Updated at 2:37 p.m. with Ameritox comments.
Humana alleges in a lawsuit that a drug testing company has received millions of dollars from the insurer through claims that were fraudulent.
Humana said Baltimore-based Ameritox engaged in a “fraudulent scheme … to improperly maximize profits” by filing claims with Humana to get reimbursed for urine drug testing services that were not covered by the insurance policies or not medically necessary.
Ameritox conducts testing to help patients and their doctors monitor drug adherence and misuse, especially for patients with chronic pain.
Humana filed the suit on Thursday in U.S. District Court in North Carolina, where Ameritox has a laboratory. Ameritox had not yet filed a response to the lawsuit as of Monday afternoon. A company spokesman told IL via email that Ameritox “cannot comment on specific allegations, other than to say we disagree vigorously.”
Humana said in the lawsuit that it began denying claims after it discovered Ameritox’s fraudulent and improper billing practices through internal investigations.
“Humana had contacted Ameritox numerous times in 2013 and 2014 to request medical records to substantiate the laboratory services billed and determine the medical necessity of the services performed,” the insurer said. “A low number of records were received, and many of the records were incomplete.”
“Based on Humana’s analysis of claims submitted by Ameritox in 2015, over 90 percent of the claims were not payable for failure to comply with Humana policies,” the company said. “The majority of denied claims were for services that were medically unnecessary and unsupported by the required documentation.”
Despite discussions with Ameritox, Humana said the company has continued to “to bill Humana for duplicative and medically unnecessary testing.”
The Louisville-based insurer has requested an unspecified amount of compensatory and punitive damages.
Ameritex spokesman Lon Wagner told IL that the company was disappointed that its efforts to work through their differences will play out in court.
“We know that both companies are working hard to find ways to address the national epidemic of prescription drug misuse and abuse. Many in the medical community believe strongly that urine drug monitoring has proven to be a critical tool in that battle, and Ameritox works with doctors to base their use of this tool on the medical needs of each individual patient,” Wagner said.