Table 8.2 Worksheet A A-6 Reclassified A-8 Net Expenses Salaries Other Total Reclassifications Trial Balance Adjustments For Allocation Cost Center Descriptions 1 2 3 4 5 6 7 General Service Cost Centers 1 Capital Related Costs - Buildings and Fixtures 0 2,000,000 2,000,000 2,000,000 2 Capital Related Costs - Movable Equipment 0 3,000,000 3,000,000 3,000,000 3 Employee Benefits B) 1,590,000 1,590,000 1,590,000 1,590,000 4 Administrative and General S) 7,000,000 U) 6,200,000 13,200,000 (5,000,000) 8,200,000 (2,500,000) 5,700,000 5 Maintenance and Repairs X) 400,000 Y) 125,000 525,000 525,000 525,000 6 Housekeeping 0 0 0 7 Dietary 0 0 0 8 Nursing Administration 0 0 0 9 Central Services and Supply 0 0 0 10 Pharmacy Z) 200,000 AA) 125,000 325,000 325,000 325,000 11 Medical Records V) 650,000 W) 325,000 975,000 975,000 975,000 12 Social Service 0 0 0 Inpatient Routine Service Cost Centers 13 Adult and Pediatrics A) 2,000,000 C) 850,000 2,850,000 2,850,000 (50,000) 2,800,000 14 Intensive Care Unit F) 1,200,000 G) 500,000 1,700,000 1,700,000 (50,000) 1,650,000 15 Nursery D) 1,000,000 E) 420,000 1,420,000 1,420,000 (20,000) 1,400,000 16 Operating Room H) 1,800,000 I) 1,400,000 3,200,000 (600,000) 2,600,000 (200,000) 2,400,000 17 Radiology - Diagnostic 0 0 0 18 Computed Tomography (CT Scan) 0 0 0 19 Magnetic Resonance Imaging (MRI) M) 1,100,000 N) 485,000 1,585,000 1,585,000 (15,000) 1,570,000 20 Laboratory K) 800,000 L) 500,000 1,300,000 1,300,000 1,300,000 21 Physical Therapy Q) 900,000 R) 1,100,000 2,000,000 2,000,000 (500,000) 1,500,000 22 Medical Supplies Charged to Patient 0 0 0 23 Implantable Devices Charged to Patients 0 600,000 600,000 600,000 24 Drugs Charged to Patients T) 175,000 175,000 175,000 175,000 25 Emergency O) 400,000 P) 2,020,000 2,420,000 2,420,000 2,420,000 26 Observation Beds 0 0 0 27 Subtotal 19,040,000 14,225,000 33,265,000 0 33,265,000 (3,335,000) 29,930,000 Non-Reimbursable Cost Centers 28 Gift Shop 0 0 0 0 0 0 29 Total 19,040,000 14,225,000 33,265,000 0 33,265,000 (3,335,000) 29,930,000
Table 8.3 Worksheet A-6 Increases Decreases Wkst A-7 Code Cost Center Line # Salary Other Cost Center Line # Salary Other Ref Explanation of Reclassifications 1 2 3 4 5 6 7 8 9 10 1 Reclass depreciation to appropriate line item Depreciation - Building 1 2,000,000 Administrative and General 4 5,000,000 2 Reclass depreciation to appropriate line item Depreciation - Equipment 2 3,000,000 3 Reclass implants to appropriate line item Implantable Devices Charged to Patients 23 600,000 Operating Room 16 600,000 4 Total 5,600,000 5,600,000
Table 8.4 Expense Classification on Worksheet A to/from which the Worksheet Description Basis/Code Amount amount is to be adjusted A-7 Ref. 1 2 3 4 5 1 Investment Income 2 Investment Income 3 Trade, Quantity and Time Discounts 4 Refunds and Rebates of Expenses 5 Rental of Provider Space by Suppliers 6 Telephone Services 7 Television and Radio Service 8 Parking Lot 9 Provider-Based Physician Adj. 1 (135,000) Worksheet A-8-2 10 Sale of Scrap, Waste, Etc 11 Related organization transactions 12 Laundry and Linen Service 13 Cafeteria Employees and guests 2 (1,500,000) Admin and General 4 14 Rental of Quarters to Employees 15 Sale of Medical and Surgical Supplies 2 (500,000) Physical Therapy 21 16 Sales of Drugs to Other Than Patients 17 Sale of Medical Records and Abstracts 18 Nursing School 19 Vending Machines 20 Depreciation - Buildings 21 Depreciation - Movable Equipment 22 Non Physician Anesthetist 1 (200,000) Operating Room 16 23 Physician Assistants 24 Adjustment for speech pathology cost in excess of limitation 25 Adjustment for occup. therapy cost in excess of limitation 26 Miscellaneous Income - Rent 2 (1,000,000) Admin and General 4 27.01 28.02 FORM CMS-2552-10 Worksheet A - 8 Total (3,335,000)
Table 8.5 Worksheet A-8-2 Cost Center Total Professional Provider RCE Physician/Provider Unadjusted 5% of Unadjusted Wkst A Line # Physician Identifier Remuneration Component Component Amount Component Hours RCE Limit RCE Limit 1 2 3 4 5 6 7 8 9 13 Adults and Peds 50,000 50,000 14 ICU 50,000 50,000 15 Nursery 20,000 20,000 19 MRI 15,000 15,000 Total 135,000 135,000
Table 8.7 Schedule B-1 STATISTICAL BASIS Capital Related Costs Capital Related Costs Employee Administrative Maintenance Nursing Central Service Medical Social Buildings/Fixtures Movable Equipment Benefits and General and Repairs Housekeeping Dietary Admin and Supply Pharmacy Records Service (square feet) (square feet) (gross salaries) (accum cost) (square feet) (drug requests) (time spent) Cost Center Description 1 2 3 4 5 6 7 8 9 10 11 12 General Service Cost Centers 1 Capital Related Costs - Buildings and Fixtures 2 Capital Related Costs - Movable Equipment 3 Employee Benefits 4 Administrative and General 25,000 25,000 7,000,000 25,000 5 Maintenance and Repairs 11,000 11,000 400,000 11,000 6 Housekeeping 7 Dietary 8 Nursing Administration 9 Central Services and Supply 10 Pharmacy 14,000 14,000 200,000 14,000 11 Medical Records 10,000 10,000 650,000 10,000 12 Social Service Inpatient Routine Service Cost Centers 13 Adult and Pediatrics 220,000 220,000 2,000,000 220,000 10,000 14 Intensive Care Unit 25,000 25,000 1,200,000 25,000 2,500 15 Nursery 10,000 10,000 1,000,000 10,000 1,250 16 Operating Room 50,000 50,000 1,800,000 50,000 5,000 17 Radiology - Diagnostic 18 Computed Tomography (CT Scan) 19 Magnetic Resonance Imaging (MRI) 20,000 20,000 1,100,000 20,000 20 Laboratory 35,000 35,000 800,000 35,000 21 Physical Therapy 30,000 30,000 900,000 30,000 250 22 Medical Supplies Charged to Patient 23 Implantable Devices Charged to Patients 24 Drugs Charged to Patients 20,000 20,000 20,000 400,000 25 Emergency 30,000 30,000 400,000 30,000 1,000 26 Observation Beds 27 Subtotal Non-Reimbursable Cost Centers 28 Gift Shop 29 Total 500,000 500,000 17,450,000 0 500,000 0 0 0 0 400,000 20,000 0
Table 8.8 Worksheet B Part 1 Net Expenses for Capital Related Costs Capital Related Costs Employee Administrative Maintenance Medical Cost Allocation Buildings/Fixtures Movable Equipment Benefits Subtotal and General and Repairs Pharmacy Records Total Cost Center Description 0 1 2 3 4 5 6 7 8 9 General Service Cost Centers 1 Capital Related Costs - Buildings and Fixtures 2,000,000 2,000,000 2 Capital Related Costs - Movable Equipment 3,000,000 3,000,000 3 Employee Benefits 1,590,000 1,590,000 4 Administrative and General 5,700,000 100,000 150,000 637,822 6,587,822 6,587,822 5 Maintenance and Repairs 525,000 44,000 66,000 36,447 671,447 189,501 860,948 6 Housekeeping 7 Dietary 8 Nursing Administration 9 Central Services and Supply 10 Pharmacy 325,000 56,000 84,000 18,223 483,223 136,379 25,977 645,580 11 Medical Records 975,000 40,000 60,000 59,226 1,134,226 320,111 18,555 1,472,892 12 Social Service Inpatient Routine Service Cost Centers 13 Adult and Pediatrics 2,800,000 880,000 1,320,000 182,235 5,182,235 1,462,573 408,208 736,446 7,789,462 14 Intensive Care Unit 1,650,000 100,000 150,000 109,341 2,009,341 567,093 46,387 184,112 2,806,933 15 Nursery 1,400,000 40,000 60,000 91,117 1,591,117 449,058 18,555 92,056 2,150,786 16 Operating Room 2,400,000 200,000 300,000 164,011 3,064,011 864,751 92,775 368,223 4,389,760 17 Radiology - Diagnostic 18 Computed Tomography (CT Scan) 19 Magnetic Resonance Imaging (MRI) 1,570,000 80,000 120,000 100,229 1,870,229 527,832 37,110 2,435,171 20 Laboratory 1,300,000 140,000 210,000 72,894 1,722,894 486,249 64,942 2,274,086 21 Physical Therapy 1,500,000 120,000 180,000 82,006 1,882,006 531,155 55,665 18,411 2,487,237 22 Medical Supplies Charged to Patient 23 Implantable Devices Charged to Patients 600,000 600,000 169,337 769,337 24 Drugs Charged to Patients 175,000 80,000 120,000 0 375,000 105,836 37,110 645,580 1,163,525 25 Emergency 2,420,000 120,000 180,000 36,447 2,756,447 777,947 55,665 73,645 3,663,704 26 Observation Beds 0 27 Subtotal 29,930,000 2,000,000 3,000,000 1,590,000 29,930,000 6,587,822 860,948 645,580 1,472,892 29,930,000 Non-Reimbursable Cost Centers 28 Gift Shop 0 0 0 29 Total 29,930,000 2,000,000 3,000,000 1,590,000 29,930,000 6,587,822 860,948 645,580 1,472,892 29,930,000
Table 8.9 Worksheet C Source Data Inpatient Charges Eliminate Drugs Charged Medical Supply Adjusted Inpatient Outpatient Charges Eliminate Drugs Charged Medical Supply Adjusted Outpatient Adjusted Total From Trial Balance Professional Fees Reclass Reclass Charge Total From Trial Balance Professional Fees Reclass Reclass Charge Total Charges 1 2 3 4 5 6 7 8 9 10 11 13 Adult and Pediatrics 15,000,000 (1,200,000) 13,800,000 0 13,800,000 14 Intensive Care Unit 7,500,000 (750,000) 6,750,000 0 6,750,000 15 Nursery 8,000,000 8,000,000 0 8,000,000 16 Operating Room 5,000,000 (400,000) (200,000) (800,000) 3,600,000 10,000,000 (200,000) (400,000) 9,400,000 13,000,000 17 Radiology - Diagnostic 0 0 0 18 Computed Tomography (CT) Scan 0 0 0 19 Magnetic Resonace Imaging (MRI) 5,000,000 (50,000) 4,950,000 3,000,000 (25,000) 2,975,000 7,925,000 20 Laboratory 4,000,000 (50,000) 3,950,000 3,000,000 (50,000) 2,950,000 6,900,000 21 Physical Therapy 5,000,000 5,000,000 3,000,000 3,000,000 8,000,000 23 Implantable Devices Charged to Patients 800,000 800,000 0 800,000 24 Drugs Charged to Patients 2,400,000 2,400,000 975,000 975,000 3,375,000 25 Emergency 2,000,000 (100,000) (150,000) 1,750,000 5,000,000 (110,000) (500,000) 4,390,000 6,140,000 28 Gift Shop 0 0 0 Total 51,500,000 (500,000) 0 0 51,000,000 24,000,000 (310,000) 0 0 23,690,000 74,690,000
Table 8.10 Worksheet C Part 1 Costs Charges Total Cost from Therapy Limit Total RCE Total Cost or TEFRA PPS IP Wkst B Part 1 Adjustment Costs Disallowance Costs Inpatient Outpatient Total Other Ratio IP Ratio Ratio Cost Center Descriptions 1 2 3 4 5 6 7 8 9 10 11 Inpatient Routine Service Cost Centers 13 Adult and Pediatrics 7,789,462 7,789,462 7,789,462 13,800,000 0 13,800,000 0.5645 14 Intensive Care Unit 2,806,933 2,806,933 2,806,933 6,750,000 0 6,750,000 0.4158 Coronary Care unit Burn Intensive Care Unit Surgical Intensive Care Unit Other Special Care Subprovider IPF Subprovider IRF Subprovider 15 Nursery 2,150,786 2,150,786 2,150,786 8,000,000 0 8,000,000 0.2688 Skilled Nursing Facility Nursing Facility Other Long Term Care 16 Operating Room 4,389,760 4,389,760 4,389,760 3,600,000 9,400,000 13,000,000 0.3377 Recovery Room Labor Room and Delivery Room Anesthesiology Radiology - Diagnostic Radiology - Therapeutic Radioisotope Computed Tomography (CT) Scan 19 Magnetic Resonace Imaging (MRI) 2,435,171 2,435,171 2,435,171 4,950,000 2,975,000 7,925,000 0.3073 Cardiac Catheterization 20 Laboratory 2,274,086 2,274,086 2,274,086 3,950,000 2,950,000 6,900,000 0.3296 PBP Clinical Laboratory Services While Blood & Packed Red Blood Cells Blood Storing, Processing & Trans Intravenous Therapy Respiratory Therapy 21 Physical Therapy 2,487,237 2,487,237 2,487,237 5,000,000 3,000,000 8,000,000 0.3109 Occupational Therapy Speech Pathology Electrocardiology Electrocephalography Medical Supplies Charged to Patients 23 Implantable Devices Charged to Patients 769,337 769,337 769,337 800,000 0 800,000 0.9617 24 Drugs Charged to Patients 1,163,525 1,163,525 1,163,525 2,400,000 975,000 3,375,000 0.3447 Renal Dialysis ASC Other Ancillary Rural Health Center Federally Qualified Health Center Clinic 25 Emergency 3,663,703 3,663,703 3,663,703 1,750,000 4,390,000 6,140,000 0.5967 Observation Beds Gift Shop 0 0 0 26 Total 29,930,000 0 29,930,000 0 29,930,000 51,000,000 23,690,000 74,690,000 0.4007
Table 8.12 Worksheet D-3 Ratio of Cost Inpatient Inpatient Description To Charges Program Charges Program Costs 1 2 3 Routine Serivce Cost Center 13 Adults and Pediatrics 0.5645 12,349,012 6,971,017 14 Intensive Care Unit 0.4158 6,469,470 2,690,006 15 Nursery** 0.2688 7,459,000 2,004,979 16 Operating Room 0.3377 3,058,018 1,032,693 17 Radiology - Diagnostic 18 Computed Tomography (CT) Scan 19 Magnetic Resonance Scan (MRI) 0.3073 4,891,000 1,503,004 20 Laboratory 0.3296 3,912,000 1,289,395 21 Physical Therapy 0.3109 5,868,000 1,824,361 Medical Supplies Charged to Patients 23 Implantable Devices Charged to Patients 0.9617 733,500 705,407 24 Drugs Charged to Patients 0.3447 2,080,000 716,976 25 Emergency 0.5967 2,445,000 1,458,932 Observation Beds 26 Total 0.4007 49,265,000 20,196,770 *Inpatient program charges were pulled from the governmental produced PSR report **Total nursery inpatient charges of $7,459,000 are not found within the PSR report. This figure predominantly represents the charges for Medicaid patients.
Table 8.13 Worksheet D-5 Ratio of Cost Outpatient Outpatient Description To Charges Program Charges Program Costs 1 2 3 Routine Serivce Cost Center 13 Adults and Pediatrics 0.5645 0 0 14 Intensive Care Unit 0.4158 0 0 15 Nursery 0.2688 0 0 16 Operating Room 0.3377 9,060,000 3,059,562 17 Radiology - Diagnostic 18 Computed Tomography (CT) Scan 19 Magnetic Resonance Scan (MRI) 0.3073 2,944,500 904,845 20 Laboratory 0.3296 2,718,000 895,853 21 Physical Therapy 0.3109 3,011,000 936,120 Medical Supplies Charged to Patients 23 Implantable Devices Charged to Patients 0.9617 0 0 24 Drugs Charged to Patients 0.3447 906,000 312,298 25 Emergency 0.5967 4,636,500 2,766,600 Observation Beds 26 Total 0.4007 23,276,000 8,875,277 *Outatient program charges were pulled from the governmental produced PSR report
Table 8.15 Worksheet E Part A Part A Inpatient Hospital Services Under PPS 1 Additional payment for high percentage of ESRD discharges 40 Total Medicare discharges on Worksheet S-3 Part 1 excluding certain discharges 41 Total ESRD Medicare discharges 42 Divide line 41 by line 40 43 Total Medicare ESRD inpatient days 44 Ratio of average length of stay to one week 45 Average weekly cost for dialysis treatments 46 Total additional payment 47 Subtotal (Operating Medicare DSH + Payments Listed on PSR) 9,023,601 48 Hospital specific payments 49 Total payment for inpatient operating costs 9,023,601 50 Payment for inpatient program capital 28,995 51 Exception payment for inpatient program capital 52 Direct graduate medical education payment 53 Nursing and allied health managed care payment 54 Special add-on payments for new technologies 55 Net organ acquisition cost 56 Cost of teaching physicians 57 Routine service other pass through costs 58 Ancillary service other pass through costs 59 Total 9,052,596 60 Primary payer amounts 61 Total amount payable for program 9,052,596 62 Deductibles billed to program beneficiaries (Found in PSR Report) 500,000 63 Coinsurance billed to program beneficiaries (Found in PSR Report) 200,000 64 Allowable bad debts 250,000 65 Adjusted reimbursable bad debts (Medicare Pass-Through Payment) 175,000 66 Allowable bad debts for dual eligible beneficiaries 67 Subtotal 8,527,596 68 Credits received from manufacturers for replaced devices applicable to MS-DRG 69 Outlier payments 70 Other adjustments 71 Amount due provider 8,527,596 72 Interim payments (From E-1 Part 1) 8,300,000 73 Tentative settlement 74 Balance due provider (Sum of lines 71 minus 72 and 73) 227,596 75 Protested amounts