REPORT ON THE COST REPORT REVIEW SAN FRANCISCO GENERAL HOSPITAL SAN FRANCISCO, CALIFORNIA _part6 doc

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
ADJUSTMENTS TO REPORTED COSTS
9 10A A 6.00 7 Administrative and General * $85,292,593 ($201,232) $85,091,361
To reverse the provider's unallocated variance adjustment to agree
with the provider's record and due to lack of documentations.
CMS Pub. 15-1, Sections 2300 and 2304
10 10A A 4.00 7 New Capital Related Costs - Moveable Equipment $3,079,983 $39,064 $3,119,047
To adjust depreciation expense to agree with the provider's
depreciation schedule.
CMS Pub. 15-1, Sections 102, 2300, 2302.4, and 2304
11 10A A 63.60 7 Adult Medical Center FQHC I * $15,900,440 $3,533,337 $19,433,777
10A A 63.61 7 Women's Health Center FQHC II * 6,068,758 1,106,124 7,174,882
10A A 63.62 7 Family Health Center FQHC III * 5,235,592 1,713,092 6,948,684
10A A 63.63 7 Children's Health Center FQHC IV * 3,549,578 856,995 4,406,573
To reverse the provider's elimination of FQHC physician expenses to
agree with the provider's supporting documentations and for proper cost
determination.
CMS Pub. 15-1, Sections 2300, 2302, 2304, and 2306
*Balance carried forward from prior/to subsequent adjustments Page 5
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
ADJUSTMENTS TO REPORTED STATISTICS
12 9 B-1 61.01 5 Psych Emergency (Gross Salaries) 4,817,197 (1,118,941) 3,698,256
9 B-1 96.01 5 Other Than Hospital 9,997,842 1,118,941 11,116,783
To adjust gross salaries statistics to agree with the provider's records
and in conjunction with audit adjustment number 2.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
13 9 B-1 61.01 12 Psych Emergency (Full Time Equivalents) 3,736 (687) 3,049
9 B-1 96.01 12 Other Than Hospital 6,896 687 7,583
To adjust Cafeteria statistics to agree with the provider's records.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
14 9 B-1 61.01 14 Psych Emergency (Nursing Full Time Equivalents) 2,304 (310) 1,994
9 B-1 96.01 14 Other Than Hospital 4,368 310 4,678
To adjust Nursing Administration statistics to agree with the provider's
records.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
15 9 B-1 61.01 15 Psych Emergency (Costed Requisitions) 7,118 (2,117) 5,001
9 B-1 96.01 15 Other Than Hospital 99,498 2,117 101,615
To adjust costed requisitions statistics to agree with the provider's
records.

CMS Pub. 15-1, Sections 2300, 2304, and 2306
16 9 B-1 55.00 15 Medical Supplies Charged to Patients (Costed Requisitions) 6,936,471 (4,405,182) 2,531,289
9 B-1 15.00 15 Total Statistics - Costed Requisitions 25,359,374 (4,405,182) 20,954,192
To adjust costed requisitions statistics to agree with the provider's
records and for proper cost determination.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
17 9 B-1 61.01 16 Psych Emergency (Costed Requisitions) 25,341 (18,946) 6,395
9 B-1 96.01 16 Other Than Hospital 842,701 18,946 861,647
To adjust costed requisitions statistics to agree with the provider's
records.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
Page 6
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
ADJUSTMENTS TO REPORTED STATISTICS
18 9 B-1 56.00 17, 18 Drugs Charged to Patients (Gross Charges) 163,163,510 32,440,245 195,603,755
9 B-1 17.00 17 Total Statistics - Gross Charges 1,396,604,442 32,440,245 1,429,044,687
9 B-1 18.00 18 Total Statistics - Gross Charges 1,396,604,442 32,440,245 1,429,044,687
To adjust Medical Records and Social Service statistics in conjunction

with audit adjustment number 21.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
19 9 B-1 25.00 22 Adults and Pediatrics (Assigned Time) 21,347 1,594 22,941
9 B-1 37.00 22 Operating Room 7,886 (82) 7,804
9 B-1 40.00 22 Anesthesiology 4,898 78 4,976
9 B-1 41.00 22 Radiology - Diagnostic 4,175 253 4,428
9 B-1 44.01 22 Laboratory Pathology 3,739 507 4,246
9 B-1 60.00 22 Clinic 40,447 6,065 46,512
9 B-1 61.00 22 Emergency 2,127 827 2,954
9 B-1 63.60 22 Adult Medical Center FQHC I 4,591 1,440 6,031
9 B-1 63.61 22 Women's Health Center FQHC II 3,141 1,560 4,701
9 B-1 63.62 22 Family Health Center FQHC III 3,162 2,357 5,519
9 B-1 63.63 22 Children's Health Center FQHC IV 2,786 1,213 3,999
9 B-1 63.64 22 Urgent Care FQHC V 1,703 677 2,380
9 B-1 22.00 22 Total Statistics - Assigned Time 100,002 16,489 116,491
To adjust Interns and Residents statistics to agree with the provider's
supporting documents.
CMS Pub. 15-1, Sections 2300, 2304, and 2306
Page 7
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments

JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
ADJUSTMENT TO REPORTED TOTAL CHARGES
20 5, DPH 5 C I 56.00 8 Drugs Charged to Patients $163,163,510 $27,175,934 $190,339,444
To adjust total Drugs Charged to Patients for proper matching of revenue
and expenses and to agree with the provider's records.
CMS Pub. 15-1, Sections 2102, 2202.4, 2206 2302.6, 2304, 2306,
2204, 2300, and 2304
Page 8
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - DESIGNATED PUBLIC HOSPITAL (DPH)
21 DPH 4 D-1 I XIX 9.00 1 Medi-Cal Days - Adults and Pediatrics 32,744 (5,099) 27,645 *
DPH 4A D-1 II XIX 42.00 4 Medi-Cal Days - Nursery 1,567 14 1,581
DPH 4A D-1 II XIX 43.00 4 Medi-Cal Days - Intensive Care Unit 2,609 474 3,083
DPH 4A D-1 II XIX 44.00 4 Medi-Cal Days - Coronary Care Unit 7 (1) 6
DPH 4A D-1 II XIX 47.00 4 Medi-Cal Days - Neonatal Intensive Care Unit 370 26 396
22 DPH 6 D-4 XIX 37.00 2 Medi-Cal Ancillary Charges - Operating Room $15,322,515 $2,947,284 $18,269,799
DPH 6 D-4 XIX 39.00 2 Medi-Cal Ancillary Charges - Delivery Room and Labor Room 1,597,863 (1,596,070) 1,793

DPH 6 D-4 XIX 40.00 2 Medi-Cal Ancillary Charges - Anesthesiology 11,192,897 2,435,045 13,627,942
DPH 6 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 13,318,217 363,215 13,681,432 *
DPH 6 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 19,463,335 1,176,541 20,639,876 *
DPH 6 D-4 XIX 44.01 2 Medi-Cal Ancillary Charges - Laboratory - Pathology 1,111,037 71,374 1,182,411
DPH 6 D-4 XIX 46.00 2 Medi-Cal Ancillary Charges - Whole Blood and Packed Red Blood 1,549,612 444,250 1,993,862
DPH 6 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 2,728,726 538,596 3,267,322
DPH 6 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 2,067,788 518,198 2,585,986 *
DPH 6 D-4 XIX 51.00 2 Medi-Cal Ancillary Charges - Occupational Therapy 1,045,026 (596,556) 448,470 *
DPH 6 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 2,320,068 696,167 3,016,235
DPH 6 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 21,082,150 4,440,029 25,522,179
DPH 6 D-4 XIX 55.01 2 Medi-Cal Ancillary Charges - Implantable Devices 63,025 110,879 173,904
DPH 6 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 38,694,153 1,079,482 39,773,635 *
DPH 6 D-4 XIX 57.00 2 Medi-Cal Ancillary Charges - Renal Dialysis 705,059 (58,703) 646,356
DPH 6 D-4 XIX 59.00 2 Medi-Cal Ancillary Charges - Other Ancillaries 173,365 8,893 182,258
DPH 6 D-4 XIX 61.00 2 Medi-Cal Ancillary Charges - Emergency 6,931,462 887,389 7,818,851
DPH 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 139,371,813 13,466,013 152,837,826 *
23 DPH 2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges $171,200,845 ($13,084,165) $158,116,680 *
DPH 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 139,371,813 13,466,013 152,837,826 *
24 DPH 3 E-3 III XIX 33.00 1 Medi-Cal Deductibles $0 $179,610 $179,610 *
DPH 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance 500,281 (108,870) 391,411 *
DPH 1 E-3 III XIX 57.00 1 Medi-Cal Interim Payments 47,718,905 4,456,875 52,175,780 *
-Continued on next page-
*Balance carried forward from prior/to subsequent adjustments Page 9
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted

Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - DESIGNATED PUBLIC HOSPITAL (DPH)
-Continued from previous page-
To adjust Medi-Cal Settlement Data to agree with the following
EDS Paid Claims Summary:
Report Date: January 26, 2011
Payment Period: July 1, 2008 through January 11, 2011
Service Period: July 1, 2008 through June 30, 2009
CMS Pub. 15-1, Sections 2304 and 2408.3
Page 10
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
SAN FRANCISCO GENERAL HOSPITAL
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - DESIGNATED PUBLIC HOSPITAL (DPH)
25 DPH 4 D-1 I XIX 9.00 1 Medi-Cal Days - Adults and Pediatrics (Administrative Days) * 27,645 8,353 35,998

26 DPH 6 D-6 I XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic * $13,681,432 $99,492 $13,780,924
DPH 6 D-6 I XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory * 20,639,876 1,179,334 21,819,210
DPH 6 D-6 I XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy * 2,585,986 565,718 3,151,704
DPH 6 D-6 I XIX 51.00 2 Medi-Cal Ancillary Charges - Occupational Therapy * 448,470 153,712 602,182
DPH 6 D-6 I XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients * 39,773,635 4,556,026 44,329,661
DPH 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total * 152,837,826 6,554,282 159,392,108
27 DPH 2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges * $158,116,680 $35,260,046 $193,376,726
DPH 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges * 152,837,826 6,554,282 159,392,108
28 DPH 3 E-3 III XIX 33.00 1 Medi-Cal Deductibles * $179,610 $11,432 $191,042
DPH 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance * 391,411 38,747 430,158
DPH 1 E-3 III XIX 57.00 1 Medi-Cal Interim Payments * 52,175,780 5,004,939 57,180,719
In accordance with SB 1115 waiver, Administrative Days will be
combined with the Designated Public Hospital Settlement. This
adjustment is to include Medi-Cal Administrative Days with the
Designated Public Hospital Settlement and to agree with the
following EDS Paid Claims Summary:
Report Date: January 26, 2011
Payment Period: July 1, 2008 through January 11, 2011
Service Period: July 1, 2008 through June 30, 2009
CMS Pub. 15-1, Sections 2304 and 2408.3
*Balance carried forward from prior/to subsequent adjustments Page 11
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
31
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
SAN FRANCISCO GENERAL HOSPITAL

Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W
Cost Report
ADJUSTMENTS TO OTHER MATTERS
29 DPNF 1 S-3 I 25.00 1 Total Hospital Licensed Capacity (All Levels) 477 121 598
To adjust the reported Skilled Nursing Facility licensed capacity
and total hospital licensed capacity to reflect the Department of
Health Services bed license, effective during the fiscal year
ended June 30, 2009.
CMS Pub. 15-1, Section 2304
30 DPNF 1 D-1 I 1.00 9 Medi-Cal Days - Skilled Nursing Facility 0 14,113 14,113
To adjust Medi-Cal Settlement Data to agree with the following
EDS Paid Claims Summary:
Report Date: January 26, 2011
Payment Period: July 1, 2008 through January 11, 2011
Service Period: July 1, 2008 through June 30, 2009
CMS Pub. 15-1, Sections 2304 and 2408.3
31 DPH 1 Not Reported Medi-Cal Overpayments $0 $1,607 $1,607
To recover Medi-Cal overpayments because the Share of Cost
was not properly deducted from the amount billed.
CCR, Title 22, Sections 50786 and 51458.1
CMS Pub. 15-1, Sections 2300 and 2409
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