BillionToOne (BLLN) Q3 2026 earnings review
BillionToOne raises its sales outlook, but unpaid bills double
BillionToOne, the maker of genetic blood tests for pregnancy and cancer, grew fast and raised its full-year sales plan while unpaid customer bills kept piling up. Third-quarter revenue rose 47% from a year ago to $123 million as cancer testing sales almost doubled and the average price per test reached $589. Chief executive Oguzhan Atay lifted the full-year outlook, which by our math leaves fourth-quarter growth slowing to 29% as last year's insurance price increases pass.
| Revenue | $123.0M +47% from a year ago |
|---|---|
| Oncology testing revenue | $17.1M +96% from a year ago |
| Accounts receivable | $88.3M +112% since December 2025 |
| Full-year revenue outlook | Raised $7.5M middle of the range: 52% growth |
⚖️ Verdict: 🟢 Bullish
The story got better because cancer testing is scaling ahead of schedule and the company set a December 15 launch date for Northstar Clear, its blood-only test for returning cancer. One caution: unpaid insurance bills jumped to $88 million even though management previously expected held claims to start clearing in the second half.
The question now is whether the jump in average price per test reflects cash that insurers will pay or accounting estimates that are building up in unpaid bills. One view is that new insurance contracts are lifting prices cleanly; the other is that collections are lagging behind booked sales. The quarterly filing's breakdown of prior-period payment adjustments and fourth-quarter cash collections will tell.
🐂 Bull Case
Cancer Testing Almost Doubled and Lifted the Outlook
BillionToOne makes genetic blood tests for pregnant women and cancer patients. Chief executive Oguzhan Atay said "more clinicians are choosing our tests in both prenatal and oncology", and the cancer business is growing much faster than the older prenatal line. That growth allowed the diagnostics maker to raise its full-year sales outlook by $7.5 million at the middle of the range.
- Cancer testing sales: $17.1 million, up 96% from a year ago and up 25% from last quarter by our math
- Prenatal testing sales: $104.3 million, up 41% from a year ago and up 11% from last quarter
- Average selling price across all tests: $589, up 18% from a year ago and up $38 from last quarter
This matters because cancer testing reached 13.9% of total sales by our math, up from 10.4% a year ago, giving the company a second growth source as prenatal growth cools. What to watch: Medicare payment approval for Northstar Response, its test that tracks whether cancer treatment is working, promised by year-end. Approval would lift the price BillionToOne collects on each cancer test.
New Blood-Only Cancer Test Launches December 15
BillionToOne has been releasing new tests all year to win hospital accounts and cancer doctors. Today it set a December 15 launch date for Northstar Clear, "a tissue-free MRD test for patients with all solid tumors" that checks blood for tiny traces of remaining cancer after treatment without needing a surgical tumor sample first.
Because the test needs only a blood draw, the company said it will be "available on day one for all solid tumors". Two medical journals also published studies backing the accuracy of Northstar Response in advanced cancer and "validating Unity Fetal Risk Screen as a first-line prenatal screen". What to watch: initial colorectal cancer study data for Northstar Clear, which will show how the blood-only test compares with rivals that use tumor tissue.
🐻 Bear Case
Uncollected Customer Bills Doubled This Year
BillionToOne books revenue using its own estimate of what health insurers will pay when it delivers a test, before the cash arrives. Last quarter the company said it was holding more than $10 million of insurance claims while national insurers set up new billing codes, and it expected those claims to get processed and paid during the second half of the year.
Instead of shrinking, unpaid bills on the balance sheet rose another 17.9% from last quarter to $88.3 million by our math. Since December 2025, unpaid bills have more than doubled, rising $46.7 million while nine-month sales rose 63%, and that buildup soaked up more than all of the $37.1 million in cash the business generated from operations.
This matters because average price per test jumped to $589 this quarter, and investors cannot tell from the release how much of that increase was collected in cash versus booked as an estimate. What to watch: the quarterly filing's note on payments collected from earlier periods and fourth-quarter accounts receivable. A drop in unpaid bills would prove insurers are paying the higher prices.
Growth Slows as Last Year's Price Gains Pass
Much of BillionToOne's revenue growth over the past year came from signing major insurance contracts in 2025 that raised the average price paid per test from $348 in the third quarter of 2024 to $501 a year later. Now the diagnostics company is comparing its results against quarters that already included those higher contract prices.
Revenue growth slowed from 84% in the first quarter to 64% in the second and 47% in the third, while test volume growth slowed from 44% to 25%. By our math, the middle of the new full-year outlook leaves $124.2 million for the fourth quarter, which means growth slows to 29.3% from a year ago and just 1.0% from the third quarter.
What to watch: fourth-quarter tests ordered, called tests accessioned, against the third quarter's 207,000 tests. If test orders keep slowing toward 20% growth, revenue growth will settle near that lower pace once price increases level off.
Higher Overhead and Cancer Mix Trimmed Operating Margin
Higher test prices lifted gross margin by 0.9 percentage points from a year ago to 70.9% by our math, even though overall cost per test rose slightly because of "the faster growth of our oncology products, which have higher costs per test" and a slight cost increase in prenatal testing.
Below gross profit, operating margin fell 2.6 percentage points from a year ago to 9.0% because selling and administrative costs rose 2.6 percentage points of revenue to 45.5%, and research and development rose 0.9 percentage points to 16.4%. Employee stock pay inside those lines rose 2.5 percentage points of revenue to 7.9%. What to watch: fourth-quarter gross margin after Northstar Clear launches in December without Medicare payment.
Risks this quarter didn't answer
Four standing items from prior quarters got no new numbers or updates in the third-quarter earnings release, so they remain open until the conference call or the quarterly filing.
- Illumina patent lawsuit against the Unity prenatal test (85% of revenue): not mentioned in the release; the quarterly filing's legal note will show any court moves.
- Medicare coverage for Northstar Response: due by year-end, with no update in the release.
- Revenue from prior-period insurance payment adjustments (true-ups): not broken out in the release; the filing will show how much of the $589 average price came from earlier quarters.
- Hospital computer integrations on Epic Aura: no count of connected health systems disclosed.
💲 Other KPIs
Free cash flow — operating cash flow minus equipment purchases — rose 9.2% from a year ago to $8.6 million, or 7.0% of revenue by our math, up from $5.1 million in the second quarter. For the first nine months, free cash flow reached $24.6 million, lifting the cash balance to $561.5 million against $89.0 million of long-term debt.
Net income attributable to common stockholders rose from $1.5 million a year ago and $8.1 million last quarter to $17.4 million, or $0.32 per diluted share. By our math, $6.4 million of that profit came from outside operations: $4.9 million of interest earned on its cash pile and a $1.5 million accounting gain on the fair value of its term loan.
Weighted-average diluted shares shrank 1.3% from the second quarter's 54.5 million after warrant exercises settled, though the count remains more than triple the 15.6 million shares from a year ago before the November 2025 initial public offering and preferred stock conversion.
🔮 Guidance
Raised. The middle of the full-year outlook moved up $7.5 million to $465.0 million, or 52.4% growth over 2025 by our math. That leaves $124.2 million for the fourth quarter at the middle of the range, which means growth slows to 29.3% from a year ago and 1.0% from the third quarter as last year's insurance price jump passes. It is the third raise this year (+$15M, +$20M, $0M, +$7.5M).
Unchanged. BillionToOne still plans to "continue to generate profitability similar to current levels, even with significant continued investments". Operating margin was 9.0% in the third quarter and 10.1% across the first nine months of 2026 by our math, so the plan indicates the company will spend additional gross profit from higher revenue on sales hiring and the December cancer test launch.
❓ Key Questions
Why did unpaid bills jump to $88 million?
Accounts receivable rose $13.4 million in the third quarter and $46.7 million this year. How much of the more than $10 million in held insurance claims from the second quarter was collected, and how much of third-quarter revenue came from prior-period payment adjustments?
Will Medicare cover Northstar Response before year-end?
Management previously expected a MolDX Medicare coverage decision for its Northstar Response cancer test by the end of 2026. Is that approval still on track for the fourth quarter, and what price per test will Medicare pay?
What is the status of the Illumina patent lawsuit?
Illumina sued BillionToOne in May 2026 alleging that the Unity prenatal test — which brings in 85% of company revenue — infringes three patents. Have there been any court rulings, settlement talks, or requests to block sales?
How much will launching Northstar Clear cost in Q4?
Northstar Clear launches on December 15 for all solid tumors before Medicare coverage is in place. What test volume does management expect in the first year, and how much will running unreimbursed tests reduce gross margin?