REPORT ON THE COST REPORT REVIEW CENTINELA HOSPITAL MEDICAL CENTER_PART5 docx

STATE OF CALIFORNIA Provider Name: CENTINELA HOSPITAL MEDICAL CENTER GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipment 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services & Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 29.00 Surgical Intensive Care 30.00 Neonatal Intensive Care Unit 31.00 Subprovider II 32.00 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 10A Page 2 Fiscal Period Ended: DECEMBER 31, 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 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: CENTINELA HOSPITAL MEDICAL CENTER 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 CAT Scan 41.02 Ultra Sound 41.03 Magnetic Resonance Imaging (MRI) 42.00 Radiology - Therapeutic 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 53.01 Cardiology 53.02 Cardiac Rehab 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 59.00 Lithotripsy 59.01 Pain Management 59.02 Rehab Nuero 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 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 99.02 99.03 99.04 99.05 100.00 Cent Transport 100.01 Public Relations 100.02 Mob I 100.03 100.07 Unoccupied Space 101.00 TOTAL SCHEDULE 10A Page 2 Fiscal Period Ended: DECEMBER 31, 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 11 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted MEMORANDUM ADJUSTMENT 1 8 B I 42.00 26 Radiology - Therapeutic $1,329,144 $40,209 $1,369,353 8 B I 43.00 26 Radioisotope 40,209 (40,209) 0 8 B I 53.01 26 Cardiology 9,344,296 184,456 9,528,752 8 B I 53.02 26 Cardiac Rehab 184,456 (184,456) 0 To reclassify the post step-down costs for Radioisotope and Cardiac Rehab to Radiology - Therapeutic and Cardiology respectively for proper matching of revenue and expenses. 42 CFR 413.5, 413.20, 413.24, 413.50, and 413.53 CMS Pub. 15-1, Sections 2102, 2202.4, 2206, 2300, 2302.6, Contract 04-83245, Amendments 7 and 8 Page 1 Report References CENTINELA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments FEBRUARY 1, 2008 THROUGH DECEMBER 31, 2008 HSC30240H Cost Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 11 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References CENTINELA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments FEBRUARY 1, 2008 THROUGH DECEMBER 31, 2008 HSC30240H Cost Report ADJUSTMENT TO REPORTED COSTS 2 10A A 61.00 7 Emergency ($1,539,659) $12,266,531 $10,726,872 To adjust the reported emergency expense to agree with the provider's detailed grouping schedule. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 Page 2 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 11 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References CENTINELA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments FEBRUARY 1, 2008 THROUGH DECEMBER 31, 2008 HSC30240H Cost Report ADJUSTMENT TO REPORTED TOTAL CHARGES 3 5 C I 53.01 8 Cardiology $19,886,733 $9,388,483 $29,275,216 5 C I 53.02 8 Cardiac Rehab 9,388,483 (9,388,483) 0 To reclassify Cardiac Rehab total charges for proper matching of revenue and expense. 42 CFR 413.5, 413.20, 413.24, 413.50, and 413.53 CMS Pub. 15-1, Sections 2102, 2202.4, 2206, 2300, 2302.6, 2304, and 2306 Contract 04-83245, Amendments 7 and 8 Page 3 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 11 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References CENTINELA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments FEBRUARY 1, 2008 THROUGH DECEMBER 31, 2008 HSC30240H Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT 4 4A Not Reported Medi-Cal Administrative Days (Feb 1, 2008 through Jul 31, 2008) 0 171 171 4A Not Reported Medi-Cal Administrative Day Rate (Feb 1, 2008 through Jul 31, 2008) $0 $318.19 $318.19 4A Not Reported Medi-Cal Administrative Days (Aug 1, 2008 through Dec 31, 2008) 0 192 192 4A Not Reported Medi-Cal Administrative Day Rate (Aug 1, 2008 through Dec 31, 2008) $0 $351.26 $351.26 5 6 Not Reported Medi-Cal Ancillary Charges - Radiology - Diagnostic $0 $16,888 $16,888 6 Not Reported Medi-Cal Ancillary Charges - Ultrasound 0 461 461 6 Not Reported Medi-Cal Ancillary Charges - Magnetic Resonance Imaging (MRI) 0 4,888 4,888 6 Not Reported Medi-Cal Ancillary Charges - Laboratory 0 214,730 214,730 6 Not Reported Medi-Cal Ancillary Charges - Physical Therapy 0 29,795 29,795 6 Not Reported Medi-Cal Ancillary Charges - Occupational Therapy 0 6,093 6,093 6 Not Reported Medi-Cal Ancillary Charges - Speech Pathology 0 355 355 6 Not Reported Medi-Cal Ancillary Charges - Drugs Charged to Patients 0 626,116 626,116 6 Not Reported Medi-Cal Ancillary Charges - Total 0 899,325 899,325 6 2 Not Reported Medi-Cal Routine Service Charges $0 $966,453 $966,453 2 Not Reported Medi-Cal Ancillary Service Charges 0 899,325 899,325 7 3 Not Reported Medi-Cal Coinsurance $0 $1,581 $1,581 1 Not Reported Medi-Cal Interim Payments 0 202,316 202,316 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: February 18, 2010 Payment Period: February 1, 2008 through December 31, 2009 Service Period : Feberuary 1, 2008 through December 31, 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 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 11 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References CENTINELA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments FEBRUARY 1, 2008 THROUGH DECEMBER 31, 2008 HSC30240H Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - CONTRACT 8 Contract 4 D-1 I XIX 9.00 1 Medi-Cal Inpatient Days - Adults and Pediatrics 13,474 (7,808) 5,666 Contract 4A D-1 II XIX 42.00 4 Medi-Cal Inpatient Days - Nursery 2,358 755 3,113 Contract 4A D-1 II XIX 43.00 4 Medi-Cal Inpatient Days - Intensive Care Unit 1,036 8,073 9,109 Contract 4A D-1 II XIX 47.00 4 Medi-Cal Inpatient Days - Neonatal Intensive Care Unit 2,071 (1,531) 540 9 Contract 6 D-4 XIX 37.00 2 Medi-Cal Ancillary Charges - Operating Room $13,705,319 ($2,835,092) $10,870,227 Contract 6 D-4 XIX 39.00 2 Medi-Cal Ancillary Charges - Delivery Room and Labor Room 6,870,523 (4,061,823) 2,808,700 Contract 6 D-4 XIX 40.00 2 Medi-Cal Ancillary Charges - Anesthesiology 5,495,246 (1,913,076) 3,582,170 Contract 6 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 4,265,489 (66,140) 4,199,349 Contract 6 D-4 XIX 41.01 2 Medi-Cal Ancillary Charges - CAT Scan 7,081,545 (1,336,602) 5,744,943 Contract 6 D-4 XIX 41.02 2 Medi-Cal Ancillary Charges - Ultra Sound 2,747,636 (1,252,158) 1,495,478 Contract 6 D-4 XIX 41.03 2 Medi-Cal Ancillary Charges - Magnetic Resonance Imaging (MRI) 1,892,411 (516,680) 1,375,731 Contract 6 D-4 XIX 42.00 2 Medi-Cal Ancillary Charges - Radiology - Therapeutic 2,232,044 (829,163) 1,402,881 Contract 6 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 34,634,380 (5,417,790) 29,216,590 Contract 6 D-4 XIX 44.01 2 Medi-Cal Ancillary Charges - Laboratory - Pathological 344,646 (183,694) 160,952 Contract 6 D-4 XIX 47.00 2 Medi-Cal Ancillary Charges - Blood Storing and Processing 615,525 (115,014) 500,511 Contract 6 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 13,272,773 (6,193,970) 7,078,803 Contract 6 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 653,702 (62,408) 591,294 Contract 6 D-4 XIX 51.00 2 Medi-Cal Ancillary Charges - Occupational Therapy 264,573 (83,824) 180,749 Contract 6 D-4 XIX 52.00 2 Medi-Cal Ancillary Charges - Speech Pathology 59,524 1,527 61,051 Contract 6 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 6,603,600 (2,697,042) 3,906,558 Contract 6 D-4 XIX 53.01 2 Medi-Cal Ancillary Charges - Cardiology 1,808,185 190,234 1,998,419 Contract 6 D-4 XIX 53.02 2 Medi-Cal Ancillary Charges - Cardiac Rehab 1,135,682 (1,135,682) 0 Contract 6 D-4 XIX 54.00 2 Medi-Cal Ancillary Charges - Electroencephalography 290,744 627,118 917,862 Contract 6 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 36,458,083 (2,295,534) 34,162,549 Contract 6 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 61,362,782 (15,859,150) 45,503,632 Contract 6 D-4 XIX 57.00 2 Medi-Cal Ancillary Charges - Renal Dialysis 4,321,788 (362,016) 3,959,772 Contract 6 D-4 XIX 61.00 2 Medi-Cal Ancillary Charges - Emergency 11,175,874 (2,901,576) 8,274,298 Contract 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 217,292,074 (49,299,555) 167,992,519 -Continued on next page- Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 11 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References CENTINELA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments FEBRUARY 1, 2008 THROUGH DECEMBER 31, 2008 HSC30240H Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - CONTRACT -Continued from previous page- 10 Contract 2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges $118,181,100 ($25,502,967) $92,678,133 Contract 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 217,292,074 (49,299,555) 167,992,519 11 Contract 3 E-3 III XIX 33.00 1 Medi-Cal Deductibles $0 $17,029 $17,029 Contract 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance 0 659,039 659,039 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: February 18, 2010 Payment Period: February 1, 2008 through December 31, 2009 Service Period : Feberuary 1, 2008 through December 31, 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 . CALIFORNIA Provider Name: CENTINELA HOSPITAL MEDICAL CENTER GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg &. AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: CENTINELA HOSPITAL MEDICAL CENTER ANCILLARY COST CENTERS 37.00 Operating Room 38.00. Col. Reported (Decrease) Adjusted Report References CENTINELA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments FEBRUARY 1, 2008 THROUGH DECEMBER 31, 2008 HSC30240H Cost Report ADJUSTMENT