SCHEDULE 5 PROGRAM: NON CONTRACT SCHEDULE OF MEDICAL ANCILLARY COSTS_PART5 docx

STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 41.02 42.00 Radiology - Therapeutic 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Patient Education & Family Counseling 59.01 Ultrasound 59.02 Magnetic Resonance Imaging 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 Community Benefits 99.02 Marketing 99.03 Dialysis 99.04 99.05 100.00 100.01 100.02 100.03 100.04 101.00 TOTAL SCHEDULE 10A Page 2 Fiscal Period Ended: JUNE 30, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS 0000000000000 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted RECLASSIFICATIONS OF REPORTED COSTS 1 10A A 99.01 7 Community Benefits $3,034,764 $320,308 $3,355,072 * 10A A 99.02 7 Marketing 692,343 22,216 714,559 * 10A A 1.00 7 Old Capital Related Costs - Building and Fixtures 7,298,703 (342,524) 6,956,179 * To reclassify building rent expense for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 2 10A A 98.00 7 Physicians' Private Offices $5,258,056 $679,531 $5,937,587 10A A 99.01 7 Community Benefits * 3,355,072 1,198 3,356,270 10A A 99.02 7 Marketing * 714,559 982 715,541 10A A 2.00 7 Old Capital Related Costs - Movable Equipment 3,661,734 (681,711) 2,980,023 To reclassify equipment depreciation expense for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 3 10A A 16.00 7 Pharmacy $3,902,773 $831,244 $4,734,017 * 10A A 6.04 7 Administrative and General 22,863,818 (18,630) 22,845,188 * 10A A 15.00 7 Central Services and Supply 1,402,116 (3,644) 1,398,472 * 10A A 25.00 7 Adults and Pediatrics 29,305,873 (108,723) 29,197,150 * 10A A 30.00 7 Neonatal Intensive Care Unit 4,715,057 (3,279) 4,711,778 * 10A A 37.00 7 Operating Room 10,868,446 (16,706) 10,851,740 * 10A A 41.00 7 Radiology - Diagnostic 6,370,702 (9,492) 6,361,210 * 10A A 49.00 7 Respiratory Therapy 5,147,146 (1,478) 5,145,668 * 10A A 56.00 7 Drugs Charged to Patients 10,018,044 (668,520) 9,349,524 10A A 59.01 7 Ultrasound 897,462 (353) 897,109 * 10A A 61.00 7 Emergency 12,967,029 (419) 12,966,610 * To adjust the provider's reclassification of pharmacy cost to Drugs Charged to Patients to agree with the provider's trial balance. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 1 Report References ANTELOPE VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30056F Cost Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ANTELOPE VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30056F Cost Report RECLASSIFICATIONS OF REPORTED COSTS 4 10A A 55.00 7 Medical Supplies Charged to Patients $11,978,119 $7,891,005 $19,869,124 10A A 6.01 7 Purchasing, Receiving and Storage 988,264 (3,982) 984,282 10A A 6.02 7 Admitting 3,233,020 (207) 3,232,813 10A A 6.04 7 Administrative and General * 22,845,188 (1,711) 22,843,477 * 10A A 7.00 7 Maintenance and Repairs 7,658,469 (119) 7,658,350 10A A 10.00 7 Housekeeping 4,245,397 (4,677) 4,240,720 10A A 14.00 7 Nursing Administration 2,131,843 (2,329) 2,129,514 10A A 15.00 7 Central Services and Supply * 1,398,472 (20,882) 1,377,590 10A A 16.00 7 Pharmacy * 4,734,017 (529,595) 4,204,422 * 10A A 25.00 7 Adults and Pediatrics * 29,197,150 (1,005,590) 28,191,560 10A A 26.00 7 Intensive Care Unit 9,638,478 (357,156) 9,281,322 10A A 30.00 7 Neonatal Intensive Care Unit * 4,711,778 (174,456) 4,537,322 * 10A A 37.00 7 Operating Room * 10,851,740 (206,954) 10,644,786 10A A 39.00 7 Delivery Room and Labor Room 7,077,366 (574,274) 6,503,092 10A A 41.00 7 Radiology - Diagnostic * 6,361,210 (1,992,694) 4,368,516 10A A 43.00 7 Radioisotope 815,709 (3,814) 811,895 10A A 44.00 7 Laboratory 12,353,616 (2,249,665) 10,103,951 10A A 49.00 7 Respiratory Therapy * 5,145,668 (678,736) 4,466,932 10A A 50.00 7 Physical Therapy 847,855 (4,880) 842,975 10A A 51.00 7 Occupational Therapy 53,370 (466) 52,904 10A A 53.00 7 Electrocardiology 535,260 (13,218) 522,042 10A A 54.00 7 Electroencephalography 199,059 (6,621) 192,438 10A A 59.00 7 Patient Education and Family Counseling 20,481 (3,302) 17,179 * 10A A 59.01 7 Ultrasound * 897,109 (30,145) 866,964 10A A 59.02 7 Magnetic Resonance Imaging 406,759 (4,329) 402,430 10A A 61.00 7 Emergency * 12,966,610 (21,203) 12,945,407 To adjust the provider's reclassification of central supplies to Medical Supplies Charged to Patients to agree with the provider's trial balance. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 2 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ANTELOPE VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30056F Cost Report RECLASSIFICATIONS OF REPORTED COSTS 5 10A A 6.04 7 Administrative and General * $22,843,477 $103,384 $22,946,861 * 10A A 5.00 7 Employee Benefits 29,366,706 (1,972) 29,364,734 10A A 16.00 7 Pharmacy * 4,204,422 (60,517) 4,143,905 10A A 17.00 7 Medical Records and Library 3,511,382 (29,340) 3,482,042 10A A 30.00 7 Neonatal Intensive Care Unit * 4,537,322 (3,809) 4,533,513 10A A 59.00 7 Patient Education and Family Counseling * 17,179 (3,604) 13,575 10A A 99.03 7 Dialysis 26,097 (4,142) 21,955 To adjust the provider's elimination of dues and subscriptions expense for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 3 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ANTELOPE VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30056F Cost Report ADJUSTMENTS TO REPORTED COSTS 6 10A A 6.04 7 Administrative and General * $22,946,861 ($1,787) $22,945,074 * To adjust the provider's elimination of nonallowable travel expense to agree with the trial balance. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 7 10A A 6.04 7 Administrative and General * $22,945,074 ($37,591) $22,907,483 To adjust the provider's elimination of nonallowable governing board expense to agree with the trial balance. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 8 10A A 1.00 7 Old Capital Related Costs - Building and Fixtures * $6,956,179 ($27,309) $6,928,870 To adjust the provider's abatement of investment income to agree with the provider's trial balance. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ANTELOPE VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30056F Cost Report ADJUSTMENT TO REPORTED TOTAL CHARGES 9 5, Contract 5 C I 37.00 8 Operating Room $64,678,604 ($11,872,068) $52,806,536 5, Contract 5 C I 53.00 8 Electrocardiology 8,650,091 100,000 8,750,091 5, Contract 5 C I 55.00 8 Medical Supplies Charged to Patients 91,497,374 18,076,516 109,573,890 5, Contract 5 C I 54.00 8 Electroencephalography 1,447,672 (100,000) 1,347,672 5, Contract 5 C I 61.00 8 Emergency 79,933,736 (6,204,446) 73,729,290 5, Contract 5 C I 103.00 8 Total Charges 652,114,812 2 652,114,814 To adjust ancillary charges to agree with the provider's general ledger. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ANTELOPE VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30056F Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT 10 4A Not Reported Medi-Cal Administrative Days (July 2007) 0 44 44 4A Not Reported Medi-Cal Administrative Day Rate (July 2007) $0.00 $310.68 $310.68 4A Not Reported Medi-Cal Administrative Days (August 1, 2007 through June 30, 2008) 0 818 818 4A Not Reported Medi-Cal Administrative Day Rate (August 1, 2007 through June 30, 2008) $0.00 $309.80 $309.80 11 6 Not Reported Medi-Cal Ancillary Charges - Radiology - Diagnostic $0 $47,249 $47,249 6 Not Reported Medi-Cal Ancillary Charges - Radioisotope 0 740 740 6 Not Reported Medi-Cal Ancillary Charges - Laboratory 0 180,794 180,794 6 Not Reported Medi-Cal Ancillary Charges - Physical Therapy 0 70,914 70,914 6 Not Reported Medi-Cal Ancillary Charges - Occupational Therapy 0 4,274 4,274 6 Not Reported Medi-Cal Ancillary Charges - Speech Pathology 0 1,620 1,620 6 Not Reported Medi-Cal Ancillary Charges - Drugs Charged to Patients 0 464,391 464,391 6 Not Reported Medi-Cal Ancillary Charges - Ultrasound 0 18,576 18,576 6 Not Reported Medi-Cal Ancillary Charges - Magnetic Resonance Imaging 0 28,505 28,505 6 Not Reported Medi-Cal Ancillary Charges - Total 0 817,063 817,063 12 2 Not Reported Medi-Cal Routine Service Charges $0 $1,677,518 $1,677,518 2 Not Reported Medi-Cal Ancillary Service Charges 0 817,063 817,063 13 3 Not Reported Medi-Cal Deductibles $0 $873 $873 3 Not Reported Medi-Cal Coinsurance 0 19,668 19,668 1 Not Reported Medi-Cal Interim Payments 0 488,241 488,241 To adjust Medi-Cal Settlement Data to agree with the following HP Enterprise Services Paid Claims Summary: Report Date: July 12, 2010 Payment Period: July 1, 2007 through July 9, 2010 Service Period: July 1, 2007 through June 30, 2008 42 CFR 413.20, 413.24, 413.50, 413.53, 413.60, 413.64, and 433.139 CMS Pub. 15-1, Sections 2304, 2404, and 2408 CCR, Title 22, Section 51541 Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ANTELOPE VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30056F Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - CONTRACT 14 Contract 4 D-1 I XIX 9.00 1 Medi-Cal Days - Adults and Pediatrics 18,143 (1,689) 16,454 Contract 4A D-1 II XIX 42.00 4 Medi-Cal Days - Nursery 8,042 (1,417) 6,625 Contract 4A D-1 II XIX 43.00 4 Medi-Cal Days - Intensive Care Unit 2,587 (1,070) 1,517 Contract 4A D-1 II XIX 47.00 4 Medi-Cal Days - Neonatal Intensive Care Unit 4,419 (3,295) 1,124 15 Contract 6 D-4 XIX 37.00 2 Medi-Cal Ancillary Charges - Operating Room $10,756,005 $2,652,171 $13,408,176 Contract 6 D-4 XIX 39.00 2 Medi-Cal Ancillary Charges - Delivery Room and Labor Room 11,357,237 (2,232,481) 9,124,756 Contract 6 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 7,809,854 (689,310) 7,120,544 Contract 6 D-4 XIX 43.00 2 Medi-Cal Ancillary Charges - Radioisotope 493,941 (160,532) 333,409 Contract 6 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 9,984,116 1,830,970 11,815,086 Contract 6 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 13,406,205 (4,406,648) 8,999,557 Contract 6 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 321,803 (100,905) 220,898 Contract 6 D-4 XIX 51.00 2 Medi-Cal Ancillary Charges - Occupational Therapy 24,612 (15,964) 8,648 Contract 6 D-4 XIX 52.00 2 Medi-Cal Ancillary Charges - Speech Pathology 24,300 (15,528) 8,772 Contract 6 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 1,145,337 4,117,442 5,262,779 Contract 6 D-4 XIX 54.00 2 Medi-Cal Ancillary Charges - Electroencephalography 295,306 (229,354) 65,952 Contract 6 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1,230,200 7,137,199 8,367,399 Contract 6 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 11,615,920 1,476,189 13,092,109 Contract 6 D-4 XIX 57.00 2 Medi-Cal Ancillary Charges - Renal Dialysis 829,101 (109,619) 719,482 Contract 6 D-4 XIX 59.01 2 Medi-Cal Ancillary Charges - Ultrasound 1,187,610 116,555 1,304,165 Contract 6 D-4 XIX 59.02 2 Medi-Cal Ancillary Charges - Magnetic Resonance Imaging 959,170 20,890 980,060 Contract 6 D-4 XIX 61.00 2 Medi-Cal Ancillary Charges - Emergency 4,354,277 695,177 5,049,454 Contract 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 75,794,994 10,086,252 85,881,246 16 Contract 2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges $44,604,908 $1,909,367 $46,514,275 Contract 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 75,794,994 10,086,252 85,881,246 17 Contract 3 E-3 III XIX 33.00 1 Medi-Cal Deductibles $0 $156,764 $156,764 Contract 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance 0 359,771 359,771 -Continued on next page- Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ANTELOPE VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30056F Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - CONTRACT -Continued from previous page- To adjust Medi-Cal Settlement Data to agree with the following HP Enterprise Services Paid Claims Summary: Report Date: July 12, 2010 Payment Period: July 1, 2007 through July 9, 2010 Service Period: July 1, 2007 through June 30, 2008 42 CFR 413.20, 413.24, 413.50, 413.53, 413.60, 413.64, and 433.139 CMS Pub. 15-1, Sections 2304, 2404, and 2408 CCR, Title 22, Section 51541 Page 8 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ANTELOPE VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30056F Cost Report ADJUSTMENT TO OTHER MATTERS 18 Contract 1 Not Reported Credit Balances $0 $2,414 $2,414 To recover outstanding Medi-Cal credit balances. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 CCR, Title 22, Sections 50761 and 51458.1 Page 9 This is trial version www.adultpdf.com . $52 ,806 ,53 6 5, Contract 5 C I 53 .00 8 Electrocardiology 8, 650 ,091 100,000 8, 750 ,091 5, Contract 5 C I 55 .00 8 Medical Supplies Charged to Patients 91,497,374 18,076 ,51 6 109 ,57 3,890 5, Contract 5 C. Private Offices $5, 258 , 056 $679 ,53 1 $5, 937 ,58 7 10A A 99.01 7 Community Benefits * 3, 355 ,072 1,198 3, 356 ,270 10A A 99.02 7 Marketing * 714 ,55 9 982 7 15, 541 10A A 2.00 7 Old Capital Related Costs - Movable. 4,117,442 5, 262,779 Contract 6 D-4 XIX 54 .00 2 Medi-Cal Ancillary Charges - Electroencephalography 2 95, 306 (229, 354 ) 65, 952 Contract 6 D-4 XIX 55 .00 2 Medi-Cal Ancillary Charges - Medical Supplies