Incredible but True: 74% Saved on ENT Surgery Claim — Even After PPO Discount

October 03, 2025 Overview
A 48-year-old female underwent multiple ENT procedures at a Northeastern ambulatory surgery center, including tonsillectomy, turbinate reduction, septum repair and removal of inflamed sinus tissue. Although the procedures were performed in-network and subject to PPO discounts, the billed amount still represented a significant liability for the plan.

Challenge
The provider billed $60,620. Even after PPO repricing, the allowed amount was $53,951, still far above a defensible payment level. Without further intervention, the plan faced unnecessary overspending.

Solution
An attorney-led negotiator conducted a detailed claim review using published and proprietary databases. Applying clinical context and historical precedent, the negotiator presented a fair and defensible offer. Direct engagement with the surgery center's decision makers led to a signed agreement that dramatically reduced the claim liability.

Results

• Billed Amount: $60,620
• PPO Allowed Amount: $53,951
• Negotiated Payment: $14,000
• Incremental Client Savings: $39,951
• % Saved vs PPO Allowed: 74.1%

Real People. Real Savings.

Even with PPO discounts in place, this claim shows how expert review and skilled negotiation can unlock substantial additional savings. In this case, liability was reduced by nearly three-quarters, protecting plan resources and reinforcing the value of proactive claim management.

Contact us to jump-start opportunities to help your organization reduce costs and protect plan assets.