Stop-Loss Win: $45K Saved on In-Network Cardiac Claim — 18% Below PPO Rate

July 29, 2025 Overview

A 39-year-old male patient with chronic congestive heart failure underwent a procedure for cardiac electrode displacement at a Pacific Northwest hospital. While the claim was in-network and subject to PPO pricing, the remaining financial liability posed a significant burden to the stop-loss carrier's client.

Challenge

The provider's billed charges totaled $296,426, with a PPO-allowed amount of $252,555 — a 15% discount off charges. But even after this "discount," the stop-loss carrier still faced a liability of $188,020 and their client would have been forced to absorb a substantial overpayment without intervention. They turned to H.H.C. Group to step in where standard discounts fell short.

Solution

H.H.C. Group's attorney-led case manager, backed by 30 years of negotiation expertise, leveraged a strong working relationship with the hospital's decision-maker to drive deeper savings. By using internal benchmarks and historical claims data, we:

• Proposed a defensible, fair payment based on real-world precedent.
• Negotiated directly and efficiently to reach agreement.
• Closed the deal with a signed provider agreement — eliminating balance billing risk and locking in savings.

Results

Billed Charges: $296,426

PPO Allowed Amount: $252,555

Stop-Loss Responsibility Pre-Negotiation: $188,020

H.H.C. Negotiated Payment: $207,498

Total Savings: $45,056

Additional Savings Beyond PPO Rate: 18% below PPO

Overall Reduction from Charges: 30% saved

Real People. Real Savings.

This case proves what many miss: in-network status doesn't mean fair pricing — and PPO discounts are just the starting point. H.H.C. Group goes further, helping stop-loss carriers and TPAs identify hidden savings and avoid overpayment. In this case, we helped the stop-loss carrier protect their client from a $45,000 overcharge. With signed agreements and skilled negotiation, we protect your bottom line — every time.