Humana sued for non-payment of cancer tests
The maker of a new test for colorectal cancer is suing Louisville-based Humana Inc., alleging its denial of payment for screenings performed on more than 4,600 patients violates state and federal law.
In a suit filed this week in U.S. District Court in the Western District of Kentucky, Exact Sciences Corp. and Exact Sciences Laboratories LLC allege that Humana improperly and illegally refused to pay claims totaling in excess of $800,000 under its commercial insurance and Medicare Advantage plans since October 2014.
The company is seeking an award of unpaid damages, lost profits and restitution for improperly withheld reimbursements, as well as legal fees.
Humana officials declined to comment. Claims made in a lawsuit give one side of a case.
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In its complaint, Exact's lawyer assert that Humana gave various reasons for denying the claims, including a contention that the company's trademarked Cologuard is "experimental or investigational." The Madison, Wisc.-based company also accuses Humana of falsely informing doctors in Kentucky and other states that Cologuard was ineffective.
The Louisville company also alerted providers that the test is not covered under its commercial plans.
Exact Sciences contends Humana is required by law to cover Cologuard, which it said has been approved by the U.S. Food and Drug Administration and the Centers for Medicare and Medicaid Services and endorsed by the American Cancer Society. Using DNA technology, the test examines patients' stools for abnormal skin cells that can point to cancer and pre-cancer.
Traditionally, doctors have used scopes inserted inside sedated patients to check the colon for abnormal polyps and other markers for cancer. Medical providers have been eager to find less risky and costly alternatives for a widely recommended screening for people age 50 and older.
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All told, since its product hit the market in October 2014, Exact Sciences performed 4,664 test in 45 states and billed Humana for more than $800,000. Despite appeals of the denials, the company has stood firm, the suit says, asserting at times that Exact had failed to get pre-authorization for the tests.
The company points to states that have enacted coverage mandates, including Kentucky, that require health insurers to underwrite screenings which are approved under current American Cancer Society guidelines. Even without mandates in other states, Exact Sciences officials said that coverage should apply for the test.
“Humana’s wholesale refusal to provide coverage for Cologuard is in clear violation of state and federal law, as well as Humana’s Plans, and has caused Exact to sustain substantial damages,” Exact Sciences suit says.
Reporter Grace Schneider can be reached at 502-582-4082 or email at gschneider@courier-journal.com.