Case Study: Out-of-Network Surgical Claim Negotiation

January 10, 2025

A 30-year-old female underwent a minimally invasive laparoscopic procedure at an ambulatory surgery center in Northern California. The out-of-network provider billed an excessive $839,565.55 for the primary procedure and assistant surgeon services.

Challenge

The claim included two components:

• Primary Procedure Claim with 10 diagnosis codes and 6 procedure codes
• Assistant Surgeon Claim with 9 diagnosis codes and 6 procedure codes

The charges were far above industry benchmarks, requiring expert negotiation to ensure a fair and defensible payment.

Solution

An H.H.C. Group attorney case manager conducted a detailed claim review, referencing CMS guidelines, proprietary databases, and prior billing precedent. The case manager identified, contacted, and convinced the provider's decision maker to reduce the bill by 85.7%, all within just 4 days.

Timeline

• 6/3 – Claim received.
• 6/4 – Provider contacted.
• 6/7 – Final signed agreement executed.

Results

• Total Billed Amount: $839,565.55
• Negotiated Payment: $120,000
• Total Savings: $719,565.55 (85.7%)
  
  • Procedure Claim: 91.7% reduction
  • Assistant Surgeon Claim: 81.1% reduction

Testimonial

"H.H.C. Group has been helping us save lots of money for our clients since 2003. Year in and year out H.H.C. delivers exceptional savings and unmatched client service. They always go the extra mile for us."

Real People. Real Savings.

H.H.C. Group's proven ability to negotiate deep savings—even on out-of-network, high-dollar claims—continues to protect client budgets and minimize overpayment risk.

Contact H.H.C. Group to learn how we can help your organization achieve comparable results.