North Carolina-based Medicare Advantage, Medicare Part D, and Dual Eligible Special Needs Plan provider Troy Health, Inc. (“Troy”) is paying a more than million criminal penalty under a non-prosecution agreement with the Department of Justice resolving its criminal exposure from a federal criminal investigation into a health care fraud and identity theft scheme involving the Troy’s use of artificial intelligence and automation software to illegally obtain Medicare beneficiary information and fraudulently enroll beneficiaries into its Medicare Advantage plans. The Justice Department Health Care Fraud Unit’s first non-prosecution agreement since it implemented its updated Corporate Enforcement and Voluntary Self‑Disclosure Policy (CEP), introduced in May 2025, the prosecution and resulting non-prosecution agreement contain critical insights for Medicare Advantage and other health industry organizations and their leaders.
Troy Fraud Investigation Behind Non-Prosecution Agreement
According to the Justice Department’s August 21, 2025, announcement of the non-agreement, following a Troy executive’s announcement 2021 board meeting announcement of an “aggressive but achievable” plan to triple Troy’s enrollment during the 2022 open enrollment period, Troy deliberately defrauded low-income Medicare beneficiaries and the Medicare system by duping low income Medicare beneficiaries into sharing their information by promising to use its proprietary artificial intelligence platform and other technologies to improve patient health outcomes, and misused patient data to enroll beneficiaries in its Medicare Advantage plan without their consent.
In the non-prosecution agreement,Troy admitted that Troy defrauded the Medicare program by enrolling beneficiaries in Troy’s Medicare Advantage plans without their knowledge or consent when Troy’s Territory Managers under a Troy executive’s direction used proprietary software developed by one of Troy’s executives to unlawfully access pharmacy records and customer lists containing beneficiaries’ names, addresses, dates of birth, Medicare ID numbers, insurance information and other sensitive personal information that Troy used to make unsolicited sales calls to potential Medicare beneficiaries.
Troy also admitted that it used information obtained from the customer lists to enroll beneficiaries in Troy’s Medicare Advantage plan without their consent. During sales calls, Troy’s sales personnel provided false and misleading information to Medicare beneficiaries. For example, Troy’s sales personnel told prospective enrollees that they were calling on behalf of the beneficiaries’ pharmacies and representing to beneficiaries that Troy’s Medicare Advantage plan was being offered as a supplement to their existing health care plans rather than as a new plan.
Troy also admitting using an artificial intelligence-based health care management platform it developed and made available to participating pharmacies, known as Troy.ai, as part of the scheme. Troy marketed Troy.ai as a product that would leverage data and machine learning to lower the cost of care and improve health outcomes. As part of its effort to obtain new enrollments, however, Troy misused the platform by offering pharmacies kickbacks for enrollment referrals submitted through Troy.ai.
At the height of the scheme, during the Medicare Advantage open enrollment period between January 1, 2022 and March 31, 2022, Troy enrolled over 2,700 new Medicare Advantage members, many through automatic or batch enrollments. For example, on March 2, 2022, Troy enrolled over 300 beneficiaries on one day, with the enrollments occurring approximately one minute apart. In addition, some Troy employees manually entered fraudulent enrollments through the Centers for Medicare and Medicaid Services (“CMS”) website.
“The defendant’s use of stolen identities to fraudulently enroll individuals in Medicare Advantage plans was a deliberate scheme to boost profits at the expense of vulnerable patients and the integrity of the Medicare program,” stated Deputy Inspector General for Investigations Christian J. Schrank of the Department of Health and Human Services Office of Inspector General (HHS-OIG). “HHS-OIG, alongside our law enforcement partners, will continue to relentlessly pursue those who exploit Medicare and threaten the security of enrollees’ personal health information.”
As part of the non-prosecution agreement, Troy admitted to and accepted responsibility for the acts of its officers, directors, employees, and agents in connection with the scheme. Troy also agreed to pay a criminal penalty of $1,430,008 and agreed to continue cooperating with the Department in any ongoing or future criminal investigation relating to this conduct.
The Department reached this resolution with Troy based on several factors, including Troy’s efforts to provide all relevant facts known to it, acceptance of responsibility for criminal conduct, extensive and timely remedial measures taken, commitment to continuing enhancement of compliance and internal control programs, absence of prior criminal history or regulatory actions, commitment to cooperation with federal agencies in any ongoing investigations, and the nature and seriousness of the offense. Troy did not receive voluntary self-disclosure credit, but did receive credit for its cooperation with the Department’s investigation and affirmative acceptance of responsibility, which included (i) self-reporting its 2022 batch member enrollment issue to CMS before it had come to the attention of the Department; (ii) providing timely updates on facts learned during its internal investigation; (iii) providing all relevant facts known to it, including information about individuals involved in the conduct. However, and particularly during the early phase of the Department’s investigation, Troy failed to preserve and produce certain documents and evidence in a timely manner and, at times, took actions that were inconsistent with full cooperation. The Justice Department also reduced the penalty amount based on evidence of Troy’s ability to pay.
Health Industry Take Aways
As the first announced settlement announced since the Justice Department announced the new CEO last May, the Troy prosecution and non-prosecution agreement opens a window for other health industry organizations and their leaders into current Justice Department health industry practices for applying the new CEP and other priorities and practices such as the following:
- Fraud Prosecution Remains A Hugh Priority. The Troy and other investigations and prosecutions make clear the Justice Department remains committed to finding and prosecuting health care fraud and identity theft.
- Medicare Advantage & Supplement Insurer Misconduct. The Troy investigation and non-prosecution agreement is the is part of a series of investigations and actions against insurers accused of engaging in fraud or other abuses recently announced. The Troy announcement also follows the Department of Health & Human Services Office of Inspector General’s addition of several projects targeting fraud and other misconduct by private insurers participating in the Federal Exchange and Medicare and Medicaid Advantage and Supplement marketplaces to its Work Plan.
- AI &Technology-Enabled Fraud: The prosecution signals the Justice Department’s growing scrutiny of tech-enabled fraud. It sends a clear warning to healthcare p companies using automation/AI or other technologies that misuse of beneficiary data, deceptive enrollment tactics or other technology -enabled misconduct carries serious consequences.
- Corporate and Individual Accountability: Although the Justice Department claims a commitment to enforcing both individuals and organizations and the announcement makes clear specific leaders at Troy participated in creating or promoting this scheme, to date the Justice Department has charged any individuals for their involvement in this scheme. This may be a sign that early cooperation and settlement can help insulate individual leaders from accountability. Stay tuned.
- Monitoring. The non-prosecution agreement applies the CEP’s “no-monitors-if-unnecessary” approach while sending a clear message companies must still demonstrate robust cooperation and remediation to benefit from relief offered under the CEP and Federal Sentencing Guidelines penalty guidelines.
If you have questions about this or other health care concerns, contact the author.
More Information
We hope this update is helpful. For more information about the or other health or other employee benefits, human resources, or health care developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297.
Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.
About the Author
Peer recognized as “Top Rated Lawyer” and “LEGAL LEADER™ “Top Rated Lawyer” and “Best Lawyer” for her work in Health Care Law, Labor and Employment Law; ERISA & Employee Benefits,” and “Business and Commercial Law,” Cynthia Marcotte Stamer is an A Martindale-Hubble “AV-Preeminent” (Top 1%) attorneys board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for her more than 35 years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications including leading edge work on PBM, pharmacy and pharmaceutical and other health care, managed care, insurance, and insured and self-insured contracting, design, administration and regulation..
Author of numerous highly regarded works on PBM and other health plan contracting and design, Immediate Past Chair of the ABA International Section Life Sciences Committee and the Tort Trial and Insurance Practice Section Medicine and Law Committee, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group and past Group Chair and current Welfare Benefit Committee Co-Chair of the ABA RPTE Employee Benefits & Other Compensation Group, Ms. Stamer is most widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health and other privacy and data security and other health industry legal, public policy and operational concerns.
Ms. Stamer’s work throughout her career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. As a part of this work, she has continuously and extensively worked with domestic and international health plans, their sponsors, fiduciaries, administrators, and insurers; managed care and insurance organizations; third party administrators and other health benefit service providers; hospitals, health care systems and other health care providers, accreditation, peer review and quality committees and organizations; billing, utilization management, management services organizations, group purchasing organizations; pharmaceutical, pharmacy, and prescription benefit management and organizations; consultants; investors; EMR, claims, payroll and other technology, billing and reimbursement and other services and product vendors; products and solutions consultants and developers; investors; managed care organizations, self-insured health and other employee benefit plans, their sponsors, fiduciaries, administrators and service providers, insurers and other payers, health industry advocacy and other service providers and groups and other health and managed care industry clients as well as federal and state legislative, regulatory, investigatory and enforcement bodies and agencies.
She also has extensive experience helping health care systems and organizations, group and individual health care providers, health plans and insurers, health IT, life sciences and other health industry clients prevent, investigate, manage and resolve sexual assault, abuse, harassment and other organizational, provider and employee misconduct and other performance and behavior; manage Section 1557, Civil Rights Act and other discrimination and accommodation, and other regulatory, contractual and other compliance; vendors and suppliers; contracting and other terms of participation, medical billing, reimbursement, claims administration and coordination, Medicare, Medicaid, CHIP, Medicare/Medicaid Advantage, ERISA and other payers and other provider-payer relations, contracting, compliance and enforcement; Form 990 and other nonprofit and tax-exemption; fundraising, investors, joint venture, and other business partners; quality and other performance measurement, management, discipline and reporting; physician and other workforce recruiting, performance management, peer review and other investigations and discipline, wage and hour, payroll, gain-sharing and other pay-for performance and other compensation, training, outsourcing and other human resources and workforce matters; board, medical staff and other governance; strategic planning, process and quality improvement; meaningful use, EMR, HIPAA and other technology, data security and breach and other health IT and data; STARK, ant kickback, insurance, and other fraud prevention, investigation, defense and enforcement; audits, investigations, and enforcement actions; trade secrets and other intellectual property; crisis preparedness and response; internal, government and third-party licensure, credentialing, accreditation, HCQIA and other peer review and quality reporting, audits, investigations, enforcement and defense; patient relations and care; internal controls and regulatory compliance; payer-provider, provider-provider, vendor, patient, governmental and community relations; facilities, practice, products and other sales, mergers, acquisitions and other business and commercial transactions; government procurement and contracting; grants; tax-exemption and not-for-profit; privacy and data security; training; risk and change management; regulatory affairs and public policy; process, product and service improvement, development and innovation, and other legal and operational compliance and risk management, government and regulatory affairs and operations concerns. to establish, administer and defend workforce and staffing, quality, and other compliance, risk management and operational practices, policies and actions; comply with requirements; investigate and respond to Board of Medicine, Health, Nursing, Pharmacy, Chiropractic, and other licensing agencies, Department of Aging & Disability, FDA, Drug Enforcement Agency, OCR Privacy and Civil Rights, Department of Labor, IRS, HHS, DOD, FTC, SEC, CDC and other public health, Department of Justice and state attorneys’ general and other federal and state agencies; JCHO and other accreditation and quality organizations; private litigation and other federal and state health care industry actions: regulatory and public policy advocacy; training and discipline; enforcement; and other strategic and operational concerns.
Author of publications on “Transparent PBM Contracting,” “ACOs, Direct Contracting: Legal & Practical Challenges For Employers, Providers & TPAs,” “The Medicare Advantage Contracting Manual,” “Third Party Administrator (TPA) Contracting Principles and Strategies and a multitude of other highly regarded publications and presentations, Stamer is widely recognized for her thought leadership on PBM and other managed care and health plan contracting and design, and a multitude of other health care, health plan and other health industry matters. In addition, Ms. Stamer contributes her time and leadership to numerous policy, professional, civil and other organizations including service as the, the American Bar Association (ABA) International Section Life Sciences Committee Vice Chair, a Scribe for the ABA Joint Committee on Employee Benefits (JCEB) Annual OCR Agency Meeting and a former Council Representative, Past Chair of the ABA Managed Care & Insurance Interest Group, former Vice President and Executive Director of the North Texas Health Care Compliance Professionals Association, past Board President of Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency, past North Texas United Way Long Range Planning Committee Member, and past Board Member and Compliance Chair of the National Kidney Foundation of North Texas, and a Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also shares her extensive publications and thought leadership as well as leadership involvement in a broad range of other professional and civic organizations. For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.
About Solutions Law Press, Inc.™
Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources.
If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.
NOTICE: These statements and materials are for general information and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation considering the specific facts and circumstances presented in their unique circumstance at the particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author reserves the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law constantly and often rapidly evolves, subsequent developments that could impact the currency and completeness of this discussion are likely. The author and Solutions Law Press, Inc. disclaim and have no responsibility to provide any update or otherwise notify anyone of any fact or law specific nuance, change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication.
Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.
©2024 Cynthia Marcotte Stamer. Non-exclusive right to republish granted to Solutions Law Press, Inc.™ For information about republication, please contact the author directly. All other rights reserved.
slphealthcareupdate.com 