Client Success Story: $38K Additional Saved on In-Network Orthopedic Surgery Claim —Even After PPO Discount

May 22, 2025

Overview:

A 58-year-old female underwent orthopedic surgery at a Southeastern U.S. medical center to repair a displaced fracture of the surgical neck of the right humerus. While the procedure was performed in-network and subject to PPO pricing, the billed amount of $188,539.58 still triggered concern for the stop-loss carrier.

Challenge:

Although the PPO reduced the claim to an allowed amount of $118,539.97—a 37% discount off billed charges—that figure still exceeded what was financially reasonable for the services provided. The stop-loss carrier turned to H.H.C. Group to negotiate a fair reimbursement and avoid unnecessary overspending.

Solution:

An H.H.C. Group attorney case manager conducted a full claim review using internal and published databases and leveraged his specialized knowledge in orthopedic procedures. The negotiator escalated discussions to the health system's Regional Accounts Receivable Director, supporting an offer and revised offer with data and documentation. Within 5 working days, a signed agreement was reached.

Results:

• Billed Amount: $188,539.58
• PPO Allowed Amount: $118,539.97
• Negotiated Payment: $80,000
• Additional Savings: $38,539.97 (32.7% below PPO Allowable)
• Turnaround Time: 5 business days

Real People. Real Savings.

Even with a substantial PPO discount, H.H.C. Group delivered an additional 32.7% in savings, demonstrating the power of combining expert review with skilled negotiation—even within network contracts. For stop-loss carriers and self-funded plans, H.H.C. is a trusted partner in maximizing value on high-dollar claims.

Looking to reduce costs beyond your network discounts? Contact us today.