STATE OF CALIFORNIA CONTRACT SCH ADJUSTMENTS TO MEDI-CAL CHARGES Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: HSC00289G 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 60.02 60.03 60.04 61.00 62.00 71.00 85.00 86.00 ANCILLARY CHARGES Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - P O B $ Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography 53,540 717,573 4,294,432 (329,559) (3,351,151) (241,594) 11,570 1,123,216 $ (1,122) (1,983,682) (226,732) (87,652) 4,493 (869,297) (13,520) 609,336 (3,232,510) (247,704) 329,559 5,065,502 809,291 Clinic Wound Care Out-Patient Psychiatry Diabetes Treatment Center OB/GYN Clinic Emergency Observation Beds Home Health Agency (15,324) 1,122 2,552,616 330,930 140,752 60,630 1,446,533 25,548 2,574,316 6,700,069 337,854 Medical Supplies Charged to Patients 46,024 (521,822) (2,432,184) 85,902 Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) Gastro Intestinal Services Cardiac Cath Lab CT/MRI TOTAL MEDI-CAL ANCILLARY CHARGES ADJUSTMENTS (Adj 11) 3,645,300 $ (2,516,717) $ 3,250,701 (2,219,628) 1,051,777 (654,672) 779,803 (479,037) 202,851 (202,851) (11,570) (550,521) 35,591,387 $ (19,528,996) $ AUDITED 1,128,583 1,031,073 397,105 300,766 0 99,564 195,751 1,862,248 70,578 0 568,934 104,198 53,100 65,123 577,236 12,028 3,183,652 3,467,559 90,150 0 1,714,351 567,697 0 0 0 572,695 0 0 16,062,391 (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: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: HSC00289G 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 DPNF SCH COMPUTATION OF DISTINCT PART NURSING FACILITY PER DIEM Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC55235G REPORTED AUDITED DIFFERENCE COMPUTATION OF DISTINCT PART (DP) NURSING FACILITY PER DIEM Distinct Part Ancillary Cost (DPNF Sch 3) $ $ $ Distinct Part Routine Cost (DPNF Sch 2) $ 24,399,595 $ 26,002,684 $ 1,603,089 Total Distinct Part Facility Cost (Lines & 2) $ 24,399,595 $ 26,002,684 $ 1,603,089 Total Distinct Part Patient Days (Adj 5) Average DP Per Diem Cost (Line / Line 4) 52,459 52,731 272 $ 465.12 $ 493.12 $ 28.00 DPNF OVERPAYMENT AND OVERBILLINGS Medi-Cal Overpayments (Adj ) $ $ $ Medi-Cal Credit Balances (Adj ) $ $ $ MEDI-CAL SETTLEMENT Due Provider (State) $ $ (To Summary of Findings) $ GENERAL INFORMATION Total Available Distinct Part Beds (C/R, W/S S-3) 153 153 428 478 50 13,692 38,135 24,443 10 Total Licensed Capacity (All levels) (Adj 15) 11 Total Medi-Cal DP Patient Days (Adj 14) CAPITAL RELATED COST 12 Direct Capital Related Cost N/A $ 129,965 N/A 13 Indirect Capital Related Cost (DPNF Sch 5) N/A $ 1,334,232 N/A 14 Total Capital Related Cost (Lines 12 & 13) N/A $ 1,464,197 N/A 15 Direct Salary & Benefits Expenses N/A $ 11,027,194 N/A 16 Allocated Salary & Benefits (DPNF Sch 5) N/A $ 8,597,872 N/A 17 Total Salary & Benefits Expenses (Lines 15 & 16) N/A $ 19,625,066 N/A TOTAL SALARY & BENEFITS This is trial version www.adultpdf.com STATE OF CALIFORNIA DPNF SCH SUMMARY OF DISTINCT PART FACILITY EXPENSES Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC55235G COST CENTER REPORTED * COL 0.00 1.00 2.00 3.00 3.01 4.00 4.01 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 21.00 21.01 22.00 23.00 24.00 DIRECT AND ALLOCATED EXPENSE Distinct Part Old Cap Rel Costs - Bldg and Fixtures Old Cap Rel Costs - Movable Equipment New Cap Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) $ 12,111,585 AUDITED * $ 236,124 128,278 211,857 134,989 Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office 3,568,995 22,929 Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Social Service 1,565,799 544,395 429,222 792,197 1,057,778 585,284 397,948 Nursing School Clinical Pastoral Education Intern and Res Service - Salary and Fringes Intern and Res - Other Program Paramedical Ed Program TOTAL DIRECT AND 101.00 ALLOCATED EXPENSES 102,590 92,667 188,959 1,474,757 219,674 8,045 139,406 386,117 $ 24,399,595 $ $ 26,002,684 $ (To DPNF Sch 1) This is trial version www.adultpdf.com * From Schedule 8, Part I, line 34 12,111,585 0 236,124 128,277 211,857 134,989 0 0 0 3,579,077 22,937 102,613 92,700 188,977 0 1,566,352 544,579 429,217 792,274 1,058,341 2,144,002 427,168 1,477,195 219,726 8,056 139,625 387,013 0 0 0 0 DIFFERENCE 0 (0) (1) 0 0 0 0 10,082 23 33 18 0 553 184 (5) 77 563 1,558,718 29,220 2,438 52 11 219 896 0 0 0 0 1,603,089 STATE OF CALIFORNIA DPNF SCH SCHEDULE OF TOTAL DISTINCT PART ANCILLARY COSTS Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC55235G TOTAL ANCILLARY COST * ANCILLARY COST CENTERS 49.00 Respiratory Therapy 55.00 Med Supply Charged to Patients 56.00 Drugs Charged to Patients 101.00 TOTAL TOTAL ANCILLARY CHARGES $ $ $ $ RATIO COST TO CHARGES 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 0.000000 0.000000 0.000000 * From Schedule 8, Column 27 ** Total Distinct Part Ancillary Charges included in the rate *** Total Distinct Part Ancillary Costs included in the rate This is trial version www.adultpdf.com TOTAL TOTAL DP ANCILLARY ANCILLARY CHARGES ** COST*** (From DPNF Sch 4) $ $ 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 0 0 $ $ (To DPNF Sch 1) STATE OF CALIFORNIA DPNF SCH ADJUSTMENTS TO TOTAL DISTINCT PART ANCILLARY CHARGES Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC55235G REPORTED ANCILLARY CHARGES 49.00 Respiratory Therapy 55.00 Med Supply Charged to Patients 56.00 Drugs Charged to Patients TOTAL DP ANCILLARY CHARGES $ $ ADJUSTMENTS (Adj ) $ $ This is trial version www.adultpdf.com AUDITED $ 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) STATE OF CALIFORNIA DPNF SCH ALLOCATION OF INDIRECT EXPENSES DISTINCT PART NURSING FACILITY Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC55235G COL 1.00 2.00 3.00 3.01 4.00 4.01 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 21.00 21.01 22.00 23.00 24.00 COST CENTER Old Cap Rel Costs - Bldg and Fixtures Old Cap Rel Costs - Movable Equipment New Cap Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) AUDITED CAP RELATED * (COL 1) $ 0 236,124 128,277 211,857 134,989 0 0 0 17,363 271 17,374 6,184 384 0 45,831 22,945 29,023 57,203 23,505 172,916 41,853 32,725 132,746 1,149 13,143 8,370 0 0 0 0 Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Social Service Nursing School Clinical Pastoral Education Intern and Res Service - Salary and Fringes Intern and Res - Other Program Paramedical Ed Program This is trial version www.adultpdf.com 101 TOTAL ALLOCATED INDIRECT EXPENSES * These amounts include Skilled Nursing Facility expenses, line 34 $ AUDITED SAL & EMP BENEFITS * (COL 2) $ N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 3,561,714 10,911 32,637 62,803 64 0 457,681 271,871 17,111 144,864 801,875 1,261,829 309,334 1,202,073 36,342 5,627 73,593 347,544 0 0 0 0 1,334,232 $ 8,597,872 (To DPNF SCH 1) STATE OF CALIFORNIA ADULT SUBACUTE SCH COMPUTATION OF ADULT SUBACUTE PER DIEM Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC70037G REPORTED AUDITED DIFFERENCE COMPUTATION OF SUBACUTE PER DIEM Adult Subacute Ancillary Cost (Adult Subacute Sch 3) $ $ $ Adult Subacute Routine Cost (Adult Subacute Sch 2) $ 12,240,180 $ 12,898,180 $ 658,000 Total Adult Subacute Facility Cost (Lines & 2) $ 12,240,180 $ 12,898,180 $ 658,000 Total Adult Subacute Patient Days (Adj ) Average Adult Subacute Per Diem Cost (L3 / L4) 15,573 15,573 $ 785.99 $ 828.24 $ 42.25 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 ) 44 44 10 Total Licensed Nursing Facility Beds (Adj) 197 197 11 Total Licensed Capacity (All levels of care)(Adj 18) 428 478 50 13,339 13,339 12 Total Medi-Cal Adult Subacute Patient Days (Adj 16) CAPITAL RELATED COST 13 Direct Capital Related Cost N/A $ 113,214 N/A 14 Indirect Capital Related Cost (Adult Subacute Sch 5) N/A $ 852,781 N/A 15 Total Capital Related Cost (Lines 13 & 14) N/A $ 965,995 N/A 16 Direct Salary & Benefits Expenses N/A $ 5,545,755 N/A 17 Alloc Salary & Benefits Expenses (Adult Subacute Sch 5) N/A $ 3,790,999 N/A 18 Total Salary & Benefits Expenses (Lines 16 & 17) N/A $ 9,336,754 N/A TOTAL SALARY & BENEFITS AUDITED ADULT SUBACUTE COST-VENTILATOR AND NONVENTILATOR 19 Ventilator (Equipment Cost Only) 20 Nonventilator 21 TOTAL $ AUDITED COSTS (Adj 17) 68,282 AUDITED TOTAL DAYS (Adj 5) 11,832 This is trial version www.adultpdf.com AUDITED MEDI-CAL DAYS (Adj 16) 10,135 N/A 3,741 N/A N/A 15,573 N/A STATE OF CALIFORNIA ADULT SUBACUTE SCH SUMMARY OF ADULT SUBACUTE FACILITY EXPENSES Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC70037G COST CENTER COL 0.00 1.00 2.00 3.00 3.01 4.00 4.01 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 21.00 21.01 22.00 23.00 24.00 DIRECT AND ALLOCATED EXPENSE Adult Subacute Old Cap Rel Costs - Bldg and Fixtures Old Cap Rel Costs - Movable Equipment New Cap Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) REPORTED $ Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office 6,462,288 $ 0 245,950 220,674 1,794,906 16,756 76,448 111,502 227,365 Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Social Service Nursing School Clinical Pastoral Education Intern and Res Service - Salary and Fringes Intern and Res - Other Program Paramedical Ed Program TOTAL DIRECT AND 101.00 ALLOCATED EXPENSES AUDITED * 853,402 225,875 178,088 127,407 180,596 192,349 712,502 310,393 24,156 167,741 111,782 $ 12,240,180 $ DIFFERENCE 6,462,288 $ 0 245,950 220,674 0 0 0 1,799,976 16,762 76,465 111,541 227,386 0 853,667 225,951 178,086 127,419 180,692 636,468 206,472 713,680 310,467 24,190 168,004 112,042 0 0 0 0 0 0 (0) 0 0 0 5,070 17 39 21 0 265 76 (2) 12 96 636,468 14,123 1,178 74 34 263 260 0 0 0 0 12,898,180 $ 658,000 (To Adult Subacute Sch 1) This is trial version www.adultpdf.com * From Schedule 8, Part I, Line 36.00 STATE OF CALIFORNIA ADULT SUBACUTE SCH SCHEDULE OF TOTAL OTHER ALLOWABLE ADULT SUBACUTE ANCILLARY COSTS** Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC70037G TOTAL ANCILLARY COST * ANCILLARY COST CENTERS 41.00 Radiology - Diagnostic 44.00 Laboratory 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 55.00 Med Supply Charged to Patients 56.00 Drugs Charged to Patients 101.00 TOTAL TOTAL ANCILLARY CHARGES $ $ $ $ RATIO TOTAL SUBACUTE SUBACUTE COST TO ANCILLARY ANCILLARY CHARGES CHARGES ** COSTS*** (Adult SA Sch 4) 0.000000 $ $ 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 0 0.000000 0 0.000000 0 $ $ (To Adult Subacute Sch * From Schedule 8, Column 27 ** Total Other Allowable Ancillary Charges included in the rate *** Total Other Ancillary Costs included in the rate This is trial version www.adultpdf.com STATE OF CALIFORNIA ADULT SUBACUTE SCH ADJUSTMENTS TO OTHER ALLOWABLE ADULT SUBACUTE ANCILLARY CHARGES Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC70037G REPORTED ANCILLARY CHARGES Radiology - Diagnostic Laboratory Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology 41.00 44.00 49.00 50.00 51.00 52.00 55.00 Med Supply Charged to Patients 56.00 Drugs Charged to Patients $ 101.00 TOTAL ANCILLARY CHARGES $ ADJUSTMENTS (Adj ) $ $ This is trial version www.adultpdf.com AUDITED $ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 $ (To Adult Subacute Sch 3) ...STATE OF CALIFORNIA CONTRACT SCH COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED PHYSICIAN''S REMUNERATION Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider. .. version www.adultpdf.com STATE OF CALIFORNIA DPNF SCH SUMMARY OF DISTINCT PART FACILITY EXPENSES Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC55235G COST. .. STATE OF CALIFORNIA DPNF SCH SCHEDULE OF TOTAL DISTINCT PART ANCILLARY COSTS Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: LTC55235G TOTAL ANCILLARY COST *