Case Study: Out-of-Network Surgical Claim Negotiation

January 10, 2025

Overview

Provider: Ambulatory Surgery Center, Northern California
Patient: 30-year-old female
Claim Type: Out-of-Network
Services Provided:

1. Minimally invasive laparoscopic procedure to diagnose conditions involving digestive and reproductive organs.
2. Assistant surgeon (Modifier 80).

H.H.C. Group successfully negotiated significant savings on two claims submitted for a laparoscopic surgery, leveraging its expertise in claims review and dispute resolution.

Challenge

Managing high-cost out-of-network claims presents unique challenges, including inflated charges and complex billing structures. This case involved two claims:

1. Procedure Claim: Containing 10 diagnostic codes and 6 procedure codes.
2. Assistant Surgeon Claim: Including 9 diagnostic codes and 6 procedure codes.

The provider initially billed a total of $839,565.55 for the procedure and assistant surgeon services, a cost far exceeding reasonable benchmarks. Ensuring fair and appropriate payment while protecting the client's financial interests required expert negotiation and claims evaluation.

Solution

H.H.C. Group's attorney case manager brought extensive experience in claims review and negotiation to this case. Using a combination of published and proprietary databases, CMS guidelines and a deep understanding of the procedure's complexity, H.H.C. Group determined the appropriate payment amounts for both claims.

• Process Timeline:
  
  • 6/3: Claim received from client.
  • 6/7: Final agreement on negotiated amount reached and signed.
• The case manager's comprehensive review and negotiation expertise resulted in significant cost reductions while maintaining fairness for all parties involved.

Results

H.H.C. Group secured substantial savings for the client:

• Total Charges: $839,565.55
• Negotiated Amount: $120,000
• Client Savings: $719,565.55 (85.7% total savings)
  
  • Procedure Charge: 91.7% reduction
  • Assistant Surgeon Charge: 81.1% reduction

Testimonial

"HHC Group has been helping us save lots of money for our clients since 2003. Year in and year out HHC delivers exceptional savings and unmatched client service. They always go the extra mile for us."

Conclusion

For 30 years, H.H.C. Group has been a trusted partner in minimizing claims spend and ensuring fairness in healthcare payments. From negotiating reductions on high-cost claims to catching overcharges through line-item bill reviews, H.H.C. Group consistently delivers exceptional results.

This case underscores H.H.C.'s unwavering commitment to helping clients save money, maintain compliance and ensure fair and reasonable payment amounts for all claims.

Contact H.H.C. Group to learn how we can help your organization achieve similar results.