$111K Saved on In-Network Cancer Surgery Claim—61.4% Below PPO Allowed Amount

June 20, 2025 Overview

A 54-year-old female patient in the Midwest underwent surgery for a malignant tumor in the uterine wall (myometrium), complicated by additional neoplasms in the lungs, kidney failure and a post-procedural reaction to psychotropic medications. Though the treatment was in-network and subject to PPO pricing, the reduce amount still threatened to push the client past their stop-loss limit, putting them at risk for significant out-of-pocket costs.

Challenge

The PPO network discounted the claim by 22.8% but even the reduced amount of $181,419 remained far above what was considered reasonable by HHC Group. To prevent the plan from exceeding its stop-loss threshold and avoid a major out-of-pocket hit, H.H.C. was brought in to push for additional savings below the contracted rate.

Solution

An experienced H.H.C. case manager:

• Conducted a comprehensive review using industry benchmarks and HHC's proprietary pricing database.
• Determined a data-backed, reasonable payment amount of $70,000.
• Reached out to a senior decision-maker at the hospital with whom the CM had a longstanding working relationship.
• Presented the clinical and financial justification for the reduced payment, emphasizing fairness and precedent.

The trust and rapport established over prior negotiations played a pivotal role in securing acceptance of the offer.

Results

• Original Billed Amount: $234,846
• PPO Discounted Amount: $181,419 (22.8% discount)
• Negotiated Amount: $70,000.00
• Total Savings: $164,846 (70.2% below billed amount)
• HHC Incremental Savings: $111,419 (61.4% below PPO rate / 47.4% additional savings)

Real People. Real Savings.

This case demonstrates how HHC Group continues to outperform standard network discounts and other cost containment companies, even on in-network claims. Through deep expertise, trusted provider relationships and rigorous analysis, we delivered an extra $111K in savings that would have otherwise been lost. Our edge? Real people negotiating with real people to deliver real results.

Don't stop at PPO discounts, get the savings you really need. Contact HHC Group today.