HC 306 Unit 3 revenue cycle trace example

One Knee, Three Injections, One Denial: A Revenue Cycle Trace of a Viscosupplementation Account From Registration to Final Collection

Student Name

Health Care Administration, Herzing University

HC 306: Healthcare Finance

Instructor Name

January 29, 2026

One Knee, Three Injections, One Denial: A Revenue Cycle Trace of a Viscosupplementation Account From Registration to Final Collection

The Account

A 61-year-old patient with osteoarthritis of the right knee is referred to the sports medicine physician at Bayside Family Medicine, the composite Florida clinic, after months of physical therapy and anti-inflammatory medication have not helped. The physician recommends a series of three weekly injections of a hyaluronic acid product into the knee under ultrasound guidance. The patient has an employer-sponsored preferred provider organization plan that requires prior authorization for hyaluronic acid injections. The clinic buys the drug, stores it, injects it and bills the plan for both the procedure and the drug. The trace follows the account from the first phone call to the final patient payment.

1. Registration and Eligibility

Who: front desk scheduler, at the time the appointment is made, then again at check-in. What must be right: the patient's name, date of birth and member number exactly as the plan has them; the plan confirmed active; the subscriber and relationship recorded. The scheduler runs an electronic eligibility inquiry, the standard transaction for eligibility questions between providers and plans (45 C.F.R. § 162.1203), which returns active coverage, the remaining deductible ($1,150 of $2,000) and 20% coinsurance for in-office procedures and drugs. What it looks like when wrong: a claim rejected weeks later because the member number was mistyped or the patient changed plans, with the drug already given.

2. Authorization

Who: the clinic's referral and authorization coordinator. What must be right: the request names the specific drug by its billing code and brand, the number of injections, the knee, and the dates, and it includes notes showing failed conservative treatment, which the plan's policy requires. The plan approved three injections of the named product within a 60-day window and issued an authorization number. What it looks like when wrong: an injection given outside the approved dates, a different product than the one approved, or more injections than authorized; each produces a denial that the patient cannot be billed for if the clinic failed to obtain proper authorization.

3. The Service

Who: the physician and a medical assistant. What must be right: the drug given is the drug authorized; the lot number, expiration date and amount are recorded; and the ultrasound image is saved, since the procedure code for guided injection requires a permanent record of the imaging. What happened: on the day of the first injection, the authorized product was out of stock, and the medical assistant substituted a different hyaluronic acid product that the clinic also stocks. Clinically, the products are similar. Financially, the substitution broke the link to the authorization.

4. Documentation

Who: the physician. What must be right: a procedure note stating the diagnosis, the knee, the guidance method, the product, the dose and the patient's tolerance, signed on the day of service. What it looks like when wrong: an unsigned note, or a note missing the image, holds the charge until corrected.

5. Coding and Charge Capture

Who: the clinic's certified coder, reviewing each procedure note. What must be right: the procedure code for knee injection with ultrasound guidance; the drug's billing code with the correct number of units; the drug's national drug code on the claim line, which many plans require for drugs; and the knee osteoarthritis diagnosis code. Charge capture means every billable element reaches the claim: the procedure, the drug, and nothing that was not given. What it looks like when wrong: a missing drug line, the clinic's largest single cost on this account, which would leave hundreds of dollars unbilled.

6. Claim Submission

Who: the billing specialist, through the clinic's clearinghouse, in the standard electronic claim format (45 C.F.R. § 162.1102). What must be right: the authorization number in the claim, and a claim that passes the clearinghouse's automated edits. The first claim passed the edits, because the edits check format, not whether the product matches the authorization.

7. Remittance

Who: the payment poster, from the plan's electronic remittance. For the first injection, the plan paid the procedure but denied the drug line with a reason code indicating that precertification or authorization was absent, because the drug billed was not the drug authorized. The second and third injections, given with the authorized product after it was restocked, were paid. The coordinator requested a retroactive authorization for the substituted product with the clinical notes and the stock record; the plan approved it on appeal 34 days later, and the corrected claim was paid 19 days after that.

8. Patient Billing and Collection

Who: the billing specialist and front desk. After all three claims were adjudicated, the patient's share, $1,150 of remaining deductible plus 20% coinsurance on the rest, was billed on one statement, with the explanation that the first injection's share had been delayed by the appeal. The patient paid in two installments over 45 days. Total days from first injection to final collection: 98. The same account without the substitution would have closed in about 45 days.

What the Trace Shows

Two lessons follow. First, most of the work that protects revenue happens before and during the service, not in the billing office; the denial began at the supply cabinet, and no later stage could catch it before the plan did. Second, a simple control at the point of service, a check of the authorized product against the product in hand before the injection, would have avoided 53 days of delay and the risk of losing the drug payment entirely. The course text's model of the revenue cycle places these front-end stages first for exactly this reason (Pink & Song, 2020).

A third, smaller lesson concerns timing. The account's 98 days were spent mostly waiting: 34 days for the appeal decision and 19 for the corrected payment. The clinic cannot shorten the plan's review, but it can shorten its own part. The coordinator filed the retroactive request eight days after the denial arrived, because denials were worked in a weekly batch. Working authorization denials within two business days of the remittance, as the clinic now does, would have cut about a week from this account and, across the clinic's roughly 40 such denials a year, would bring cash in sooner without any extra staff.

References

Pink, G. H., & Song, P. H. (2020). Gapenski's fundamentals of healthcare finance (3rd ed.). Health Administration Press.

Standards for eligibility for a health plan transaction, 45 C.F.R. § 162.1203 (2025).

Standards for health care claims or equivalent encounter information transaction, 45 C.F.R. § 162.1102 (2025).