A True Win-Win-Win on a High-Cost Cardiac Claim — 47% Saved Beyond PPO Discounts

December 03, 2025 Overview
A 59-year-old female was admitted to a Southern U.S. hospital with sick sinus syndrome, a hypertensive heart and chronic kidney disease experiencing heart failure. She required insertion of a defibrillator in the chest along with defibrillator leads placed in the right atrium and ventricle. She remained inpatient for five days. Even after PPO repricing, the claim still carried a sizable financial hit for both the group and the stop-loss carrier.

Challenge
The hospital billed $131,888.25 PPO repricing brought the allowed amount down to $112,195.18 but liability for the group still topped $102,000 and the stop-loss carrier faced more than $10,000 in exposure. Without deeper review and negotiation, both parties were locked into paying far more than a fair and defensible amount.

Solution
H.H.C. Group's negotiation team performed a detailed review of the claim and used clinical context and benchmark data to support a more reasonable payment. They engaged the hospital with a clear rationale, based on industry standards to justify a reduction that protected the group without undermining provider relationships. With expertise, transparency and a strong foundation of experience, HHC secured a significant reduction that benefited every stakeholder involved.

Results

• Billed Amount: $131,888.25
• PPO Discounted Amount: $112,195.18
• HHC Negotiated Payment: $59,349.71
• Group Savings: $42,692.71
• Stop-Loss Carrier Savings: $10,152.00
• Total Savings: $52,845.47
• Percent Saved vs PPO Allowed: 47.1%

Everyone Won

• Stop-Loss Carrier: Reduced liability to zero while delivering tens of thousands of dollars in added value to their client.
• Group: Saved more than $40,000 and lowered the dollars hitting their aggregate, helping prevent a premium spike at renewal.
• Broker: Strengthened client trust by recommending a partner who delivered measurable results on large claims.

Real People. Real Savings.

This case shows how expert review, fair negotiation and a clear strategy can create shared wins. H.H.C. Group helped the stop-loss carrier avoid unnecessary expense, protected the group from inflated liability and supported the broker's role as a trusted advisor. A true win-win-win, driven by experience and focused, effective negotiation.