Managing High-Cost Claims in Today's Healthcare Landscape: Proven Strategies You Can't Afford to Miss

February 06, 2026 High-cost claims are no longer rare events. They're accelerating, driven by private equity-backed provider groups, specialty drug inflation, opaque hospital pricing and increasingly complex catastrophic cases.

For TPAs, stop-loss carriers, brokers and plan sponsors, this isn't just a cost issue. It's a fiduciary risk issue. Every large claim left unchecked puts financial stability, compliance and client trust on the line.

That's why HHC Group joined The Granite List for a recent webinar focused on practical, real-world strategies to manage and reduce high-cost claims, without sacrificing fairness, speed or compliance.

If you weren't able to attend live, here's what you need to know and why waiting to act could cost far more than you think.

High-Cost Claims Are Rising Faster Than Plans Can Absorb

High-dollar claims are becoming the rule, not the exception.

Seven-figure claims are rising sharply across self-insured plans, with employers far more likely today to face catastrophic exposure than in prior years. The top drivers are clear:

• Private equity consolidation in healthcare.
• Specialty drugs and gene therapies.
• Hospital pricing opacity.
• Increasing regulatory complexity.

As discussed during the webinar, inaction is no longer neutral. Fiduciary responsibility now extends into how claims are reviewed, negotiated and paid. Overpaying a claim, even unintentionally, can expose plans and advisors to scrutiny long after the check clears.

Where Costs Hide — Even After PPO Discounts

One of the most dangerous misconceptions addressed in the webinar:

"If it's in-network, it must be accurate."

In reality:

• 8–12% of large claims contain billing errors, upcoding or non-billable services.
• DRG manipulation can inflate reimbursement by 20–50%.
• In-network claims often include inappropriate modifiers and inflated supply charges that survive PPO discounts.

Automation alone doesn't catch this. By the time errors surface, it's often too late to recover missed savings.

This is where human expertise becomes the difference between paying fast and paying right.

Human in the Middle of Smart Negotiations

At H.H.C. Group, cost containment is not automated and forgotten. It's executed by real people with real credentials.

During the webinar, the team emphasized why attorney-led, expert-driven oversight matters:

• Licensed health insurance adjusters handling negotiations.
• Attorney-led strategy to ensure contracts, compliance and defensibility.
• Certified coders and licensed pharmacists validating accuracy line by line.
• Registered nurses performing medical record–level DRG validation.
• URAC-accredited independent reviews supporting medical necessity decisions.

This isn't about being aggressive. It's about being accurate, fair and defensible, while still securing meaningful savings.

Real-World Results: Proof, Not Promises

The webinar didn't rely on theory. It showed what happens when expertise meets urgency.

Examples discussed included:

• A $476,000 out-of-network surgical claim resolved for $90,000 — an 81% reduction.
• A $2.34M in-network cancer claim negotiated down to $531,000 — delivering three times the savings of the PPO discount alone.
• Dialysis claims reduced by more than 90% through flat-rate repricing.
• Most large claims resolved within 5–7 business days.

These results aren't anomalies. H.H.C. Group consistently achieves:

• ~70% success rate on out-of-network claims.
• Average reductions exceeding 40%.
• Savings often reaching 60–90% on complex cases.

Critically, these outcomes come without balance billing, reversals or member disruption.

Speed Matters — But Only When It's Right

In high-cost claims, speed is essential. Speed without strategy creates risk.

The webinar emphasized that the most effective outcomes occur when:

• Experts engage early.
• Providers are approached by people they recognize and trust.
• Clinical, financial and legal review happens simultaneously.
• Negotiations occur before disputes escalate.

H.H.C. Group's hybrid model, combining smart automation with deep human oversight, allows claims to move quickly without sacrificing accuracy or compliance.

What This Means for TPAs, Stop-Loss Carriers and Advisors

If you're responsible for managing, advising on or underwriting large claims, the message from the webinar was clear:

• High-cost claims are increasing.
• Fiduciary pressure is intensifying.
• Automation alone is not enough.
• Waiting exposes plans to unnecessary loss.

The organizations that protect their plans best are the ones that verify, negotiate and defend every large claim, every time.

Don't Walk Away From Savings You Can Still Capture

Every large claim is an opportunity, either to protect your plan or to quietly overpay.

If your current approach relies too heavily on automation, assumes PPO discounts are sufficient or lacks true human oversight, you may already be missing savings you'll never get back.

The strategies shared in this webinar prove one thing:

Real people, applied at the right moment, deliver real savings, fast.

Bring your toughest claims. Protect your plan. Stop leaving money on the table.

Contact H.H.C. Group today to learn how expert-led cost containment can make the difference when it matters most.