Troy Health: Automated Enrollment Without Consent

Troy Health’s Medicare Advantage fraud turned pharmacy customer information into plan enrollments without beneficiaries’ knowledge or consent. Troy admitted that the scheme ran from approximately October 2020 through the end of 2022. Sales personnel claimed to represent beneficiaries’ pharmacies and described a new plan as a supplement to existing coverage. The beneficiaries lost control over their coverage, and taxpayers funded the program Troy defrauded.

Troy is a North Carolina-based provider of Medicare Advantage, Medicare Part D and Dual Eligible Special Needs Plans. The Justice Department’s August 20, 2025 announcement describes a business using pharmacy data, referral payments and automation to gain members. Troy accepted responsibility for the conduct of its officers, directors, employees and agents in the scheme.

Pharmacy Records Became Sales Leads

Troy’s enrollment operation began with information held by pharmacies. Under an executive’s direction, some territory managers used proprietary software developed by a Troy executive to unlawfully access pharmacy records and customer lists. Those records contained beneficiaries’ names, addresses, dates of birth, Medicare ID numbers and insurance information.

The information served different purposes inside the scheme. Troy used it to make unsolicited sales calls. It also used information from the customer lists to enroll people without consent.

During the calls, sales personnel falsely said they were calling on behalf of the beneficiaries’ pharmacies. They also represented Troy’s Medicare Advantage plan as a supplement to an existing healthcare plan, rather than a new plan. The first claim borrowed the pharmacy’s relationship with its customer. The second concealed what the company was selling.

The sales pitch offered continuity. The enrollment put the beneficiary in a new plan. Someone familiar with the calls could see a different transaction from the one recorded as a new member.

Troy.ai Put Referral Incentives Inside the Platform

Troy offered pharmacies kickbacks for enrollment referrals submitted through Troy.ai, its artificial intelligence-based health care management platform. The company had made the platform available to participating pharmacies and marketed it as a way to use data and machine learning to lower care costs and improve health outcomes. The referral arrangement made it a way to obtain new enrollments as well.

The incentive to add members also runs through Medicare Advantage broker compensation, which includes initial payments and renewal payments when members remain enrolled, as the Centers for Medicare & Medicaid Services describes in its agent and broker compensation guidance.

For a pharmacy employee, the referral entered through Troy.ai is a specific transaction to recognize. The software’s advertised purpose was better care. The kickback offer rewarded bringing the insurer new business.

The Justice Department described artificial intelligence and automation software as part of the scheme. Its account also identifies the people directing access to customer data, making misleading calls and entering enrollments.

A Growth Target Followed by Batch Enrollments

A Troy executive announced a plan at a 2021 board meeting to triple enrollment during the following year’s open-enrollment period. The executive described the plan as “aggressive but achievable.” The admitted conduct followed that growth target.

During the Medicare Advantage open-enrollment period from January 1 through March 31, 2022, Troy enrolled more than 2,700 new members. Many entered through automatic or batch enrollments.

On March 2, 2022, Troy enrolled more than 300 beneficiaries, with enrollments occurring approximately one minute apart.

Some Troy employees also manually entered fraudulent enrollments through the Centers for Medicare & Medicaid Services website.

Medicare Advantage Enrollment Without Consent

The American Institutes for Research’s 2026 report, Medicare Advantage Fraud, Waste, and Abuse Policy Options, describes enrollment as a choice that should be voluntary, informed and documented. Its analysis identifies both financial incentives and information gaps as sources of enrollment risk. Those concerns meet in Troy’s admitted conduct: the company sought referrals and new members while misrepresenting the plan to the people it contacted.

The report explains what can go wrong before an enrollment ever reaches the insurer:

Troy’s pharmacy-affiliation and supplement claims made those information gaps concrete. The caller misrepresented whom they spoke for and what the beneficiary was being offered. An enrollment system could then record a new member while the person whose information it held had never agreed to join.

The report also proposes linking enrollments to the agents or brokers who facilitated them and examining disenrollment patterns. Applied to Troy’s conduct, that approach would connect the enrollment back to the people and instructions behind it. A growth report counts new members. The sales interaction can show whether those people ever understood that they were joining the plan.

Nursing Homes Moved Residents Out of Medicare Advantage Without Consent

Plaza Rehab and Nursing Center and Citadel Consulting Group admitted that staff often changed residents’ coverage without obtaining consent. The changes moved residents out of Medicare Advantage without consent from the resident or an authorized representative. The Justice Department explained the financial incentive: Original Medicare was usually more profitable for skilled nursing facilities.

Troy sought members for its plans. The nursing-home arrangement moved residents out of Medicare Advantage. In both accounts, a business’s financial interest displaced the beneficiary’s control over coverage.

The Records Behind Troy’s Enrollments

Troy’s own admissions connect executive direction, pharmacy-data access, sales representations, referral incentives and enrollment activity. A pharmacy employee may recognize how customer information became available. A sales employee may know what callers were instructed to say. Someone working in enrollment operations may understand how a batch or a manually entered enrollment reached the system. Those views can connect a management decision to a particular beneficiary’s coverage.

For an insider who knows a similar enrollment practice, we assess the connection between the sales operation, the coverage change and the payment to determine whether the facts support a civil whistleblower case. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know How the Enrollment Happened

If you saw pharmacy data, misleading calls or batch processing turn people into plan members without their agreement, speak with our whistleblower experts about what happened inside the enrollment operation. We develop the case with you and bring in Medicare Advantage whistleblower lawyers who understand enrollment schemes and referral payments. We stay beside you as your firsthand knowledge becomes a case for recovering public money.