Troy Health Enters Groundbreaking Non-Prosecution Agreement With DOJ
November 21, 2025 | JacobiJournal.com — Troy Health, a Medicare Advantage provider, recently entered a non-prosecution agreement (NPA) with the U.S. Department of Justice, marking a first-of-its-kind healthcare resolution under the revised Corporate Enforcement Policy (CEP). The DOJ alleges Troy engaged in misconduct, including improper enrollment of Medicare beneficiaries and misuse of personal identifying information facilitated by AI tools. The agreement requires Troy Health to pay approximately $1.4 million and comply with an 18-month NPA, acknowledging its role in a scheme that impacted beneficiaries without their knowledge or consent. How Did Troy Health’s Alleged Fraud Occur? Investigators say Troy’s employees used customer lists from contract pharmacies to enroll beneficiaries into the company’s Medicare Advantage plan. Misleading calls, automated batch enrollments, and AI-driven sales tactics allegedly bypassed proper consent and documentation protocols. Some patients were auto-enrolled in batches of up to 300 at a time, and verification calls were misrepresented as genuine confirmations. The DOJ highlighted that Troy’s AI-enabled platform, Troy.ai, played a central role in orchestrating these enrollment activities. While some pharmacy staff participated, others were unaware that their customer data was being used to enroll individuals without consent. Why This NPA Matters This resolution underscores several critical trends in healthcare fraud enforcement: For healthcare providers and insurers, the case emphasizes the need for robust compliance governance, transparent self-reporting, and proactive auditing of AI-driven systems. How Companies Can Avoid Similar Compliance Pitfalls By proactively addressing these areas, organizations can reduce the risk of enforcement action and protect patient trust. For additional insights into this non-prosecution agreement and healthcare compliance trends, visit: JD Supra – Troy Health NPA. FAQs About Troy Health NPA What is a non-prosecution agreement (NPA)? An NPA is a legal agreement where the government agrees not to prosecute a company for alleged misconduct, provided the company meets certain conditions, such as paying fines or cooperating with investigations. Why did Troy Health enter an NPA with the DOJ? Troy Health admitted to allegations of enrolling Medicare beneficiaries without consent and cooperating partially with the DOJ, making it eligible for an NPA under the revised Corporate Enforcement Policy. How did Troy Health allegedly misuse AI in Medicare enrollments? Troy’s AI platform, Troy.ai, was used to manage enrollment lists and automate outreach, sometimes facilitating unauthorized beneficiary enrollments without consent or proper verification. What are the lessons for other healthcare companies? Healthcare organizations should maintain strong governance, compliance monitoring, and transparent self-reporting, especially when using AI systems that handle sensitive patient data. Stay informed and subscribe to JacobiJournal.com for up-to-date reporting on healthcare fraud and regulatory developments. 🔎 Read More from JacobiJournal.com:
Kaiser Permanente Faces Near $1 Billion Settlement Over Medicare Fraud Allegations
November 6, 2025 | JacobiJournal.com — Federal authorities allege that Kaiser Permanente manipulated patient records within its Medicare Advantage plans to obtain higher reimbursements. The claims center on the company’s documentation and coding practices, which may have inflated patient “risk scores,” leading to increased payments from the federal government. This alleged conduct, if proven, illustrates how system-wide documentation practices can become vulnerable points for fraudulent reimbursement. What This Means for Health Systems and Insurers A settlement approaching $1 billion would mark one of the largest fraud exposures involving an integrated U.S. health system. For other insurers and provider networks, the case highlights the need for stronger internal controls, compliance audits, and accurate reporting mechanisms. Regulatory bodies are signaling that risk-adjusted programs are under close scrutiny, particularly where documentation and billing practices intersect. Why It Matters The potential settlement underscores the broader consequences of documentation irregularities in Medicare Advantage programs. Employers sponsoring health plans, self-insured plans, and healthcare providers should monitor how provider agreements, coding procedures, and audit protocols can create compliance and fraud risks. In California, where Kaiser Permanente has extensive operations, these developments may prompt insurers and employers to review internal audits and strengthen fraud-prevention practices. For a detailed review of the 2025 Employer Health Benefits Survey, visit the Kaiser Family Foundation’s official report: Kaiser Family Foundation. FAQs: Kaiser Permanente Medicare Fraud Settlement What is the basis of the Kaiser Permanente Medicare fraud allegation? It involves allegations that Kaiser Permanente inflated patient risk scores and manipulated medical records to receive higher Medicare Advantage payments. Regulators contend that some documentation may have been added retrospectively to maximize reimbursements. What are the Kaiser Permanente allegations? Federal authorities allege that the health system systematically altered records and coding practices to increase federal payments, potentially violating the False Claims Act. The allegations center on Medicare Advantage risk-adjustment programs, where payments are linked to patient “risk scores.” Is Kaiser laying off employees? There have been reports that some operational adjustments and workforce changes are occurring in response to ongoing audits and compliance reviews. While specific layoffs tied to the settlement have not been confirmed, internal restructuring is common when large-scale investigations occur. What is the largest fraud settlement in history? Historically, the largest settlements have involved pharmaceutical companies, healthcare providers, and financial institutions. Multi-billion-dollar settlements are rare, but the Kaiser case, approaching $1 billion, ranks among the largest involving a health system under Medicare. How could this affect employers or self-insured health plans? Employer-sponsored plans may face indirect exposure if providers in their networks engage in similar practices, or if audits uncover misrepresented claims. Why are Medicare Advantage risk-adjustment programs prone to fraud? Payments depend on patient “risk scores,” creating incentives to document higher-severity diagnoses. Without proper oversight, these programs can be exploited, making them a primary target for regulatory enforcement. What steps can healthcare compliance teams take? Implement audits for coding accuracy, enforce clear documentation standards, and maintain training programs to prevent fraudulent or misleading billing practices. For continued updates on healthcare fraud, compliance investigations, and financial crime enforcement, subscribe to JacobiJournal.com and receive weekly coverage straight to your inbox. 🔎 Read More from JacobiJournal.com:
Sunnyvale Executive Charged in $137M Medicare Advantage Fraud Scheme
August 1, 2025 | JacobiJournal.com — A federal investigation has unveiled a massive Medicare Advantage fraud scheme involving a Sunnyvale medical supply executive who allegedly submitted thousands of false claims using stolen identities and unneeded medical equipment.According to the U.S. Department of Justice, Sevendik Huseynov, CEO of Vonyes, Inc., was charged with orchestrating a billing operation that funneled more than $137 million in fraudulent claims to multiple Medicare Advantage Organizations (MAOs). From January to June 2025, Huseynov allegedly submitted over 7,200 claims for durable medical equipment (DME), including orthopedic braces and wound care items—most of which were never requested, medically necessary, or even delivered to beneficiaries. Massive Fraud Uncovered in Medicare Advantage DME Claims Federal prosecutors allege that Huseynov relied on a network of stolen beneficiary identities to populate fabricated patient files. The company submitted detailed billing codes to at least eight separate Medicare Advantage plans. Investigators say that while only $761,000 was paid before the fraud was flagged, the total scope of attempted fraud is one of the largest recent busts involving Medicare Advantage billing. Court records describe the operation as a “bust-out fraud”—a scheme where perpetrators flood insurers with claims in a short period before detection systems can flag anomalies. Authorities say there was no physician oversight, medical necessity documentation, or evidence the patients had ever spoken with the company. Medicare Advantage Plans Targeted Through System Gaps Unlike traditional Medicare, Medicare Advantage plans rely on private insurers to process and pay claims. Critics argue that the decentralized nature of MAOs leaves vulnerabilities in place for vendors to exploit gaps in documentation, encounter data validation, and claims auditing—particularly for high-volume services like DME. “Medicare Advantage fraud involving DME has become increasingly sophisticated, exploiting lagging controls in encounter data systems,” noted federal prosecutors in their filing. The complaint also suggests the company leveraged software tools to mass-generate claim forms, auto-fill billing codes, and route submissions to different carriers to avoid detection. FAQs: Understanding Medicare Advantage Fraud and Your Rights What is Medicare Advantage fraud involving DME? Medicare Advantage fraud occurs when vendors, providers, or third parties submit false claims to MAOs for services or equipment that were not medically necessary, not delivered, or never ordered. In this case, durable medical equipment like braces and dressings were fraudulently billed under stolen identities. How does this type of fraud affect beneficiaries? Victims may find false entries in their medical records or Explanation of Benefits (EOB) statements, potentially harming their future care or eligibility. It may also raise flags during audits and result in billing disputes, even if the person did not knowingly participate. Where can suspected Medicare Advantage fraud be reported? Consumers can report suspected fraud directly to the Office of Inspector General (OIG) or through the Medicare Fraud Hotline at 1-800-MEDICARE. You may also file a complaint online via the OIG Fraud Reporting Portal — a legitimate federal resource for patients and professionals. For more updates on Medicare compliance, legal enforcement, and healthcare fraud investigations, subscribe to JacobiJournal.com. 🔎 Read More from JacobiJournal.com: