SCHEDULE 5 PROGRAM: NON CONTRACT SCHEDULE OF MEDICAL ANCILLARY COSTS_part3 pdf

STATE OF CALIFORNIA SCHEDULE 7-1 PROGRAM: REHABILITATION COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED PHYSICIAN'S REMUNERATION Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: HSC 30281H PROFESSIONAL SERVICE COST CENTERS HBP REMUNERATION (Adj ) 40.00 41.00 43.00 44.00 53.00 54.00 61.00 Anesthesiology Radiology - Diagnostic Radioisotope Laboratory Electrocardiology Electroencephalography Emergency TOTAL $ $ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL CHARGES MEDI-CAL RATIO OF MEDI-CAL TO ALL PATIENTS REMUNERATION CHARGES COST TO CHARGES (Adj ) (Adj ) $ 0.000000 $ $ 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 0 0.000000 $ $ $ (To Schedule 3-1) This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH COMPUTATION OF MEDI-CAL CONTRACT COST Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: HSC 30281H REPORTED AUDITED Net Cost of Covered Services Rendered to Medi-Cal Patients (Contract Sch 3) $ 6,256,465 $ 7,145,013 Excess Reasonable Cost Over Charges (Contract Sch 2) $ $ Medi-Cal Inpatient Hospital Based Physician Services $ $ $ $ $ 6,256,465 $ 7,145,013 $ $ $ $ Subtotal (Sum of Lines through 4) Total Medi-Cal Cost (Sum of Lines through 7) $ Medi-Cal Overpayments (Adj ) $ $ 10 Medi-Cal Credit Balances (Adj ) $ $ 11 $ $ 12 $ $ 13 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ This is trial version www.adultpdf.com 6,256,465 $ 7,145,013 (To Summary of Findings) $ (To Summary of Findings) STATE OF CALIFORNIA CONTRACT SCH COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: HSC 30281H REPORTED AUDITED REASONABLE COST OF MEDI-CAL INPATIENT SERVICES Cost of Covered Services (Contract Sch 3) $ 6,256,465 $ 7,421,125 CHARGES FOR MEDI-CAL INPATIENT SERVICES Inpatient Routine Service Charges (Adj 24) $ 11,257,102 $ 8,599,224 Inpatient Ancillary Service Charges (Adj 24) $ 15,471,109 $ 16,905,504 Total Charges - Medi-Cal Inpatient Services $ 26,728,211 $ 25,504,728 Excess of Customary Charges Over Reasonable Cost (Line minus Line 1) * $ 20,471,746 $ 18,083,603 Excess of Reasonable Cost Over Customary Charges (Line minus Line 4) $ * If charges exceed reasonable cost, no further calculation necessary for this schedule This is trial version www.adultpdf.com $ (To Contract Sch 1) STATE OF CALIFORNIA CONTRACT SCH COMPUTATION OF MEDI-CAL NET COST OF COVERED SERVICES Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: HSC 30281H REPORTED AUDITED Medi-Cal Inpatient Ancillary Services (Contract Sch 5) $ 3,094,396 $ 3,579,546 Medi-Cal Inpatient Routine Services (Contract Sch 4) $ 3,162,069 $ 3,841,579 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ $ $ $ $ $ SUBTOTAL (Sum of Lines through 5) $ 6,256,465 $ 7,421,125 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Contract Sch 7) $ $ SUBTOTAL $ Coinsurance (Adj 25) $ $ (272,303) 10 Patient and Third Party Liability (Adj 25) $ $ (3,809) 11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ This is trial version www.adultpdf.com 6,256,465 $ 7,421,125 (To Contract Sch 2) 6,256,465 $ 7,145,013 (To Contract Sch 1) STATE OF CALIFORNIA CONTRACT SCH COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: HSC 30281H GENERAL SERVICE UNIT NET OF SWING-BEDS COSTS REPORTED INPATIENT DAYS Total Inpatient Days (include private & swing-bed) (Adj 14) Inpatient Days (include private, exclude swing-bed) Private Room Days (exclude swing-bed private room) (Adj 14) Semi-Private Room Days (exclude swing-bed) (Adj ) Medicare NF Swing-Bed Days through Dec 31 (Adj ) Medicare NF Swing-Bed Days after Dec 31 (Adj ) Medi-Cal NF Swing-Bed Days through July 31 (Adj ) Medi-Cal NF Swing-Bed Days after July 31 (Adj ) Medi-Cal Days (excluding swing-bed) (Adj 22) AUDITED 18,923 18,923 18,923 0 0 3,913 22,644 22,644 22,644 0 0 4,340 SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) 18 Medicare NF Swing-Bed Rates after Dec 31(Adj ) 19 Medi-Cal NF Swing-Bed Rates through July 31(Adj ) 20 Medi-Cal NF Swing-Bed Rates after July 31(Adj ) 21 Total Routine Serv Cost (Sch 8, Part I, Line 25, Col 27) 22 Medicare NF Swing-Bed Cost through Dec 31 (L x L 17) 23 Medicare NF Swing-Bed Cost after Dec 31 (L x L 18) 24 Medi-Cal NF Swing-Bed Cost through July 31 (L x L 19) 25 Medi-Cal NF Swing-Bed Cost after July 31 (L x L 20) 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ $ $ $ $ $ $ $ $ $ $ 0.00 0.00 0.00 0.00 10,987,464 0 0 10,987,464 $ $ $ $ $ $ $ $ $ $ $ 0.00 0.00 0.00 0.00 14,724,680 0 0 14,724,680 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges)(Adj 15) 29 Private Room Charges (excluding swing-bed charges)(Adj ) 30 Semi-Private Room Charges (excluding swing-bed charges)(Adj 15) 31 Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) 32 Average Private Room Per Diem Charge (L 29 / L 3) 33 Average Semi-Private Room Per Diem Charge (L 30 / L 4) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) 36 Private Room Cost Differential Adjustment (L 35 x L 3) 37 Inpatient Rout Cost Net of Swing-Bed & Prvt Rm (L 27 minus L 36) $ $ $ $ $ $ $ $ $ $ 28,137,750 28,137,750 0.390488 0.00 1,486.96 0.00 0.00 10,987,464 $ $ $ $ $ $ $ $ $ $ 34,105,250 34,105,250 0.431742 0.00 1,506.15 0.00 0.00 14,724,680 PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) 39 Program General Inpatient Routine Service Cost (L x L 38) $ $ 580.64 $ 2,272,044 $ 650.27 2,822,172 40 41 Cost Applicable to Medi-Cal (Contract Sch 4A) Cost Applicable to Medi-Cal (Contract Sch N/A) $ $ 890,025 $ $ 1,019,407 42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39, 40 & 41) $ This is trial version www.adultpdf.com 3,162,069 $ 3,841,579 (To Contract Sch 3) STATE OF CALIFORNIA CONTRACT SCH 4A COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: HSC 30281H SPECIAL CARE AND/OR NURSERY UNITS NURSERY Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj ) Cost Applicable to Medi-Cal INTENSIVE CARE UNIT Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj 22) 10 Cost Applicable to Medi-Cal CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8, Line 27, Col 27) 12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8, Line 28, Col 27) 17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost 19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8, Line 29, Col 27) 22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost 24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal REPORTED $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 26 27 28 29 30 Total Inpatient Routine Cost (Sch 8, Line , Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj ) Cost Applicable to Medi-Cal $ $ 31 Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ $ This is trial version www.adultpdf.com AUDITED $ 0.00 $ 0 $ 0 0.00 0 4,339,417 $ 2,979 1,456.67 $ 611 890,025 $ 4,283,221 2,979 1,437.81 709 1,019,407 $ 0.00 $ 0 $ 0 0.00 0 $ 0.00 $ 0 $ 0 0.00 0 $ 0.00 $ 0 $ 0 0.00 0 $ 0.00 $ 0 $ 0 0.00 0 890,025 $ 1,019,407 (To Contract Sch 4) STATE OF CALIFORNIA CONTRACT SCH 4B COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: HSC 30281H SPECIAL CARE UNITS REPORTED Total Inpatient Routine Cost (Sch 8, Line _, Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj ) Cost Applicable to Medi-Cal $ 10 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj ) Cost Applicable to Medi-Cal 11 12 13 14 15 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj ) Cost Applicable to Medi-Cal 16 17 18 19 20 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj ) Cost Applicable to Medi-Cal 21 22 23 24 25 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj ) Cost Applicable to Medi-Cal 26 27 28 29 30 Total Inpatient Routine Cost (Sch 8, Line _, Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj ) Cost Applicable to Medi-Cal $ 31 Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ This is trial version www.adultpdf.com AUDITED $ 0.00 $ 0 $ 0 0.00 0 $ 0.00 $ 0 $ 0 0.00 0 $ 0.00 $ 0 $ 0 0.00 0 $ 0.00 $ 0 $ 0 0.00 0 $ 0.00 $ 0 $ 0 0.00 0 $ 0.00 $ 0 $ 0 0.00 0 $ (To Contract Sch 4) STATE OF CALIFORNIA CONTRACT SCH SCHEDULE OF MEDI-CAL ANCILLARY COSTS Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: HSC 30281H TOTAL ANCILLARY COST* 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 59.01 59.02 59.03 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 TOTAL TOTAL ANCILLARY CHARGES (Adj ) $ 3,167,973 0 2,434,853 0 431,248 3,175,765 873,403 0 2,532,287 699,685 77,916 735,125 75,249 3,159,034 4,077,315 447,219 0 0 0 3,003,592 0 0 0 $ 15,068,745 0 10,756,349 0 1,854,743 21,740,181 623,641 0 19,155,590 3,958,002 530,593 4,110,438 105,813 6,182,537 28,451,429 1,789,364 0 0 0 6,232,588 0 0 0 $ 24,890,663 $ RATIO COST TO CHARGES 0.210235 0.000000 0.000000 0.000000 0.226364 0.000000 0.000000 0.000000 0.232511 0.146078 0.000000 1.400490 0.000000 0.000000 0.132196 0.176777 0.000000 0.146847 0.178843 0.711149 0.510961 0.143308 0.249932 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.481917 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 120,560,013 * From Schedule 8, Column 27 This is trial version www.adultpdf.com MEDI-CAL CHARGES (Contract Sch 6) $ 425,526 0 1,358,244 0 257,720 3,059,727 145,900 0 3,175,810 214,804 64,516 782,435 17,798 1,663,095 4,969,574 351,966 0 0 0 418,389 0 0 0 $ 16,905,504 MEDI-CAL COST $ 89,460 0 307,458 0 59,923 446,959 204,331 0 419,828 37,972 9,474 139,933 12,657 849,776 712,179 87,967 0 0 0 201,629 0 0 0 $ 3,579,546 (To Contract Sch 3) STATE OF CALIFORNIA CONTRACT SCH ADJUSTMENTS TO MEDI-CAL CHARGES Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: HSC 30281H REPORTED 37.00 38.00 39.00 40.00 41.00 41.01 41.02 42.00 43.00 44.00 44.01 46.00 47.00 48.00 49.00 50.00 51.00 52.00 53.00 54.00 55.00 56.00 57.00 58.00 59.00 59.01 59.02 59.03 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 ANCILLARY CHARGES Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic $ 1,145,081 1,030,893 4,499,013 354,888 40,356 89,993 17,798 632,202 470,561 (2,922) 499,261 $ (418,312) 144,347 24,160 692,442 Clinic Other Clinic Services Emergency Observation Beds (499) 3,594,122 70,457 Medical Supplies Charged to Patients (45,903) 684,975 146,399 Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) 213,163 303,623 2,374,752 Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography TOTAL MEDI-CAL ANCILLARY CHARGES ADJUSTMENTS (Adj 23) 736,018 $ (310,492) $ (80,872) 15,471,109 $ 1,434,395 $ AUDITED 425,526 0 1,358,244 0 257,720 3,059,727 145,900 0 3,175,810 214,804 64,516 782,435 17,798 1,663,095 4,969,574 351,966 0 0 0 418,389 0 0 0 16,905,504 (To Contract Sch 5) This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED PHYSICIAN'S REMUNERATION Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: HSC 30281H PROFESSIONAL SERVICE COST CENTERS HBP REMUNERATION (Adj ) 40.00 41.00 43.00 44.00 53.00 54.00 61.00 Anesthesiology Radiology - Diagnostic Radioisotope Laboratory Electrocardiology Electroencephalography Emergency TOTAL $ $ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL CHARGES RATIO OF MEDI-CAL MEDI-CAL TO ALL PATIENTS REMUNERATION CHARGES COST TO CHARGES (Adj ) (Adj ) $ 0.000000 $ $ 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 $ $ $ (To Contract Sch 3) This is trial version www.adultpdf.com 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 STATE OF CALIFORNIA ADULT SUBACUTE SCH COMPUTATION OF ADULT SUBACUTE PER DIEM Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 Provider No: LTC 70043G REPORTED AUDITED DIFFERENCE COMPUTATION OF SUBACUTE PER DIEM Adult Subacute Ancillary Cost (Adult Subacute Sch 3) $ 1,907,829 $ 2,000,563 $ 92,734 Adult Subacute Routine Cost (Adult Subacute Sch 2) $ 3,834,924 $ 3,843,377 $ 8,453 Total Adult Subacute Facility Cost (Lines & 2) $ 5,742,753 $ 5,843,940 $ 101,187 Total Adult Subacute Patient Days (Adj ) Average Adult Subacute Per Diem Cost (L3 / L4) 9,089 9,089 $ 631.84 $ 642.97 $ 11.13 ADULT SUBACUTE OVERPAYMENT & OVERBILLINGS Medi-Cal Overpayments (Adj ) $ $ $ Medi-Cal Credit Balances (Adj ) $ $ $ MEDI-CAL SETTLEMENT Due Provider (State) $ $ $ (To Summary of Findings) GENERAL INFORMATION Contracted Number of Adult Subacute Beds (Adj ) 26 26 26 26 144 144 8,937 8,852 10 Total Licensed Nursing Facility Beds (Adj ) 11 Total Licensed Capacity (All levels of care)(Adj ) 12 Total Medi-Cal Adult Subacute Patient Days (Adj 26) (85) CAPITAL RELATED COST 13 Direct Capital Related Cost N/A $ N/A 14 Indirect Capital Related Cost (Adult Subacute Sch 5) N/A $ 401,268 N/A 15 Total Capital Related Cost (Lines 13 & 14) N/A $ 401,268 N/A 16 Direct Salary & Benefits Expenses N/A $ 1,828,926 N/A 17 Alloc Salary & Benefits Expenses (Adult Subacute Sch 5) N/A $ 387,122 N/A 18 Total Salary & Benefits Expenses (Lines 16 & 17) N/A $ 2,216,048 N/A TOTAL SALARY & BENEFITS AUDITED ADULT SUBACUTE COST-VENTILATOR AND NONVENTILATOR 19 Ventilator (Equipment Cost Only) 20 Nonventilator 21 TOTAL $ AUDITED COSTS (Adj 28) 32,438 AUDITED TOTAL DAYS (Adj 27) 4,325 This is trial version www.adultpdf.com AUDITED MEDI-CAL DAYS (Adj 26) 4,212 N/A 4,764 N/A N/A 9,089 N/A ... 44.01 46.00 47.00 48.00 49.00 50 .00 51 .00 52 .00 53 .00 54 .00 55 .00 56 .00 57 .00 58 .00 59 .00 59 .01 59 .02 59 .03 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85. 00 86.00 ANCILLARY CHARGES Operating... TOTAL ANCILLARY CHARGES (Adj ) $ 3,167,973 0 2,434, 853 0 431,248 3,1 75, 7 65 873,403 0 2 ,53 2,287 699,6 85 77,916 7 35, 1 25 75, 249 3, 159 ,034 4,077,3 15 447,219 0 0 0 3,003 ,59 2 0 0 0 $ 15, 068,7 45 0 10, 756 ,349... 1,663,0 95 4,969 ,57 4 351 ,966 0 0 0 418,389 0 0 0 16,9 05, 504 (To Contract Sch 5) This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL