STATE OF CALIFORNIA SCHEDULE 7 PROGRAM: NONCONTRACT COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED PHYSICIAN''''S REMUNERATION_part5 docx

State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report RECLASSIFICATIONS OF REPORTED COSTS 6 10A A 6.00 7 Administrative and General * $28,649,240 ($434) $28,648,806 * 10A A 7.00 7 Maintenance and Repairs 4,854,230 (25) 4,854,205 10A A 15.00 7 Central Services and Supply 402,079 (560) 401,519 10A A 16.00 7 Pharmacy * 2,400,878 (5,116) 2,395,762 10A A 25.00 7 Adults and Pediatrics * 13,741,910 (116,521) 13,625,389 10A A 26.00 7 Intensive Care Unit 3,454,404 (40,874) 3,413,530 10A A 33.00 7 Nursery * 1,482,652 (3,583) 1,479,069 10A A 34.00 7 Distinct Part Nursing Facility 4,705,466 (6,283) 4,699,183 10A A 37.00 7 Operating Room 4,955,402 (45,173) 4,910,229 10A A 37.01 7 Gastro Intestinal Service 212,687 (766) 211,921 10A A 37.02 7 Cardiac Cath Laboratory 1,117,357 (21,331) 1,096,026 10A A 39.00 7 Delivery Room and Labor Room 4,136,680 (40,547) 4,096,133 10A A 40.00 7 Anesthesiology 146,802 (11,303) 135,499 10A A 41.00 7 Radiology - Diagnostic 3,328,053 (11,292) 3,316,761 10A A 41.01 7 CT Scan and MRI 516,039 (2,195) 513,844 10A A 43.00 7 Radioisotope 1,291,377 (4,371) 1,287,006 10A A 44.00 7 Laboratory 5,140,846 (12,720) 5,128,126 10A A 49.00 7 Respiratory Therapy 1,854,927 (3) 1,854,924 10A A 50.00 7 Physical Therapy 1,686,912 (20) 1,686,892 10A A 53.00 7 Electrocardiology 1,090,149 (542) 1,089,607 10A A 57.00 7 Renal Dialysis 290,849 (557) 290,292 10A A 59.00 7 Ultrasound 345,883 (5,902) 339,981 10A A 60.00 7 Clinic 504,893 (816) 504,077 10A A 61.00 7 Emergency 5,328,437 (118,512) 5,209,925 10A A 55.00 7 Medical Supplies Charged to Patients 6,334,741 449,446 6,784,187 To reclassify IV sets and supplies expenses 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 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report ADJUSTMENTS TO REPORTED COSTS 7 10A A 100.03 7 Community Relations * $1,472,320 $772,882 $2,245,202 To reestablish marketing expenses in a nonreimbursable cost center. 42 CFR 413.5, 413.9, and 413.24 CMS Pub. 15-1, Sections 2136.2, 2328, and 2304 8 10A A 12.00 7 Cafeteria $1,369,291 $106,572 $1,475,863 To reverse provider's guests meal revenue abatement for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 9 10A A 8.00 7 Operation of Plant $2,605,898 ($197,296) $2,408,602 To eliminate planning costs that should have been capitalized. 42 CFR 413.20 and 413.134 CMS Pub. 15-1, Sections 108 and 2300 10 10A A 3.00 7 New Capital Related Cost - Building and Fixtures $6,429,449 ($53,218) $6,376,231 * To abate sublease revenues against the related costs. 42 CFR 413.5 and 413.9 / CMS Pub. 15-1, Section 2328 CMS Pub. 15-2, Section 3613 11 10A A 6.00 7 Administrative and General * $28,648,806 ($80,760) $28,568,046 * To reconcile the allocated home office expenses to agree with the provider's supporting documentation. 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 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report ADJUSTMENTS TO REPORTED COSTS 12 10A A 3.00 7 New Capital Related Cost - Building and Fixtures * $6,376,231 $101,989 $6,478,220 * 10A A 4.00 7 New Capital Related Cost - Movable Equipment 5,342,064 1,633,874 6,975,938 10A A 5.00 7 Employee Benefits 23,297,357 (557,257) 22,740,100 10A A 6.00 7 Administrative and General * 28,568,046 (5,474,857) 23,093,189 To adjust reported home office costs to agree with the Catholic Healthcare West Home Office Audit Report for fiscal period ended June 30, 2009. 42 CFR 413.17 and 413.24 CMS Pub. 15-1, Sections 2150.2 and 2304 13 10A A 3.00 7 New Capital Related Cost - Building and Fixtures * $6,478,220 ($1,818,188) $4,660,032 * To eliminate bond interest expenses related to the inssuance and refinancing of bonds issued prior to October 26, 2006. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Section 202.1, 202.2, 2300 and 2304 Final Decision Pursuant to Stipulation of the Parties in the matter of Mercy Medical Center - Mt. Shasta, Appeal N. HA4-0601-438-DN 14 10A A 3.00 7 New Capital Related Cost - Building and Fixtures * $4,660,032 ($200,239) $4,459,793 To eliminate bond interest expenses due to unnecessary borrowing. 42 CFR 413.134,413.20 and 413.24. CMS Pub. 15-1, Section 202.1, 202.2, 2300 and 2304. *Balance carried forward from prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report ADJUSTMENTS TO REPORTED STATISTICS 15 9 B-1 5.00 1,3 Employee Benefits (Square Feet) 2,000 2,000 4,000 9 B-1 6.00 1,3 Administrative and General 107,838 60,113 167,951 9 B-1 7.00 1,3 Maintenance and Repairs 289 18,981 19,270 9 B-1 8.00 1,3 Operation of Plant 0 127 127 9 B-1 11.00 1,3,7,8,10 Dietary 3,255 (825) 2,430 9 B-6 12.00 1,3,7,8,10 Cafeteria 4,154 825 4,979 9 B-1 17.00 1,3,7,8,10 Medical Records and Library 467 1,727 2,194 9 B-1 25.00 1,3,7,8,10 Adults and Pediatrics 24,519 89 24,608 9 B-1 33.00 1,3,7,8,10 Nursery 1,912 (225) 1,687 9 B-1 39.00 1,3,7,8,10 Delivery Room and Labor Room 6,312 (648) 5,664 9 B-1 50.00 1,3,7,8,10 Physical Therapy 3,711 (200) 3,511 9 B-1 51.00 1,3,7,8,10 Occupational Therapy 949 579 1,528 9 B-1 53.00 1,3,7,8,10 Electrocardiology 0 6,207 6,207 9 B-1 60.00 1,3,7,8,10 Clinic 0 9,339 9,339 9 B-1 71.00 1,3,7,8,10 Home Health Agency 11,033 (2,593) 8,440 9 B-1 93.00 1,3,7,8,10 Hospice 2,022 2,918 4,940 9 B-1 98.00 1,3,7,8,10 Physicians' Private Office 63,968 (63,968) 0 9 B-1 100.01 1,3,7,8,10 Foundation 2,000 2,000 4,000 9 B-1 100.03 1,3,7,8,10 Community Relations 7,885 (3,456) 4,429 9 B-1 1.00, 3.00 1,3 Total - Square Feet 324,767 32,990 357,757 9 B-1 7,00, 8.00 7,8 Total - Square Feet 214,640 (48,231) 166,409 9 B-1 10.00 10 Total - Square Feet 198,883 (48,556) 150,327 To adjust square footage statistics to agree with the provider's documentation. 42 CFR 413.24 and 413.50 CMS Pub. 15-1, Sections 2304 and 2306 Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report ADJUSTMENTS TO REPORTED STATISTICS 16 9 B-1 11.00 2,4 Dietary (Dollar Value) 14,399 (8,072) 6,327 9 B-1 12.00 2,4 Cafeteria 0 8,072 8,072 To adjust equipment depreciation statistics to agree with provider's documentation. 42 CFR 413.24 and 413.50 CMS Pub. 15-1, Sections 2304 and 2306 *Balance carried forward from prior/to subsequent adjustments Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report ADJUSTMENTS TO REPORTED STATISTICS 17 9 B-1 6.00 2,4 Administrative and General (Dollar Value) 683,091 (10,969) 672,122 9 B-1 100.03 2,4 Community Relations 4,791 10,969 15,760 To reclassify equuipment depreciation statistics for mission service for proper cost determination. 42 CFR 413.24 and 413.50 CMS Pub. 15-1, Sections 2304 and 2328 18 9 B-1 12.00 11 Cafeteria (Meals Served) 410,563 (410,563) 0 9 B-1 11.00 11 Total - Meals Served 646,012 (410,563) 235,449 To adjust diatary statistics for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2304 and 2306 19 9 B-1 25.00 12 Adults and Pediatrics (FTEs) 15,618 (635) 14,983 9 B-1 33.00 12 Nursery 459 635 1,094 To reclassify cafeteria statistics for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2304 and 2306 20 9 B-1 100.03 12 Community Relations (FTEs) 851 11,963 12,814 9 B-1 12.00 12 Total - FTEs 63,333 11,963 75,296 To adjust FTEs statistics for guest meals for proper cost determination. 42 CFR 413.24 and 413.50 CMS Pub. 15-1, Sections 2304 and 2328 21 9 B-1 25.00 14 Adults and Pediatrics (Nurse Hours) 297,279 (13,031) 284,248 9 B-1 33.00 14 Nursery 9,422 13,028 22,450 9 B-1 100.03 14 Community Relations 1,721 1,723 3,444 9 B-1 14.00 14 Total - Nurse Hours 754,662 1,720 756,382 To adjust nurse hours statistics to agree with the provider's documentation. 42 CFR 413.24 and 413.50 CMS Pub. 15-1, Sections 2304 and 2328 Page 8 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report ADJUSTMENTS TO REPORTED STATISTICS 22 9 B-1 25.00 17 Adults and Pediatrics (Gross Revenues) 89,651,824 (1,747,028) 87,904,796 9 B-1 17.00 17 Total - Gross Revenues 755,835,816 (1,747,028) 754,088,788 To adjust gross revenue statistics to agree with the provider's documentation. 42 CFR 413.24 and 413.50 CMS Pub. 15-1, Sections 2304 and 2328 23 9 B-1 55.00 15 Medical Supplies Charged to Patients (Costed Requisitions) 7,570,513 443,311 8,013,824 9 B-1 25.00 15 Adults and Pediatrics 308,663 (116,521) 192,142 9 B-1 26.00 15 Intensive Care Unit 71,995 (40,874) 31,121 9 B-1 33.00 15 Nursery 16,982 (3,583) 13,399 9 B-1 34.00 15 Distinct Part Nursing Facility 131,589 (6,283) 125,306 9 B-1 37.00 15 Operating Room 4,369,775 (45,173) 4,324,602 9 B-1 37.01 15 Gastro Intestinal Service 21,117 (766) 20,351 9 B-1 37.02 15 Cardiac Cath Laboratory 2,351,092 (21,331) 2,329,761 9 B-1 39.00 15 Delivery Room and Labor Room 170,011 (40,547) 129,464 9 B-1 40.00 15 Anesthesiology 113,387 (11,303) 102,084 9 B-1 41.00 15 Radiology - Diagnostic 179,492 (11,292) 168,200 9 B-1 41.01 15 CT Scan and MRI 42,165 (2,195) 39,970 9 B-1 43.00 15 Radioisotope 433,384 (4,371) 429,013 9 B-1 44.00 15 Laboratory 51,489 (12,720) 38,769 9 B-1 49.00 15 Respiratory Therapy 102,193 (3) 102,190 9 B-1 50.00 15 Physical Therapy 5,452 (20) 5,432 9 B-1 53.00 15 Electrocardiology 9,371 (542) 8,829 9 B-1 57.00 15 Renal Dialysis 776 (557) 219 9 B-1 59.00 15 Ultrasound 6,738 (5,902) 836 9 B-1 60.00 15 Clinic 3,231 (816) 2,415 9 B-1 61.00 15 Emergency 185,091 (118,512) 66,579 To reclassify IV sets and supplies statistics to agree with the auditor's reclassification. 42 CFR 413.24 and 413.50 CMS Pub. 15-1, Sections 2300, 2304 and 2306 Page 9 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report ADJUSTMENT TO REPORTED PATIENT DAYS 24 4 D-1 I 1.00 1 Adults and Pediatrics - Total 34,331 1,187 35,518 4A D-1 II 43.00 2 Intensive Care Unit - Total 3,602 (94) 3,508 4A D-1 II 42.00 2 Nursery - Total 6,834 (394) 6,440 DPNF 1 S-3 II 15.00 6 Distinct Part Nursing Facility - Total 30,806 167 30,973 To adjust total patient days to agree with the provider's patient census reports. 42 CFR 413.20, 413.24, and 413.50 CMS Pub. 15-1, Sections 2205, 2300 and 2304 Page 10 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT 25 4A Not Reported Medi-Cal Days - Administrative Day Rate (July 01, 2008 - July 31, 2008) $0.00 $318.19 $318.19 4A Not Reported Medi-Cal Days - Administrative Days (July 01, 2008 - July 31, 2008) 0 3 3 4A Not Reported Medi-Cal Days - Administrative Day Rate (August 01, 2008 - June 30, 2009) $0.00 $351.26 $351.26 4A Not Reported Medi-Cal Days - Administrative Days (August 01, 2008 - June 30, 2009) 0 3 3 26 4 D-1 I XIX 9.00 1 3,884 117 4,001 4A D-1 II XIX 42.00 4 3,291 99 3,390 4A D-1 II XIX 43.00 4 23 3 26 27 6 D-4 XIX 37.00 2 Medi-Cal Ancillary Charges - Operating Room $5,144,446 $218,849 $5,363,295 6 D-4 XIX 37.01 2 Medi-Cal Ancillary Charges - Gastro Intestinal Service 17,965 1,517 19,482 6 D-4 XIX 37.20 2 Medi-Cal Ancillary Charges - Cardiac Cath Lab 176,410 22,359 198,769 6 D-4 XIX 39.00 2 Medi-Cal Ancillary Charges - Delivery & Labor Room 6,573,360 110,786 6,684,146 6 D-4 XIX 40.00 2 Medi-Cal Ancillary Charges - Aneshesiology 2,376,637 80,311 2,456,948 6 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 189,731 12,355 202,086 6 D-4 XIX 41.01 2 Medi-Cal Ancillary Charges - CR Scan & MRI 424,407 20,129 444,536 6 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 2,710,437 177,774 2,888,211 6 D-4 XIX 46.00 2 Medi-Cal Ancillary Charges - Whole Blood and Pack Red Blood 230,593 25,586 256,179 6 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 59,233 2,790 62,023 6 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 199,864 5,050 204,914 6 D-4 XIX 51.00 2 Medi-Cal Ancillary Charges - Occupational Therapy 5,087 525 5,612 6 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 12,980 1,350 14,330 6 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1,114,072 54,360 1,168,432 6 D-4 XIX 55.01 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients - Implant 145,677 2,977 148,654 6 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 5,111,707 263,634 5,375,341 6 D-4 XIX 59.00 2 Medi-Cal Ancillary Charges - Ultrasound 197,001 20,237 217,238 6 D-4 XIX 61.00 2 Medi-Cal Ancillary Charges - Emergency 274,093 6,397 280,490 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total Ancillary Charges 25,001,239 1,026,986 26,028,225 28 2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges $10,287,521 $2,402,118 $12,689,639 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 25,001,239 1,026,986 26,028,225 -Continued on next page- Page 11 Medi-Cal Days - Adults and Pediatrics Medi-Cal Days - Nursery Medi-Cal Days - Intensive Care Unit This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT -Continued from previous page- 29 3 E-3 III XIX 33.00 Medi-Cal Deductibles $0 $74,721 $74,721 3 E-3 III XIX 36.00 Medi-Cal Coinsurance 83,045 (73,916) 9,129 1 E-3 III XIX 57.00 Medi-Cal Interim Payments 8,260,723 220,635 8,481,358 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: September 06, 2010 Payment Period: July 01, 2008 through August 31, 2010 Service Period: July 01, 2008 through June 30, 2009 42 CFR 413.20, 413.50, 413.53, 413.60, and 413.64 CMS Pub. 15-1, Sections 2304 and 2408 Page 12 This is trial version www.adultpdf.com . 4 ,70 5,466 (6,283) 4,699,183 10A A 37. 00 7 Operating Room 4,955,402 (45, 173 ) 4,910,229 10A A 37. 01 7 Gastro Intestinal Service 212,6 87 (76 6) 211,921 10A A 37. 02 7 Cardiac Cath Laboratory 1,1 17, 3 57. $101,989 $6, 478 ,220 * 10A A 4.00 7 New Capital Related Cost - Movable Equipment 5,342,064 1,633, 874 6, 975 ,938 10A A 5.00 7 Employee Benefits 23,2 97, 3 57 (5 57, 2 57) 22 ,74 0,100 10A A 6.00 7 Administrative. 3,316 ,76 1 10A A 41.01 7 CT Scan and MRI 516,039 (2,195) 513,844 10A A 43.00 7 Radioisotope 1,291, 377 (4, 371 ) 1,2 87, 006 10A A 44.00 7 Laboratory 5,140,846 (12 ,72 0) 5,128,126 10A A 49.00 7 Respiratory