STATE OF CALIFORNIA COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST_part4 doc

STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: SUTTER MEDICAL CENTER - SACRAMENTO DECEMBER 31, 2007 GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg & Fixtures $ $ 0 $ 0 2.00 Old Cap Rel Costs-Movable Equipment 0 0 3.00 New Cap Rel Costs-Bldg & Fixtures 7,861,187 (4,236,376) 3,624,811 3.01 New Cap Bldg. Memorial 2,058,835 0 2,058,835 3.02 New Cap Bldg. - Midtown 81,184 0 81,184 3.03 New Cap Bldg. Infusion 85,371 0 85,371 4.00 New Cap Rel Costs-Movable Equipment 10,482,996 (1,434,000) 9,048,996 4.01 New Equip Memorial 9,337,189 (1,702,612) 7,634,577 4.02 New Equip - Midtown 68,804 (12,704) 56,100 4.03 New Equip Infusion 15,753 (2,909) 12,844 4.07 00 4.08 00 5.00 Employee Benefits 61,015,301 (6,727,865) 54,287,436 6.01 Communication 676,657 (676,657) 0 6.02 Data Processing 10,316,463 (6,737,584) 3,578,879 6.03 Purchasing 2,020,126 (1,452,308) 567,818 6.04 Admitting 3,629,837 (2,840,815) 789,022 6.05 Business Office 1,477,941 4,500,026 5,977,967 6.06 00 6.07 00 6.08 00 6.00 Administrative and General 83,632,712 (8,618,946) 75,013,766 7.00 Maintenance and Repairs 8,585,410 389,604 8,975,014 8.00 Operation of Plant 2,296,035 (1,401,571) 894,464 9.00 Laundry and Linen Service 308,632 0 308,632 10.00 Housekeeping 6,609,326 (426,223) 6,183,103 11.00 Dietary 1,767,455 0 1,767,455 12.00 Cafeteria 3,962,807 0 3,962,807 13.00 Maintenance of Personnel 0 0 14.00 Nursing Administration 7,229,372 0 7,229,372 15.00 Central Services & Supply 804,773 0 804,773 16.00 Pharmacy 10,152,599 685,355 10,837,954 17.00 Medical Records and Library 5,709,737 1,053,556 6,763,293 18.00 Social Service 3,782,897 0 3,782,897 19.00 00 19.02 00 19.03 00 20.00 00 21.00 Nursing School 00 22.00 Intern & Res Service-Salary & Fringes 1,168,403 1,635,713 2,804,116 23.00 Intern & Res Other Program 1,635,712 (1,635,712) 0 24.00 Paramedical Ed Program 518,315 0 518,315 INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 49,678,121 3,291,548 52,969,669 26.00 Intensive Care Unit 11,040,256 496,943 11,537,199 27.00 Coronary Care Unit 6,094,102 0 6,094,102 28.00 00 29.00 00 30.00 Neonatal Intensive Care Unit 14,564,614 0 14,564,614 30.01 Pediatric ICU 4,680,840 0 4,680,840 32.00 00 33.00 Nursery 2,905,606 0 2,905,606 34.00 Medicare Certified Nursing Facility 0 0 35.00 Distinct Part Nursing Facility 1,882,523 2,774,038 4,656,561 36.00 Adult Subacute Care Unit 5,040,827 (2,774,038) 2,266,789 36.01 Subacute Care Unit II 0 0 36.02 Transitional Care Unit 0 0 REPORTED ADJUSTMENTS TRIAL BALANCE OF EXPENSES (From Sch 10A) AUDITED This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: SUTTER MEDICAL CENTER - SACRAMENTO DECEMBER 31, 2007 REPORTED ADJUSTMENTS TRIAL BALANCE OF EXPENSES (From Sch 10A) AUDITED ANCILLARY COST CENTERS 37.00 Operating Room $ 27,675,926 $ 0 $ 27,675,926 37.01 Lithotripsy 230,652 0 230,652 39.00 Delivery Room and Labor Room 8,926,636 0 8,926,636 40.00 Anesthesiology 2,227,337 0 2,227,337 41.00 Radiology - Diagnostic 8,918,663 0 8,918,663 41.01 Ultrasound 1,629,422 0 1,629,422 41.02 Gamma Knife 404,246 0 404,246 42.01 CT Scan 1,807,193 0 1,807,193 43.00 Radioisotope 2,256,256 0 2,256,256 44.00 Laboratory 10,755,367 0 10,755,367 44.01 Pathology 749,468 0 749,468 47.00 Blood Storing, Processing & Tra 5,194,563 0 5,194,563 49.00 Respiratory Therapy 6,804,891 0 6,804,891 50.00 Physical Therapy 2,532,546 0 2,532,546 51.00 Occupational Therapy 504,046 0 504,046 52.00 Speech Pathology 452,350 0 452,350 53.00 Electrocardiology 785,849 0 785,849 54.00 Electroencephalography 1,324,453 0 1,324,453 55.00 Medical Supplies Charged to Patients 70,229,730 0 70,229,730 56.00 Drugs Charged to Patients 16,532,760 (685,355) 15,847,405 57.00 Renal Dialysis 5,607,350 0 5,607,350 59.00 Cath Lab Invasive 5,777,620 0 5,777,620 59.01 O/P Pediatric Treatment 773,912 0 773,912 60.01 Heart Fail Clinic 354,986 0 354,986 60.02 Sleep Center 1,292,632 0 1,292,632 60.03 Peds Audiology 335,960 0 335,960 60.04 Development OP Clinic 2,396,734 0 2,396,734 60.05 Infusion 8,051,600 0 8,051,600 60.00 Clinic 527,547 0 527,547 60.06 Cancer Risk Assess Clinic 167,151 0 167,151 61.00 Emergency 11,820,076 0 11,820,076 62.00 Observation Beds 0 0 64.00 Home Program Dialysis 9,492 0 9,492 83.00 Kidney Acquisition 1,263,589 0 1,263,589 85.00 Heart Acquistion 273,900 0 273,900 85.01 Pancreas Acquisition 40,137 0 40,137 88.00 Interest Expense 0 0 0 90.00 Other Capital Related Costs 0 0 0 SUBTOTAL $ 551,813,758 $ (26,538,892) $ 525,274,866 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 0 0 97.00 Research 75,265 1,095,904 1,171,169 98.00 Physicians' Private Office 0 0 99.00 Nonpaid Workers 0 0 100.00 Beauty Clinic 17,894 0 17,894 100.01 Grants 1,300,542 987,662 2,288,204 100.02 Dialysis Contract Services 237,159 0 237,159 100.03 Home Infusion 00 100.04 Long Term Care Pharmacy 261,593 0 261,593 100.05 Spa OP Lab 20,358 0 20,358 100.06 Foundation 00 100.08 SHSSR Home Office 0 0 100.09 Other Related Organization 0 0 100.10 SCP 00 100.99 SUBTOTAL $ 1,912,811 $ 2,083,566 $ 3,996,377 101 TOTAL $ 553,726,569 $ (24,455,326) $ 529,271,243 (To Schedule 8) This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10A Page 1 Provider Name: Fiscal Period Ended: SUTTER MEDICAL CENTER - SACRAMENTO DECEMBER 31, 2007 TOTAL 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 (Page 1 & 2)123456789101112 GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures $0 2.00 Old Cap Rel Costs-Movable Equipment 0 3.00 New Cap Rel Costs-Bldg & Fixtures (4,236,376) (4,505,904) (1,074) 3.01 New Cap Bldg. Memorial 0 3.02 New Cap Bldg. - Midtown 0 3.03 New Cap Bldg. Infusion 0 4.00 New Cap Rel Costs-Movable Equipment (1,434,000) (1,867,552) (343,456) 716,965 4.01 New Equip Memorial (1,702,612) (1,702,612) 4.02 New Equip - Midtown (12,704) (12,704) 4.03 New Equip Infusion (2,909) (2,909) 4.07 0 4.08 0 5.00 Employee Benefits (6,727,865) (5,098,628) (6,527,297) 220,042 2,798,009 1,134,866 6.01 Communication (676,657) (676,657) 6.02 Data Processing (6,737,584) (8,509,614) (1,806,849) 3,578,879 6.03 Purchasing (1,452,308) (2,020,126) 567,818 6.04 Admitting (2,840,815) (3,629,837) 789,022 6.05 Business Office 4,500,026 (1,458,979) 5,959,005 6.06 0 6.07 0 6.08 0 6.00 Administrative and General (8,618,946) 12,095,391 (2,916,739) (374,810) (384,733) (10,264,669) (67,329,154) 54,355,755 7.00 Maintenance and Repairs 389,604 (673,318) 1,062,922 8.00 Operation of Plant (1,401,571) (2,296,035) 894,464 9.00 Laundry and Linen Service 0 (308,631) 308,631 10.00 Housekeeping (426,223) (426,223) 11.00 Dietary 0 12.00 Cafeteria 0 13.00 Maintenance of Personnel 0 14.00 Nursing Administration 0 15.00 Central Services & Supply 0 16.00 Pharmacy 685,355 685,355 17.00 Medical Records and Library 1,053,556 (5,665,811) 6,719,367 18.00 Social Service 0 19.00 0 19.02 0 19.03 0 20.00 0 21.00 Nursing School 0 22.00 Intern & Res Service-Salary & Fringes 1,635,713 (1,168,403) 2,804,116 23.00 Intern & Res Other Program (1,635,712) (1,635,712) 24.00 Paramedical Ed Program 0 INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 3,291,548 2,916,739 374,809 26.00 Intensive Care Unit 496,943 496,943 27.00 Coronary Care Unit 0 28.00 0 29.00 0 30.00 Neonatal Intensive Care Unit 0 30.01 Pediatric ICU 0 32.00 0 33.00 Nursery 0 34.00 Medicare Certified Nursing Facility 0 35.00 Distinct Part Nursing Facility 2,774,038 25,853 47,448 2,700,737 36.00 Adult Subacute Care Unit (2,774,038) (25,853) (47,448) (2,700,737) 36.01 Subacute Care Unit II 0 36.02 Transitional Care Unit 0 ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10A Page 1 Provider Name: Fiscal Period Ended: SUTTER MEDICAL CENTER - SACRAMENTO DECEMBER 31, 2007 TOTAL 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 (Page 1 & 2)123456789101112 ADJUSTMENTS TO REPORTED COSTS ANCILLARY COST CENTERS 37.00 Operating Room 0 37.01 Lithotripsy 0 39.00 Delivery Room and Labor Room 0 40.00 Anesthesiology 0 41.00 Radiology - Diagnostic 0 41.01 Ultrasound 0 41.02 Gamma Knife 0 42.01 CT Scan 0 43.00 Radioisotope 0 44.00 Laboratory 0 44.01 Pathology 0 47.00 Blood Storing, Processing & Tra 0 49.00 Respiratory Therapy 0 50.00 Physical Therapy 0 51.00 Occupational Therapy 0 52.00 Speech Pathology 0 53.00 Electrocardiology 0 54.00 Electroencephalography 0 55.00 Medical Supplies Charged to Patients 0 56.00 Drugs Charged to Patients (685,355) (685,355) 57.00 Renal Dialysis 0 59.00 Cath Lab Invasive 0 59.01 O/P Pediatric Treatment 0 60.01 Heart Fail Clinic 0 60.02 Sleep Center 0 60.03 Peds Audiology 0 60.04 Development OP Clinic 0 60.05 Infusion 0 60.00 Clinic 0 60.06 Cancer Risk Assess Clinic 0 61.00 Emergency 0 62.00 Observation Beds 0 64.00 Home Program Dialysis 0 83.00 Kidney Acquisition 0 85.00 Heart Acquistion 0 85.01 Pancreas Acquisition 0 88.00 Interest Expense 0 90.00 Other Capital Related Costs 0 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 0 97.00 Research 1,095,904 1,095,904 98.00 Physicians' Private Office 0 99.00 Nonpaid Workers 0 100.00 Beauty Clinic 0 100.01 Grants 987,662 987,662 100.02 Dialysis Contract Services 0 100.03 Home Infusion 0 100.04 Long Term Care Pharmacy 0 100.05 Spa OP Lab 0 100.06 Foundation 0 100.08 SHSSR Home Office 0 100.09 Other Related Organization 0 100.10 SCP 0 101.00 TOTAL ($24,455,326) 0 0000(1)2,083,566 (5,098,628) (6,912,030) (10,044,627) (91,147,086) 79,387,679 (To Sch 10) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SUTTER MEDICAL CENTER - SACRAMENTO 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 3.01 New Cap Bldg. Memorial 3.02 New Cap Bldg. - Midtown 3.03 New Cap Bldg. Infusion 4.00 New Cap Rel Costs-Movable Equipment 4.01 New Equip Memorial 4.02 New Equip - Midtown 4.03 New Equip Infusion 4.07 4.08 5.00 Employee Benefits 6.01 Communication 6.02 Data Processing 6.03 Purchasing 6.04 Admitting 6.05 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 30.00 Neonatal Intensive Care Unit 30.01 Pediatric ICU 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, 2007 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 13 14 270,602 60,043 745,143 6,627,485 (427,472) ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SUTTER MEDICAL CENTER - SACRAMENTO ANCILLARY COST CENTERS 37.00 Operating Room 37.01 Lithotripsy 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 Ultrasound 41.02 Gamma Knife 42.01 CT Scan 43.00 Radioisotope 44.00 Laboratory 44.01 Pathology 47.00 Blood Storing, Processing & Tra 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 59.00 Cath Lab Invasive 59.01 O/P Pediatric Treatment 60.01 Heart Fail Clinic 60.02 Sleep Center 60.03 Peds Audiology 60.04 Development OP Clinic 60.05 Infusion 60.00 Clinic 60.06 Cancer Risk Assess Clinic 61.00 Emergency 62.00 Observation Beds 64.00 Home Program Dialysis 83.00 Kidney Acquisition 85.00 Heart Acquistion 85.01 Pancreas Acquisition 88.00 Interest Expense 90.00 Other Capital Related Costs NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 100.00 Beauty Clinic 100.01 Grants 100.02 Dialysis Contract Services 100.03 Home Infusion 100.04 Long Term Care Pharmacy 100.05 Spa OP Lab 100.06 Foundation 100.08 SHSSR Home Office 100.09 Other Related Organization 100.10 SCP 101.00 TOTAL SCHEDULE 10A Page 2 Fiscal Period Ended: DECEMBER 31, 2007 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 13 14 ADJUSTMENTS TO REPORTED COSTS 0 7,703,273 (427,472) 0 0 0 000000000 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 47 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted MEMORANDUM ADJUSTMENT A The provider reported Subacute Care Unit data on cost center line 34, Skilled Nursing Facility, in the filed cost report, Worksheets A, B, B-1, C and D-4. For proper cost determination, Subacute Care Unit data should be reported on cost center lines below the Distinct Nursing Care Facility cost center. Therefore, Subacute Care Unit data will be included on line 36, Adult Subacute Care Unit, in the audit report. This is in accordance with: 42 CFR 413.20, 413.24, and 413.53 CMS Pub. 15-1, Sections 2300, 2304, and 2336 Page 1 Report References SUTTER MEDICAL CENTER - SACRAMENTO Adjustments Explanation of Audit Adjustments JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 HSC00108F / 1811946734 Cost Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 47 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SUTTER MEDICAL CENTER - SACRAMENTO Adjustments Explanation of Audit Adjustments JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 HSC00108F / 1811946734 Cost Report RECLASSIFICATIONS OF REPORTED COSTS 1 10A A 35.00 7 Distinct Part Nursing Facility $1,882,523 $25,853 $1,908,376 * 10A A 36.00 7 Adult Subacute Care Unit 5,040,827 (25,853) 5,014,974 * To reclassify provider's medical supplies reclassification for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 2 10A A 35.00 7 Distinct Part Nursing Facility * $1,908,376 $47,448 $1,955,824 * 10A A 36.00 7 Adult Subacute Care Unit * 5,014,974 (47,448) 4,967,526 * To reclassify provider's laundry reclassification for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 3 10A A 4.00 7 New Cap Rel Costs-Movable Equipment $10,482,996 ($1,867,552) $8,615,444 * 10A A 4.01 7 New Cap Rel Costs-Movable Equipment-Memorial 9,337,189 (1,702,612) 7,634,577 10A A 4.02 7 Equipment-Midtown 68,804 (12,704) 56,100 10A A 4.03 7 Equipment-Infusion 15,753 (2,909) 12,844 10A A 6.02 7 Data Processing 10,316,463 (8,509,614) 1,806,849 * 10A A 6.00 7 Administrative and General 83,632,712 12,095,391 95,728,103 * To reverse the provider's IT chargeback reclassification for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 4 10A A 6.00 7 Administrative and General * $95,728,103 ($2,916,739) $92,811,364 * 10A A 25.00 7 Adults & Pediatrics (Gen Routine) 49,678,121 2,916,739 52,594,860 * To reclassify the provider's uncompensated / on-call adjustment to agree with the provider's general ledger. 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 47 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SUTTER MEDICAL CENTER - SACRAMENTO Adjustments Explanation of Audit Adjustments JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 HSC00108F / 1811946734 Cost Report RECLASSIFICATIONS OF REPORTED COSTS 5 10A A 35.00 7 Distinct Part Nursing Facility * $1,955,824 $2,700,737 $4,656,561 10A A 36.00 7 Adult Subacute Care Unit * 4,967,526 (2,700,737) 2,266,789 To reclassify distinct part nursing facility expense, per provider's general ledger, to the Distinct Part Nursing Facility cost center, for proper cost determination. 42 CFR 413.5, 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2304 and 2306 *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 47 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SUTTER MEDICAL CENTER - SACRAMENTO Adjustments Explanation of Audit Adjustments JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 HSC00108F / 1811946734 Cost Report ADJUSTMENTS TO REPORTED COSTS 6 10A A 6.00 7 Administrative and General * $92,811,364 ($374,810) $92,436,554 * 10A A 16.00 7 Pharmacy 10,152,599 685,355 10,837,954 10A A 25.00 7 Adults & Pediatrics (Gen Routine) * 52,594,860 374,809 52,969,669 10A A 56.00 7 Drugs Charged to Patients 16,532,760 (685,355) 15,847,405 To adjust provider's revenue abatement to agree with the provider's general ledger. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 7 10A A 97.00 7 Research $75,265 $1,095,904 $1,171,169 10A A 100.01 7 Grant 1,300,542 987,662 2,288,204 To reverse the provider's abatement of revenue against nonreimbursable cost centers. 42 CFR 413.9, 413.20, and 413.24 CMS Pub. 15-1, Sections 2300, 2304, and 2328 CMS Pub. 15-2, Section 3613 8 10A A 5.00 7 Employee Benefits $61,015,301 ($5,098,628) $55,916,673 * To reverse Worksheet A-8 adjustment to increase worker's compensation expense. For proper cost determination, cost should be included on the Sutter Health home office cost statement. 42 CFR 413.17, 413.20 and 413.24 CMS Pub. 15-1, Sections 2102.3, 2150.2, 2300 and 2304 9 10A A 5.00 7 Employee Benefits * $55,916,673 ($6,527,297) $49,389,376 * 10A A 6.00 7 Administrative and General * 92,436,554 (384,733) 92,051,821 * To eliminate recorded home office worker's compensation expense per the general ledger. For proper cost determination, cost should be included on the Sutter Health home office cost statement. 42 CFR 413.17, 413.20 and 413.24 CMS Pub. 15-1, Sections 2102.3, 2150.2, 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 4 This is trial version www.adultpdf.com . version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SUTTER MEDICAL CENTER - SACRAMENTO GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00. SACRAMENTO Adjustments Explanation of Audit Adjustments JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 HSC00108F / 1811946734 Cost Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider. ADJ 13 14 ADJUSTMENTS TO REPORTED COSTS 0 7,703,273 (427,472) 0 0 0 000000000 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period