Blue Cross – Blue Shield Sued


Sciences Sues BCBS of North Carolina for refusing to pay Colo Guard Claims

a GenomeWeb staff reporter

NEW YORK (GenomeWeb) – Exact Sciences has instituted a suit against Blue Cross Blue Shield of North Carolina (BCBS-NC). In the District Court of Middle District of North Carolina for illegal adoption of a policy  that gives them room to deny exact their benefit and they refuse to pay for colorectal cancer screening test known as colo guard.

The company claims BCBS-NC has taken an illegal stand and has declined more than $ 410,000 in payments, starting from  October 2014 and the continuation to  the present.

Earlier this month, Exact also sued insurer Humana for denying same test payments. In that suit, filed at the Louisville Division of the District Court for the Western District of Kentucky. Exact said the insurance company  refused to pay  claims for the said  Colo Guard testing  right from October 2014 and estimates Humana owes it at least $ 800,000 in payments for 4664 Colo Guard test it has done ever since.

As in the Humana lawsuit, exact claims BCBS-NC have neglected its obligation based on the Employee Retirement Income Security Act (ERISA) and the state laws. The company said it billed BCBS-NC for 936 Colo Guard tests carried out in   nine (9) states which is more than $ 568,000.

Exact said, that the laws of North Carolina allow insurers to test for colorectal cancer by the American Cancer Society, or otherwise be recommended cover by established medical practice. But BCBS-NC “an official policy appears to have adopted a clear violation to exclude from coverage mandate Colo Guard and, according to the BCBS-NC is saying the said test is for research purpose.

Exactly also said it has exhausted all available legal remedies, filing 211 internal appeals body, 204 of which were denied or ignored.

What is colorectal cancer?
Cancer is a class of diseases characterized by molding out of control cell growth and colon cancer when this uncontrolled cell growth initiates with cells in the large intestine. The majority of colon cancer comes from the small, non-malignant (benign) tumors called adenomatous polyps that form on the inner walls of the large intestine. Some of these polyps can develop into malignant cancer over time if they are not removed during colonoscopy. Colon cancer cells will invade and damage to healthy tissue in the vicinity of the tumor caused a lot of complications.

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