STATE OF CALIFORNIA SCHEDULE A-4PROGRAM: NONCONTRACT Provider No.: ZZT30107H Audited Medi-Cal Cost Per Day 2.. Less: Medi-Cal Administrative Day Cost Schedule 4A, Lines 28 and 31 3...
Trang 1STATE OF CALIFORNIA SCHEDULE A-4
PROGRAM: NONCONTRACT
Provider No.:
ZZT30107H
Audited Medi-Cal Cost Per Day
2 Less: Medi-Cal Administrative Day Cost (Schedule 4A, Lines 28 and 31)
3 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 minus Line 2) $ 0
4 Total Audited Medi-Cal Days (Schedules 4, 4A, and 4B, excludes Administrative Days)
10 % Cost Reduction For Services From 07/01/08 Through 06/30/2009
6 Audited Medi-Cal Days of Service from 07/01/08 - 06/30/2009 (excludes Administrative Days)
7 Audited Medi-Cal Cost Per Day for 07/01/08 - 06/30/2009 (Line 5 X Line 6) $ 0
(To Schedule A, Ln 4)
10% REDUCTION FOR SERVICES FROM JULY 1, 2008 THROUGH JUNE 30, 2009
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
HFPAs WITH LESS THAN 3 HOSPITALS
AB 5
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Trang 2Provider Name: Fiscal Period Ended:
Provider No.
ZZT30107H
Audited Medi-Cal Cost Per Day
2 Less: Medi-Cal Administrative Day Cost (Schedule 4A, Lines 28 and 31)
3 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 minus Line 2) $ 0
4 Total Audited Medi-Cal Days (Schedules 4, 4A, and 4B, excludes Administrative Days)
10% Cost Reduction For Services From 07/01/08 Through 10/31/08
6 Audited Medi-Cal Days of Service from 07/1/08 - 10/31/08 (excluding Administrative Days)
7 Audited Medi-Cal Cost Per Day for 07/01/08 - 10/31/08 (Line 5 X Line 6) $ 0
(To Schedule A, Ln 5)
10% REDUCTION FOR SERVICES FROM JULY 1, 2008 THROUGH OCTOBER 31, 2008
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
RURAL HEALTH HOSPITALS
AB 5
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Trang 3STATE OF CALIFORNIA SCHEDULE 1
PROGRAM: NONCONTRACT
Provider No.
ZZT30107G
1 Net Cost of Covered Services Rendered to
5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 8,960,121 $ 8,991,725
(To Summary of Findings)
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
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Trang 4Provider Name: Fiscal Period Ended:
Provider No.
ZZT30107G
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 9,043,166 $ 9,075,575
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 28) $ 10,287,523 $ 12,689,639
3 Inpatient Ancillary Service Charges (Adj 28) $ 25,001,239 $ 26,028,225
4 Total Charges - Medi-Cal Inpatient Services $ 35,288,762 $ 38,717,864
5 Excess of Customary Charges Over Reasonable Cost
6 Excess of Reasonable Cost Over Customary Charges
(To Schedule 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 5STATE OF CALIFORNIA SCHEDULE 3
PROGRAM: NONCONTRACT
Provider No.
ZZT30107G
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 4,634,401 $ 4,636,499
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4,408,765 $ 4,439,076
3 Medi-Cal Inpatient Hospital Based Physician
for Intern and Resident Services (Sch ) $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 9,043,166 $ 9,075,575
7 Medi-Cal Inpatient Hospital Based Physician
for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
(To Schedule 2)
10 Patient and Third Party Liability (Adj 29) $ 0 $ (74,721)
11 Net Cost of Covered Services Rendered to Medi-Cal
(To Schedule 1)
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
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Trang 6Provider Name: Fiscal Period Ended:
Provider No.
ZZT30107G
INPATIENT DAYS
1 Total Inpatient Days (include private & swing-bed) (Adj 24) 34,331 35,518
2 Inpatient Days (include private, exclude swing-bed) 34,331 35,518
3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0
4 Semi-Private Room Days (exclude swing-bed) (Adj ) 34,331 34,331
5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0
7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0
9 Medi-Cal Days (excluding swing-bed) (Adj 26) 3,884 4,001 SWING-BED ADJUSTMENT
17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 0.00 $ 0.00
18 Medicare NF Swing-Bed Rates after Dec 31(Adj ) $ 0.00 $ 0.00
19 Medi-Cal NF Swing-Bed Rates through July 31(Adj ) $ 0.00 $ 0.00
20 Medi-Cal NF Swing-Bed Rates after July 31(Adj ) $ 0.00 $ 0.00
21 Total Routine Serv Cost (Sch 8, Line 25, Col 27) $ 28,112,680 $ 27,321,085
22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0
23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0
24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0
25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0
26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0
27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 28,112,680 $ 27,321,085 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 115,992,479 $ 115,992,479
29 Private Room Charges (excluding swing-bed charges) $ 0 $ 0
30 Semi-Private Room Charges (excluding swing-bed charges) $ 115,992,479 $ 115,992,479
31 Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) $ 0.242366 $ 0.235542
32 Average Private Room Per Diem Charge (L 29 / L 3) $ 0.00 $ 0.00
33 Average Semi-Private Room Per Diem Charge (L 30 / L 4) $ 3,378.65 $ 3,378.65
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
36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0
37 Inpatient Rout Cost Net of Swing-Bed & Prvt Rm (L 27 minus L 36) $ 28,112,680 $ 27,321,085 PROGRAM INPATIENT OPERATING COST
38 Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) $ 818.87 $ 769.22
39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3,180,491 $ 3,077,649
40 Cost Applicable to Medi-Cal (Sch 4A) $ 1,228,274 $ 1,361,427
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39,40 & 41) $ 4,408,765 $ 4,439,076
( To Schedule 3 )
MEDI-CAL INPATIENT ROUTINE SERVICE COST
COMPUTATION OF
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Trang 7STATE OF CALIFORNIA SCHEDULE 4A
PROGRAM: NONCONTRACT
Provider No.
ZZT30107G
NURSERY
1 Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) $ 2,462,658 $ 2,492,392
5 Cost Applicable to Medi-Cal $ 1,185,912 $ 1,311,998 INTENSIVE CARE UNIT
6 Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) $ 6,634,315 $ 6,398,014
CORONARY CARE UNIT
11 Total Inpatient Routine Cost (Sch 8, Line 27, Col 27) $ 0 $ 0
NEONATAL INTENSIVE CARE UNIT
16 Total Inpatient Routine Cost (Sch 8, Line 28, Col 27) $ 0 $ 0
SURGICAL INTENSIVE CARE UNIT
21 Total Inpatient Routine Cost (Sch 8, Line 29, Col 27) $ 0 $ 0
ADMINISTRATIVE DAYS (JULY 1, 2008 THROUGH JULY 31, 2008)
ADMINISTRATIVE DAYS (AUGUST 1, 2008 THROUGH JUNE 30, 2009)
32 Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,28,31) $ 1,228,274 $ 1,361,427
(To Schedule 4)
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
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Trang 8Provider Name: Fiscal Period Ended:
Provider No.
ZZT30107G
1 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) $ 0 $ 0
6 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) $ 0 $ 0
11 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) $ 0 $ 0
16 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) $ 0 $ 0
21 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) $ 0 $ 0
26 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) $ 0 $ 0
31 Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 0 $ 0
(To Schedule 4)
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
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Trang 9STATE OF CALIFORNIA SCHEDULE 5
PROGRAM: NONCONTRACT
Provider No:
ZZT30107G
RATIO COST TO CHARGES ANCILLARY COST CENTERS
37.00 Operating Room $ 11,051,806 $ 106,344,799 0.103924 $ 5,363,295 $ 557,377 37.01 Gastro Intestinal Service 443,025 1,170,465 0.378504 19,482 7,374 37.20 Cardicac Cath Lab 2,706,650 30,631,594 0.088361 198,769 17,564 38.00 Recovery Room 0 0 0.000000 0 0 39.00 Delivery Room and Labor Room 7,254,402 19,550,277 0.371064 6,684,146 2,480,245 40.00 Anesthesiology 346,015 36,937,085 0.009368 2,456,948 23,016 41.00 Radiology - Diagnostic 8,300,061 52,095,736 0.159323 202,086 32,197 41.01 CT Scan and MRI 1,870,488 36,694,158 0.050975 444,536 22,660 43.00 Radioisotope 1,777,070 16,706,218 0.106372 31,812 3,384 44.00 Laboratory 8,154,976 73,924,038 0.110316 2,888,211 318,615 44.01 Pathological Lab 0 0 0.000000 0 0 46.00 Whole Blood & Packed Red Blood 1,987,954 4,811,561 0.413162 256,179 105,843 47.00 Blood Storing and Processing 0 0 0.000000 0 0 48.00 Intravenous Therapy 180,685 625,923 0.288670 0 0 49.00 Respiratory Therapy 3,502,733 8,505,764 0.411807 62,023 25,542 50.00 Physical Therapy 2,800,043 10,407,977 0.269029 204,914 55,128 51.00 Occupational Therapy 1,235,588 4,038,475 0.305954 5,612 1,717 52.00 Speech Pathology 0 0 0.000000 0 0 53.00 Electrocardiology 2,533,069 11,279,552 0.224572 14,330 3,218 54.00 Electroencephalography 113,498 267,478 0.424326 2,812 1,193 55.00 Medical Supplies Charged to Patients 9,262,769 35,024,732 0.264464 1,168,432 309,008 55.01 Medical Supplies Chrg Pat - IMP 10,610,140 37,696,037 0.281466 148,654 41,841 56.00 Drugs Charged to Patients 8,085,390 79,938,761 0.101145 5,375,341 543,688 57.00 Renal Dialysis 381,009 655,266 0.581457 2,915 1,695 58.00 ASC (Non-Distinct Part) 0 0 0.000000 0 0 59.00 Ultrasound 694,280 7,805,337 0.088949 217,238 19,323
60.00 Clinic 1,793,163 4,012,970 0.446842 0 0 60.01 Other Clinic Services 0 0 0.000000 0 0 61.00 Emergency 10,105,355 43,030,654 0.234841 280,490 65,871 62.00 Observation Beds 0 1,747,028 0.000000 0 0 71.00 Home Health Agency 16,300,486 0 0.000000 0 0 89.00 Utilization Review 980,387 0 0.000000 0 0 93.00 Hospice 2,970,702 0 0.000000 0 0
TOTAL $ 115,441,744 $ 623,901,885 $ 26,028,225 $ 4,636,499
(To Schedule 3)
* From Schedule 8, Column 27
ANCILLARY
MEDI-CAL
(Adj )
COST CHARGES
(From Schedule 6)
MEDI-CAL
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
TOTAL
COST *
CHARGES TOTAL ANCILLARY
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Trang 10Provider Name: Fiscal Period Ended:
Provider No:
ZZT30107G
ANCILLARY CHARGES
0 0 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 25,001,239 $ 1,026,986 $ 26,028,225
(To Schedule 5)
ADJUSTMENTS TO MEDI-CAL CHARGES
REPORTED ADJUSTMENTS AUDITED
(Adj 27)
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