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July 29 — Humana Inc. is seeking to recover millions of dollars it allegedly overpaid a Maryland-based urine drug testing company for services that weren't covered under the insurer's health plans ( Humana Inc. v. Ameritox, LLC , M.D.N.C., No. 1:16-cv-01006, complaint filed 7/28/16 ).
Ameritox LLC fraudulently sought and received substantial payments from Humana by submitting “false and fraudulent claims” for urine testing services Ameritox knew or should have known weren't covered, according to the complaint, filed July 28 in the U.S. District Court for the Middle District of North Carolina. Ameritox directed its “deceptive and fraudulent conduct” toward Humana's plans, including its Medicare Advantage, Medicaid and employer-sponsored plans that provide coverage to millions of members nationwide, the complaint said.
Humana, one of the largest health insurance companies in the nation, alleges that earlier this year it met with Ameritox representatives to discuss the submission of improper claims and reiterate the reasons for Humana's denials. However, Ameritox allegedly continued to bill Humana for duplicative and medically unnecessary testing, the complaint said.
“It's disappointing that our on-going talks with Humana to work through some differences of opinion will now have to play out in court,” an Ameritox spokesperson told Bloomberg BNA in a July 29 e-mail.
Ameritox tests specimens and monitors results for health-care providers that prescribe medications used to treat patients for chronic pain and addiction.
“Both companies are working hard to find ways to address the national epidemic of prescription drug misuse and abuse,” an Ameritox spokesperson said. “Many in the medical community believe strongly that urine drug monitoring has proven to be a critical tool in that battle.”
Humana alleges that Ameritox submitted claims for the payment of testing services that were duplicative and weren't medically necessary, or for testing that wasn't ordered by the treating provider or was unsupported by the required medical necessity documentation.
As a result, Humana paid Ameritox millions of dollars for claims that weren't valid and wouldn't have otherwise been payable, the complaint said.
Humana now seeks a court declaration that enjoins Ameritox from continuing to engage in the alleged deceptive billing practices under the Employee Retirement Income Security Act.
Ameritox declined to comment on specific allegations in the lawsuit but said that it disagreed “vigorously.”
Tuggle Duggins P.A. represents Humana.
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Text of the complaint is at http://www.bloomberglaw.com/public/document/HUMANA_INC_v_AMERITOX_LLC_Docket_No_116cv01006_MDNC_Jul_28_2016_C.
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