Troy Health, a North Carolina-based Medicare Advantage insurer, has entered into a non-prosecution agreement with the Department of Justice after admitting to a scheme involving fraudulent Medicare enrollments and identity theft.
The company used automation and artificial intelligence software to unlawfully obtain Medicare beneficiary information and enroll them in its plans without consent, according to an Aug. 20 news release from the DOJ.
The scheme took place between October 2020 and December 2022. Using stolen personal data, Troy made unsolicited sales calls and falsely presented itself as a representative of the beneficiaries’ healthcare providers.
Troy also misused its proprietary AI-based healthcare management platform, Troy.ai, to solicit enrollment referrals from pharmacies, which were offered kickbacks in an effort to boost enrollment. Troy also processed some enrollments through automatic systems, with over 2,700 new members signed up during the MA open enrollment period in 2022.
The fraudulent activities were driven by executives at the company who aimed to triple Troy’s enrollment during the enrollment period. At its peak, Troy enrolled over 300 beneficiaries in a single day, with the enrollments occurring about one minute apart.
Under the terms of the non-prosecution agreement, Troy admitted to its wrongdoing and accepted responsibility for the actions of its employees involved in the scheme. The company has agreed to pay a criminal penalty of $1.43 million.
