Guidelines Manual in
    effect on the date that the defendant is
    sentenced." The one-book rule expresses the
    intent of the Sentencing Commission that the
    Guidelines reflect a cohesive whole and the
    Commission’s resistance to application of various
    Guidelines in a piecemeal fashion. See United
    States v. Bousa, 
    997 F.2d 263
    , 266 (7th Cir.
    1992). When faced with the possibility of an ex
    post facto violation, the court is normally
    directed to "use the Guidelines Manual in effect
    on the date that the offense of conviction was
    committed." U.S.S.G. sec. 1B1.11(b)(1).
    However, the Guidelines also indicate that "[i]f
    the defendant is convicted of two offenses, the
    first committed before, and the second after, a
    revised edition of the Guidelines Manual became
    effective, the revised edition of the Guidelines
    Manual is to be applied to both offenses."
    U.S.S.G. sec. 1B1.11(b)(3). In this case, Vivit
    was convicted on count 17, the final count of his
    indictment for conduct that was committed in
    August 1996, well after November 1, 1995.
    Therefore, on its face, sec. 1B1.11(b)(3) should
    apply, and absent ex post facto concerns we would
    find no error in the application of sec. 3B1.4.
    Vivit contests the application of sec.
    1B1.11(b)(3) on two bases: (1) the only post-
    revision count, count 17, does not involve the
    use of a minor, so sec. 1B1.11(b)(3) is
    inapplicable; and (2) sec. 1B1.11(b)(3) violates
    the Ex Post Facto Clause. The former argument
    ignores the plain language of sec. 1B1.11(b)(3),
    which requires only that two crimes be committed
    on different dates, before and after the
    enactment of the Guidelines revision in question.
    The one-book rule does not require that both
    these crimes involve the same course of conduct,
    or that both involve conduct giving rise to the
    same sentencing enhancement. Therefore, it is
    immaterial whether the conduct predicate to
    Vivit’s conviction on count 17 involved the use
    of a minor.
    However, if we find application of sec.
    1B1.11(b)(3) violates the Ex Post Facto Clause,
    sec. 1B1.11(b)(1) requires that we instead apply
    the 1994 Sentencing Guidelines to all Vivit’s
    convictions, which would preclude a sec. 3B1.4
    enhancement. See United States v. Ortland, 
    109 F.3d 539
    , 547 (9th Cir. 1997) (finding that mail
    fraud is not a continuing offense, so the
    defendant may properly be sentenced under
    multiple sets of guidelines); United States v.
    Bertoli, 
    40 F.3d 1384
    , 1404 (3d Cir. 1994). But
    see United States v. Kimler, 
    167 F.3d 889
    , 893
    (5th Cir. 1999); United States v. Santopietro,
    
    166 F.3d 88
    , 95-96 (2d Cir. 1999). The settled
    law of this circuit is that when a defendant
    commits crimes that straddle the date of
    promulgation of new guidelines provisions, the
    defendant can be punished under a guideline
    effective after the beginning of the straddle
    period. See, e.g., United States v. Boyd, 
    208 F.3d 638
    , 648 (7th Cir. 2000); United States v.
    Korando, 
    29 F.3d 1114
    , 1119-20 (7th Cir. 1994).
    The rationale for this rule is that "a statute
    increasing the penalty for [an offense] beginning
    before the date of enactment but continuing
    afterwards does not offend the Constitution."
    United States v. Baresh, 
    790 F.2d 392
    , 404 (5th
    Cir. 1986).
    The government contends that because the
    district court found the conduct committed by
    Vivit similar enough for sec. 3D1.2(d) grouping
    to apply, Vivit’s actions constituted a
    continuing offense which straddled the
    promulgation of sec. 3B1.4, quieting any
    potential ex post facto concerns about the use of
    the 1995 Guidelines. However, the government’s
    position is controversial. In United States v.
    
    Ortland, 109 F.3d at 547
    , the Ninth Circuit found
    that because the predicate conduct constituting
    mail fraud was completed on mailing, a mail fraud
    scheme constituted a series of completed
    offenses, rather than a continuing course of
    conduct. On this basis, the court felt that
    applying the grouping rules and the one-book rule
    to a series of mail fraud crimes constituted a
    violation of the Ex Post Facto Clause on offenses
    completed before a revision of the Guidelines.
    See id.; see also 
    Bertoli, 40 F.3d at 1404-07
    (finding error in the district court’s failure to
    analyze offenses independently for ex post facto
    problems). However, in United States v. 
    Kimler, 167 F.3d at 895
    , the Fifth Circuit reached the
    opposite conclusion, relying on the Eleventh
    Circuit’s reasoning in United States v. Bailey,
    
    123 F.3d 1381
    , 1403-07 (11th Cir. 1997), that the
    adoption of the one-book rule and the grouping
    rules put criminals on notice that "the version
    of the sentencing guidelines in effect at the
    time he committed the last of a series of grouped
    offenses will apply to the entire group," 
    Kimler, 167 F.3d at 895
    , to determine that there was no
    ex post facto violation in using a revised
    guideline to sentence grouped mail fraud
    convictions. In that case, the court noted that
    although mail fraud offenses were completed
    offenses, rather than continuing offenses like
    conspiracies, because the grouping rules were in
    effect at the time a defendant committed acts of
    mail fraud, "a defendant has notice that if he
    continues to commit offenses that are grouped
    together, the revised guidelines will apply to
    the group." 
    Id. at 894
    n.6; see also 
    Bailey, 123 F.3d at 1406-07
    ; United States v. Cooper, 
    35 F.3d 1248
    , 1252 (8th Cir. 1994).
    In this circuit, the question whether to apply
    sec. 1B1.11(b)(3) depends on whether we perceive
    a defendant’s course of conduct to straddle the
    enactment of revisions to the Sentencing
    Guidelines. See 
    Boyd, 208 F.3d at 648-49
    . With
    continuing offenses, such as conspiracies, we
    have never questioned the applicability of ex
    post facto principles to this practice, because
    by agreeing to engage in a conspiracy, a
    defendant becomes culpable for all subsequent
    acts committed by the conspiracy. See 
    Korando, 29 F.3d at 1119
    . However, we have held that mail
    fraud is a completed offense, implying that "the
    crime of mail fraud is completed, for sentencing
    purposes, at the time of the mailing. The actual
    duration of the scheme is of no import." United
    States v. Barger, 
    178 F.3d 844
    , 847 (7th Cir.
    1999). For this reason, we have determined that
    mail fraud is not a straddle offense, in which
    case sec. 1B1.11 (b)(3) might not apply. See 
    id. at 848.
    However, in Barger, we were not confronted with
    a situation in which mail fraud convictions were
    grouped together according to sec. 3D1.2, because
    the criminal conduct committed in that case
    occurred before the enactment of the Guidelines.
    According to the rationale of the Eleventh
    Circuit in Bailey, the enactment of the grouping
    Guidelines places criminals on notice that
    committing additional criminal acts that are
    subject to grouping after a revision of the
    Guidelines makes all the defendant’s conduct
    susceptible to the one-book rule. 
    Bailey, 143 F.3d at 1406-07
    . On this basis, a series of mail
    fraud convictions that are grouped may be
    considered to straddle a revision without a
    presumptive ex post facto violation because of
    the criminal’s prior notice of the grouping
    rules. Because the grouping rules were not
    available to provide notice when the defendants
    in Barger committed the predicate offenses that
    formed the basis for their convictions, we find
    that the result in Barger, that a series of mail
    fraud offenses do not straddle the enactment of
    the Guidelines, does not require us to conclude
    that applying a revised Guidelines Manual to a
    series of grouped mail fraud convictions
    constitutes an ex post facto violation.
    By banning ex post facto application of new
    criminal laws, "the Framers sought to assure that
    legislative Acts give fair warning of their
    effect and permit individuals to rely on their
    meaning until explicitly changed." Weaver v.
    Graham, 
    450 U.S. 24
    , 28-29 (1981); see also
    Miller v. Florida, 
    482 U.S. 423
    , 430 (1987);
    Dobbert v. Florida, 
    432 U.S. 282
    , 293 (1977). The
    clause was also intended to check governmental
    power "by restraining arbitrary and potentially
    vindictive legislation." 
    Weaver, 450 U.S. at 29
    .
    "Critical to relief under the Ex Post Facto
    Clause is not an individual’s right to less
    punishment, but the lack of fair notice and
    governmental restraint when the legislature
    increases punishment beyond what was prescribed
    when the crime was consummated." 
    Id. at 30.
    Viewed in this context, the relevant inquiry
    becomes whether the grouping rules give the
    defendant fair notice at the time a crime is
    consummated that the commission of further crimes
    subject to grouping would subject the defendant
    to sentencing under revised Guidelines. The
    grouping rules, enacted in 1987, provide warning
    to criminals that completing another criminal
    offense similar to one committed previously
    places them in peril of sentencing under a
    revised version of the Guidelines. The
    introductory commentary to the grouping rules
    explains that because the offense guideline for
    fraud, sec. 2F1.1, "deal[s] with repetitive or
    ongoing behavior," multiple fraud convictions are
    appropriately grouped when the convictions
    involve substantially the same harm. See U.S.S.G.
    sec. 3D introductory commentary. We believe that
    this conclusion reflects the intent of the
    Sentencing Commission to provide notice to
    criminals that engaging in ongoing fraudulent
    behavior involving the same type of harm risks
    grouping of convictions, which because of the
    one-book rule, will all be sentenced according to
    the Guidelines in effect when the latest conduct
    occurred.
    For this reason, we believe that the enactment
    of the grouping rules provides fair notice such
    that the application of sec.sec. 1B1.11(b)(3) and
    3D1.2 does not violate the Ex Post Facto Clause.
    To violate the Ex Post Facto Clause, the
    application of amended Guidelines must
    disadvantage the defendant without providing the
    defendant with prior notice. See 
    Miller, 482 U.S. at 430
    . Because the grouping rules provide such
    prior notice, we favor the position advanced by
    the Eighth Circuit in Cooper that "it was not the
    amendments to the Sentencing Guidelines that
    disadvantaged [the defendant], it was his
    election to continue his criminal 
    activity." 35 F.3d at 1250
    .
    Vivit does not argue that his conduct did not
    involve "substantially the same harm," in which
    case the grouping rules should not have been
    applied. Nor does he provide any other reason
    that the enactment of the grouping rules should
    not be construed to place him on notice that the
    commission of further fraudulent mailings would
    subject him to sentencing under amended
    Guidelines. For this reason, we find no Ex Post
    Facto Clause violation in the district court’s
    determination to apply the "use of minors"
    enhancement to all of the grouped offenses
    committed by Vivit.
    2.   Findings of Fact
    Vivit also argues that the district court
    committed clear error in finding that minors
    participated in his scheme. Vivit was convicted
    on two counts in which the predicate conduct
    involved false insurance claims filed on behalf
    of a minor, and Vivit admits that he treated many
    minors in the course of his operation of the
    clinic. However, he contends that the role of the
    minor patients in his scheme was too minimal or
    unintentional for the finding that he used minors
    to commit the fraud offenses.
    Application note 1 to sec. 3B1.4 includes
    within the definition of use "directing,
    commanding, encouraging, intimidating,
    counseling, training, procuring, recruiting, or
    soliciting." In United States v. Benjamin, 
    116 F.3d 1204
    , 1206 (7th Cir. 1997), we initially
    reviewed the "use" requirement of sec. 3B1.4 and
    found it met when the defendant took some
    affirmative action to involve a minor. See also
    United States v. Butler, 
    207 F.3d 839
    , 848 (6th
    Cir. 2000) ("[B]y deeming age relevant, Congress
    likely imagined an offender who actually
    exercised some control or took some affirmative
    role in involving the minor."). In United States
    v. 
    Brack, 188 F.3d at 765
    , we found that the fact
    bases for an enhancement under sec. 3B1.4 had
    been met when the defendant performed affirmative
    acts to involve a minor in her crimes. Therefore,
    Vivit "used minors in the commission of his
    crimes" if his affirmative actions involved
    minors in his criminal activities.
    Vivit treated Jennifer Cailles for injuries
    suffered in an automobile accident. At that time,
    she was sixteen years old. As a part of the
    treatment, Vivit directed Cailles to sign the
    attendance sheet fraudulently to inflate the
    number of visits she paid Vivit. Vivit eventually
    submitted a bill to Cailles’s insurer that showed
    forty-nine visits made, when Cailles actually
    made only eight or ten visits. Vivit also treated
    nine-year-old Laquita Barnett and her seven-year-
    old sister Johnetta Johnson for injuries suffered
    in an automobile accident. Laquita visited Vivit
    twice, and was given hot pad therapy. However,
    Vivit submitted a bill claiming that she had been
    given a comprehensive examination and had made
    two follow-up visits and twelve visits for
    therapy. Johnetta only visited Vivit once, but
    Vivit filed a bill with her insurer indicating
    twelve visits had occurred. Vivit directed both
    these girls to falsify an attendance sheet eleven
    times.
    The facts presented about Jennifer Cailles,
    Laquita Barnett and Johnetta Johnson support the
    district court’s finding that Vivit directed
    these minors to create a false attendance record.
    Therefore, Vivit’s direction to falsify
    attendance records involved these minors in his
    crime and fell within the definition of "use" of
    minors contemplated by sec. 3B1.4.
    C.   Risk of Serious Bodily Injury
    Vivit also challenges the district court’s
    determination that the medical treatment Vivit
    provided, or failed to provide, placed some of
    his patients at risk of serious bodily injury, on
    which basis the court increased Vivit’s total
    offense level two levels, according to U.S.S.G.
    sec. 2F1.1(b)(6)(A). Vivit claims that this
    finding of fact was clearly erroneous because it
    was based on speculation as to potential injury.
    The determination that Vivit’s conduct posed a
    conscious or reckless risk of serious bodily
    injury to his patients is a finding of fact, and
    we review for clear error. See United States v.
    Turner, 
    102 F.3d 1350
    , 1357 (4th Cir. 1996).
    However, to the extent that we review whether a
    sentencing enhancement is appropriate under this
    type of offense conduct, we face a question of
    law that we review de novo. See 
    id. Guidelines sec.
    2F1.1(b)(6) directs courts to
    enhance a defendant’s total offense level by two
    levels if the fraud perpetrated by the defendant
    involves "the conscious or reckless risk of
    serious bodily injury." U.S.S.G. sec. 2F1.1(b)
    (6)(A). "Serious bodily injury" is a phrase of
    general applicability used frequently throughout
    the Guidelines, and the phrase has been explained
    to mean "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. sec. 1B1.1 application note 1(j).
    Guidelines sec. 2F1.1 does not provide any
    insight into the type of conduct that should be
    considered reckless, but application note 1 to
    sec. 2A1.4 describes recklessness as "a situation
    in which the defendant was aware of the risk
    created by his conduct and the risk was of such
    a nature and degree that to disregard that risk
    constituted a gross deviation from the standard
    of care that a reasonable person would exercise
    in such a situation." U.S.S.G. sec. 2A1.4
    application note 1 (involuntary manslaughter).
    On appeal, Vivit contends that because no
    patient was injured, any risk of serious injury
    was purely conjectural, and for this reason, the
    district court lacked any evidentiary basis on
    which to base its enhancement. See United States
    v. Greene, 
    71 F.3d 232
    , 236 (6th Cir. 1995)
    (requiring district courts to base reckless risk
    enhancement on evidence of risk). Improper
    medical procedures, such as unnecessary surgery,
    performed for fraudulent purposes obviously may
    pose a risk of serious bodily injury. See, e.g.,
    United States v. Laughlin, 
    26 F.3d 1523
    , 1531
    (10th Cir. 1994) (finding that unnecessary
    surgery creates a risk of serious bodily injury).
    However, as the Eighth Circuit noted in United
    States v. McCord, Inc., "for most frauds, risk of
    serious bodily injury is less direct and less
    obvious." 
    McCord, 143 F.3d at 1098
    . In cases of
    fraud, where sec. 2F1.1(6)(A) applies, we are not
    concerned with whether actual injury occurred,
    but whether the defendant’s fraudulent course of
    conduct created a risk that others would suffer
    serious bodily injury. In addition, Guidelines
    sec. 2F1.1(6)(A) demands that such a risk be
    undertaken recklessly. See 
    id. Whether improper
    medical treatment may form the basis for an
    enhancement under sec. 2F1.1 (6)(A) is a question
    of first impression for this circuit.
    The government provided three bases on which
    Vivit’s sentence might have been enhanced: (1)
    his failure to supervise an unlicensed individual
    performing potentially dangerous physical
    therapy; (2) his direction to apply heat therapy
    to bruised areas, increasing the risk of injury;
    (3) his failure to examine physically certain
    patients he knew to have been injured in
    automobile accidents. The district court enhanced
    Vivit’s sentence for reckless risk of serious
    bodily injury, but the court did not state
    directly on which of these theories it based the
    enhancement. The court did note its
    dissatisfaction with Vivit’s diagnostic
    techniques by saying, "what [Vivit]’s position in
    this court is ’you know, I really didn’t do very
    much. I used the most conservative treatment.’ .
    . . But the fact of the matter is that the most
    conservative treatment is not always best. . . .
    [H]e was, given his medical examination
    practices, a very lucky man that he did not miss
    something more serious, and for all we know maybe
    he did."
    Vivit contends that the government failed to
    prove either that Vivit ignored a known risk of
    serious injury or that any of the treatments that
    he employed could have caused serious bodily
    injury. The rehabilitative techniques employed by
    Vivit, which included ultrasound therapy,
    electric muscle stimulation and using heat pads,
    are much less intrusive or inherently dangerous
    than surgical procedures. The experts provided by
    the government at trial testified that it was
    possible to cause injury using electric muscle
    stimulation if the electrodes used in the therapy
    are improperly applied or placed close to the
    heart. These experts also indicated that
    providing heat or ultrasound therapy to bruised
    areas was contraindicated. In addition, these
    experts also testified that these therapies
    provided no health benefits.
    None of the government’s twenty-six patient
    witnesses testified that electrical muscle
    stimulation was used in the chest area, and given
    the purpose of this therapy, we find the risk of
    injury from that type of treatment to be slight,
    even if the therapist who performed the therapy
    lacked a license. In addition, although applying
    heat to bruised areas may increase the internal
    bleeding from this bruising, this type of
    treatment does not rise to the level of "extreme
    physical pain or protracted function" required by
    the serious bodily injury standard. In fact, the
    risk of increased injury created by the
    treatments that Vivit actually performed or
    ordered performed seems quite slight, certainly
    too slight to justify an enhancement for reckless
    risk of serious bodily injury.
    The medical procedures that Vivit failed to
    perform raise more troubling questions. To
    conceal his ongoing fraud from insurers, Vivit
    engaged in rudimentary examination procedures
    better designed to generate additional visits in
    his attendance log than to diagnose injury. On
    multiple occasions, Vivit failed to perform
    physical examinations on patients who visited him
    following automobile accidents. In addition,
    Vivit failed to perform certain basic diagnostic
    tests, such as taking blood pressure, on certain
    patients such as Avelina De La Rosa who later
    proved to be at risk. While we do not believe
    that Vivit created a risk by failing to treat
    patients such as the Sansanos who visited him to
    inflate their own insurance settlements knowing
    that he would not provide adequate care, patients
    such as De La Rosa relied on Vivit’s medical
    opinion and treatment to ensure that they had not
    suffered serious injury. By failing to examine
    such patients properly, Vivit created a risk
    that, had these patients suffered serious
    injuries, their injuries would remain untreated.
    Moreover, by presenting evidence that certain of
    his patients were at risk of serious bodily
    injury without treatment, for example by virtue
    of their high blood pressure, the government has
    presented sufficient evidence to show that the
    risk here was actual, not conjectural. The facts
    also clearly demonstrate that Vivit acted
    recklessly in ignoring the risk that his failure
    to treat created. Therefore, we conclude that the
    district court did not err in enhancing Vivit’s
    sentence under sec. 2F1.1(6)(A) for reckless risk
    of serious bodily injury.
    D.   Leadership Role
    Vivit contends that the district court erred in
    increasing his total offense level four points
    based on his leadership role in the scheme. He
    argues that the record does not support such a
    finding of fact, and the court failed to make
    express findings as to which of his patients
    constituted members of the scheme for purposes of
    establishing a leadership role under U.S.S.G.
    sec. 3B1.1(a). The court’s determination that
    Vivit played a leadership role in the scheme is
    a finding of fact, and we review for clear error.
    See United States v. Lewis, 
    79 F.3d 688
    , 690 (7th
    Cir. 1996).
    Guidelines sec. 3B1.1 directs the sentencing
    court to enhance a defendant’s offense level four
    levels "[i]f the defendant was an organizer or
    leader of a criminal activity that involved five
    or more participants or was otherwise extensive."
    U.S.S.G. sec. 3B1.1(a). A "participant" is "a
    person who is criminally responsible for the
    commission of the offense." U.S.S.G. sec. 3B1.1
    application note 1. To determine whether a
    defendant is an organizer or leader, we consider
    "the defendant’s exercise of decision-making
    authority, the nature of his participation in
    committing the crime, his recruitment of
    accomplices, his claimed right to a larger share
    of the criminal proceeds, the extent of his
    participation in planning or organizing the
    crime, the nature and scope of the illegal
    activity, and the degree of control and authority
    exercised over others." United States v. Sierra,
    
    188 F.3d 798
    , 803-04 (7th Cir. 1999); see also
    U.S.S.G. sec. 3B1.1 application note 4. These
    factors are not exhaustive, nor must all be
    present in order to enhance the defendant’s
    sentence. See United States v. Mankiewicz, 
    122 F.3d 399
    , 406 (7th Cir. 1997). Instead, we weigh
    these factors "in light of the Guidelines’ intent
    to punish with greater severity leaders and
    organizers of criminal activity." 
    Sierra, 188 F.3d at 804
    .
    The district court adopted the statements in
    the PSR that Vivit’s scheme involved at least
    five other participants: Estrella Del Moral, his
    receptionist; the Sansano family, Roy, Myla and
    Lauro; and Veronica Leighton. Even though four of
    these named participants were Vivit’s patients,
    the district court felt that the four-level
    enhancement was especially appropriate because
    Vivit "in a moral sense and maybe in a legal
    sense, made criminals out of some of his
    patients." Vivit instructed Del Moral to create
    false records and order patients to file false
    claims and allowed her to perform therapy without
    a license, which he billed to insurers. Vivit
    taught Leighton how to obtain disability payments
    fraudulently and convinced her to create false
    records inflating her insurance claim. Vivit also
    instructed each of the Sansanos to create false
    medical records to inflate their insurance
    claims.
    The argument that the sentencing court failed
    to identify five participants on which to base
    the enhancement lacks merit. In this case, the
    district court adopted the findings of fact in
    the PSR, which isolated five individuals who were
    deemed to be participants, and a sentencing court
    may adopt the conclusions in the PSR as its own.
    See United States v. Spears, 
    965 F.2d 262
    , 273
    (7th Cir. 1992); United States v. Musa, 
    946 F.2d 1297
    , 1308 (7th Cir. 1991). By adopting the
    conclusions of the PSR, the sentencing court
    adopted by reference the individuals isolated
    therein as participants.
    Vivit’s argument that those patients of his who
    were deemed participants lacked criminal intent
    proves equally unavailing. To count as a
    "participant" in Vivit’s scheme, his patients
    must have been criminally responsible. See
    U.S.S.G. sec. 3B1.1 application note 1. This
    responsibility requires criminal intent, which
    belies these patients’ status as victims. To this
    extent, Vivit raises a valid objection; none of
    those patients who were victimized by Vivit’s
    poor treatment necessarily shared Vivit’s
    criminal intent to defraud their insurers.
    However, Vivit treated more than 130 patients,
    and although many of these patients may have been
    innocent victims, some of these patients
    performed acts that suggest criminal
    responsibility.
    Vivit does not contest that Del Moral and
    Leighton were participants in his scheme.
    Instead, he focuses on the criminal
    responsibility of the Sansanos. Vivit presented
    each of the Sansanos with an attendance sheet and
    asked them to sign and date it, which they each
    did twenty-seven times. Vivit contends that this
    procedure was done to set up future appointments,
    and the Sansanos testified that they "pretty much
    followed instructions," in signing the sheets.
    However, the Sansanos back-dated many of these
    "appointments" to cover up the lapse of time
    between their automobile accident and their first
    consultation with Vivit. Roy Sansano also
    testified that his family visited Vivit because
    a friend told him that Vivit would create a large
    medical bill for him and his family to be used in
    their insurance claim.
    In reference to their claim, the Sansanos
    signed false documents misrepresenting the extent
    of treatment that they received from Vivit. The
    facts presented at Vivit’s trial suggest that the
    Sansanos filed these documents intending to
    defraud their insurer. They also demonstrate that
    Vivit directed them on how to create a false
    record of treatment, and this false record of
    treatment constituted the basis on which the
    Sansanos filed false insurance claims. Therefore,
    the Sansanos were all participants in Vivit’s
    scheme within the meaning of sec. 3B1.1.
    Considering Vivit’s activities within the rubric
    of sec. 3B1.1, the evidence presented at trial
    demonstrates that he was the principal organizer
    of numerous fraudulent insurance claims, that he
    recruited patients to file these false claims and
    that the primary financial benefit from these
    activities accrued to him. For this reason, we
    find no error in the sentencing court’s
    enhancement of Vivit’s total offense level as a
    leader and organizer.
    E.   Position of Trust
    Finally, Vivit claims error in the district
    court’s determination that Vivit abused his
    position of trust relative to the insurance
    companies he defrauded, on which basis the court
    increased his total offense level an additional
    two levels according to U.S.S.G. sec. 3B1.3.
    Vivit argues that he did not occupy a position of
    trust in relation to the insurance companies that
    he defrauded, and he contends that this
    enhancement actually constitutes impermissible
    double counting. Interpretation of the term
    "position of trust" is a legal question that we
    review de novo. See United States v. Hathcoat, 
    30 F.3d 913
    , 919 (7th Cir. 1994). However, the
    determination that Vivit occupied a position of
    trust is a finding of fact, which we review only
    for clear error. See United States v. Boyle, 
    10 F.3d 485
    , 489 (7th Cir. 1993). The determination
    whether a court has engaged in impermissible
    double counting is a question of law, which we
    review de novo. See United States v. Compton, 
    82 F.3d 179
    , 183 (7th Cir. 1996) (citation omitted).
    Guidelines sec. 3B1.3 requires courts to
    increase the total offense level of a defendant
    by two levels "[i]f the defendant abused a
    position of public or private trust . . . in a
    manner that significantly facilitated the
    commission or concealment of the offense."
    U.S.S.G. sec. 3B1.3. The district court felt that
    the insurance companies to whom Vivit submitted
    claims trusted the doctor, and increased
    accordingly on this ground. However, Vivit claims
    that because his relationship with these
    insurance companies was commercial rather than
    fiduciary, the enhancement is not applicable.
    We recently disposed of this argument in United
    States v. Hoogenboom, 
    209 F.3d 665
    , 671 (7th Cir.
    2000), when we noted that "[m]edical service
    providers occupy positions of trust with respect
    to private or public insurers (such as Medicare)
    within the meaning of guideline sec. 3B1.3." 
    Id. (citations omitted).
    We explained that "[m]edical
    providers . . . enjoy significant discretion and
    consequently a lack of supervision in determining
    the type and quality of services that are
    necessary and appropriate for their patients.
    This forces [the insurer] to depend, to a
    significant extent, on a presumption of honesty
    when dealing with statements received from
    medical professionals." 
    Id. Although in
    Hoogenboom, we were faced with fraud committed
    against a public insurer, Medicare, rather than
    against private insurers, we made no distinction
    between the two in determining whether the
    enhancement was applicable, and we believe that
    no distinction exists. For this reason, the facts
    presented by Vivit cannot be distinguished from
    those presented in Hoogenboom, and we find the
    logic in that case controlling.
    Vivit also claims that enhancement under sec.
    3B1.3 constitutes impermissible double counting,
    because it punished him for both acting as a
    leader and abusing a "special skill." Guidelines
    sec. 3B1.3 prohibits the enhancement under sec.
    3B1.3 for use of a "special skill" in addition to
    enhancement under sec. 3B1.1 for a leadership
    role in the offense, but permits the enhancement
    for an "abuse of trust" in addition to a sec.
    3B1.1 enhancement. U.S.S.G. sec. 3B1.3. The
    district court enhanced Vivit’s sentence under
    both sec.sec. 3B1.1 and 3B1.3, but the court’s
    articulated basis for the sec. 3B1.3 enhancement
    was that "it is fair to say that he counted upon
    that the insurance companies would extend trust
    to him, and certainly after a period of time
    doing this it is quite clear that he understood
    that they did trust him; so that he did abuse his
    trust relative to the insurance companies."
    Therefore, the court based its enhancement on
    "abuse of trust," not on "use of a special
    skill." There is no impermissible double counting
    to enhance under both sec.sec. 3B1.1 and 3B1.3 in
    these circumstances.
    III.   Conclusion
    For all the foregoing reasons, we find no error
    in the district court’s computation of Vivit’s
    sentence. Therefore, the decision of the district
    court is Affirmed.
    Easterbrook, Circuit Judge, concurring. I join
    the court’s opinion but add one thought. The
    gymnastics performed in Part II.B.1 to show that
    a two-level increase in Vivit’s offense level is
    compatible with the ex post facto clause are
    unnecessary, because the sentencing guidelines
    are not "laws" within the scope of that clause.
    See United States v. Seacott, 
    15 F.3d 1380
    , 1391-
    93 (7th Cir. 1994) (concurring opinion); cf.
    Prater v. U.S. Parole Commission, 
    802 F.2d 948
    ,
    951-52 (7th Cir. 1986) (en banc) (parole release
    guidelines are not "laws" for ex post facto
    purposes). Many cases say, and a few hold, that
    changes in the guidelines must be treated like
    changes in statutory punishments for purposes of
    the ex post facto clause, and the parties to this
    case accept that view, but these decisions are
    unconvincing. The only "law" at issue is the
    Sentencing Reform Act of 1984, enacted long
    before Vivit’s crimes. Nothing that has occurred
    since Vivit committed his acts changed the
    definition of the offense, its maximum
    punishment, or the evidence that may be used to
    support conviction. See Carmell v. Texas, 
    68 U.S.L.W. 4325
    , 4328-29 (U.S. May 1, 2000). When
    open-ended discretion prevailed before the
    guidelines, no one would have doubted that
    Presidents could appoint hard-nosed judges who
    handed out steep penalties, provided they did not
    exceed the statutory maximum at the time of the
    defendant’s deeds. Large swings in effective
    punishment occurred because of changes in the
    composition of the bench and prevailing views
    about the seriousness of particular offenses.
    What judges used to do without offending the ex
    post facto clause, the Sentencing Commission may
    do. The Sentencing Reform Act moves discretion
    from the individual judge to the Commission.
    Because the ex post facto clause does not apply
    to the judicial branch, see Marks v. United
    States, 
    430 U.S. 188
    , 191 (1977), and the
    Commission is in the judicial branch, see
    Mistretta v. United States, 
    488 U.S. 361
    , 384-97
    (1989), the effective constraint is the due
    process clause, which requires judges to refrain
    from adopting startling interpretations of
    existing rules. E.g., Bouie v. Columbia, 
    378 U.S. 347
    (1964); 
    Prater, 802 F.2d at 952
    . Vivit does
    not contend that the increase in his sentence is
    so surprising that it violates the due process
    clause, and given the history of variability in
    sentencing practices over time (and across
    judges) such an argument would be untenable.
    "Changing the guidelines after the commission of
    a crime does not deprive the criminal of notice
    of the elements of the offense or the statutory
    limits of punishment. It may upset the
    expectations of the few would-be wrongdoers who
    study sentencing practices to determine their
    risks--though even a small change in the
    probability of arrest or prosecution will have a
    much greater effect on the anticipated punishment
    than does a change in the guidelines, and no one
    believes that pouring extra resources into the
    detection and prosecution of crime violates the
    ex post facto or due process clause." 
    Seacott, 15 F.3d at 1392-93
    . So although my colleagues
    faithfully implement the complex rules that have
    sprouted up to limit the damage caused by
    applying the ex post facto clause to a subject
    outside its proper domain, I would prefer a
    shorter path to affirmance. Congress has told
    courts to use the guidelines in force at the time
    of sentencing. 18 U.S.C. sec.3553(a)(4). That
    command is constitutional, and I would follow it
    notwithstanding the United States Attorney’s
    failure to defend (or even cite) the governing
    statute.
    

Document Info

Docket Number: 99-3773

Judges: Per Curiam

Filed Date: 6/6/2000

Precedential Status: Precedential

Modified Date: 9/24/2015

Authorities (45)

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