ZZT30240H To Schedule 4 COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com... STATE OF CALIFORNIA SCHEDULE 6PROGRAM: NONCONTRACT Provider Name:
Trang 1STATE OF CALIFORNIA SCHEDULE 4B
PROGRAM: NONCONTRACT
Provider No.
ZZT30240H
(To Schedule 4)
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
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Trang 2STATE OF CALIFORNIA SCHEDULE 5
PROGRAM: NONCONTRACT
Provider No:
ZZT30240H
RATIO COST TO CHARGES ANCILLARY COST CENTERS
37.00 Operating Room $ 18,934,192 $ 107,341,144 0.176393 $ 0 $ 0
39.00 Delivery Room and Labor Room 4,781,770 8,964,037 0.533439 0 0 40.00 Anesthesiology 388,502 22,301,238 0.017421 0 0 41.00 Radiology - Diagnostic 6,616,923 32,512,124 0.203522 16,888 3,437 41.01 CAT Scan 1,514,471 57,470,248 0.026352 0 0 41.02 Ultra Sound 1,438,472 16,361,285 0.087919 461 41 41.03 Magnetic Resonance Imaging (MRI) 1,040,649 13,178,801 0.078964 4,888 386 42.00 Radiology - Therapeutic 1,369,353 11,432,966 0.119772 0 0
44.00 Laboratory 10,642,370 162,889,960 0.065335 214,730 14,029 44.01 Pathological Lab 733,891 1,211,146 0.605948 0 0
47.00 Blood Storing and Processing 2,785,082 2,563,444 1.086461 0 0 49.00 Respiratory Therapy 7,520,142 53,903,767 0.139511 0 0 50.00 Physical Therapy 1,858,158 4,641,624 0.400325 29,795 11,928 51.00 Occupational Therapy 650,986 1,594,903 0.408166 6,093 2,487 52.00 Speech Pathology 319,970 406,182 0.787751 355 280 53.00 Electrocardiology 2,095,525 40,462,624 0.051789 0 0 53.01 Cardiology 9,528,752 29,275,216 0.325489 0 0
54.00 Electroencephalography 255,057 1,579,673 0.161462 0 0 55.00 Medical Supplies Charged to Patients 2,135,134 234,412,470 0.009108 0 0 56.00 Drugs Charged to Patients 15,706,800 241,708,950 0.064982 626,116 40,686 57.00 Renal Dialysis 2,198,142 17,837,132 0.123234 0 0 59.00 Lithotripsy 17,136 190,845 0.089792 0 0 59.01 Pain Management 65,785 541,722 0.121437 0 0
61.00 Emergency 15,000,989 86,098,626 0.174230 0 0
TOTAL $ 107,658,744 $ 1,148,880,737 $ 899,326 $ 73,274
(To Schedule 3)
* From Schedule 8, Column 27
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
TOTAL
COST *
CHARGES
MEDI-CAL
(Adj 3)
COST CHARGES
(From Schedule 6) ANCILLARY
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Trang 3STATE OF CALIFORNIA SCHEDULE 6
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 Provider No:
ZZT30240H
ANCILLARY CHARGES
(To Schedule 5)
(Adj 5)
ADJUSTMENTS TO MEDI-CAL CHARGES
REPORTED ADJUSTMENTS AUDITED
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Trang 4STATE OF CALIFORNIA SCHEDULE 7
PROGRAM: NONCONTRACT
Provider No:
ZZT30240H
PROFESSIONAL SERVICE COST CENTERS
(To Schedule 3)
TO CHARGES
PHYSICIAN'S REMUNERATION
TOTAL CHARGES
TO ALL PATIENTS
MEDI-CAL MEDI-CAL
COST
RATIO OF REMUNERATION CHARGES
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
REMUNERATION HBP
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Trang 5STATE OF CALIFORNIA CONTRACT SCH 1
Provider No:
HSC30240H
1 Net Cost of Covered Services Rendered to
3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ N/A
8 Total Medi-Cal Cost (Sum of Lines 5 through 7) $ 39,169,928 $ 39,228,184
(To Summary of Findings)
(To Summary of Findings)
COMPUTATION OF MEDI-CAL CONTRACT COST
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Trang 6STATE OF CALIFORNIA CONTRACT SCH 2
Provider No:
HSC30240H
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Contract Sch 3) $ 39,169,928 $ 39,904,252
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 10) $ 118,181,100 $ 92,678,133
3 Inpatient Ancillary Service Charges (Adj 10) $ 217,292,074 $ 167,992,519
4 Total Charges - Medi-Cal Inpatient Services $ 335,473,174 $ 260,670,652
5 Excess of Customary Charges Over Reasonable Cost
6 Excess of Reasonable Cost Over Customary Charges
(To Contract Sch 1)
* If charges exceed reasonable cost, no further calculation necessary for this schedule
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
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Trang 7STATE OF CALIFORNIA CONTRACT SCH 3
Provider No:
HSC30240H
1 Medi-Cal Inpatient Ancillary Services (Contract Sch 5) $ 19,714,567 $ 14,987,303
2 Medi-Cal Inpatient Routine Services (Contract Sch 4) $ 19,455,361 $ 24,916,949
3 Medi-Cal Inpatient Hospital Based Physician
7 Medi-Cal Inpatient Hospital Based Physician ( See
(To Contract Sch 2)
11 Net Cost of Covered Services Rendered to Medi-Cal
(To Contract Sch 1)
MEDI-CAL NET COST OF COVERED SERVICES
COMPUTATION OF
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Trang 8STATE OF CALIFORNIA CONTRACT SCH 4
Provider No:
HSC30240H
INPATIENT DAYS
1 Total Inpatient Days (include private & swing-bed) (Adj ) 62,121 62,121
SWING-BED ADJUSTMENT
21 Total Routine Serv Cost (Sch 8, Part I, Line 25, Col 27) $ 64,008,208 $ 63,347,793
27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 64,008,208 $ 63,347,793 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)(Adj ) $ 369,411,300 $ 369,411,300
30 Semi-Private Room Charges (excluding swing-bed charges)(Adj ) $ 369,411,300 $ 369,411,300
31 Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) $ 0.173271 $ 0.171483
33 Average Semi-Private Room Per Diem Charge (L 30 / L 4) $ 5,946.64 $ 5,946.64
34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 0.00 $ 0.00
35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 0.00 $ 0.00
37 Inpatient Rout Cost Net of Swing-Bed & Prvt Rm (L 27 minus L 36) $ 64,008,208 $ 63,347,793 PROGRAM INPATIENT OPERATING COST
38 Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) $ 1,030.38 $ 1,019.75
39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 13,883,340 $ 5,777,904
40 Cost Applicable to Medi-Cal (Contract Sch 4A) $ 5,572,021 $ 19,139,045
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39, 40 & 41) $ 19,455,361 $ 24,916,949
(To Contract Sch 3)
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
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Trang 9STATE OF CALIFORNIA CONTRACT SCH 4A
Provider No:
HSC30240H
NURSERY
1 Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) $ 1,244,249 $ 1,231,396
INTENSIVE CARE UNIT
6 Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) $ 17,992,564 $ 17,806,741
CORONARY CARE UNIT
NEONATAL INTENSIVE CARE UNIT
16 Total Inpatient Routine Cost (Sch 8, Line 30, Col 27) $ 3,892,517 $ 3,852,313
SURGICAL INTENSIVE CARE UNIT
31 Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 5,572,021 $ 19,139,045
(To Contract Sch 4)
MEDI-CAL INPATIENT ROUTINE SERVICE COST
COMPUTATION OF
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Trang 10STATE OF CALIFORNIA CONTRACT SCH 4B
Provider No:
HSC30240H
(To Contract Sch 4)
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
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Trang 11STATE OF CALIFORNIA CONTRACT SCH 5
Provider No:
HSC30240H
RATIO COST TO CHARGES ANCILLARY COST CENTERS
37.00 Operating Room $ 18,934,192 $ 107,341,144 0.176393 $ 10,870,227 $ 1,917,428
39.00 Delivery Room and Labor Room 4,781,770 8,964,037 0.533439 2,808,700 1,498,271 40.00 Anesthesiology 388,502 22,301,238 0.017421 3,582,170 62,404 41.00 Radiology - Diagnostic 6,616,923 32,512,124 0.203522 4,199,349 854,659 41.01 CAT Scan 1,514,471 57,470,248 0.026352 5,744,943 151,392 41.02 Ultra Sound 1,438,472 16,361,285 0.087919 1,495,478 131,481 41.03 Magnetic Resonance Imaging (MRI) 1,040,649 13,178,801 0.078964 1,375,731 108,633 42.00 Radiology - Therapeutic 1,369,353 11,432,966 0.119772 1,402,881 168,026
44.00 Laboratory 10,642,370 162,889,960 0.065335 29,216,590 1,908,858 44.01 Pathological Lab 733,891 1,211,146 0.605948 160,952 97,529
47.00 Blood Storing and Processing 2,785,082 2,563,444 1.086461 500,511 543,786 49.00 Respiratory Therapy 7,520,142 53,903,767 0.139511 7,078,803 987,567 50.00 Physical Therapy 1,858,158 4,641,624 0.400325 591,294 236,710 51.00 Occupational Therapy 650,986 1,594,903 0.408166 180,749 73,776 52.00 Speech Pathology 319,970 406,182 0.787751 61,051 48,093 53.00 Electrocardiology 2,095,525 40,462,624 0.051789 3,906,558 202,317 53.01 Cardiology 9,528,752 29,275,216 0.325489 1,998,419 650,463
54.00 Electroencephalography 255,057 1,579,673 0.161462 917,862 148,200 55.00 Medical Supplies Charged to Patients 2,135,134 234,412,470 0.009108 34,162,549 311,168 56.00 Drugs Charged to Patients 15,706,800 241,708,950 0.064982 45,503,632 2,956,930 57.00 Renal Dialysis 2,198,142 17,837,132 0.123234 3,959,772 487,979 59.00 Lithotripsy 17,136 190,845 0.089792 0 0 59.01 Pain Management 65,785 541,722 0.121437 0 0
61.00 Emergency 15,000,989 86,098,626 0.174230 8,274,298 1,441,633
TOTAL $ 107,658,744 $ 1,148,880,737 $ 167,992,519 $ 14,987,303
(To Contract Sch 3)
* From Schedule 8, Column 27
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
CHARGES
TOTAL ANCILLARY MEDI-CAL ANCILLARY
COST*
COST (Contract Sch 6)
CHARGES (Adj 3)
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