STATE OF CALIFORNIA SCHEDULE 4B PROGRAM: NONCONTRACT COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST _part2 pptx

STATE OF CALIFORNIA DESIG PUB HOSP SCH 7Provider No: HSC00228W PROFESSIONAL SERVICE COST CENTERS To Desig Pub Hosp Sch 3 HBP TOTAL CHARGES TO ALL PATIENTS RATIO OF REMUNERATION MEDI-CA

Provider Name: Fiscal Period Ended:

Provider No:

HSC00228W

ANCILLARY CHARGES

55.00 Medical Supplies Charged to Patients 21,082,150 4,440,029 25,522,179

TOTAL MEDI-CAL ANCILLARY CHARGES $ 139,371,813 $ 20,020,295 $ 159,392,108

(To Desig Pub Hosp Sch 5)

AUDITED ADJUSTMENTS

REPORTED

(Adjs 22, 26) ADJUSTMENTS TO MEDI-CAL CHARGES

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STATE OF CALIFORNIA DESIG PUB HOSP SCH 7

Provider No:

HSC00228W

PROFESSIONAL

SERVICE COST CENTERS

(To Desig Pub Hosp Sch 3)

HBP TOTAL CHARGES

TO ALL PATIENTS

RATIO OF REMUNERATION

MEDI-CAL COST CHARGES

COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED

REMUNERATION

(Adj )

PHYSICIAN'S REMUNERATION

TO CHARGES

MEDI-CAL

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Provider Name: Fiscal Period Ended:

Provider No:

LTC55660F

COMPUTATION OF DISTINCT PART (DP)

NURSING FACILITY PER DIEM

2 Distinct Part Routine Cost (DPNF Sch 2) $ 20,673,166 $ 20,235,317 $ (437,849)

3 Total Distinct Part Facility Cost (Lines 1 & 2) $ 20,673,166 $ 20,235,317 $ (437,849)

5 Average DP Per Diem Cost (Line 3 / Line 4) $ 653.37 $ 639.53 $ (13.84)

DPNF OVERPAYMENT AND OVERBILLINGS

(To Summary of Findings)

GENERAL INFORMATION

9 Total Available Distinct Part Beds (C/R, W/S S-3) (Adj) 89 89 0

CAPITAL RELATED COST

13 Indirect Capital Related Cost (DPNF Sch 5) N/A $ 2,230,042 N/A

14 Total Capital Related Cost (Lines 12 & 13) N/A $ 2,278,380 N/A

TOTAL SALARY & BENEFITS

16 Allocated Salary & Benefits (DPNF Sch 5) N/A $ 3,939,048 N/A

17 Total Salary & Benefits Expenses (Lines 15 & 16) N/A $ 12,499,819 N/A

COMPUTATION OF DISTINCT PART NURSING FACILITY PER DIEM

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STATE OF CALIFORNIA DPNF SCH 2

SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009

Provider No:

LTC55660F

COST CENTER COL DIRECT AND ALLOCATED EXPENSE

TOTAL DIRECT AND

* From Hospital Audit Report Sch 8, Part I, line 34 (To DPNF Sch 1)

REPORTED * AUDITED *

SUMMARY OF DISTINCT PART FACILITY EXPENSES

DIFFERENCE

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Provider Name: Fiscal Period Ended:

Provider No:

COST TO CHARGES

49.00 Respiratory Therapy $ 5,914,642 $ 21,779,813 0.271565 $ 0 $ 0 55.00 Med Supply Charged to Patients 4,151,690 58,257,007 0.071265 0 0 56.00 Drugs Charged to Patients 6,037,873 8,387,370 0.719877 0 0

0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 101.00 TOTAL $ 16,104,205 $ 88,424,190 $ 0 $ 0

(To DPNF Sch 1)

* From Acute care Schedule 8, Column 27.

** Total Distinct Part Ancillary Charges included in the rate.

*** Total Distinct Part Ancillary Costs included in the rate.

TOTAL

DP ANCILLARY CHARGES **

TOTAL ANCILLARY COST***

TOTAL ANCILLARY COST *

SCHEDULE OF TOTAL DISTINCT PART ANCILLARY COSTS

TOTAL ANCILLARY CHARGES

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STATE OF CALIFORNIA DPNF SCH 4

Provider No:

LTC55660F

ANCILLARY CHARGES

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

(To DPNF Sch 3)

ADJUSTMENTS TO TOTAL DISTINCT PART ANCILLARY CHARGES

(Adj )

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Provider Name: Fiscal Period Ended:

SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009

Provider No:

LTC55660F

RELATED * EMP BENEFITS * COL COST CENTER (COL 1) (COL 2)

101 TOTAL ALLOCATED INDIRECT EXPENSES $ 2,230,042 $ 3,939,048

* These amounts include Skilled Nursing Facility (To DPNF SCH 1)

expenses, line 34.

AUDITED CAP AUDITED SAL &

ALLOCATION OF INDIRECT EXPENSES DISTINCT PART NURSING FACILITY

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000000000000 T

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0 0

000000000000 0

000000000000 0000

000000000000 0

000000000000 000000000000 000000000000 000000000000

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000000000000 000000000000 000000000000 000000000000 0

000000000000 000000000000 000000000000 000000000000 0000

000000000000 0000

000000000000 0

000000000000 000000000000 0

000000000000 000000000000 000000000000 000000000000 000000000000 0

000000000000 0

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