Exact Sciences files lawsuit against Humana over unpaid claims: 7 takeaways

Madison, Wis.-based Exact Sciences filed a lawsuit against Humana in Kentucky federal court over the payer's refusal to reimburse for the company's non-invasive colorectal cancer screening test Cologuard, according to a WisBusiness report. 

Here are seven takeaways.

1. Exact Sciences' lawsuit alleges Humana refused to pay for more than $800,000 in claims for Cologuard, according to the report.

2. Humana enrollees, 4,664 in total, in 45 states have used the Cologuard test, but the payer has yet to pay any of the claims.

3. Humana has been sending notices saying "Cologuard is not covered under Humana's commercial plans" to in-network providers in Kentucky and potentially other states, according to the report.

4. Lawyers with Exact Sciences sent a cease and desist notice to the payer. Humana promised to stop sending notices and reprocess claims denied since the first of this year.

5. Exact Sciences' lawsuit focuses heavily on mandates requiring payers to cover colorectal cancer screening in some states, including Kentucky. Kentucky's colorectal cancer rate is significantly higher than the national rate.

6. The mandate states "all colorectal cancer examinations and laboratory tests specified in current American Cancer Society guidelines" be covered, according to the report. Cologuard has been included in ACS guidelines for two years.

7. Cologuard is covered by CMS and a number of commercial payers. Most recently, Anthem BlueCross of California agreed to cover the test, according to the report.

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Webinars

Featured Whitepapers

Featured Podcast