As Heart Month highlights the ongoing impact of cardiovascular disease, new data reinforces an important reality for employers, TPAs, brokers and stop-loss carriers. Cardiac risk is not declining and the claims tied to that risk are becoming more frequent, more complex and more expensive.
That's why payors and advisors are turning to HHC Group to review, negotiate and ensure high-cost cardiac-related claims are paid accurately, reasonably and defensibly early – before leverage disappears and savings are lost. That focus is becoming increasingly critical as the clinical and financial burdens of heart disease continue to grow.
Cardiology claims are among the most technically complex claims plans encounter. They often involve multiple providers, expensive implants, layered coding decisions and billing practices that survive PPO repricing while still exceeding what is fair or defensible.
Even when network discounts are applied, significant exposure frequently remains. Without more in depth review, plans can end up paying inflated assistant surgeon charges, missing required multiple-procedure discounts or allowing bundled services to be billed separately. Once those claims are finalized, opportunities to correct or negotiate them largely disappear.
As cardiac utilization increases, the risk of assuming a claim has already been handled correctly increases as well.
As Bruce Roffe, P.D., M.S., H.I.A., president and CEO of H.H.C Group explains recently in BenefitsPRO, These high-cost procedures and chronic conditions lead to expensive treatments and multi-million dollar claims even in younger workers. Hidden billing abuses -- like inflated assistant surgeon fees -- exacerbate costs, stressing the need for proactive management and negotiation for self-funded plans. The key is to scrutinize cardiology bills for overcharges and billing abuses. Every inflated cardiology claim that goes unchallenged contributes to rising employer health care costs, higher stop-loss renewals and increased financial strain on self-insured plans.
In the article, Roffe suggests that benefits professionals can help employers with self-funded plans fight the abuse by watching for three important red flags.
In surgical procedures, it's a standard industry practice for an assistant surgeon to receive only 16% to 20% of the primary surgeon's fee. However, many claims reveal that assistant surgeons are billing at rates far beyond this threshold. In some cases, they're nearly matching the primary surgeon's charges.
Assistant surgeon charges should be flagged and adjusted if they exceed 20% of the primary surgeon's fee. Claim review teams should be trained to apply industry-standard reductions before payments are processed. Additionally, direct negotiation with providers can help challenge these inflated charges, ensuring that self-funded employers pay only what is fair and reasonable.
When multiple cardiology procedures are performed during the same surgical session, standard industry guidelines require secondary procedures to be billed at a 50% discount. This reduction accounts for the overlap in resources and time, ensuring fair and reasonable reimbursement. However, many providers fail to apply this discount, instead billing every procedure at full price to maximize their reimbursement — at the direct expense of employers and their health plans. Every claim involving multiple procedures should be carefully reviewed to ensure the 50% reduction is correctly applied. And here, too, direct negotiations can defend employers against excessive charges.
For many surgical procedures, some services and equipment should already be included the cost of the primary cost and should not be billed separately. For example, the use of an operating microscope in cardiovascular procedures is considered incidental to the surgery itself. However, some providers unbundle these charges, billing them separately to increase reimbursement. Claim review teams can be trained to watch for this problem and compare the actual billing with national coding benchmarks.
Heart Month is a reminder that cardiovascular disease remains widespread and deadly. For those responsible for managing claims, it is also a reminder that cardiac utilization will continue to drive high-dollar exposure.
Plans that rely solely on automation or PPO discounts often walk away from savings they will never recover. Plans that apply expert oversight early protect their financial position, support fiduciary responsibility and avoid unnecessary escalation.
Every high-cost cardiac claim represents a narrow opportunity to verify accuracy, challenge assumptions and secure a fair outcome.
H.H.C. Group helps ensure cardiac claims receive the level of scrutiny today's environment demands.
Don't walk away from savings you should be capturing.
A study released in January by the Journal of the American College of Cardiology examined the state of heart health in the United States, analyzing disease prevalence, risk factors, quality of care and mortality trends. The findings make clear that cardiovascular disease remains a dominant driver of utilization and cost.
The study found no meaningful change in the prevalence of hypertension among U.S. adults over the past decade. Despite that stability, deaths linked to hypertension-related cardiovascular disease nearly doubled between 2000 and 2019. At the same time, diabetes prevalence increased steadily, with deaths related to type 2 diabetes rising sharply over the past decade.
These trends matter because hypertension, diabetes, obesity, smoking and stroke are not abstract risk factors. They are the conditions that lead to inpatient admissions, device implants, surgical interventions and prolonged hospital stays. In other words, they are the upstream drivers of high-cost cardiac claims.
H.H.C. Group's role is to step in before the window of opportunity closes. Our team applies experienced, human-led judgment at the claim level, combining clinical understanding, billing expertise and negotiation strategy to reach fair, defensible outcomes.
This includes attorney-led negotiations conducted by licensed health insurance adjusters, detailed line-item and medical-record-level review, DRG validation and independent clinical assessments to support medical necessity and appropriateness. The goal is not to delay care or disrupt relationships but to ensure claims are paid accurately and reasonably the first time.
Contact HHC Group today to discuss your cardiac claims strategy and see how early, human-led oversight can make a measurable difference.
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