HI555 Unit 2 Account Trace Example

One Copied Coverage Field, 151 Days: A Unit 2 Account Trace of a Kidney Infection Stay From the Emergency Door to Zero Balance

[Student Name]

Purdue University Global

HI555: Revenue Cycle Management

Unit 2 Account Trace

[Instructor Name]

[Date]

Bellcourt Health, the patient, the plan and every date and amount are composite; the sources cited are real.

The Account

A 74-year-old patient arrived at Bellcourt Health's main emergency department on a Saturday evening in January with fever and flank pain and was admitted the next morning with acute pyelonephritis. The stay lasted three days. The patient had seen a Bellcourt clinic in October under traditional Medicare and had enrolled in a Medicare Advantage plan effective January 1. The plan's contract with Bellcourt requires notice of any inpatient admission no later than one business day after it happens and reduces payment for late notice. The account reached a zero balance 151 days after arrival.

The Trace

Each line gives the day counted from arrival, the step, the department and system, what happened, and the account status afterward.

1. Day 0. Emergency registration, patient access, registration system. Coverage copied from the October visit because the system treats coverage verified within 90 days as current; no eligibility inquiry sent. Status: open, traditional Medicare primary.

2. Day 1. Inpatient order, emergency physician, record system. Patient admitted. Status: inpatient.

3. Day 1. Admission notification worklist, case management. Account not listed, since the worklist shows only Medicare Advantage and commercial plans. Status: unchanged.

4. Day 2. End of the plan's notice window (next business day after a weekend admission). Status: notice not given.

5. Day 3. Discharge home. Status: discharged, awaiting coding.

6. Day 5. Coding complete, health information. Status: final coded.

7. Day 6. Claim drops to traditional Medicare, patient financial services, billing system. Status: billed.

8. Day 8. Claim rejected by Medicare, which shows the patient enrolled in a Medicare Advantage plan. Status: rejected.

9. Day 8. Rejection routed to the traditional Medicare follow-up queue because the account still lists Medicare as primary. Status: in queue.

10. Day 41. Follow-up specialist opens the rejection, runs an eligibility inquiry and finds the plan. Status: coverage corrected.

11. Day 42. Late notice sent to the plan, case management. Status: plan notified.

12. Day 43. Claim submitted to the plan. Status: billed to the plan.

13. Day 57. Plan denies the claim for lack of timely notice. Status: denied.

14. Day 60. First-level appeal filed with the clinical record. Status: in appeal.

15. Day 89. Plan approves the stay as medically necessary but applies the contract's late-notice reduction of $3,050. Status: approved, reduced.

16. Day 104. Payment posts. Status: patient responsibility open.

17. Day 108. Statement for the inpatient copay sent to the patient. Status: billed to patient.

18. Day 122. Patient calls and sets up a two-payment plan. Status: on plan.

19. Day 151. Second payment posts. Status: zero balance.

Of nineteen events, only three could have changed what Bellcourt was paid, and all three happened in the first two days.

Three Moments That Are Easy to Confuse

The error was created on day 0, when registration copied coverage instead of checking it. The registration system's ninety-day rule exists to save time on repeat visits, and it works for patients whose coverage has not changed. January is the month it fails most, because changes made during Medicare's fall enrollment period all begin together on January 1.

The loss became fixed on day 2, when the plan's notice window closed. Up to that point a single eligibility inquiry would have revealed the plan, and case management would have sent notice on time. After it, no later action could recover the $3,050, because the reduction is written into the contract. Every event from day 3 onward recorded or worked an outcome that was already set.

The loss was discovered on day 41, when a specialist finally opened the rejection. The rejection had arrived on day 8, but it sat in a queue meant for traditional Medicare accounts, where it ranked below claims with higher balances and clearer next steps.

Separating these moments matters for the remedy. Fixing the queue would have moved discovery from day 41 to perhaps day 10, which would have shortened the time in receivables by about a month. It would not have saved any of the $3,050. Only a change at registration or at the notice worklist could have done that.

What the Account Cost

The reduced payment is the visible cost: $3,050. Rework adds about four and a half staff hours across eligibility, notice, rebilling, the appeal and the patient payment plan. Studies of billing and insurance work have found that this kind of activity consumes a substantial share of revenue at academic systems (Tseng et al., 2018). The delay also has a carrying cost. The payment that should have posted around day 20 posted on day 104, so Bellcourt waited roughly 84 extra days for the plan's share. The patient, finally, received a statement more than three months after discharge for a stay they had assumed was settled.

Where the Remedy Belongs

The trace implicates two departments. Patient access owns the registration rule that allowed copied coverage, and the simplest change is to require a live eligibility inquiry on every inpatient admission and on every January visit, whatever the date of last verification. Case management owns the notice worklist, which shows only accounts already flagged as plan members. A worklist built from eligibility responses rather than from the registration field would have listed this patient on day 1.

Patient financial services owns the queue routing, and it should be fixed too, but the trace shows it belongs in a second tier: it affects time and cost of collection, not the amount collected. Payer denials of this kind are common in Medicare Advantage, where review rules differ from traditional Medicare (Office of Inspector General [OIG], 2022), so a system that leans on Medicare coverage being stable will keep meeting them. The broader lesson is that billing complexity spreads the effect of one front-end shortcut across many departments (Gottlieb et al., 2018).

What the Trace Says About January

The trace also suggests a seasonal test. If copied coverage fails mostly in January, then the same rule should produce a spike in plan rejections every winter, and the rejection queue should swell in the same weeks. Bellcourt's billing system can count rejections by month for the last three years in under an hour. If the spike appears, the cost of a live inquiry on every visit could be limited to the first quarter, when coverage changes cluster, and the registration staff who object to the extra step would see why it is needed.

Limits

One account cannot show how often this path occurs. A search of January admissions for copied coverage would estimate the frequency and the revenue at stake, and that is the natural next step for the denial analysis later in the course.

References

Gottlieb, J. D., Shapiro, A. H., & Dunn, A. (2018). The complexity of billing and paying for physician care. Health Affairs, 37(4), 619-626. https://doi.org/10.1377/hlthaff.2017.1325

Office of Inspector General. (2022). Some Medicare Advantage organization denials of prior authorization requests raise concerns about beneficiary access to medically necessary care (OEI-09-18-00260). U.S. Department of Health and Human Services.

Tseng, P., Kaplan, R. S., Richman, B. D., Shah, M. A., & Schulman, K. A. (2018). Administrative costs associated with physician billing and insurance-related activities at an academic health care system. JAMA, 319(7), 691-697. https://doi.org/10.1001/jama.2017.19148