STATE OF CALIFORNIA COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST_part5 potx

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 TOTAL CHARGES 27 Contract 5, 5 C I 42.01 8 CT Scan $92,277,232 ($133,277) $92,143,955 Contract 5, 5 C I 55.00 8 Medical Supplies Charged to Patients 256,901,590 (31,747,355) 225,154,235 * Contract 5, 5 C I 56.00 8 Drugs Charged to Patients 218,109,077 2,283,401 220,392,478 * Contract 5, 5 C I N/A 8 Total Ancillary Charges 1,886,023,750 (29,597,231) 1,856,426,519 * To adjust ancillary charges to agree with the provider's records. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 28 Contract 5, 5 C I 37.00 8 Operating Room $395,716,342 $21,825 $395,738,167 Contract 5, 5 C I 39.00 8 Delivery Room and Labor Room 77,250,411 12,752 77,263,163 Contract 5, 5 C I 40.00 8 Anesthesiology 72,266,112 5,728 72,271,840 Contract 5, 5 C I 41.00 8 Radiology - Diagnostic 68,659,216 61,902 68,721,118 Contract 5, 5 C I 44.00 8 Laboratory 185,054,848 41,912 185,096,760 Contract 5, 5 C I 49.00 8 Respiratory Therapy 100,773,338 8,713 100,782,051 Contract 5, 5 C I 55.00 8 Medical Supplies Charged to Patients * 225,154,235 9,282 225,163,517 Contract 5, 5 C I 56.00 8 Drugs Charged to Patients * 220,392,478 685,355 221,077,833 Contract 5, 5 C I 60.00 8 Clinic 1,245,531 20,000 1,265,531 Contract 5, 5 C I 60.02 8 Sleep Center 5,031,264 (1,199) 5,030,065 Contract 5, 5 C I 60.04 8 Development OP Clinic 2,602,825 302,166 2,904,991 Contract 5, 5 C I 60.05 8 Infusion 23,314,408 120,963 23,435,371 Contract 5, 5 C I 103.00 8 Total Charges * 1,856,426,519 1,289,399 1,857,715,918 To adjust ancillary charges which were offset by other revenues to properly reflect total charges. 42 CFR 413.20, 413.24, and 413.50 CMS Pub. 15-1, Sections 2205, 2300, and 2304 *Balance carried forward from prior/to subsequent adjustments Page 15 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 MEDI-CAL SETTLEMENT DATA - NONCONTRACT 29 4 D-1 I XIX 9.00 1 Medi-Cal Inpatient Days 351 (351) 0 4A Not Reported Medi-Cal Administrative Days (January 1, 2007 through July 31, 2007) 0 193 193 4A Not Reported Medi-Cal Administrative Day Rate (January 1, 2007 through July 31, 2007) $0.00 $310.68 $310.68 4A Not Reported Medi-Cal Administrative Days (August 1, 2007 through December 31, 2007) 0 158 158 4A Not Reported Medi-Cal Administrative Day Rate (August 1, 2007 through December 31, 2007) $0.00 $317.95 $317.95 30 6 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic $2,074 $882 $2,956 6 D-4 XIX 41.01 2 Medi-Cal Ancillary Charges - Ultrasound 3,312 1,536 4,848 6 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 96,272 25,897 122,169 6 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 34,588 21,848 56,436 6 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drug Charges to Patients 150,344 63,905 214,249 6 D-4 XIX 57.00 2 Medi-Cal Ancillary Charges - Renal Dialysis 106 (106) 0 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 291,886 113,962 405,848 31 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges $291,886 $113,962 $405,848 32 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance $0 $544 $544 1 E-3 III XIX 57.00 1 Medi-Cal Interim Payments 188,954 38,361 227,315 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: December 19, 2008 Payment Period: January 1, 2007 through December 19, 2008 Service Period: January 1, 2007 through December 31, 2007 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 16 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 MEDI-CAL SETTLEMENT DATA - CONTRACT 33 Contract 4 D-1 I XIX 9.00 1 Medi-Cal Days - Adults and Pediatrics 18,972 610 19,582 Contract 4A D-1 II XIX 42.00 4 Medi-Cal Days - Nursery 0 2,764 2,764 Contract 4A D-1 II XIX 43.00 4 Medi-Cal Days - Intensive Care Unit 1,650 250 1,900 Contract 4A D-1 II XIX 47.00 4 Medi-Cal Days - Neonatal Intensive Care Unit 9,533 445 9,978 Contract 4A D-1 II XIX 47.01 4 Medi-Cal Days - Pediatric Intensive Care Unit 769 (233) 536 34 Contract 6 D-4 XIX 37.00 2 Medi-Cal Ancillary Charges - Operating Room $28,325,260 $5,087,965 $33,413,225 Contract 6 D-4 XIX 39.00 2 Medi-Cal Ancillary Charges - Delivery Room and Labor Room 11,662,639 1,670,739 13,333,378 Contract 6 D-4 XIX 40.00 2 Medi-Cal Ancillary Charges - Anesthesiology 5,179,363 942,670 6,122,033 Contract 6 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 5,312,494 1,030,211 6,342,705 Contract 6 D-4 XIX 41.01 2 Medi-Cal Ancillary Charges - Ultrasound 2,437,460 406,527 2,843,987 Contract 6 D-4 XIX 42.01 2 Medi-Cal Ancillary Charges - CT Scan 6,209,338 1,250,936 7,460,274 Contract 6 D-4 XIX 43.00 2 Medi-Cal Ancillary Charges - Radioisotope 1,462,031 301,535 1,763,566 Contract 6 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 22,317,652 4,467,677 26,785,329 Contract 6 D-4 XIX 44.01 2 Medi-Cal Ancillary Charges - Pathology 1,867,375 336,922 2,204,297 Contract 6 D-4 XIX 47.00 2 Medi-Cal Ancillary Charges - Blood Storing, Processing and Transfusion 806,469 159,707 966,176 Contract 6 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 22,145,034 6,020,301 28,165,335 Contract 6 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 2,074,466 382,755 2,457,221 Contract 6 D-4 XIX 51.00 2 Medi-Cal Ancillary Charges - Occupational Therapy 205,135 60,274 265,409 Contract 6 D-4 XIX 52.00 2 Medi-Cal Ancillary Charges - Speech Pathology 186,926 61,458 248,384 Contract 6 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 423,349 145,980 569,329 Contract 6 D-4 XIX 54.00 2 Medi-Cal Ancillary Charges - Electroencephalography 1,043,333 134,386 1,177,719 Contract 6 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 17,019,140 3,016,896 20,036,036 Contract 6 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 29,882,584 5,834,456 35,717,040 Contract 6 D-4 XIX 57.00 2 Medi-Cal Ancillary Charges - Renal Dialysis 1,259,506 274,063 1,533,569 Contract 6 D-4 XIX 59.00 2 Medi-Cal Ancillary Charges - Cath Lab Invasive 6,149,721 1,043,826 7,193,547 Contract 6 D-4 XIX 60.03 2 Medi-Cal Ancillary Charges - Peds Audiology 445,625 63,015 508,640 Contract 6 D-4 XIX 61.00 2 Medi-Cal Ancillary Charges - Emergency 3,060,596 529,835 3,590,431 Contract 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 169,475,496 33,222,134 202,697,630 35 Contract 2 DHS 3092 Medi-Cal Routine Service Charges $132,875,349 $27,273,625 $160,148,974 Contract 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 169,475,496 33,222,134 202,697,630 -Continued on next page- Page 17 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 MEDI-CAL SETTLEMENT DATA - CONTRACT -Continued from previous page- 36 Contract 3 E-3 III XIX 33.00 1 Medi-Cal Deductibles $27,072 $3,835 $30,907 Contract 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance 213,302 58,221 271,523 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: December 19, 2008 Payment Period: January 1, 2007 through December 19, 2008 Service Period: January 1, 2007 through December 31, 2007 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 18 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 MEDI-CAL SETTLEMENT DATA - DPNF 37 DPNF1 S-3 I XIX 16.00 5 Medi-Cal Days - Distinct Part Nursing Facility 6,996 15,169 22,165 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: December 19, 2008 Payment Period: January 1, 2007 through December 19, 2008 Service Period: January 1, 2007 through December 31, 2007 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 51511 38 DPNF1 S-3 I 16.00 1 Total Available Distinct Part Beds 66 100 166 To adjust the number of total available distinct part beds to agree with the state license. CMS Pub. 15-1, Sections 2304 39 DPNF4 D-4 XIX 55.00 2 DPNF Ancillary Charges - Medical Supplies Charged to Patients $126,649 ($126,649) $0 DPNF4 D-4 XIX 56.00 2 DPNF Ancillary Charges - Drugs Charged to Patients 207,549 (207,549) 0 DPNF4 D-4 XIX 101.00 2 DPNF Ancillary Charges - Total 334,198 (334,198) 0 To eliminate total DPNF ancillary charges to properly determine the Medi-Cal per diem rate. CCR, Title 22, Section 51510 (c) and 51511 (c) Page 19 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 MEDI-CAL SETTLEMENT DATA - SUBACUTE 40 Subacute4 D-4 XIX 37.00 2 Subacute Ancillary Charges - Operating Room $7,916 ($7,916) $0 Subacute4 D-4 XIX 41.00 2 Subacute Ancillary Charges - Radiology - Diagnostic 19,699 24,512 44,211 Subacute4 D-4 XIX 41.01 2 Subacute Ancillary Charges - Ultrasound 1,524 (1,524) 0 Subacute4 D-4 XIX 42.01 2 Subacute Ancillary Charges - CT Scan 21,517 (21,517) 0 Subacute4 D-4 XIX 44.00 2 Subacute Ancillary Charges - Laboratory 197,539 245,795 443,334 Subacute4 D-4 XIX 44.01 2 Subacute Ancillary Charges - Pathology 478 594 1,072 Subacute4 D-4 XIX 47.00 2 Subacute Ancillary Charges - Blood Storing, Processing and Tran 1,617 (1,617) 0 Subacute4 D-4 XIX 49.00 2 Subacute Ancillary Charges - Respiratory Therapy 1,213,950 1,510,495 2,724,445 Subacute4 D-4 XIX 50.00 2 Subacute Ancillary Charges - Physical Therapy 1,407 1,751 3,158 Subacute4 D-4 XIX 51.00 2 Subacute Ancillary Charges - Occupational Therapy 6,527 8,122 14,649 Subacute4 D-4 XIX 52.00 2 Subacute Ancillary Charges - Speech Pathology 2,911 3,623 6,534 Subacute4 D-4 XIX 53.00 2 Subacute Ancillary Charges - Electrocardiology 818 (818) 0 Subacute4 D-4 XIX 54.00 2 Subacute Ancillary Charges - Electroencephalography 3,072 (3,072) 0 Subacute4 D-4 XIX 55.00 2 Subacute Ancillary Charges - Medical Supplies Charged to Patients 254,769 317,004 571,773 Subacute4 D-4 XIX 56.00 2 Subacute Ancillary Charges - Drugs Charged to Patients 1,577,915 (1,577,915) 0 Subacute4 D-4 XIX 60.03 2 Subacute Ancillary Charges - Peds Audiology 2,845 (2,845) 0 Subacute4 D-4 XIX 101.00 2 Subacute Ancillary Charges - Total 3,314,504 494,672 3,809,176 To adjust the reported Medi-Cal ancillary charges to Total Subacute ancillary charges in determining the cost of services. CCR, Title 22, Section 51511.5 41 Subacute1 Not Reported Medi-Cal Subacute Days - Ventilator 0 1,230 1,230 To adjust Medi-Cal Settlement Data to agree with the provider's records. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 CCR, Title 22, Section 51511.5 42 Subacute1 Not Reported Total Subacute Days - Ventilator 0 2,525 2,525 Subacute1 Not Reported Total Subacute Days - Nonventilator 0 5,386 5,386 To adjust total subacute patient days and to include total ventilator and nonventilator patient days in the audit report. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 Page 20 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 MEDI-CAL SETTLEMENT DATA - SUBACUTE 43 Subacute1 S-3 I 15.00 1 Contracted Number of Adult Subacute Beds 100 (54) 46 To adjust the number of total contracted adult subacute beds to agree with the state contract. CMS Pub. 15-1, Sections 2304 44 Subacute1 S-3 I XIX 15.00 5 Medi-Cal Subacute Days - Total 21,965 (14,054) 7,911 To adjust Medi-Cal Settlement Data to agree with the provider's record. 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 51511.5 Page 21 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 OTHER MATTERS 45 Contract 1 N/A Overpayment $0 $15,950 $15,950 To recover Medi-Cal duplicate payment. 42 CFR 433.139 / CMS Pub. 15-1, Section 2409 CCR, Title 22, Section 51458.1 / Medi-Cal Contract, Article 4.X 46 Contract 1 N/A Credit Balance $0 $84,630 $84,630 To recover outstanding Medi-Cal credit balances. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 CCR, Title 22, Sections 50761 and 51458.1 47 1 E-3 III XIX 50.00 1 Other Adjustments ($281,098) $281,098 $0 To reverse the provider's Other Adjustment for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 Page 22 This is trial version www.adultpdf.com . determine the Medi-Cal per diem rate. CCR, Title 22, Section 51510 (c) and 51511 (c) Page 19 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider. prior/to subsequent adjustments Page 15 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. 2408 CCR, Title 22, Section 51541 Page 16 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