Dr. Pamela Antell Sentencing Memorandums

Case: 1:18-cr-00584 Document #: 85 Filed: 08/20/19 Page 1 of 38 PageID #:1077
IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ILLINOIS
UNITED STATES OF AMERICA,
Plaintiff,
v. Case No. 1:18-cr-00584
PAMELA ANTELL, Hon. Jorge L. Alonso
Defendant.
DR. ANTELL’S SENTENCING MEMORANDUM

TABLE OF CONTENTS
Page
I. INTRODUCTION ............................................................................................................. 1
II. DR. ANTELL’S HISTORY AND CHARACTERISTICS ............................................... 2
A. Dr. Antell’s Upbringing, Career Achievements .................................................... 2
B. Dr. Antell’s Mental Illness ..................................................................................... 9
C. Dr. Antell’s Age and Physical Condition ............................................................ 13
D. Dr. Antell’s Lack of Criminal History Points ...................................................... 16
III. THE NATURE AND CIRCUMSTANCES OF THE OFFENSE ................................... 17
A. The Enhancement Under the Monetary Loss Table Vastly Overstates the
Nature of the Offense ........................................................................................... 17
B. The Offense Conduct Here Is Not Egregious in Comparison to Other
Healthcare Fraud Cases Resulting in Custodial Sentences .................................. 19
IV. RESPECT FOR THE LAW AND JUST PUNISHMENT .............................................. 20
V. DETERRENCE AND PROTECTION OF THE PUBLIC .............................................. 22
A. Specific Deterrence .............................................................................................. 22
B. General Deterrence .............................................................................................. 23
VI. THE KINDS OF SENTENCES AVAILABLE AND THE PROVISION OF
MEDICAL CARE IN THE MOST EFFECTIVE MANNER ......................................... 24
VII. THE NEED TO AVOID UNWARRANTED SENTENCE DISPARITIES ................... 27
VIII. CONCLUSION ................................................................................................................ 29
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TABLE OF AUTHORITIES
Page
CASES
Booker v .United States,

543 U.S. 220 (2005) .................................................................................................................27
Doe v. United States,

No. 14 MC 1412 (JG), 2015 WL 2452613 (E.D.N.Y. May 21, 2015) ....................................24
Gall v. United States,

552 U.S. 38 (2007) .........................................................................................................1, 20, 24
United State v. Aggarwal,

No. 2:18-cr-00111 (E.D. Pa.) ...................................................................................................28
United States. ex rel. Hawks v. Heart and Vascular Institute of Florida,

No. 8:16-cv-01574 (M.D. Fla.) ................................................................................................29
United States v. Adelson,

441 F. Supp. 2d 506 (S.D.N.Y. 2006)......................................................................................19
United States v. Anderson,

267 F. App’x 847 (11th Cir. 2008) ..........................................................................................22
United States v. Baker,

445 F.3d 987 (7th Cir. 2006) ...................................................................................................25
United States v. Baraban,

No. 4:19-cr-00068 (W.D. Mo.) ................................................................................................28
United States v. Brady,

No. 02-cr-1043 (JG), 2004 WL 86414 (E.D.N.Y. Jan. 20, 2004) ...........................................24
United States v. Brown,

No. 96 CR 451, 1997 WL 786643 (N.D. Ill. Dec. 18, 1997)...................................................12
United States v. Cabrera,

567 F. Supp. 2d 271 (D. Mass. 2008) ......................................................................................23
United States v. Carter,

538 F.3d 784 (7th Cir. 2008) ...................................................................................................14
-ii-
United States v. Chase,

560 F.3d 828 (8th Cir. 2009) ...................................................................................................16
United States v. Clay,

583 F.3d 739 (11th Cir. 2007) .................................................................................................22
United States v. Colletti, et al.,

No. 1:15-cr-00260 (N.D. Ill.) ...................................................................................................28
United States v. Corsey,

723 F.3d 366 (2d Cir. 2013).....................................................................................................18
United States v. Coughlin,

No. 06-20005, 2008 WL 313099 (W.D. Ark. Feb. 1, 2008)....................................................24
United States v. Duhon,

541 F.3d 391 (5th Cir. 2008) ...................................................................................................13
United States v. Edwards,

595 F.3d 1004 (9th Cir. 2010) ...........................................................................................26, 29
United States v. Emmenegger,

329 F. Supp. 2d 416 (S.D.N.Y. Aug. 4, 20114) .......................................................................19
United States v. Faibish,

No. 12-CR-265 ENV, 2015 WL 4637013 (E.D.N.Y. Aug. 3, 2015).......................................18
United States v. Gyambibi,

No. 3:18-cr-00136 (D. Conn.)..................................................................................................28
United States v. Hamilton,

323 Fed. Appx. 27 (2d Cir. 2009) ............................................................................................22
United States v. Henry,

No. 2:18-cr-00249 (M.D. Ala.) ................................................................................................28
United States v. Holt,

486 F.3d 997 (7th Cir. 2007) ...................................................................................................14
United States v. Iyer,

No. 8:18-cr-00378 (M.D. Fla.).................................................................................................28
United States v. Jackson,

860 F.3d 438 (7th Cir. 2017) ...................................................................................................16
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United States v. Kirk,

No. 2:19-cr-00047 (S.D. Ohio) ................................................................................................28
United States v. Morrison,

No. 2:18-cr-00175 (D. Me.) .....................................................................................................28
United States v. Pallowick,

364 F. Supp. 2d 923 (E.D. Wis. 2005).....................................................................................12
United States v. Parris,

573 F. Supp. 2d 744 (E.D.N.Y. 2008) .....................................................................................18
United States v. Powell,

576 F.3d 482 (7th Cir. 2009) ...................................................................................................14
United States v. Properi,

686 F.3d 32 (1st Cir. 2012) ......................................................................................................20
United States v. Rodriguez,

724 F. Supp. 1118 (S.D.N.Y. 1989).........................................................................................22
United States v. Roque,

536 F. Supp. 2d 987 (E.D. Wis. 2008).................................................................................9, 10
United States v. Severio,

No. 3:17-cr-00085 (M.D. La.) .................................................................................................28
United States v. Toback,

No. 01 CR 410, 2005 WL 992004 (S.D.N.Y. April 14, 2005) ................................................16
United States v. Tomko,

562 F.3d 558 (3d Cir. 2009).......................................................................................................9
United States v. Vigil,

998 F. Supp. 2d 1121 (D.N.M. 2014) ......................................................................................23
United States v. Warner,

792 F.3d 847 (7th Cir. 2015) ...................................................................................................24
United States v. Williams,

662 F. App’x 366 (6th Cir. 2016) ............................................................................................16
United States v. Zohfeld,

595 F.3d 740 (7th Cir. 2010) ...................................................................................................13
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STATUTES
18 U.S.C. § 3553(a) ............................................................................................................... passim
18 U.S.C. § 3563(b) .......................................................................................................................25
28 U.S.C. § 994(j) ..........................................................................................................................25
OTHER AUTHORITIES
American Diabetes Association, Stress (2013), available at

http://www.diabetes.org/living-with-diabetes/complications/mental-
health/stress.html .....................................................................................................................15
American Medical Association, Increased Mortality Risk in Women With

Depression and Diabetes Mellitus (2011), available at
https://www.ncbi.nlm.nih.gov/pubmed/21199964 ..................................................................15
CoreCivic Lawsuit, American Diabetes Association, available at

http://www.diabetes.org/living-with-diabetes/know-your-
rights/discrimination/law-enforcement/trousdale-turner-lawsuit.html ....................................26
Jaye Anno et al., Correctional Health Care: Addressing the Needs of Elderly,
Chronically III, and Terminally III Inmates vii (2004), available at
http://nicic.gov/library/018735 ................................................................................................16
Derick R. Vollrath, Losing the Loss Calculation: Toward a More Just Sentencing
Regime In White-Collar Criminal Cases, 59 DUKE L.J. 1001, 1020 (2009) ...........................18
Evan A. Jenness, The ‘Silver Tsunami’ and Sentencing—Age and Health As

Mitigating Factors, THE CHAMPION 30, 30–31 (Sept./Oct. 2013) ....................................14
Frank O. Bowan III, Sentencing High Loss Corporate Insider Frauds After
Booker, 20 FED. SENTENCING REPORTER 167 (2008) ..............................................................18
Kyle Crawford, Health Care Fraud Sentencing, 105 GEO. L.J. 1079, 1088 (2017) ......................27
Maurizio Pompili, et al., 4 NEUROPSYCHIATRIC DISEASE AND TREATMENT 247

(Feb. 2008), available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515901/pdf/ndt-0401-
247.pdf .....................................................................................................................................10
Richard Surwit, Mark Schneider & Mark Feinglos, Stress and Diabetes Mellitus,
15 DIABETES CARE 1413 (1992) ..............................................................................................15
-v-
U.S. Sentencing Commission, Proposed Amendments to the Sentencing

Guidelines 20–37 (2017), available at
https://www.ussc.gov/sites/default/files/pdf/amendment-process/reader-
friendly-amendments/20170824_rf_proposed.pdf...................................................................17
United States Sentencing Commission, The Effects of Aging on Recidivism Among

Federal Offenders 25 (2017) ...................................................................................................13
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Defendant Pamela Antell, by and through her undersigned counsel, respectfully submits
this Sentencing Memorandum, and states as follows: 1
I. INTRODUCTION
While much of the sentencing phase of any case naturally focuses on technical aspects of
the Sentencing Guidelines, in this case, it is particularly important that the technical analysis not
obscure the true purpose of sentencing—to fashion a sentence that adequately reflects not just the
offense conduct, but also the person who stands before the Court.
Accordingly, this submission, in addition to discussing relevant aspects of the offense, will
describe for this Court who Dr. Antell is as a human. As this Court will see, Dr. Antell is complex
in a way wholly uncaptured by rote application of the Guidelines. As countless acquaintances
have experienced first-hand outside the context of this prosecution, she is an accomplished mother,
wife, and professional, as well as an involved member of her community. But as only she and her
psychiatrist have seen, Dr. Antell is also profoundly depressed, bipolar, and sometimes exhibits
psychotic features. And she is also the person known to the government—someone who engaged
in fraud for years.
In her execution of this scheme, Dr. Antell was deeply flawed. She is now even more
remorseful. And, going forward, having relinquished her professional license, she is ready to apply
her energy and skills to productive pursuits that will benefit her family and her community.
The Supreme Court has long recognized that criminal defendants are more than their
Sentencing Guidelines ranges. See, e.g., Gall v. United States, 552 U.S. 38, 49–50 (2007). The
Guidelines are neither mandatory nor presumptively reasonable, and are just one of many factors
1
The defendant moves instanter for leave to file a brief in excess of 15 pages, pursuant to Local Rule 7.1.
The defendant’s sentencing memorandum focuses on numerous mitigating factors, as well as all of the relevant
sentencing factors, and is therefore over the page limit.
for this Court to weigh when determining a sentencing that is sufficient but not greater than
necessary to satisfy the purposes and goals set forth in 18 U.S.C. § 3553(a). Id. Under 18 U.S.C.
§ 3553(a), the Court is directed to consider, among other things:
(1) “the history and characteristics of the defendant,”
(2) “the nature and circumstances of the offense,”
(3) the need “to promote respect for the law, and to provide just punishment for the
offense,”
(4) the need “to afford adequate deterrence to criminal conduct” and “protect the
public from further crimes of the defendant,”
(5) the need to provide “medical care . . . in the most effective manner” and to take
account of “the kinds of sentences available,” and
(6) “the need to avoid unwarranted sentence disparities among defendants with
similar records who have been found guilty of similar conduct.”
Below, we tell the complicated story of Dr. Antell through the lens of these considerations.
We respectfully submit that, applied here, these considerations strongly support the imposition of
a non-custodial sentence.
II. DR. ANTELL’S HISTORY AND CHARACTERISTICS
Above all else, Dr. Antell’s personal history and characteristics militate in favor of a non-
custodial sentence. Indeed, Dr. Antell’s past, present, and future are all filled with mitigating
factors that not only render her an incredibly low risk of recidivism, but also demonstrate why a
term of incarceration would accomplish nothing in this case.
A. Dr. Antell’s Upbringing, Career Achievements
Dr. Antell’s entire life has been a juxtaposition of profound mental illness and
extraordinary accomplishments. Dr. Antell is genetically predisposed to mental illness, and so
personal and professional challenges associated with this condition were likely unavoidable.
Indeed, mental illness is prevalent within her immediate family and was a constant in her
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childhood; her brother intermittently took a variety of “heavy duty” psychiatric medications, while
both her mother and father took antidepressants. PSR ¶¶ 52, 64. Dr. Antell’s older brother’s
struggles were the most extreme—he was violent and physically abusive toward her, and her
parents, suffering from their own depression, were unable to protect her. PSR ¶ 52. Dr. Antell
grew up feeling terrified, unsafe, and insecure, and she was unable to express these feelings to her
parents. Id.
Against this backdrop, it comes as no surprise that Dr. Antell too fell victim to mental
illness. Dr. Antell’s long history with mental illness began in 1974, the year she graduated cum
laude from Queens College. PSR ¶¶ 65, 74. She decided to attend graduate school out-of-state
primarily to distance herself from her brother. PSR ¶ 52. But she nevertheless experienced a
debilitating depression at the thought of leaving her family in New York. Just this threat of loss
led Dr. Antell to seek treatment, delaying her graduate school plans for an entire year. PSR ¶ 65.
Once in graduate school, Dr. Antell’s depression subsided until she finished a brief internship in
New York and needed to return to Illinois to work on her dissertation. This time, Dr. Antell spent
four years in therapy. As described in more detail below, Dr. Antell’s struggle with depression
continued throughout her entire life.
Despite her own struggles and inability to handle change, Dr. Antell not only pursued a
career as a mental health professional, but excelled in doing so. After overcoming her first two
major bouts of depression, Dr. Antell obtained her Ph.D. at Northern University in DeKalb,
Illinois. PSR ¶ 74. Before long, Dr. Antell established herself as a successful consultant for non-
profit agencies in Chicago, where she provided psycho-diagnostic services to clients, consulted
several Head Start locations, and supervised doctoral students placed at the agencies for practicum
experiences. Ex. A, Letter from Edgewater-Uptown Community Mental Health Center Former
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COO, JM, at 1; 2 PSR ¶ 79. As a former administrator from one of these agencies recalls, “[Dr.
Antell] has enjoyed a wonderful reputation within the clinical psychology community in Chicago.
She was often praised by our clients and the students she supervised.” Ex. B, Letter from Former
Vice President Child and Family Counseling Centers of Chicago, VP, at 1. In addition to all of
this, Dr. Antell started building her own practice. PSR ¶ 78.
In 1983, Dr. Antell’s already complicated life became even more so. At that time, in
addition to her status as both a mental health patient and a mental health professional, she became
the head of a household. She met her husband, Mike, and together they had two children, Alyssa
and Marc. PSR ¶¶ 53–54. Dr. Antell’s children are what she holds most dear, and consequently
her greatest sources of potential loss. In 1989, when Alyssa was born, Dr. Antell’s mother was
dying and in the hospital in New York. See Dr. Antell’s Letter, at 4. 3 As Dr. Antell recalls: “The
juxtaposition of these two events, one, the most joyous event in life and the other, the saddest,
became the basis of my incessant need to be in contact with my daughter and my extreme fears for
her safety.” Id. Looking back, Dr. Antell realizes she put off mourning completely in order to
continue functioning. She simply “did not mourn at all.” Id. It wasn’t until 1999, the ten-year
anniversary of her mother’s death and Alyssa’s birth, that Dr. Antell suffered her third and most
serious bout of depression. As discussed in more detail below, this is when Dr. Antell began
treatment with Dr. Lauren Jacker, the psychiatrist she still sees to this day.
For the sake of her children, Dr. Antell somehow managed to compartmentalize her
worsening mental state. She was a “loving, motivating, and supportive figure” through every step
The undersigned counsel plans to move to seal all character letters cited herein at the sentencing hearing on
2
September 3, 2019. Prior to that date, all character letters will be sent to the Court under separate cover.
3
Dr. Antell’s Letter will be provided under separate cover prior to the sentencing hearing on September 3,
2019.
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of her children’s lives. Ex. C, Letter from Dr. Antell’s Daughter, Alyssa Gordon, at 3. Dr. Antell
continued thriving in her professional life as well, and by 1999, she decided to focus solely on her
booming private practice. Her work ethic became a model for Alyssa and Marc when it was time
for them to pursue their own goals and careers. Ex. C, Letter from Dr. Antell’s Daughter, Alyssa
Gordon, at 1; Ex. D, Letter from Dr. Antell’s Son, Marc Gruenhut, at 1. As a result, both of her
children have grown into successful, contributing members of society: “[Dr. Antell] has been a
tireless advocate for her children, involved in their academics, sports, and the community. She
and her husband have raised two wonderful, hardworking children, the kind of solid adults who
would make any parent proud.” Ex. E, Letter from Family Friend, LJF, at 1; see also Ex. F, Letter
from Family Friend, MSL, at 1 (“Nothing has been handed to [Dr. Antell’s] kids. They worked
for everything they got because of the great upbringing and strong work ethic instilled in them by
their parents. They are hard-working and respectful. Every parent wishes their kids would turn
out like Alyssa and Marc.”).
Dr. Antell’s children have given her a reason to live and the strength to continue fighting
against her mental illnesses, and she has been wholly and selflessly devoted to them. Her fondness
for her children has also, however, been the catalyst for extreme anxiety, primarily focused around
her children’s safety and security, doing anything in her power to provide and to not lose them.
In addition to catering to her family, Dr. Antell always remained devoted to her craft. That
is what makes the caricature of Dr. Antell portrayed by the government in its version of the offense
so inaccurate and misleading. While the government included communications between Dr. Antell
and three out of the hundreds of patients she has seen over the years, those communications are
not only the result of extreme stress and dysfunction, but also wholly out of character for someone
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whose career is otherwise distinguished for passionate and devoted patient care. See Defendant’s
Version, at 18–21. 4
For better or for worse, and in stark contrast to the government’s portrayal, Dr. Antell cared
for her patients so much that it became an all-consuming task. As her son recalls, “My mom takes
her clients so very personally, and she cared and thought about them whether or not she was at
work.” Ex. D, Letter from Dr. Antell’s Son, Marc Gruenhut, at 2. In the vast majority of occasions,
Dr. Antell’s sincere concern for, and positive feelings towards, her patients benefited them. She
would, for instance, loan money to patients’ parents so they could afford additional healthcare for
their child. See Ex. G, Email from Dr. Antell to MHN. She would spend significant amounts of
time outside of therapy sessions helping her younger patients’ parents navigate any and all
parenting issues—with no request or expectation of payment. See, e.g., Ex. H, Email from Dr.
Antell to SP; Ex. I, Email from Dr. Antell to MD and JM; Ex. J, Email from Dr. Antell to PH. And,
she never stopped assessing and problem-solving for her patients, even when other medical
professionals were incapable of diagnosing the problem or gave up trying. As one patient explains,
“I believe Dr. Antell contributed to saving my life. She was able to pick up on the fact that I was
addicted [to pain medication] when no other healthcare provider was able to detect this.” See Ex.
K, Letter from Patient, JP, at 1.
Unfortunately, Dr. Antell’s attachments to her patients did not always manifest positively.
As this case has shown, her communications with some patients resemble the kind of outbursts
one might expect from a mentally ill individual who was feeling betrayed, abandoned, or ignored
by a close family member or friend. It is in these moments when Dr. Antell’s own struggles with
4
The government obtained all of Dr. Antell’s emails, but only included those in which she exhibited
aggressive behavior.
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mental illness suppressed who she really was as a practitioner, “an insightful therapist who has
always displayed wisdom and good judgment.” Ex. L, Letter from Patient, MHN, at 1. While
these interactions were inappropriate and unprofessional, they are not representative of, and should
not overshadow, the overwhelmingly positive impact she has made on dozens of her clients. The
real Dr. Antell was a devoted and loving mental health professional, one without a single blemish
on her license in 36 years. See Ex. M, Illinois Department of Financial and Professional
Regulation License Lookup Detail of Pamela A. Antell, at 1. She has contributed a “lifetime of
good . . . in the community and in the personal lives of others.” Ex. N, Letter from Graduate
School Student, RKN, at 1. She “never put her own interests first.” Ex. O, Letter from Patient,
JMS, at 2. Even V.S., one of the individuals to whom Dr. Antell communicated unprofessionally
in this case, knows this to be true. See Ex. FF, FBI Interview with V.S., FBI_004-000005 (“this
wasn’t ‘the Pam’ [V.S.] was used to”).
In addition to her private practice, Dr. Antell spent many years contributing to society
through her pro bono work. For fifteen years, Dr. Antell consulted Edgewater-Uptown
Community Mental Health Center while providing pro bono services to various agencies that had
partnered with the Center. As the Center’s former Chief Operating Officer explains, “[Dr. Antell]
understood the many facets of mental health treatment with a very diverse, multicultural,
underserved population,” and “[h]er provision of pro bono services to various Head Start centers
was a great benefit to the Uptown area of Chicago.” Ex. A, Letter from Edgewater-Uptown
Community Mental Health Center Former COO, JM, at 1. Dr. Antell “showed a strong interest in
assisting, in whatever way possible, these multi-problem individuals and families who were very
under-resourced yet very much in need of mental health services.” Ex. B, Letter from Former Vice
President Child and Family Counseling Centers of Chicago, VP, at 1. “She had a wonderful ability
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to connect with our clientele who were very different from her in so many ways,” and “had a very
solid presence in the neighborhoods she served in and near the Uptown community.” Id.
Since Dr. Antell’s retirement, pro bono work has once again become a significant part of
her life. She is a “Champion Volunteer” with Cradles to Crayons, a member of the Social Action
Committee at her synagogue, and a volunteer with Moms Demand Action, a grassroots
organization that encourages legislative action for firearms safety laws and to prevent firearm
violence. PSR ¶ 55; Ex. P, Letters from Pro Bono Organizations, at 1. As part of the Social Action
Committee, Dr. Antell recently helped a Rwandan refugee family’s relocation to the United States,
providing them with furniture, money, and assistance with getting settled in their new community.
See Ex. P, Letters from Pro Bono Organizations, at 2. Thus, although relinquishing her license
has been difficult for her, Dr. Antell has already reintegrated herself into society by finding
alternative, but similarly productive ways to help people and communities through her time, skills,
and energy.
As a final matter relating to Dr. Antell’s practice, we note for the Court the unfortunate fact
that practicing as a mental health therapist can be a draining, lonely and, at times, even thankless
job. The level of responsibility required to handle and care for mentally ill individuals is difficult
to imagine. No call can go unanswered; no email ignored. And that is precisely how Dr. Antell
lived and performed: “Pam always prioritized the needs of her clients. She worked long hours and
has always been very available to her clients and students.” Ex. Q, Letter from Family Friend, JK,
at 1. Dr. Antell had “always been available outside of normal business hours.” Ex. O, Letter from
Patient, JMS, at 2. “She has done so much work to help [her patients] in therapy and outside of
[their] therapy sessions.” Ex. L, Letter from Patient, MHN, at 1. One patient even recalls that “Dr.
Antell made home visits when [he] was unable to drive.” Ex. K, Letter from Patient, JP, at 1.
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Simply put, “she [was] always available to lend an ear and provide sage advice, any day of the
week, at any time.” Ex. R, Letter from Patient, EFD, at 1.
And while many patients are thankful for Dr. Antell’s hard work; a few were not. Along
with other manifestations of mental illness—as Dr. Antell herself well knows—sometimes comes
abusive and irrational reactions. This meant that “doing the right thing” for the patients Dr. Antell
was treating often “carr[ied] significant personal and professional risks.” Ex. O, Letter from
Patient, JMS, at 1. Over her 35 years of practice, Dr. Antell has been blamed for failed marriages,
children’s failures, and other patient problems over which she had no control. She has also been
the target of vindictive and nasty reactions from her patients. While “many psychologists [] would
have put his or her interests first and would have cowered to the threats,” Dr. Antell “stood her
ground.” Ex. O, Letter from Patient, JMS, at 2. While Dr. Antell loved her job, it was not always
easy and she did not always feel appreciated.
Dr. Antell’s long history of gainful employment and positive contributions to her patients
and the greater community clearly weigh in favor of a non-custodial sentence. See United States
v. Tomko, 562 F.3d 558, 571 (3d Cir. 2009) (Affirming below-guideline sentence of probation,
community service, restitution, and fine on a conviction for tax evasion where the district court’s
“variance took into account his negligible criminal history, his employment record, his community
ties, and his extensive charitable works as reasons for not incarcerating [the defendant].”). Further,
when a defendant is “on the right path,” changing course “[does] not seem to make much sense.”
United States v. Roque, 536 F. Supp. 2d 987, 990–91 (E.D. Wis. 2008) (varying from 87–108
month range to probation). Dr. Antell is certainly “on the right path.”
B. Dr. Antell’s Mental Illness
The most curious aspect of the offense in this case is why it happened at all. Throughout
her career, and during the entire span of the offense, Dr. Antell owned a successful psychology
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practice and lived frugally. Significant sums of money that she collected through her practice
remained untouched, until the issuance of the indictment and the subsequent seizure of funds.
While difficult to understand, it is evidence Dr. Antell’s long-term struggle with serious and
debilitating mental illness is at the heart of her otherwise inexplicable offense and weighs heavily
in favor of a non-custodial sentence.
As described above, Dr. Antell has struggled with depression since her early twenties,
experiencing her first depressive episode shortly after graduating from college. PSR ¶¶ 65, 74. At
that time she sought outpatient mental health care treatment and was prescribed an antidepressant.
Id. Dr. Antell resumed mental health treatment in 1999, when she began seeing her psychiatrist,
Dr. Lauren Jacker. See Ex. S, Letter from Dr. L. Jacker, at 1. That year, Dr. Antell was diagnosed
with severe major depressive disorder with psychotic features. Id.; PSR ¶ 66. As described by
Dr. Jacker, Dr. Antell meets a staggering eight out of nine criteria for major depressive disorder,
including diminished interest or pleasure in most activities, feelings of worthlessness or excessive
or inappropriate guilt, diminished ability to think or concentrate, recurrent thoughts of death, and
suicidal ideation. 5 Id. Dr. Antell also exhibits symptoms of bipolar disorder and has dissociative
tendencies which allow her to hide her deepest issues from even herself and split off those areas
and actions from her conscious awareness. Id.
These issues stem, in part, from her difficult childhood. Ex. S, Letter from Dr. L. Jacker,
at 4. And as an adult, she focused her anxieties on ensuring that her children grew up with the
safety and security that she never felt that she had as a child. Id. Indeed, despite her profound
5
See Maurizio Pompili et al., Suicide Risk in Depression and Bipolar Disorder: Do Impulsiveness-
Aggressiveness and Pharmacotherapy Predict Suicidal Intent?, 4 NEUROPSYCHIATRIC DISEASE AND TREATMENT 247
(Feb. 2008), available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515901/pdf/ndt-0401-247.pdf (noting that
“individuals with BPD are 30 times more likely to attempt suicide than those with no psychiatric disorder” and that
“[s]uicide behavior in major affective disorders [such as major depressive disorder or bipolar disorder] is also
characterized by high lethality”).
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mental illness, Dr. Antell was sustained throughout the last two decades by her relationships with
her loving husband and two children, Alyssa and Marc. Her children have given her a reason to
live and the strength to continue fighting against her mental illnesses, and she has been wholly
devoted to them. In other ways, though, her children exacerbated her mental illness, as her severe
and pathological anxiety is primarily focused around her children and providing them with the best
lives possible. Id.
As another escape from her mental illness—and as a way to care for her children—Dr.
Antell also became increasingly dedicated to her work and growing her practice as a clinical
psychologist. Dr. Antell was, and still is, a “workaholic,” and although she grew a large and
successful psychology practice over the course of the last thirty years, she lived well within her
means, choosing to save most of the proceeds from her practice year after year. Dr. Antell’s family
described the long hours she spent working and acknowledged that, looking back on it, the extreme
dedication to work was likely “not quite normal.” See Ex. C, Letter from Dr. Antell’s Daughter,
Alyssa Gruenhut, at 3 (“Now, however, I understand what her excessive work was all about: it
helped her to avoid depression, but was just a bit too much and abnormal.”); Ex. T, Letter from
Dr. Antell’s Husband, Mike Gruenhut, at 1 (“Now I know that her busy schedule was to allow her
to avoid a deep, underlying depression that she tried to hide from us the best she could.”).
As Dr. Antell approached retirement age, and her children grew older and became more
independent, her anxiety and depression became unbearable. She was terrified about the future
and felt an uncontrollable and irrational need to provide even more for her children than she already
had and thus greater assure their safety and security. She began committing fraud in order to
soothe these symptoms of her mental illness and meet this urge to provide. Ex. S, Letter from Dr.
L. Jacker, at 4. This is why money related to the fraud has sat untouched in Dr. Antell’s bank
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account for the last six years. As the defense has repeatedly noted, Dr. Antell does not offer her
mental illness as an excuse for her offense conduct, but in order to put this otherwise completely
out-of-character conduct into perspective.
And of course, mental illness such as that suffered by Dr. Antell is itself a sufficient reason
to depart from the Guidelines and impose a non-custodial sentence. In this regard, Guidelines
Section 5K2.13 states: “A downward departure may be warranted if (1) the defendant committed
the offense while suffering from a significantly reduced mental capacity; and (2) the significantly
reduced mental capacity contributed substantially to the commission of the offense.” Courts
within the Seventh Circuit “regularly have held that depression and anxiety may cause a
substantially reduced mental capacity, supporting mitigation of punishment for crime.” United
States v. Pallowick, 364 F. Supp. 2d 923, 928 (E.D. Wis. 2005) (collecting cases); see also United
States v. Brown, No. 96 CR 451, 1997 WL 786643, at *6 (N.D. Ill. Dec. 18, 1997) (holding that
defendant’s “major depression contributed to the commission of his offense” where it “suppressed
[his] ability to rationally consider the consequences of his actions” and granting a downward
departure in sentencing). Dr. Antell’s illness “need only be a contributing cause, not a but-for
cause or sole cause, of the offense” to be considered for a downward departure. Brown, 1997 WL
786643, at *5 (citing United States v. Cantu, 12 F.3d 1506, 1515 (9th Cir. 1993) (collecting cases)).
In addition, a non-custodial sentence is warranted so that Dr. Antell’s commitment to
addressing her mental health issues can continue without disruption. Since indictment, Dr. Antell
has been forced to come squarely to terms with her actions. While she has received many years
of mental health treatment, she now knows she needs much more and is committed more than ever
to pursuing an effective treatment regimen and achieving sustained beneficial therapeutic results.
Incarceration would be counterproductive, as it would very likely derail these efforts. As the
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Seventh Circuit has recognized, § 3553(a)(2)(D) requires the court to consider the need for the
sentence imposed to “provide the defendant with needed . . . medical care, or other correctional
treatment in the most effective manner.” See, e.g., United States v. Zohfeld, 595 F.3d 740, 743
(7th Cir. 2010) (holding that the district court may consider the need for mental health treatment
when imposing sentence); see also United States v. Duhon, 541 F.3d 391, 399 (5th Cir. 2008)
(affirming sentencing of probation where district court determined that defendant “would benefit
most from continuing his medical treatment with his psychologist”). The crucial mental health
care that Dr. Antell is currently receiving can only be achieved through continuity of care with the
same physician who she has known and trusted for the last twenty years.
C. Dr. Antell’s Age and Physical Condition
The combination of Dr. Antell’s age and poor health further renders a custodial sentence
unnecessary to fulfill the purposes of punishment under § 3553(a).
Dr. Antell is 68 years old. As such, coupled with the other circumstances present here, she
is unlikely to re-offend. See U.S.S.G. § 5H1.1 (authorizing downward departure based on
defendant’s age.). As the Court in United States v. Payton explained:
[T]he Guidelines and our Circuit’s cases explicitly acknowledge that a defendant’s
age, and specifically old age, is a relevant consideration in sentencing. U.S.S.G.
§ 5H1.1 . . . . And observers of the criminal justice system have long
acknowledged the “key” argument “that elderly offenders pose so low a risk to the
public that long or otherwise harsh sentences have little to no utilitarian benefit.”
Indeed, they observe that “because of health or other reasons, elderly offenders
have the lowest rate of recidivism of all types of offenders . . . .”
754 F.3d 375, 379 (6th Cir. 2014) (internal citations omitted).
The Sentencing Commission has found that nearly 89% of offenders who are 60 years old
and older do not reoffend. United States Sentencing Commission, The Effects of Aging on
Recidivism Among Federal Offenders 25 (2017). And this figure actually over-states Dr. Antell’s
recidivism risk, as it does not account for the many other characteristics that further decrease her
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risk of recidivism, including criminal history, gender, and education level. See id. at 30 (“After
accounting for age, criminal history as measured by the offenders’ Criminal History Category was
closely correlated with recidivism rates. Demographic factors including gender (males had higher
rates), race and ethnicity (minorities had higher rates), and education levels (those with lower
education levels had higher rates) also stood out.”).
Because the Guidelines “do not factor in a defendant’s age,” the Seventh Circuit has
repeatedly recognized that age is a legitimate basis for finding a decreased risk of recidivism. See,
e.g., United States v. Powell, 576 F.3d 482, 499 (7th Cir. 2009) (remanding with the instruction
that the district court “should consider [the defendant’s] arguments about his advance age and
infirm health in light of the factors outlined in 18 U.S.C. § 3553(a)”); United States v. Carter, 538
F.3d 784, 792 (7th Cir. 2008) (affirming lower sentence for tax fraud partially based on age);
United States v. Holt, 486 F.3d 997, 1004 (7th Cir. 2007) (affirming below-range sentence based
solely on age).
Moreover, given Dr. Antell’s age, a term of imprisonment in this case would represent a
greater, disproportionate punishment relative to materially younger defendants sentenced to the
same prison term. Indeed, evidence has established this:
[Older inmates] may experience relatively greater social isolation, depression, and
harassment by other inmates. Prison also has a greater adverse impact on older
inmates' physical and mental well-being. They “are more likely to develop
disabilities that require the use of assistive devices such as glasses, hearing aids,
wheelchairs, walkers, and canes.” Their mental health, too, may suffer
disproportionately. Older inmates suffer more from depression, and even have a
“higher rate of successful suicide.” Health and other problems of older inmates can
“accelerate their aging processes to an average of 11.5 years older than their
chronological ages after age 50.”
Evan A. Jenness, The ‘Silver Tsunami’ and Sentencing—Age and Health As Mitigating Factors,
THE CHAMPION 30, 30–31 (Sept./Oct. 2013) (internal citations omitted).
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Additionally, Dr. Antell’s poor health would make a custodial sentence even more punitive.
Dr. Antell has numerous physical and mental conditions. She has suffered from Type II diabetes
since 1999. PSR ¶ 60. This past August, she was diagnosed with beginning kidney impairment
(albuminuria), a result of the damage caused by uncontrolled diabetes. PSR ¶ 61. This summer,
Dr. Antell was diagnosed with basal cell carcinoma and she had cancerous tissue excised from her
chest. Ex. U, Note from Dr. Antell’s Dermatologist May 21, 2019. This condition requires follow-
up appointments twice per year. See id. She also suffers from severe osteoarthritis, irritable bowel
syndrome, high cholesterol, and sleep apnea. PSR ¶ 60; Defendant’s Version at 17; Ex. V, Letter
from Dr. John Hefferon, at 1. She takes 11 medications—10 of which are daily and the other of
which is weekly. Two of her 11 medications are injectables. PSR ¶¶ 53, 71. Further, Dr. Antell
faces accelerated aging processes due to her compounding diagnoses of diabetes and depression.
Studies show that Dr. Antell’s combination of diabetes and depression significantly increases her
risk of mortality, substantially reducing her life expectancy from that of a typical 68 year old. See
American Medical Association, Increased Mortality Risk in Women With Depression and Diabetes
Mellitus (2011), available at https://www.ncbi.nlm.nih.gov/pubmed/21199964.
Dr. Antell’s mental health issues magnify the punitive aspects of a custodial sentence
because they rid her of the ability to appropriately manage high levels of stress. This in turn
exacerbates her diabetes, as the stress leads to high cortisol and reduces her body’s ability to both
produce and use insulin. See Richard Surwit, Mark Schneider & Mark Feinglos, Stress and
Diabetes Mellitus, 15 DIABETES CARE 1413 (1992) (“Stress stimulates the release of various
hormones, which can result in elevated blood glucose levels. Although this is of adaptive
importance in a healthy organism, in diabetes, as a result of the relative or absolute lack of insulin,
stress-induced increases in glucose cannot be metabolized properly.”); see also American Diabetes
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Association, Stress (2013), available at http://www.diabetes.org/living-with-
diabetes/complications/mental-health/stress.html. This is not a theoretical issue potentially facing
Dr. Antell; since her indictment, her diabetes has gone from controlled to uncontrolled. PSR ¶ 60;
compare Ex. W, Note from Dr. Antell’s Endocrinologist Nov. 20, 2018, JA, at 1, with Ex. X, Note
from Dr. Antell’s Endocrinologist May 13, 2019, JA, at 1. In addition, her A1C went from 6.9 to
9.6, a 40% increase in her blood glucose levels. Ex. Y, Message from Dr. Antell’s Endocrinologist
May 31, 2019, JA, at 1. Dr. Antell’s documented medical responses to this indictment make it
abundantly clear that “the stress imposed by incarceration [will] exacerbate [her] health problems.”
U.S. Dep't of Justice, National Institute of Corrections, Correctional Health Care: Addressing the
Needs of Elderly, Chronically III, and Terminally III Inmates vii (2004), available at
http://nicic.gov/library/018735 (“The stress imposed by incarceration can exacerbate the health
problems of elderly and infirm inmates.”).
D. Dr. Antell’s Lack of Criminal History Points
Dr. Antell has no prior criminal history points. Apart from just assessing criminal history
in the determination of a defendant’s Guidelines range, courts have routinely taken this absence of
criminal history into account when proceeding to fashion a just sentence. See, e.g., United States
v. Jackson, 860 F.3d 438, 445 (7th Cir. 2017) (affirming imposition of sentence “substantially
below the Guidelines range,” which the lower court had determined was “appropriate in light of
[the defendant’s] lack of criminal history and the unlikelihood that she would recidivate”); United
States v. Williams, 662 F. App’x 366, 377 (6th Cir. 2016) (affirming a below-guidelines sentence
and noting that “the district court emphasized that its decision to issue a below-Guidelines
sentence—despite the severity of Ms. William’s offense—was motivated primarily by Ms.
Williams’s lack of criminal history and her low risk of recidivism”); United States v. Chase, 560
F.3d 828, 831 (8th Cir. 2009) (noting that “Chase’s lack of criminal history, even though already
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taken into account in calculating his advisory guidelines range, could nevertheless have formed
the basis for a variance”); United States v. Toback, No. 01 CR 410, 2005 WL 992004 (S.D.N.Y.
April 14, 2005) (granting downward variance in part because “[t]he instance offense is Toback’s
first criminal conviction”).
Dr. Antell is an especially appropriate candidate for such a variance, since unlike some
offenders in the Criminal History I category, Dr. Antell has no criminal history points whatsoever.
Indeed, the U.S. Sentencing Commission has recognized that Criminal History Category I can
comprise both those who have no criminal history points at all (like Dr. Antell) and those who do.
And the Commission has recently considered a proposed addition to the Guidelines—one that
addresses this potential inequity by providing a one-level reduction for true first offenders like Dr.
Antell. See U.S. Sentencing Commission, Proposed Amendments to the Sentencing Guidelines
20–37 (2017), available at https://www.ussc.gov/sites/default/files/pdf/amendment-
process/reader-friendly-amendments/20170824_rf_proposed.pdf. The same considerations
motivating the Sentencing Commission to consider this addition to the Guidelines, and that have
guided other courts as noted above, should guide this Court as it fashions Dr. Antell’s sentence.
III. THE NATURE AND CIRCUMSTANCES OF THE OFFENSE
Dr. Antell committed a serious crime, one for which she has fully accepted responsibility.
While she only submitted fraudulent claims once per year, she continued to do so for a number of
years. But while her conduct thus persisted for some time and resulted in a substantial loss amount,
an appropriate sentence here should also take into account the various mitigating factors discussed
below.
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A. The Enhancement Under the Monetary Loss Table Vastly Overstates the
Nature of the Offense
Because Dr. Antell’s offense resulted in financial losses (to insurance companies), the
seriousness of her crime is largely defined by the loss amount. While the parties have vastly
different estimates of the total loss amount, the corresponding offense-level enhancements under
either estimate would result in an excessive and unfair Guidelines range in any event. No other
enhancement in § 2B, the Guidelines section applicable to this case, provides for anything near a
14-level, let alone 16-level, upward adjustment. By contrast, in § 2A, governing violent crimes,
there are no double-digit enhancements. Examples of other double-digit enhancements in the
Guidelines include a 15-level enhancement for trafficking in portable rockets (§ 2K2.1(b)(3)(A))
and for boarding air planes with bombs (§ 2K1.5(b)(1)), and 12-level enhancements for
committing a felony to promote terrorism (§ 3A1.4(a)) and for obstruction of justice related to
terrorism (§ 2J1.2(b)(1)(C)). In striking contrast, the enhancement in a sexual assault offense if
the victim is under 12 years old is only 4 levels (§ 2A3.4(b)(4)).
Courts have recognized that a wooden application of the loss table under § 2B would
produce unjustified, exaggerated sentences. “[T]he loss guideline is fundamentally flawed,”
United States v. Corsey, 723 F.3d 366, 377 (2d Cir. 2013) (Underhill, J., concurring), and “a black
stain on common sense,” United States v. Parris, 573 F. Supp. 2d 744, 754 (E.D.N.Y. 2008). “The
loss table is but one example of the seemingly mindless acceleration of penalties for economic
crimes incorporated in the current Sentencing Guidelines regime.” United States v. Faibish, No.
12-CR-265 ENV, 2015 WL 4637013, at *2 (E.D.N.Y. Aug. 3, 2015). “[S]trict application of the
Guidelines derived from the loss table can “unfairly balloon [a defendant’s] sentencing range
beyond any reasonable proportion to his crimes.” Id. Scholars too have commented on the
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excessive nature of Guidelines ranges in fraud cases, driven by the enhancements generated by
calculations of the monetary loss. 6
In sum, the loss table ignores the differences between violent and non-violent crimes and
is a “relatively weak indicator of the moral seriousness of the offense or the need for deterrence.”
United States v. Emmenegger, 329 F. Supp. 2d 416, 427 (S.D.N.Y. Aug. 4, 2014). It fails to
account for important distinguishing factors for different crimes. And the ranges are so broad as
to assign the same number to vastly different frauds. All of these factors have led courts to find
that the loss table is “patently absurd on [its] face.” United States v. Adelson, 441 F. Supp. 2d 506,
515 (S.D.N.Y. 2006).
B. The Offense Conduct Here Is Not Egregious in Comparison to Other

Healthcare Fraud Cases Resulting in Custodial Sentences
This District sees many healthcare fraud cases, a number of which involve particularly
egregious conduct. Those cases include, for example, instances in which patients received
medically unnecessary treatments; patients themselves were overbilled and incurred large out of
pocket losses; and conduct resulting in millions of dollars of losses to government-funded
programs, like Medicare. Dr. Antell’s crime is none of those things. Indeed, Dr. Antell in fact
provided many legitimate and helpful services to her patients. And this was not a Medicare fraud
case. The primary victims in this case are private insurance companies (e.g., Blue Cross Blue
Shield). Search Warrant Application, Table 1. Additionally—although this is no excuse—Dr.
Antell’s fraudulent conduct stemmed from a misguided attempt to support her children.
6
See, e.g., Derick R. Vollrath, Losing the Loss Calculation: Toward a More Just Sentencing Regime In
White-Collar Criminal Cases, 59 DUKE L.J. 1001, 1020 (2009) (“The sentencing of federal white-collar criminal
defendants is deeply flawed. The guidelines recommend sentences that are generally too harsh. Moreover, the
guidelines place undue emphasis on the loss calculation, an imprecise measure that fails to accurately correlate with
the defendant’s culpability.”); Frank O. Bowan III, Sentencing High Loss Corporate Insider Frauds After Booker, 20
FED. SENTENCING REPORTER 167, 169 (2008) (“Since Booker, virtually every judge faced with a top-level corporate
defendant in a very large fraud has concluded sentences called for by the guidelines were too high.”).
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Sentencing Recommendation at 2. Looking back, (and with clarity of thought derived from
consistent mental health treatment), Dr. Antell now “realizes the illogical nature of [her thought
process],” while also realizing that “in the throes of her illness, it made sense to her.” Id.
IV. RESPECT FOR THE LAW AND JUST PUNISHMENT
The Supreme Court recognized in Gall v. United States that fashioning a sentence “to
promote respect for the law” does not invariably point towards harsher sentences. 552 U.S. 38,
54 (2007). Rather, such sentences “may work to promote not respect, but derision, of the law if
the law is viewed merely as a means to dispense harsh punishment without taking into account the
real conduct and circumstances involved in sentencing.” Id. (quotation omitted). Dr. Antell has
already suffered immensely for the offense in this case. Prior to the indictment, Dr. Antell had an
“impeccable reputation as an experienced and intelligent therapist.” Ex. O, Letter from Patient,
JMS, at 1. “She was known in the teaching community as knowledgeable, moral, conscientious
and with high integrity.” Ex. N, Letter from Graduate School Student, RKN, at 1. She has “always
impressed [others] as a very honorable, giving, competent professional who could be trusted to
conduct herself most appropriately.” Ex. B, Letter from Former Vice President of Child and
Family Counseling Centers of Chicago, VP, at 1.
With her very public arrest and conviction, her good standing, and esteem in which she
was held, are now gone. While this was a foreseeable (and justifiable) result of the fraud, it is still
an exacting punishment for Dr. Antell. “Having an otherwise exemplary 35 year career tarnished
by these allegations is a very great price to pay.” Ex. Q, Letter from Family Friend, JK, at 1. As
the court in United States v. Properi, 686 F.3d 32, 48 (1st Cir. 2012), insightfully observed:
I think it is very difficult at times, for those of us who are judges or prosecutors or
lawyers, to put ourselves in the shoes of a person with no prior experience with the
criminal justice system who finds himself or herself accused of a crime. I do not
think, sometimes, we fully recognize the anguish and the penalty and the burden
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that persons face when called to account, as these men are, for the wrong that they
committed.
As would be expected, Dr. Antell’s arrest and conviction have been devastating for her and
her family. See Ex. T, Letter from Dr. Antell’s Husband, Michael Gruenhut, at 2 (“The extreme
humiliation she and all of us have experienced has taken over our lives. She will suffer for the rest
of her life because of her mistakes.”); see also Ex. Q, Letter from Family Friend, JK, at 1
(“Knowing Pam I’m sure there is no greater punishment than having her children suffer because
of her misconduct in many ways.”).
Perhaps most tellingly, a series of consistent statements from her former patients lend
strong support to our position that the purposes of punishment will not be met by sending Dr.
Antell to prison:
“I cannot think of any justification for requiring Dr. Antell to serve jail time. From
my experiences with her, the mere fact that she has been charged and is going
through this process is enough punishment (and deterrence).” Ex. R, Letter from
Patient, EFD, at 1.
“I cannot see that [Dr. Antell] deserves any period of incarceration. She is a help
to people, not a threat. I also think she can make very good contributions to the
community, whether in Chicago or near her office or home.” Ex. K, Letter from
Patient, JP, at 2.
“I do not condone Dr. Antell’s behavior. But she is worthy of the most lenient
sentence available. She is already paying for her mistakes as I can see in her face
how sad and remorseful she is and how she is not able to practice any longer. She
has a lot to offer as a human being and I think being away would be a waste for her
and for the community where she is.” Ex. Z, Letter from Patient, ESC, at 2.
“[Dr. Antell’s] incarceration would serve no purpose as she has already been
discredited professionally through this public shaming and the loss of her
license. . . . The stigma of an incarceration does not reflect the decades of good
work she has done for me and I’m sure for other clients.” Ex. AA, Letter from
Patient, HR, at 1.
“I do not believe that sentencing Pam to prison time would benefit our community.
She may have made a mistake but she has so much to offer our community at large
which could not be done behind prison walls.” Ex. BB, Letter from Parent of
Patient, MC, at 1.
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“It is unfathomable to me that Dr. Antell may currently be facing the possibility of
jail time. This would be a tremendous loss to so many people in the community
she has spent decades serving.” Ex. L, Letter from Patient, MHN, at 1.
“I am aware that there will be consequences for Dr. Antell’s illegal behavior.
However, she is not someone who deserves incarceration because of the decades of
service to others, her extreme remorse, and the loss of her ability to continue in her
profession. Those are severe consequences.” Ex. CC, Letter from Patient, CS, at
1.
Courts have taken into account devastating collateral consequences, like those already
visited upon Dr. Antell, when imposing a sentence “sufficient, but not greater than necessary” to
embody the principles in 18 U.S.C. § 3553(a). In United States v. Anderson, 267 F. App’x 847,
850 (11th Cir. 2008), the court affirmed a downward variance in an insider trading case for a
defendant who was “over 50 years old and supports college-aged children,” on the ground that he
“lost his high paying job and has been forced to relocate to obtain any employment in his field and
only then at a significantly reduced salary . . . [with] an uphill battle to regain his professional
credibility.”
The defense urges this Court to likewise consider the wide-ranging collateral consequences
in this case—“the relinquishing of [Dr. Antell’s] license, the need to say good-bye to 30 patients
at once, the shame and humiliation to her and her family, the devastation to her reputation and the
realization that she cannot work in her profession again has been as punishing as it can get.” Ex.
D, Letter from Dr. Antell’s Son, Marc Gruenhut, at 3. Put simply, Dr. Antell is “bereft of all her
life stood for.” Ex. DD, Letter from Dr. Antell’s Son-in-Law’s Grandmother, MG, at 2; see also
Ex. EE (compiling additional letters in support of Dr. Antell).
V. DETERRENCE AND PROTECTION OF THE PUBLIC
A. Specific Deterrence
This factor “unquestionably envisions more severe sentences for defendants considered
more likely to commit further crimes and less severe sentences for those unlikely to commit
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crimes.” United States v. Rodriguez, 724 F. Supp. 1118, 1120 (S.D.N.Y. 1989). A defendant’s
low probability of recidivism is a central factor in fashioning a just sentence. See, e.g., United
States v. Hamilton, 323 F. App’x 27, 31 (2d Cir. 2009) (vacating and remanding for resentencing
because the district court did not consider the effect of the defendant’s advanced age on the
possibility of recidivism); United States v. Clay, 483 F.3d 739 (11th Cir. 2007) (affirming variance
from 188–235 to 60 months imprisonment due to finding that the defendant was not likely to
reoffend); United States v. Cabrera, 567 F. Supp. 2d 271, 279 (D. Mass. 2008) (granting variance
because defendants “with zero criminal history points are less likely to recidivate than all other
offenders”).
With respect to the underlying conduct here, Dr. Antell is not just unlikely to re-offend—
there is no realistic possibility that Dr. Antell could re-offend. The nature of her offense required
her to run a psychotherapy practice. She will never be able to do that again. Moreover, as
discussed above, other relevant characteristics (e.g., age, education, gender, and lack of criminal
history) make it extremely unlikely that she will re-offend. See supra Part II.C.
B. General Deterrence
Beyond the specific deterrence that considers the effect of a sentence on Dr. Antell, the
collateral consequences noted above—i.e., the complete, public ruination of Dr. Antell’s personal,
professional and financial life—is sufficient to deter others in a position to commit a similar
offense. United States v. Vigil, 998 F. Supp. 2d 1121, 1158 (D.N.M. 2014) (finding that, for a
nurse who improperly prescribed narcotics, the move from an offense level of 29 to 22 “is a
considerable variance, [but] the sentence is still long enough to deter most people—particularly
professionals—who might be tempted to engage in similar crime”). A long prison sentence, on
top of the already crushing consequences of Dr. Antell’s conviction, would be far “greater than
necessary” to deter other professionals from committing similar offenses.
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VI. THE KINDS OF SENTENCES AVAILABLE AND THE PROVISION OF MEDICAL CARE IN THE
MOST EFFECTIVE MANNER
In determining an appropriate sentence, the Court must also consider the different kinds of
sentences available, as well as the provision of necessary medical care to Dr. Antell. 18 U.S.C.
§§ 3553(a)(3), (a)(2)(D). The Court is not required to impose an unduly excessive sentence of
incarceration when a non-custodial sentence is sufficient to reflect the seriousness of the offense,
afford adequate deterrence, protect the public, and provide Dr. Antell with necessary medical and
mental health care. 18 U.S.C. § 3553(a).
As the Supreme Court made clear in Gall, even a non-custodial sentence, such as probation,
constitutes significant punishment. Such a sentence is not “an act of leniency, [but] a substantial
restriction of freedom.” Gall, 552 U.S. at 44 (quotation omitted); see also United States v. Warner,
792 F.3d 847, 861 (7th Cir. 2015) (affirming term of probation as “a sufficiently serious
sentence”); United States v. Coughlin, No. 06-20005, 2008 WL 313099, at *5 (W.D. Ark. Feb. 1,
2008) (recognizing that “[h]ome detention and probation can be severe punishments, hugely
restrictive of liberty, highly effective in the determent of crime and amply retributive”, and that
“[n]ot all defendants must be sentenced to imprisonment to be duly punished”); United States v.
Brady, No. 02-cr-1043 (JG), 2004 WL 86414, at *8 (E.D.N.Y. Jan. 20, 2004) (noting that probation
is a "punitive measure").
Congress and the Sentencing Commission have similarly recognized that probation, "a
sentence in and of itself,” may constitute an appropriate alternative to incarceration that fully meets
the statutory purposes of sentencing. U.S.S.G., ch. 5, pt. B, introductory cmt. (citing 18 U.S.C.
§ 3561). Probationers remain subject to “several standard conditions that substantially restrict
their liberty,” including restraints on their ability to associate freely or to leave the judicial district.
Gall, 552 U.S. at 48; see also Doe v. United States, No. 14 MC 1412 (JG), 2015 WL 2452613, at
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*5 n.25 (E.D.N.Y. May 21, 2015) (describing the “myriad conditions of probation that
significantly impair [probationers’] freedom”). The Court can also impose a variety of
“discretionary conditions” to probation, 18 U.S.C. § 3563(b), and the violation of any condition
can be grounds for revocation and the subsequent imposition of a term of incarceration.
A non-custodial sentence was not intended by Congress to be an exceptional or unusual
kind of punishment. To the contrary, Congress directed more than three decades ago that the
Guidelines should reflect the “general appropriateness of imposing a sentence other than
imprisonment in cases in which the defendant,” like Dr. Antell, “is a first-time offender who has
not been convicted of a crime of violence or an otherwise serious offense.” 28 U.S.C. § 994(j)
(emphasis added); see United States v. Baker, 445 F.3d 987, 992–93 (7th Cir. 2006) (district court’s
finding that a prison term would be more significant to an individual who had no prior criminal
history justified sentence below guideline). Congress issued this directive to ensure that “prison
resources are, first and foremost, reserved for those violent and serious criminal offenders who
pose the most dangerous threat to society” and that in cases of nonviolent and first time offenders,
like Dr. Antell, “the interests of society as a whole, as well as individual victims of crime, can
continue to be served through the imposition of alternative sentences, such as restitution and
community service.” See Pub. L. No. 98-473, § 239, 98 Stat. 1987, 2039 (1984).
Consequently, in this case, a non-incarceration sentence with discretionary conditions such
as community confinement, home detention, community service, or curfew restricting Dr. Antell’s
liberty would be an appropriate alternative sentence to incarceration. Such a non-incarceration
sentence is not an act of leniency and is a sufficiently severe punishment for a first time offender
like Dr. Antell, who wishes only to make amends by proceeding to live a law-abiding and
productive life and contributing to her community. A non-custodial sentence is sufficient to meet
-25-
the goals of § 3553, would constitute just punishment for Dr. Antell’s offense conduct, and would
in fact better serve the public good than a wasteful prison term.
Furthermore, a non-custodial sentence is essential to allow Dr. Antell the necessary and
indeed life-saving medical and mental health treatment she is currently undergoing. While the
BOP may be capable of providing care for Dr. Antell’s medical conditions, serious concerns about
the agency’s ability to provide effective care bear strong consideration. See CoreCivic Lawsuit,
American Diabetes Association, available at http://www.diabetes.org/living-with-diabetes/know-
your-rights/discrimination/law-enforcement/trousdale-turner-lawsuit.html (“In general, it is very
common for people with diabetes to receive extremely inadequate care in jail or prison. Across
the nation, many people have died in custody because they were denied access to insulin, blood
sugar monitoring, or appropriate low blood sugar treatment. Those who do not die from inadequate
care usually face a higher risk of serious complications such as vision impairment, amputations,
heart attack, and stroke.”).
Section 3553(a)(2)(D) requires this Court to consider the need to provide medical care “in
the most effective manner.” Indeed, it is not enough for the Court to consider whether the BOP
could provide adequate care for a defendant, but rather whether the BOP could provide medical
care in the most effective manner. See United States v. Edwards, 595 F.3d 1004, 1011 (9th Cir.
2010) (affirming a sentence of probation in a bankruptcy fraud and false statements case,
notwithstanding the 27–33 month Guideline, for a 63-year-old diabetic defendant because, despite
the BOP’s capability to provide for his medical care, “probation would satisfy the requirement of
providing needed care in the most effective manner”). Because it is highly unlikely the BOP would
be able to effectively care for Dr. Antell’s array of physical and mental health conditions, a term
of imprisonment would be too severe in this case.
-26-
VII. THE NEED TO AVOID UNWARRANTED SENTENCE DISPARITIES
18 U.S.C. § 3553(a)(6) instructs that “[t]he court, in determining the particular sentence to
be imposed, shall consider . . . the need to avoid unwarranted sentence disparities among
defendants with similar records who have been found guilty of similar conduct.” In this case, there
is a great danger that a custodial sentence would ignore this consideration.
Consideration of parity in sentencing is not only mandated by § 3553; it is the ultimate goal
of the Guidelines. See Booker v .United States, 543 U.S. 220, 250 (2005) (“Congress’ basic
statutory goal—a system that diminishes sentencing disparity”). However, while the Guidelines’
basic aim is reduction of unwarranted disparities, the percentage of sentences issued within the
Guidelines has steadily and significantly decreased in recent years:
Since Booker was decided in 2005, the proportion of all offenders sentenced within
the Guidelines has steadily decreased. In 2006, 61.7% of all offenders were
sentenced within the Guidelines. By 2014, only 46% of offenders were sentenced
within the Guidelines, reflecting a 15.7% decrease. Between 2006 and 2014, health
fraud offenders received fewer Guidelines-range sentences than other white collar
offenders and general crimes offenders. In 2014, for example, health fraud
offenders were nearly 13% more likely than white collar offenders and nearly 19%
more likely than general crimes offenders to receive a sentence outside the
Guidelines.
Kyle Crawford, Health Care Fraud Sentencing, 105 GEO. L.J. 1079, 1088 (2017) (study examining
data from health care fraud sentencing hearings and collecting statements from judges). This trend
is particularly marked in cases like Dr. Antell’s within this District. Id. (noting that “76.5% of
health fraud offenders received a below-Guidelines sentence in the Northern District of Illinois”).
This statistic, of course, includes defendants who, unlike Dr. Antell, had prior criminal history,
went to trial and were found guilty, and/or pled guilty without cooperating or entering into a plea
agreement. With this in mind, it is clear that the goal of consistency in sentences among health
care fraud cases in this District would be served by a below-Guidelines sentence.
-27-
The PSR recommended a sentence of 8 months, which, while below Guidelines, would
introduce unwarranted disparities between Dr. Antell and other defendants in similar cases. Even
in fraud cases involving more culpable conduct and/or higher Guidelines ranges, courts have
routinely imposed no (or only nominal) prison terms. See, e.g., United States v. Colletti, et al.,
No. 1:15-cr-00260, (N.D. Ill.) (Alonso, J.) (eight defendants in wire fraud scheme sentenced
respectively to 42 months imprisonment with 2 years supervised release, 18 months imprisonment,
9 months’ imprisonment with 18 months supervised release, 6 months’ imprisonment with 1 year
supervised release, 1 year home confinement with 4 years’ supervised release, 6 months home
confinement with 4 years’ supervised release, 1 year home confinement with 4 years’ supervised
release, and 3 years supervised release); United States v. Baraban, No. 4:19-cr-00068 (W.D. Mo.)
(pharmacist sentenced to probation for fraudulent $9.5 million Medicaid billing scheme in part
due to amount of restitution paid and agreement to surrender professional license); United States
v. Kirk, No. 2:19-cr-00047 (S.D. Ohio) (nurse practitioner sentenced to 5 years’ probation for role
in $750,000 health care fraud conspiracy); United States v. Gyambibi, No. 3:18-cr-00136 (D.
Conn.) (physician sentenced to three months in prison for defrauding Connecticut’s state employee
prescription benefit plan out of $877,882 by, among other things, writing prescriptions for patients
she never saw or examined); United States v. Henry, No. 2:18-cr-00249 (M.D. Ala.) (sentence of
two years’ probation for Former Alabama Representative Ed Henry for his role in health care fraud
scheme); United States v. Iyer, No. 8:18-cr-00378 (M.D. Fla.) (physician sentenced to six months
imprisonment for submitting false claims for patient visits); United States v. Clark et al., No. 3:17-
cr-00085 (M.D. La.) (health clinic billing supervisor sentenced to two years’ probation for health
care fraud scheme resulting in approximately $515,000 in fraudulent claims); United States v.
Aggarwal, No. 2:18-cr-00111 (W.D. Pa.) (physician sentenced to three years’ probation with six
-28-
months home detention for unlawful distribution of controlled substances and health care fraud);
United States v. Morrison, No. 2:18-cr-00175 (D. Me.) (manager of physical therapy practice
sentenced to four months imprisonment for submitting false claims for reimbursement).
Notably, many similar offenses result in only civil claims that are accordingly resolved
through restitution and payment of fines, without any criminal charges, much less custodial or
even probation sentences. See, e.g., United States ex rel. David Nutter, M.D. v. Sherif F. Khalil,
M.D., et al., No. 5:17-cv-02035 (C.D. Cal.); United States. ex rel. Hawks v. Heart and Vascular
Institute of Florida, No. 8:16-cv-01574 (M.D. Fla.); United States v. Rose O. Uradu, M.D., et al.,
No. 0:18-cv-00066 (E.D. Ky.). Given Dr. Antell’s full payment of restitution, together with any
fines, she has already paid essentially the same penalty as each of these defendants. A custodial
sentence would present even further unwarranted disparities between the consequences of her
offense and those of similarly situated defendants.
Considering this precedent and the circumstances of Dr. Antell’s offense, a non-custodial
sentence will avoid an unwarranted sentencing disparity and would be sufficient to achieve the
goals of § 3553(a)(2). See, e.g., United States v. Edwards, 595 F.3d 1004, 1011, 1017 (9th Cir.
2010) (noting the deterrent effect of probation and concluding “Section 3553(a) . . . does not
require the goal of general deterrence be met through a period of incarceration”). In light of the
statutory imperative to “avoid unwarranted sentence disparities among defendants with similar
records who have been found guilty of similar conduct,” 18 U.S.C. § 3553(a)(6), these data points
underscore that a non-custodial sentence would be a fair and appropriate sentence for Dr. Antell.
VIII. CONCLUSION
As the defense has sought to demonstrate above, the consideration of an appropriate
sentence in this case should go beyond the offense conduct and include the relevant characteristics
and circumstances associated with Dr. Antell. As the Probation Officer so aptly observed, Dr.
-29-
Antell is “a kind, generous, compassionate woman. . . . . [and] [h]er good character matters, not
only to her family but to those who benefit from her generosity and spirit.” Sentencing
Recommendation at 2. Dr. Antell respectfully requests the opportunity to continue to realize the
best aspects of her character to the benefit of others and without any appreciable risk of re-
offending. A non-custodial sentence will afford her that opportunity, as well as the opportunity to
gain more ground in her ongoing battle against mental illness.
Dated: August 20, 2019 Respectfully submitted,
s/ Bethany K. Biesenthal
Bethany K. Biesenthal
bbiesenthal@jonesday.com
Jamie N. Ward
jamieward@jonesday.com
Taylor M. Grode
tgrode@jonesday.com
JONES DAY
77 West Wacker, Suite 3500
Chicago, IL 60601.1692
Telephone: +1.312.782.3939
Facsimile: +1.312.782.8585
Counsel for Defendant Pamela Antell
-30-
CERTIFICATE OF SERVICE
I hereby certify that on August 20, 2019, I electronically filed the foregoing with the
Clerk of the Court by using the CM/ECF system, which will effectuate service on all counsel of
record.
s/ Jamie N. Ward
Counsel for Defendant Pamela Antell
-31-
UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
UNITED STATES OF AMERICA

18 CR 584
v.
Honorable Jorge L. Alonso
PAMELA ANTELL
GOVERNMENT’S POSITION PAPER AS TO SENTENCING FACTORS
i
TABLE OF CONTENTS
I. SUMMARY OF CONDUCT ……………………………………………………….1
II. THE FACTORS SET FORTH IN 18 USC § 3553(A) WARRANT

A SENTENCE OF 48 MONTHS’ IMPRISONMENT…………..………….…..3
A. Nature and Circumstances of the Offense………………………………...…3
1. The Lengthy, Intentional, Egregious Billing Fraud Scheme…………3
2. The $2.5 Million Loss Amount is an Appropriate Indicator

of the Serious Nature of the Offense…………………………………..…6
3. Impact on Patients………………………………………………………….7
B. History and Characteristics of the Defendant………………………………9
1. Defendant’s Position of Affluence and Opportunity…………………...9
2. Defendant’s Abusive Communications with Patients………………..11
3. Defendant’s Mental and Physical Ailments……………………………20
4. Defendant’s Lack of Criminal History Points………………………….23
C. The Need to Afford Adequate Deterrence and Protect the Public……….23
D. The Need to Reflect the Seriousness of the Offense, Promote

Respect for the Law, Provide Just Punishment, and Provide
Correctional Treatment………………………………………………………..26
E. The Need to Avoid Unwarranted Sentencing Disparities………………...27
III. RESTITUTION……………………………………………………………………32
IV. SUPERVISED RELEASE……………………………………………………….33
V. CONCLUSION……………………………………………………………………..33
ii
TABLE OF AUTHORITIES
Gall v. United States, 552 U.S. 38, 49–50 (2007)…………………………………..3
Rita v. United States, 551 U.S. 338, 350 (2007)……………………………………28
United States v. Anderson, 260 F. Supp. 2d 310, 315 (D. Mass. 2003)…………22
United States v. Baraban, No. 19 CR 68 (W.D. Mo.)………………………………30
United States v. Bistline, 665 F.3d 758, 765 (6th Cir. 2012)……………………..27
United States v. Boscarino, 437 F.3d 634, 638 (7th Cir. 2006)…………………..28
United States v. Brown, 880 F.3d 399, 405 (7th Cir. 2018)………………………23
United States v. Cano-Rodriguez, 552 F.3d 637, 639 (7th Cir. 2009)…………...3
United States v. Clark, et al, No. 17 CR 85 (M.D. La.)……………………………31
United States v. Colletti, et al., No. 15 CR 260 (N.D. Ill.)…………………………30
United States v. Corsey, 723 F.3d 366, 378-79 (2d Cir. 2013)…………………...6
United States v. DeCecco, 467 F. App’x 85, 88 (2d Cir. 2012)…………………….6
United States v. Goldberg, 491 F.3d 668, 673 (7th Cir. 2007)……………………29
United States v. Gordin, et al, 15 CR 513, Sent. Tr., R. 209, p. 76

(N.D. Ill., June 29, 2017)………………………………………………………………10
United States v. Gyambibi, No. 18 CR 136 (D. Conn.)…………………………….30
United States v. Hagerman, 525 F. Supp. 2d 1058, 1065 (S.D. Ind. 2007)…….28
United States v. Hall, 441 F. App’x 817, 820 (2d Cir. 2011)……………………...6
United States v. Heffernan, 43 F.3d 1144, 1149 (7th Cir. 1994)…………………24
United States v. Henry, No. 18 CR 249 (M.D. Ala.)………………………………..30
United States v. Iyer, No. 18 CR 378 (M.D. Fla.)…………………………………..31
United States v. Kirk, No. 19 CR 47 (S.D. Ohio)……………………………………30
United States v. Krilich, 257 F.3d 689, 693-94 (7th Cir. 2001)…………………..22
United States v. Kuhlman, 711 F.3d 1321, 1328 (11th Cir. 2013)……………….24
iii
United States v. Masters, 613 F. App’x 618, 621 (9th Cir. 2015)………………...6
United States v. Mattson, 11 CR 580, R. 105 (N.D. Ill. Dec. 10, 2012)………….29
United States v. Morrison, No. 18 CR 175 (D. Me.)………………………………..31
United States v. Mueffelman, 470 F.3d 33, 40 (1st Cir. 2006)……………………28
United States v. Musgrave, 761 F.3d 602, 609 (6th Cir. 2014)…………………...24
United States v. Mykytiuk, 415 F.3d 606, 608 (7th Cir. 2005)……………………28
United States v. Parris, 573 F. Supp. 2d 744, 754 (E.D.N.Y. 2008)……………..6
United States v. Podhorn, 2010 WL 4723360, at *2 (7th Cir. 2010)…………….22
United States v. Poetz, 582 F.3d 835, 837–38 (7th Cir. 2009)…………………….22
United States v. Posada, No. 17 CR 165, Sent. Tr., R. 102, p. 54

(N.D. Ill., May 11, 2018)…....................................................................................7
United States v. Rivera, 994 F.2d 942, 955 (1st Cir. 1993)……………………..28
United States v. Skodnek, 933 F. Supp. 1108, 1121 (D. Mass. 1996)…………...9
United States v. Stefonek, 179 F.3d 1030, 1038 (7th Cir. 1999)………………..10
United States v. Warner, 792 F.3d 847, 860–61 (7th Cir. 2015)………………..24
United States v. Washington, 385 F. App’x 570, 573 (7th Cir. 2010)…………..22
United States v. Zohfeld, 595 F.3d 740, 743 (7th Cir. 2010)…………………….21
iv
The UNITED STATES OF AMERICA, by its attorney, JOHN R. LAUSCH, Jr.,
United States Attorney for the Northern District of Illinois, hereby submits its
position paper as to sentencing factors, and asks this Court to impose a sentence of
48 months’ imprisonment, with no period of supervised release.
SUMMARY OF CONDUCT1
Between 2010 and 2017, defendant Pamela Antell, a clinical psychologist,
submitted fraudulent claims for reimbursement to five victim insurers for services
she knew she had not provided to mental health patients.2 The fraudulent claims
included both excessive claims for actual patients, as well as claims for at least one
individual who was not, in fact, a patient of hers. It was not unusual for her to bill for
over 100 excessive mental health visits in one year for a single patient. Over the
course of 8 years, she received over $2.5 million from insurers based on false claims
that she had submitted for patient visits that did not occur.
The defendant knew she was submitting the false claims and repeatedly lied
to cover up her fraud. She created false records in response to an insurer’s audit in
2014. And when confronted by patients about bills for visits that never happened,
rather than correct the errors, she doubled down. This included trying to coerce a
patient into not alerting her insurer by telling the patient that she would owe the
defendant $1,800 if the claims were corrected; suggesting that a patient’s
1 A detailed recitation of the facts is included in the Government’s Version of the Offense.
2 Defendant received reimbursements from the victim insurers for the fraudulent claims as
late as January 2018.
1
understandable concern about fraudulent billing was a manifestation of the patient’s
emotional shortcomings that they had previously discussed in treatment; and
dangling a threat to falsely accuse a patient of being in on her scheme.
What’s more, the defendant’s manipulative conduct did not stop after she was
charged. When her office was searched on the date of her arrest, she did not have any
records of patient visits beyond her planners—she had only a limited set of
handwritten notes for certain patients, but no comprehensive treatment records. So
calculating the loss amount by identifying legitimate versus fake visits became a
central issue in plea negotiations. While those negotiations were ongoing, the
defendant reached out to one of the patients for whom she had submitted bills for
fake visits. In a call with the patient, she asked that he lie if he receives a call from
investigators about her billing practices. Specifically, she told him to say that he had
seen her far more frequently than he had, that he had always paid copayments in
cash, and that it was “just a little fib.”
In addition to the significant losses to insurers, the defendant harmed her
patients in ways that are harder to quantify. Patients lost their trust in her, and some
have described losing trust in her profession, questioning whether they could ever
seek psychological treatment again. The defendant’s conduct created false records of
the patients’ need for psychological counseling, and their medical histories, if
uncorrected, will include these fake psychological counseling visits. She thoughtlessly
used them for her own personal gain and without regard to these consequences.
2
The defendant’s truly appalling conduct deserves a substantial period of
imprisonment. At the same time, the government has considered the arguments in
mitigation presented by the defense—in particular, her age, health, lack of criminal
history, and the unlikelihood of recidivism—and believes a period of 48 months’
imprisonment is an appropriate sentence based on consideration of all of the factors
under Title 18, United States Code, Section 3553(a).
THE FACTORS SET FORTH IN 18 U.S.C. § 3553(A) WARRANT A

SENTENCE OF 48 MONTHS’ IMPRISONMENT
The Sentencing Guidelines provide a starting point and initial benchmark for
sentencing. Gall v. United States, 552 U.S. 38, 49–50 (2007). Here, the government
has calculated a Guidelines range of 63 to 78 months’ imprisonment, based on an
offense level of 26 and a criminal history category of I. The range accounts for the loss
caused by the defendant’s fraud; her abuse of a position of trust with respect to the
insurers; her attempted obstruction of justice; and her limited criminal history.
Although a sentence within the Guidelines range is presumptively reasonable, United
States v. Cano-Rodriguez, 552 F.3d 637, 639 (7th Cir. 2009), the court must consider
the factors set forth in Title 18, United States Code, Section 3553(a) in determining
an appropriate sentence. Considering these factors, a sentence of 48 months’
imprisonment is sufficient, but not greater than necessary, to reflect the seriousness
of defendant’s offense, promote respect for the law, provide just punishment for
defendant’s crime, and afford adequate deterrence to similar criminal conduct.
A. Nature and Circumstances of the Offense
1. The Lengthy, Intentional, Egregious Billing Fraud Scheme
3
This was not a one-time lapse in judgment. Defendant submitted thousands of
fraudulent claims to five separate insurers between 2010 and 2017, causing an actual
loss of approximately $2,532,901.96. For each fraudulent claim, she filled out a
handwritten form on which she purported to have provided services to patients that
never occurred.
Over the years, when opportunities presented themselves for defendant to stop
her fraudulent billing practices, defendant doubled down instead. In 2013, for
example, defendant was confronted by Patient R.S. about false billings in her name,
including, for example, 150 claims for 2012 when R.S. believed she saw defendant
only 25 times that year. See GVO, Exhibits B and C. But instead of taking that
opportunity to stop lying and stealing exorbitant amounts of money from the victim
insurers, defendant “urge[d R.S.] to accept” 29 dates from 2012 as “true visits,” even
though they “may be off by a few days,” and continued her fraud for another four
years.3 GVO Exhibit C at 30.
Similarly, when defendant was audited by Aetna for patient records in support
of particular services purportedly rendered in 2014, defendant falsified medical
records in support of services that she never provided, in order to conceal her false
billing. In August 2014, Aetna informed defendant that it was “conducting a
retrospective review of services rendered” to patients J.G., J.S.1, J.S.2, F.D., J.B.,
W.Z., S.C., and L.S., and requested medical records for those patients. See GVO,
3 Defendant billed for 158 services in R.S.’s name for 2012 and was reimbursed for 145 of
those services. As far as the government is aware, defendant never reimbursed Cigna for the
116 2012 services she had received reimbursement for in R.S.’s name.
4
Exhibit H at 1. Aetna’s letter included requests for, among other records, each
“patient’s complete chart including daily notes by attending physicians,” “daily
treatment or progress notes,” and “record of the treating provider’s findings.” Id. In
response, defendant sent Aetna notes detailing individual sessions with each of these
patients. Id. at 2-39. These notes were handwritten, dated, and signed by defendant.
According to defendant’s handwritten notes submitted to Aetna, she saw each
of these patients for individual sessions regularly between March 13, 2014, and April
1, 2014. Id. This is demonstrably false, as defendant was in South America for those
dates. See GVO at p. 15. Defendant did not submit just one or two false dates: Instead,
just in response to Aetna’s August 2014 request, defendant handwrote and submitted
individualized patient notes for at least 54 60-minute sessions that did not occur.4
See GVO, Exhibit H at 3-6 (at least 8 false dates for Patient J.G.); 8-10 (at least 5
false dates for Patient J.B.); 13-14 (at least 6 false dates for Patient J.S.1); 16-18 (at
least 7 false dates for Patient F.D.); 21-23 (at least 8 false dates for Patient J.S.2); 26-
28 (at least 6 false dates for Patient L.S.); 30-33 (at least 6 false dates for Patient
W.Z.) and 36-39 (at least 8 false dates for Patient S.C.). Defendant’s attempts to
conceal her fraud can hardly be attested to “sloppy billing.” Defendant had been out
of town for a significant portion of March 2014, which she would have recalled just a
few months later, and could not have seen any of these patients at all, much less
regularly, during that time.
4For each and every session, defendant handwrote “60 min” in the bottom right corner of the
dated note. The only exception is on page 36 of GVO, Exhibit H, in which, although the
notation is slightly cut off in the record provided to the government, it appears that defendant
wrote “180 min.” for one session purportedly provided to Patient S.C. on March 15, 2014.
5
2. The $2.5 Million Loss Amount is an Appropriate Indicator of

the Serious Nature of the Offense
Defendant contends that the Section 2B1.1 enhancement for the loss amount
“vastly overstates the nature of the offense.” R. 85 at 25-26. The Sentencing
Commission has made clear its intention to ensure that the sentences of fraud
offenses “reflect the nature and magnitude of the loss caused or intended by their
crimes.” See U.S.S.G. § 2B1.1, Background. “Accordingly, along with other relevant
factors under the guidelines, loss serves as a measure of the seriousness of the offense
and the defendant’s relative culpability and is a principal factor in determining the
offense level under this guideline.” Id. Courts have regularly determined that, in
fraud cases, the Section 2B1.1 loss table does not overstate the seriousness of the
offense and that double-digit enhancements for large loss amounts are appropriate.
See, e.g., United States v. Masters, 613 F. App’x 618, 621 (9th Cir. 2015) (concluding
that loss table did not overstate the seriousness of $400,000 fraud); United States v.
DeCecco, 467 F. App’x 85, 88 (2d Cir. 2012) (concluding the loss table did not overstate
the seriousness of a $2.5 million fraud); United States v. Hall, 441 F. App’x 817, 820
(2d Cir. 2011) (concluding that loss table did not overstate the seriousness of $28
million fraud).5
5 Several of the cases defendant cites to support her contention that the 2B1.1 loss guideline
overstates the seriousness of fraud offenses are clearly distinguishable from this case, where
defendant is directly responsible for defrauding the victim insurers out of $2.5 million.
See United States v. Corsey, 723 F.3d 366, 378-79 (2d Cir. 2013) (Underhill, J., concurring)
(defendants intended “to defraud a non-existent investor of three billion dollars” but that
scheme, which was “laughable,” “never came to fruition” and “was not dangerous because
they had absolutely no hope of success”); United States v. Parris, 573 F. Supp. 2d 744, 754
(E.D.N.Y. 2008) (court’s statement that the loss guideline was a “black stain on common
sense” was a critique that “any officer or director of virtually any public corporation who has
6
Defendant further contends that the millions of dollars she caused in loss is
less egregious than other health care fraud cases because “this was not a Medicare
fraud case.” R. 85 at 26. Defendant appears to be arguing that, because the primary
victims are private insurance companies, the nature of the offense is somehow less
serious. Id. First, Medicare is one of the victim insurers in this case, albeit with a
smaller amount of associated loss than other insurers. See R. 72 at 2-3; GVO at 30.
Second, the fact that private insurers suffered the greatest financial loss as a result
of defendant’s scheme is far from a mitigating factor. In a world that has limited
funds to pay for health care, insurance providers paid defendant for fraudulent claims
that could have been used to pay for necessary medical services. In addition, the costs
associated with defendant’s crime are not limited to the insurance companies she
defrauded; they are ultimately passed on to the consumers in the form of increased
costs. See United States v. Posada, No. 17 CR 165, Sent. Tr., R. 102, p. 54 (N.D. Ill.,
May 11, 2018) (Chang, J.) (“We have a health care system that is unfortunately
replete with fraud. And it affects both private insurers and Medicare. And society
ends up paying for that because private insurers have to incorporate the cost of doing
business. . . and . . . charge more because they know they are going to be defrauded.”).
3. Impact on Patients
As detailed further in Section II.B.2. below, in addition to the $2.5 million in
loss suffered by the victim insurers, defendant’s egregious conduct caused feelings of
committed securities fraud will be confronted with a guidelines calculation either calling for
or approaching lifetime imprisonment” due to several newer guidelines enhancements that
were now applicable to that fact pattern).
7
betrayal, distrust, and sadness in her former mental health patients. Patients who
confronted defendant about false billing (and received aggressive and abusive
communications in response from defendant, as detailed further below) stated that
they lost trust in defendant, felt “shocked” and “hurt,” and felt as though defendant
used things she’d learned in counseling sessions against them.6 See GVO, Exhibit A
at 5; GVO, Exhibit B at 6.
Another patient, Patient B.S., received a call from defendant in January 2019
in which defendant asked B.S. to lie if approached by investigators asking about
billing. (This conversation is the basis for an obstruction of justice enhancement, as
detailed further in the Government’s Objections to the PSR). In describing his
reaction to defendant’s request, Patient B.S. stated that he felt “betrayed,”
“frustrated,” and like defendant was using information she had learned in their
sessions about difficult times in his life to “manipulate” him. See Gov. Obj. to PSR,
Exhibit 5, at 4. Patient B.S. stated that this experience had broken his trust, and that
he would find it difficult to trust another therapist again. Id. at 6.
For each of the patients the defendant submitted false bills for her
psychological counseling services the defendant created false records in their medical
histories of their need for mental health treatment. The potential ramifications of
this are exemplified by Patient R.S., who reached out to the defendant after
discovering that the defendant had billed for over 150 visits in a year that Patient
6Defendant objects to the PSR’s reliance on these patients’ feelings of betrayal. R. 84 at 11-
12. These patients’ experiences with defendant are relevant, appalling, and corroborated by
the record.
8
R.S. recalled seeing the defendant at most 25 times, because Patient R.S. was
concerned that this could impact her ongoing custody dispute. This harm, while
difficult to quantify, also has the potential to impact patients’ insurance rates,
employment options, and eligibility for government and military service. See United
States v. Skodnek, 933 F. Supp. 1108, 1121 (D. Mass. 1996) (applying upward
departure for psychiatrist who submitted false records of mental health treatment
for patients, noting that these false entries “may determine whether an
individual will be given a health insurance policy; it may decide whether he or she
will receive government clearance; it may affect a whole host of other situations.”)
The defendant, who no doubt was aware of these ramifications given her professional
experience, callously disregarded this impact on her patients so that she could enrich
herself.
B. History and Characteristics of the Defendant
1. Defendant’s Position of Affluence and Opportunity
Defendant’s history paints a picture of someone who had every opportunity to
lead a law-abiding life. She had a stable job, a loving family, and her own home in an
affluent suburb. Unlike many defendants who appear before this Court, defendant
was not desperate for money to put food on the table or a roof over her family’s head.
On the contrary, she was highly educated, had a profitable practice, and enjoyed a
high standard of living before she began her fraud scheme. As the Seventh Circuit
has noted, “[c]riminals who have the education and training that enables people to
make a decent living without resorting to crime are more rather than less culpable
9
than their desperately poor and deprived brethren in crime.” United States v.
Stefonek, 179 F.3d 1030, 1038 (7th Cir. 1999); see also United States v. Gordin, et al,
15 CR 513, Sent. Tr., R. 209, p. 76 (N.D. Ill., June 29, 2017) (Chang, J.) (in sentencing
defendant who engaged in false billing to 84 months’ imprisonment, court noted that
“this crime was not born of financial desperation” and instead defendant “could have
provided for [his family] without turning to this scheme”). Here, defendant could have
easily continued her lucrative psychology practice in a lawful manner. Instead, she
made the choice to defraud her patients’ insurers over and over again for eight years,
stealing millions of dollars, and using her patients and their families in the process.
Defendant asserts that her fraud stems from her “misguided attempt to
support her children.” R. 85 at 26. (Both of her children are successful adults, see PSR
at ¶ 54). She states that she felt “an uncontrollable and irrational need to provide
even more for her children than she already had and thus greater assure their safety
and security,” and that “[t]his is why money related to the fraud has sat untouched
in [her] bank account.” Id. at 18-19. While it is difficult to imagine a parent who does
not share the desire to provide their children with a substantial nest egg in order to
ensure their future security and happiness, not all parents lie and steal to achieve
that goal. In any event, the defendant’s claim that the money was “untouched”
demands context. The $2.5 million she stole enabled her to live an affluent lifestyle
without having to worry about how to save for the future. In 2016, for example
defendant’s practice reported an income of $546,654. See PSR at ¶ 87. In 2016 and
2017, defendant traveled to St. Croix, Curacao, Japan, New York (six times), Los
10
Angeles, Atlanta (three times), Boston, and Las Vegas. See GVO p. 15-16. Defendant
asserts that she “lived frugally,” see R. 85 at 17, but her frequent travel during the
scheme and her recently reported need for a $1,000-per-month clothing budget, for
example, paint a different picture. See GVO p. 15-16; PSR at ¶ 83. Defendant’s fraud
gave her these luxuries, without needing to count pennies or be concerned about
saving her legitimate earnings for the future. Finally, defendant cannot have it both
ways: she cannot claim, on the one hand, that her fraudulent billing was largely
attributable to mere “sloppiness,” and on the other hand, that she had an
“uncontrollable and irrational need” to fraudulently obtain a substantial nest egg for
her children. R. 84 at 3. Defendant’s own words during the scheme—explaining that
it was the only way she could make up for the “meager benefit” she received from an
insurer, GVO, Exhibit D, at 5—reveal her true intent. The defendant appears
incapable of accepting the simple truth that she stole $2.5 million for herself.
2. Defendant’s Abusive Communications with Patients
The government recognizes in mitigation that defendant has raised two
accomplished, loving children and has the support of her family and several
community members, as evidenced by the character letters submitted to the Court.
See R. 85, Exhibits A-F, N, P, Q, T, DD, EE (sealed exhibits). The defendant also
provided letters of support from patients. See R. 85, Exhibits K, L, O, R, Z, AA-CC.
(sealed exhibits). While the government does not question these eight patients’
declarations that defendant helped them, any statements that defendant’s criminal
conduct is “very uncharacteristic,” “an anomaly,” “an aberration,” or “a mistake” must
11
be taken with a grain of salt. See, e.g., R. 85, Exhibits K, L, AA, BB. First, as described
in the prior section, defendant’s conduct was far from a one-time mistake. Instead,
this behavior took place over years and years, with defendant continuously filling out
and submitting handwritten bills to the victim insurance companies, knowingly
defrauding them out of millions of dollars. Such a longstanding fraud, with so many
individual executions, can hardly be considered “uncharacteristic.” In addition, not
one of the patients who submitted letters on defendant’s behalf described ever
questioning her about billing for services not provided to them. And the record clearly
portrays the very specific way that defendant reacted to those individuals who dared
to question her about billing and other issues: She lashed out with threats,
manipulation, and insults, using information she had learned over the course of
treatment against them.
Patient S.C.
One of the most egregious examples of defendant’s abusive behavior with her
former mental health patients is defendant’s treatment of Patient S.C. In or around
early 2018, D.E.C. (Patient S.C.’s husband) had informed their insurance company
(Optum / United Healthcare) that he believed defendant had engaged in false billing
for services not rendered to their family. In early May 2018, defendant emailed
Patient S.C., who was no longer seeing defendant for treatment, asking to meet.
When Patient S.C. didn’t respond to defendant’s emails right away, defendant
emailed again asking if S.C. was “worried about insurance issues” and again
requested a response. Two days later, defendant began threatening Patient S.C.:
12
[S.C.], you realize that [D.E.C.] opened a can of worms. Your insurance
company will be asking why in the world neither of you told them that
there were charges being billed for several years that you cannot account
for. You realize that they will automatically believe that, the reason is
you obviously benefitted from it. How? Guess. [D.E.C.] threw me under
the bus. I can certainly throw both of you right under the same bus. Yes,
you did benefit. They will have no doubt but to believe me. I don’t intend
to do that, however.
But again, can I speak with you? I plan on paying money to them
because I want to and cannot be bothered. My records are not totally
available as I am downsizing. But your husband did not realize he put
you both in a stupid position if I were interested in that. Why can’t we
have a conversation?
GVO at 3.
On May 25, 2018, Patient S.C. spoke to defendant over a consensually recorded
phone call. During that call, Patient S.C. confronted defendant about billing under
her and other family members’ information, when those services had not been
rendered, as well as defendant’s threats. A portion of that conversation is below:7
Def: Well, here’s the issue – I am owed thousands and thousands of

dollars…by [D.E.C.]…which I’ll never collect. I’m only allowed to
bill once a week for a person, so I had to bill some under [S.C.’s
minor son, B.C.], but… I figured you knew…all this time.
SC: I didn’t know that. [B.C.] is a child. [B.C.]’s never been there.
Def: Well, he was…but…that’s…that’s neither here nor there. I don’t

care what the insurance company does. They either send me a
request, or they don’t. So far, they haven’t. But what I’m telling
you is this – the insurance company is going to say ‘Why have you
allowed this to go on so long?’
SC: I didn’t know about it.
Def: OK – and they’ll ask [D.E.C.] – “Why have you allowed this to go
on? What do you mean you didn’t know about it?” That’s what I’m
telling you, OK? That this is not a matter of “Dr. Antell, you did
7 The full draft transcript can be found at GVO Exhibit A.

13
a bad thing” – it’s a matter of “[S.C. family’s last name]’s, why did
you allow this to go on? There must be something going on there.”
SC: So, how is this my fault or [D.E.C.]’s fault? Like, how would we
know?
Def: Why? Because you’re supposed to be…they have every reason to

believe that you have seen this and that you have allowed it to go
on and what that means is that I must have given you some of the
money. That’s the way insurance companies think.
SC: OK, but that’s…we both know that that is not true.
Def: OK, but he opened up a can of worms, that’s all I can say. That’s
all I can say.
SC: OK, but that is not true and we both know that. I mean…
Def: OK – but you know what? Two can play the same game [S.C.]. It’s
just not right for him to come back, years later after he owes me
all this money, and do this – and you know it. You know it.
SC: Mm-kay.
Def: You think that was…You think that was right?
SC: I…I don’t know. I don’t think any of it’s right. I don’t think that
billing every single family member is right. I don’t think…
Def: I did not.
SC: [UI] …for years when…I mean, I didn’t see you for five years,
and…I…I was shocked…I was hurt…like, I’ve trusted you…I’ve
shared like…my heart with you.
Def: Mm hmm. [S.C.] – I asked you, you knew that this was going on
all this time. I don’t understand how you can claim you had no
idea.
SC: I most certainly did not know this was going on. How would I
know this was going on? I did not, at all, know this was going on…
Def: OK.
14
SC: …which is why I’m asking about it.
Def: OK, well…[OV]
SC: I’ve…before…before I started seeing you this past year…so, we’re

in 2018 now…I think the first time I saw you might have been
December 2017. Before that, I hadn’t seen you…I think it might
have been 2012. There was like…[OV]
Def: [OV] No one… [OV]
SC: [OV] a five year span that I didn’t see you…or talk to you…
Def: [OV] No one… [OV]
SC: [OV]…because when I contacted to you, I thought you were in

retirement.
Def: I was supposed to retire, but as it turns out, I still had too many
people that…I wasn’t able to retire. But the fact of the matter
is…I am owed thousands and thousands of dollars and this is the
only way I can recoup that.
SC: OK, well…that’s not right. I don’t agree with that.
Def: OK, but…in any event…it’s up to me and the insurance company.

That’s…that’s the way it goes.
GVO Exhibit A at 4-6. As shown above, defendant told Patient S.C. that, if the
insurance company learns of defendant’s false billings under B.C.’s name, the
company will assume S.C. and her spouse knew about it and were receiving money
from defendant. This is a clear threat issued by the defendant to her own patient,
someone who “trusted” and “shared [her] heart” with defendant. Id.
Defendant’s response to this recording is that she was “extremely angry”
because, in her mind, she had disclosed to Patient S.C. that she was falsely billing
and so when S.C. said she didn’t know anything about it, defendant was “confounded.”
15
DVO at p. 19. First, the 2013 email between defendant and S.C. that defendant cites
to prove that S.C. knew about the fraud, doesn’t establish that at all. In the email,
defendant said she was retiring in 2014 and realized that she had fees unpaid for
sessions with D.E.C. and S.C., and so she would be billing in 2013 and 2014 for those
older, unpaid sessions. See DVO, Exhibit B. Patient S.C.’s response was “Ok, while it
could be confusing, it makes sense.” Id. Tellingly, defendant did not inform Patient
S.C. that she would be billing for services that never took place, nor did she state that
she would be billing under S.C.’s and D.E.C.’s children’s names (including B.C., who,
according to S.C. and D.E.C., never saw defendant as a patient) for services
purportedly provided to other members of the family. See id. Second, and most
importantly, even if Patient S.C. had been put on notice of defendant’s fraud scheme
(which the government disputes), defendant’s aggressive and threatening reaction
(including, for example, the threat that, if S.C.’s family informed the insurance
company about the false billing, the company would assume they too were receiving
money from the fraud, and the ominous warning that S.C.’s husband had “opened up
a can of worms”) is appalling. As Patient S.C. stated to defendant, she felt “shocked”
and “hurt” by defendant’s reaction. See GVO, Exhibit A at 5. Patient S.C. had “shared
. . . [her] heart” with and “trusted” defendant. Id. By threatening and manipulating
her former mental health patient in an attempt to conceal her fraud, defendant
shattered that trust.
16
Patient R.S.
When Patient R.S. contacted defendant in 2013 over email about false billings
in Patient R.S.’s name, she also suffered defendant’s reactionary and inappropriate
response. See GVO, Exhibit B at 3-4. Patient R.S. had dug into her explanations of
benefits because she was concerned about having a large amount of mental health
services she never received on her record during her ongoing custody battle. Id.
Patient R.S. emailed defendant, stating that she noticed there were over 150 visits
billed to Cigna for 2012, when she believed she had no more than 25 visits that year.
Id. at 3; GVO Exhibit C at 5. The defendant responded by saying that, if Patient R.S.
pursued the issue with Cigna, “whatever amount the insurance company paid is whAt
[sic] you will owe,” which she then calculated as $1,800, writing, “I would appreciate
a payment of 50% before refunding the charges to CIGNA” and making clear that she
would not refund fees to CIGNA until R.S. confirmed that this is what she wanted to
do. GVO Exhibit C at 7, 15. After some additional back and forth, see GVO Exhibit C,
Patient R.S. informed defendant that she had spoken with Cigna about the billing
dates because she wanted the matter corrected. See id. at 17. Once again, when
confronted with her own fraud, defendant lashed out, using her intimate knowledge
of Patient R.S. gained during treatment against Patient R.S. See, e.g., GVO Exhibit
C at 19 (“You tend to make things into fights and there’s no need here.”), at 25 (“I
hate to inform you of this, but calling CIGNA 11 days before the date you said you
would did nothing to speed up the process. Things don’t happen when you want them
to happen outside of normal procedures. . . . calling CIGNA only caused this process
17
to take on a different tone. Maybe you can file this with other, similar experiences
under the category of ‘things yet to learn.’”); GVO, Exhibit B at 6 (Patient R.S. stated
that “these comments felt very personal to [her] and that it felt like [defendant] was
using things she’d learned in counseling sessions against [her]”).
Patient R.S. described losing trust in defendant as a result of this experience.
See GVO, Exhibit B at 6. According to Patient R.S., defendant “reappeared” in her
life five years later during a reevaluation into her child’s custody status. Id. at 4. The
consulting psychiatrist spoke with defendant, and, according to Patient R.S.,
defendant told the psychiatrist things about Patient R.S. that were “blatantly
untrue,” such as Patient R.S. was a “reactionary” and that defendant had only seen
R.S. interact with her son one time. Id. Patient R.S. believes that defendant may have
said these things because Patient R.S. had complained about defendant to Cigna. Id.
Patient V.S.
In February of this year, defendant reached out to former Patient V.S. (father
of former Patient B.S., see Government’s Objections to the PSR) to request that he
and his wife send a letter on her behalf to this Court for sentencing. GVO Exhibit Q
at 8-10. When V.S. responded that he was busy and would get back to defendant
“tomorrow,” defendant replied:
[A]re you going to meet with me or should I simply consider you

unwilling to hear the story? You are also not being a good parent,
especially a parent who is a lawyer, by assuming I’m guilty til proven
innocent. That is not how this country works. You know nothing at all
but now, have destroyed an essential aspect of the relationship I’ve had
with your sons. For their sake, it would have been smarter to hear what
went on. There are liars and unscrupulous reporters who had made
serious mistakes.
18
I no longer want any letter from you; I do have many others. You are one
of two people who have proven to be unworthy of my respect. You know
absolutely nothing.
GVO Exhibit Q at 14-15.
Defendant argues that each of these communications were “the result of
extreme stress and dysfunction.” R. 85 at 12; see also DVO, p. 19 (claiming the text
messages to V.S. are the result of “extreme pressure, anxiety, panic, and
disassociation”). Defendant’s “stress” and “panic” about being caught engaging in
criminal behavior and the subsequent consequences, which are completely
foreseeable, are no excuse for verbally lashing out at her mental health patients and
their families. Defendant further contends that this behavior was “out of character.”
Id. This is contradicted by the egregious examples laid out above: Every time
defendant was confronted with her criminal conduct (or, in Patient V.S.’s case, with
a patient who did not immediately rush to vouch for her character to this Court),
whether it be in 2013, 2018 (pre-indictment), or 2019 (post-indictment), she
responded aggressively and abusively. This is a characteristic of defendant’s, not an
anomaly.8 It is even more concerning that defendant was so willing and able to lash
out at mental health patients, with whom a trust-based relationship was especially
important. But when defendant’s back was against the wall, her interests came first.
8 To substantiate her claim that this behavior was anomalous, defendant cites to V.S.’s
statement that “this wasn’t ‘the Pam’ [he] was used to talking to.” R. 85, Exhibit FF, at 5.
But defendant’s behavior with V.S. appears to be very much in line with her conduct every
time she was confronted with her own conduct (as detailed above), or, in V.S.’s case, when
she simply didn’t receive the answer she was hoping for.
19
3. Defendant’s Mental and Physical Ailments
Defendant’s sentencing submissions detail what she calls a “profound mental
illness,” including depression, symptoms of bipolar disorder, and dissociative
tendencies. R. 85 at 9, 16-20. The government agrees that defendant’s depression is
a mitigating factor to be considered at sentencing. However, defendant’s conduct
cannot be excused by a history of depression. It is concerning that defendant may
assert at sentencing that she entered a dissociative “trance like fugue state” when
engaging in the offense conduct. See DVO at 15 (“When Dr. Antell suffers from
dissociative episodes she is often unable to even recall taking certain actions; it is as
if another Dr. Antell exists and operates independently”); R. 85 at 17 (stating that
defendant has “dissociative tendencies which allow her to hide her deepest issues
from even herself and split off those areas and actions from her conscious awareness);
R. 85, Exhibit S (letter from defendant’s psychiatrist, stating that defendant
“describes entering a trance like fugue state when she finally does her billing at the
end of the year” and “I could finally start to believe that when she was fraudulently
billing, it really was possible that another fragment of herself was responsible.”).
While the government does not doubt that defendant has suffered from
depression, once again, she cannot have it both ways: Defendant describes her
overwhelming depression and apparent “dissociative” state, but then also contends
that she accepts full responsibility for knowingly engaging in fraudulent billing for
years, that she can account for approximately $745K in loss based on her own review
of “every single claim” she submitted, and that she has a perfect recollection, for
20
example, of her critical conversation with Patient B.S. (the basis for the government’s
position on the obstruction of justice enhancement). See DVO at 8-13. Defendant was
not too crippled by depression to enjoy a successful career, which included running
her own private practice and consulting for various non-profit agencies, as well as
raise two children. R. 85 at 10-12. Nor was defendant unable to engage in regular
domestic and international travel. GVO at 14-16. And there is no evidence
whatsoever that defendant was in a “dissociative” state when she falsified medical
records to Aetna, lashed out at former patients who confronted her about false billing,
or told Patient K.P., for example, that she submitted false claims to Optum under his
name because “this is the only way she could make up for the meager benefit that
United Healthcare [Optum] supplies.” GVO, Exhibit D, at 10. Her conscious ─ not
disassociated ─ intent to engage in this false billing for years is clear from the
overwhelming evidence in the record.
While her mental health is a factor in mitigation, the government submits that
it is not a reason to impose a non-custodial sentence. The Federal Bureau of Prisons,
which “provides a full range of mental health treatment through staff psychologists
and psychiatrists,” is capable of providing appropriate mental health care to
incarcerated individuals who need it, including psychiatric care. See Bureau of
Prisons, Mental Health, https://www.bop.gov/inmates/custody_and_care/
mental_health.jsp (last visited Aug. 26, 2019); United States v. Zohfeld, 595 F.3d 740,
743 (7th Cir. 2010).
21
In addition, defendant argues that her diabetes and additional ailments favor
a non-custodial sentence. R. 85 at 22-23. The Bureau of Prisons has substantial
experience and practices in place for treating inmates with medical conditions,
including chronic care clinics for diabetes. See Bureau of Prisons, Medical Care,
https://www.bop.gov/inmates/custody_and_care/medical_care.jsp (last visited Aug.
26, 2019); see also United States v. Anderson, 260 F. Supp. 2d 310, 315 (D. Mass. 2003)
(defendant’s diabetes not ground for downward departure or to sentence defendant to
probation with home arrest rather than imprisonment, where Bureau of Prisons
could adequately treat defendant’s medical needs). More specifically, as the Seventh
Circuit has noted, there are ways short of a more lenient sentence that medical
conditions can be handled, including through placement in a properly-equipped
prison facility. United States v. Podhorn, 2010 WL 4723360, at *2 (7th Cir. 2010);
see also United States v. Krilich, 257 F.3d 689, 693-94 (7th Cir. 2001) (“Older
criminals do not receive sentencing discounts. Many persons in poor health are
confined in federal prisons.”). And “the Sentencing Commission has concluded that
medical issues, unless they arise to the level of an ‘extraordinary physical
impairment,’ generally do not provide a reason for imposing a below-range sentence.”
United States v. Washington, 385 F. App’x 570, 573 (7th Cir. 2010) (citing U.S.S.G.
§ 5H1.4; United States v. Poetz, 582 F.3d 835, 837–38 (7th Cir. 2009). Defendant’s
diabetes and other physical ailments do not constitute extraordinary physical
impairments.
22
4. Defendant’s Lack of Criminal History Points
The government acknowledges that defendant, who has just one prior
conviction, for which she received no criminal history points, has very little criminal
history. But that is taken into account in her Guidelines calculation and does not
differentiate her from other, similar offenders. For Fiscal Year 2017, for example, the
United States Sentencing Commission reported that almost 88 percent of health care
fraud defendants were assigned to Criminal History Category I, just like defendant.
See United States Sentencing Commission, Quick Facts: Health Care Fraud Offenses,
https://www.ussc.gov/sites/default/files/pdf/research-and-publications/quick-
facts/Health_Care_Fraud_FY17.pdf (last visited August 26, 2019). And, as discussed
further below, approximately 80 percent of health care fraud offenders that year were
sentenced to a term of imprisonment, the average length of which was 37 months. Id.
In addition, a lack of criminal history is less persuasive where the crime itself took
place in thousands of executions over the course of years. See, e.g., Gordin, et al, 15
CR 513, Sent. Tr., R. 209, p. 77-78 (“[T]he point about no criminal history, though,
would have been . . . stronger . . . if this crime was more of a spur-of-the-moment, one-
time lack of judgment. . . . Because this crime took place over six years . . . it’s less
persuasive that you don’t have a criminal history.”).
C. The Need to Afford Adequate Deterrence and Protect the Public9
Health care fraud is lucrative, pervasive, and often very difficult to detect.
Thus, general deterrence is a serious consideration in this case. See United States v.
9The government acknowledges that specific deterrence is of diminished import in this case,
as defendant is 67 years old and her license to practice is inactive.
23
Brown, 880 F.3d 399, 405 (7th Cir. 2018) (“The district court was entitled to conclude
that, given that health-care fraud is widespread and that therefore there is a lower
likelihood of getting caught, a serious penalty was necessary to ensure deterrence.”);
United States v. Kuhlman, 711 F.3d 1321, 1328 (11th Cir. 2013) (“[D]eterrence is an
important factor in the sentencing calculus because health care fraud is so rampant
that the government lacks the resources to reach it all.”); see also United States v.
Heffernan, 43 F.3d 1144, 1149 (7th Cir. 1994) (“Considerations of (general) deterrence
argue for punishing more heavily those offenses that either are lucrative or are
difficult to detect and punish, since both attributes go to increase the expected
benefits of a crime and hence the punishment required to deter it.”). The Seventh
Circuit has repeatedly concluded that white-collar criminals (including those engaged
in health care fraud) often “act rationally, calculating and comparing the risks and
the rewards before deciding whether to engage in criminal activity.” Brown, 880 F.3d
at 405 (quoting United States v. Warner, 792 F.3d 847, 860–61 (7th Cir. 2015)).
Because these defendants often calculate the costs and benefits of their actions,
“[t]hey are . . . ‘prime candidates for general deterrence.’” Id. at 405 (quoting Warner,
792 F.3d at 860); see also United States v. Musgrave, 761 F.3d 602, 609 (6th Cir. 2014)
(“Because economic and fraud-based crimes are more rational, cool, and calculated
than sudden crimes of passion or opportunity, these crimes are prime candidates for
general deterrence.” (internal citations omitted).
Defendant contends that a sentence of probation, coupled with the collateral
consequences she has already experienced, is sufficient to deter others in a position
24
to commit a similar offense. R. 85 at 30. It is not. A non-custodial sentence would
“encourage[] rather than discourage[] health care providers from engaging in the
commission of health care fraud because they might conclude that the only penalties
they will face if they are caught are disgorgement and community service.” Kuhlman,
711 F.3d at 1328. In Kuhlman, the Eleventh Circuit reversed a sentence of probation
for a health care fraud defendant as substantively unreasonable, stating that “[h]e
stole nearly $3 million and did not receive so much as a slap on the wrist ─ it was
more like a soft pat.” 711 F.3d at 1328 (internal citations omitted). The court
concluded:
[W]hen the government obtains a conviction in a health care fraud

prosecution, one of the primary objectives of the sentence is to send a
message to other health care providers that billing fraud is a serious
crime that carries with it a correspondingly serious punishment. In
awarding Kuhlman probation for the time he served while out on pre-
trial release, the district court disregarded the importance of delivering
such a message.
Id. It is imperative that a strong message of deterrence is received by other would-be
health care fraud offenders who see an easy way to steal large sums of money with a
low risk of getting caught.
In addition, while health care fraud is a national issue, it is also specifically
problematic in the Northern District of Illinois. For Fiscal Year 2017, for example,
the United States Sentencing Commission reported that the Northern District of
Illinois was one of the top five districts nationwide for health care fraud offenders.
See United States Sentencing Commission, Quick Facts: Health Care Fraud Offenses,
https://www.ussc.gov/sites/default/files/pdf/research-and-publications/quick-
25
facts/Health_Care_Fraud_FY17.pdf (last visited August 22, 2019). Providers’
continued engagement in health care fraud in this district demonstrates the ongoing
need for sentencing enforcement to act as a deterrent to future violations. A sentence
of 48 months’ imprisonment is sufficient, but not greater than necessary, to
accomplish that goal.
D. The Need to Reflect the Seriousness of the Offense, Promote

Respect for the Law, Provide Just Punishment, and Provide
Correctional Treatment
A sentence of 48 months’ imprisonment would also reflect the seriousness of
the offense, promote respect for the law, provide just punishment, and provide
correctional treatment. Defendant’s sentence must be significant enough to reflect
the egregious nature of the offense, as outlined above, in terms of length, loss,
conduct, and impact.
Defendant contends that the “wide-ranging collateral consequences” in this
case, including the loss of her license (which she has voluntarily allowed to go
inactive, following multiple years in which she claimed she would retire), inability to
practice, loss of reputation, and public shame, support a non-custodial sentence. R. 85
at p. 20-21. First, these foreseeable consequences of defendant’s actions “are the types
of things that arise from administrative agency action,” not the sentence imposed by
this Court. See Posada, No. 17 CR 165, Sent. Tr., R. 102, p. 60. Section 3553(a)(2)(A)
plainly states that “the sentence imposed” should “reflect the seriousness of the
offense,” (emphasis added) and defendant’s public shame and voluntarily
relinquishment of her license are not part of her sentence. See United States v.
26
Bistline, 665 F.3d 758, 765 (6th Cir. 2012). “Nor are they consequences of [her]
sentence, as opposed to consequences of [her] prosecution and conviction.” Id. A
court’s reliance on these factors “does nothing to show that [the defendant’s] sentence
reflects the seriousness of his offense. Were it otherwise, these sorts of
consequences—particularly ones related to a defendant’s humiliation before [her]
community, neighbors, and friends—would tend to support shorter sentences in cases
with defendants from privileged backgrounds, who might have more to lose along
these lines.” Musgrave, 761 F.3d at 608 (quoting Bistline, 665 F.3d at 765–66. While
defendant’s inability to practice again and the loss of her professional reputation are
appropriate factors to consider in the context of specific deterrence (which, the
government agrees, is of diminished import in this case), they are not appropriate
considerations in the context of the seriousness of the offense or the need to provide
just punishment.10
E. The Need to Avoid Unwarranted Sentencing Disparities
The best way to avoid unwarranted sentencing disparities is to give serious
consideration to the Guidelines, which serve as a mechanism to assess the
seriousness of federal crimes throughout the United States, so that defendants are
10In addition, defendant’s loss of license and “inability to practice” are especially irrelevant
where she had been discussing retirement for years prior to her conviction and was partially
retired as of at least 2017. See, e.g., DVO, Exhibit C (2017 emails in which Patient S.C. and
defendant discuss defendant’s previous plan to retire, and defendant informing Patient S.C.
that she is “down to half time” and “expect[s] to be totally retired by the end of 2018”);
Government’s Objections to the PSR, Exhibit 3 (2017 email in which defendant states: “I don’t
understand these people who retire and say they’re so busy every day. What do they do???? I
work 25 hours a week and play tennis in the mornings. I started 3 years ago and I’m addicted.
But you can’t do that 5 days a week!”); DVO, Exhibit B (October 11, 2013 email, in which
defendant states: “I am retiring in 2014”).
27
treated relatively equally for the same conduct wherever they are prosecuted.
See, e.g., United States v. Mykytiuk, 415 F.3d 606, 608 (7th Cir. 2005) (“The
Guidelines remain an essential tool in creating a fair and uniform sentencing regime
across the country”); United States v. Boscarino, 437 F.3d 634, 638 (7th Cir. 2006)
(“Sentencing disparities are at their ebb when the Guidelines are followed, for the
ranges themselves were designed to treat similar offenders similarly”). In adopting
the applicable Guidelines, Congress and the Sentencing Commission wanted to
ensure that the Guidelines would reflect the seriousness of white collar offenses,
which prior sentencing had not always done. See United States v. Hagerman, 525 F.
Supp. 2d 1058, 1065 (S.D. Ind. 2007) (Hamilton, J.). The impositions of sentences of
incarceration were seen as necessary as a matter of fairness and for purposes of
deterrence. See S. Rep. No. 98–225, at 76 (1983), as reprinted in 1984 U.S.C.C.A.N.
3182, 3259 (noting that “major white collar criminals often are sentenced to small
fines and little or no imprisonment,” creating the impression that “certain offenses
are punishable only by a small fine that can be written off as a cost of doing business”);
United States v. Rivera, 994 F.2d 942, 955 (1st Cir. 1993) (Breyer, J.) (noting
Commission’s intent to equalize punishment for white collar and blue collar crime);
United States v. Mueffelman, 470 F.3d 33, 40 (1st Cir. 2006) (noting the importance
of “the minimization of discrepancies between white- and blue-collar offenses”). As
the Supreme Court explained in Rita v. United States, 551 U.S. 338, 350 (2007), it is
fair to assume that the Guidelines “reflect a rough approximation of sentences that
might achieve § 3553(a)’s objectives.” See also id. at 348 (“The upshot is that the
28
sentencing statutes envision both the sentencing judge and the Commission as
carrying out the same basic § 3553(a) objectives, the one, at retail, the other at
wholesale. . . . [The Commission] has tried to embody in the Guidelines the factors
and considerations set forth in § 3553(a).”); United States v. Goldberg, 491 F.3d 668,
673 (7th Cir. 2007) (describing the Guidelines as “drafted by a respected public body
with access to the best knowledge and practices of penology.”).
Defendant, however, requests not just a below-guidelines sentence, but a non-
custodial sentence. In making this request, defendant cites to a 2017 study indicating
that health care fraud sentences often fall below the guidelines. See R. 85 at 34 (citing
Kyle Crawford, Health Care Fraud Sentencing, 105 GEO. L.J. 1079 1088 (2017). That
same year, however, the Sentencing Commission’s data showed that “the majority of
health care fraud offenders were sentenced to imprisonment (80.3%)” and “[t]he
average sentence length for health care fraud offenders was 37 months.” See United
States Sentencing Commission, Quick Facts: Health Care Fraud Offenses,
https://www.ussc.gov/sites/default/files/pdf/research-and-publications/quick-facts/
Health_Care_Fraud_FY17.pdf (last visited August 26, 2019). In this district as well,
courts have imposed significant prison terms for defendants who engage in significant
false billing. See, e.g., Posada, No. 17 CR 165 (N.D. Ill.) (Chang, J.) (imposing
sentence of 60 months’ imprisonment for chiropractor who engaged in $4 million false
billing scheme, where defendant had significant physical and mental health issues,
no criminal history, and little to no risk of recidivism); United States v. Mattson, 11
CR 580, R. 105 (N.D. Ill. Dec. 10, 2012) (Guzman, J.) (imposing sentence of 78 months’
29
imprisonment for chiropractor who billed for services that were not rendered or were
medically unnecessary and received $2.1 million, where defendant had no criminal
history, substance abuse issues, and young children).
Defendant provides a list of cases in which defendants have received probation
(or “nominal” prison terms), see R. 85 at 35-36, almost all of which are clearly
distinguishable from this case based on either the nature of the offense, the
defendant’s role in the offense, the amount of loss, or the defendant not individually
receiving the fraud proceeds. See, e.g., United States v. Colletti, et al., No. 15 CR 260
(N.D. Ill.) (Alonso, J.) (wire fraud defendants, who were sentenced to terms ranging
from 42 months’ imprisonment for scheme leader to one year’ home confinement for
lower level member, engaged in scheme to defraud victim beer brewery); United
States v. Baraban, No. 19 CR 68 (W.D. Mo.) (defendant pharmacist entered into Rule
11(c)(1)(C) plea agreement for three years’ probation where the pharmacy he
managed billed Medicaid for over $119,000 worth of pain creams that did not ship
and for over $5,000 of antibiotics that the pharmacy had later returned, resulting in
a guidelines range of 12-18 months’ imprisonment); United States v. Kirk, No. 19 CR
47 (S.D. Ohio) (defendant sentenced to five years’ probation where she did not
individually receive any fraud proceeds, only financially benefitting from the salary
and commission paid to her significant other/co-defendant); United States v.
Gyambibi, No. 18 CR 136 (D. Conn.) (defendant physician sentenced to three months’
imprisonment where she signed prescriptions for patients she never saw or examined,
but did not individually receive the fraud proceeds); United States v. Henry, No. 18
30
CR 249 (M.D. Ala.) (defendant sentenced to two years’ probation where his chronic
care management practice entered into agreements with doctors to waive co-
payments for patients, all of whom did receive services, resulting in loss amount of
less than $250,000); United States v. Iyer, No. 18 CR 378 (M.D. Fla.) (defendant
physician sentenced to six months’ imprisonment where false billings resulted in loss
of less than $53,000); United States v. Clark, et al, No. 17 CR 85 (M.D. La.) (defendant,
the office biller, sentenced to two years’ probation where she “unbundled” billings to
maximize reimbursements from victim insurers at co-defendant medical director’s
direction, but did not receive any fraud proceeds); United States v. Morrison, No. 18
CR 175 (D. Me.) (defendant manager of physical therapy practice sentenced to four
months’ imprisonment where only approximately 1/6 of the $175,000 loss went to
defendant individually). Unlike the defendants in these cases, defendant completed
all of the false billing herself, at no one else’s direction, defrauding the victim insurers
out of over $2.5 million, and kept the entirety of the fraud proceeds in her own
individual accounts.
In sum, a sentence of 48 months’ imprisonment is sufficient, but not greater
than necessary for this defendant. In making this recommendation, the government
takes into account the egregious nature of the offense, the high loss amount,
defendant’s aggressive behavior towards her mental health patients, and the great
need for general deterrence, but also the mitigating factors cited by the defendant,
including her age, health, and the unlikelihood of recidivism.
31
RESTITUTION
Restitution is mandatory pursuant to Title 18, United States Code, Section
3663A. As discussed extensively in the Government’s Version of the Offense and the
Government’s Objections to the PSR, the defendant’s lack of medical files required
the government to reasonably estimate loss without relying on actual patient records.
The government engaged in a loss calculation that generously credited defendant for
12 patient visits per day, 7 days per week, over the entirety of the scheme, including
weekends and holidays. The government even credited defendant for seeing 12
patients per day on the dates of her flights to and from Chicago, regardless of what
time those flights left or arrived. The only days the government did not provide
defendant credit for were days that travel records prove she was out of state (and
often, country).
The government then determined how many unique patient visits the health
care benefit programs reimbursed defendant for that are over 12 patients per day, 7
days per week, over the course of the scheme. To arrive at this number, the
government subtracted from the total amount of unique patient visits over that time
(56,547) the number of credited visits (33,216), for a total “overage” of 23,331 patient
visits. The total loss was then calculated by multiplying the 23,331 overage visits by
the average reimbursement per patient visit, $108.40, for a total of $2,532,901.96.
The $2,532,901.96 number is 41% of defendant’s total reimbursements over
the period of the scheme. To arrive at specific restitution numbers for the individual
health care benefit programs, the government thus calculated 41% of the total
32
reimbursements each victim paid defendant over the course of the scheme. Those
numbers are below:
Blue Cross Blue Shield of Illinois: $1,675,587.83

Optum Health (United Health Care): $409,648.75
Aetna: $181,660.85
Cigna: $119,687.28
Centers for Medicare & Medicaid Services: $146,317.25
Total: $ 2,532,901.96
SUPERVISED RELEASE
The government does not recommend a term of supervised release. If this
Court were to impose a term of supervised release, the government agrees with the
proposed conditions in the PSR.
CONCLUSION
For the reasons set forth above, the government respectfully requests that the
Court sentence defendant to 48 months’ imprisonment. This sentence reflects the
serious nature of the offense and the history and circumstances of the defendant, but
is not greater than necessary to reflect the goals of sentencing espoused in 18 U.S.C.
§ 3553.
Dated: August 27, 2019 Respectfully submitted,
JOHN R. LAUSCH, Jr.

United States Attorney
By: /s/ L. Heidi Manschreck

L. HEIDI MANSCHRECK
KELLY M. GREENING
Assistant United States Attorney
219 South Dearborn Street, 5th Floor
Chicago, Illinois 60604
(312) 469-6205
(312) 353-4095
33
UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
UNITED STATES OF AMERICA

18 CR 584
v.
Honorable Jorge L. Alonso
PAMELA ANTELL
CERTIFICATE OF SERVICE
The undersigned Assistant United States Attorney hereby certifies that in

accordance with Fed.R.Crim.P. 49, Fed.R.Civ.P. 5, LR 5.5, and the General Order
on Electronic Case Filing (ECF), the following document:
GOVERNMENT’S POSITION PAPER AS TO SENTENCING FACTORS
was served pursuant to the district court’s ECF system.
Respectfully submitted,
JOHN R. LAUSCH, Jr.

United States Attorney
By: /s/ L. Heidi Manschreck

L. HEIDI MANSCHRECK
Assistant United States Attorney
219 South Dearborn Street, 5th Floor
Chicago, Illinois 60604
(312) 469-6205
Dated: August 27, 2019
34

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Case: 1:18-cr-00584 Document #: 85 Filed: 08/20/19 Page 1 of 38 PageID #:1077

IN THE UNITED STATES DISTRICT COURT

UNITED STATES OF AMERICA,

v. Case No. 1:18-cr-00584

PAMELA ANTELL, Hon. Jorge L. Alonso

DR. ANTELL’S SENTENCING MEMORANDUM

Booker v .United States,

Doe v. United States,

Gall v. United States,

United State v. Aggarwal,

United States. ex rel. Hawks v. Heart and Vascular Institute of Florida,

United States v. Adelson,

United States v. Anderson,

United States v. Baker,

United States v. Baraban,

United States v. Brady,

United States v. Brown,

United States v. Cabrera,

United States v. Carter,

United States v. Chase,

United States v. Clay,

United States v. Colletti, et al.,

United States v. Corsey,

United States v. Coughlin,

United States v. Duhon,

United States v. Edwards,

United States v. Emmenegger,

United States v. Faibish,

United States v. Gyambibi,

United States v. Hamilton,

United States v. Henry,

United States v. Holt,

United States v. Iyer,

United States v. Jackson,

United States v. Kirk,

United States v. Morrison,

United States v. Pallowick,

United States v. Parris,

United States v. Powell,

United States v. Properi,

United States v. Rodriguez,

United States v. Roque,

United States v. Severio,

United States v. Toback,

United States v. Tomko,

United States v. Vigil,

United States v. Warner,

United States v. Williams,

United States v. Zohfeld,

18 U.S.C. § 3553(a) ............................................................................................................... passim

18 U.S.C. § 3563(b) .......................................................................................................................25

28 U.S.C. § 994(j) ..........................................................................................................................25

American Diabetes Association, Stress (2013), available at

American Medical Association, Increased Mortality Risk in Women With

CoreCivic Lawsuit, American Diabetes Association, available at

Evan A. Jenness, The ‘Silver Tsunami’ and Sentencing—Age and Health As

Maurizio Pompili, et al., 4 NEUROPSYCHIATRIC DISEASE AND TREATMENT 247

U.S. Sentencing Commission, Proposed Amendments to the Sentencing

United States Sentencing Commission, The Effects of Aging on Recidivism Among

this Sentencing Memorandum, and states as follows: 1

in a way wholly uncaptured by rote application of the Guidelines. As countless acquaintances

in fraud for years.

§ 3553(a), the Court is directed to consider, among other things:

(1) “the history and characteristics of the defendant,”