STATE OF CALIFORNIA SCHEDULE 7 PROGRAM: NONCONTRACT COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED PHYSICIAN''''S REMUNERATION_part1 pdf

STATE OF CALIFORNI
A
SCHEDULE A-4
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30,2009
Provider No.:
ZZT30107H
Audited Medi-Cal Cost Per Day
1. Medi-Cal Cost of Covered Services (Schedule 3, Line 8) $
2. Less: Medi-Cal Administrative Day Cost (Schedule 4A, Lines 28 and 31)
3. Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 minus Line 2) $ 0
4. Total Audited Medi-Cal Days (Schedules 4, 4A, and 4B, excludes Administrative Days)
5. Audited Medi-Cal Cost Per Day (Line 3 ÷ Line 4) $ 0.00
10 % Cost Reduction For Services From 07/01/08 Through 06/30/2009
6. Audited Medi-Cal Days of Service from 07/01/08 - 06/30/2009 (excludes Administrative Days)
7. Audited Medi-Cal Cost Per Day for 07/01/08 - 06/30/2009 (Line 5 X Line 6) $ 0
8. 10% Cost Reduction for 07/01/08 - 06/30/2009 (Line 7 X 10%) $ 0
(To Schedule A, Ln 4)
10% REDUCTION FOR SERVICES FROM JULY 1, 2008 THROUGH JUNE 30, 2009
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
HFPAs WITH LESS THAN 3 HOSPITALS
AB 5
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STATE OF CALIFORNI
A
SCHEDULE A-5 (RURAL HEALTH
)
PROGRAM: NONCONTRAC
T

Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTE
R
JUNE 30,2009
Provider No.
ZZT30107H
Audited Medi-Cal Cost Per Da
y
1. Medi-Cal Cost of Covered Services (Schedule 3, Line 8) $
2. Less: Medi-Cal Administrative Day Cost (Schedule 4A, Lines 28 and 31)
3. Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 minus Line 2) $ 0
4. Total Audited Medi-Cal Days (Schedules 4, 4A, and 4B, excludes Administrative Days)
5. Audited Medi-Cal Cost Per Day (Line 3 ÷ Line 4) $ 0.00
10% Cost Reduction For Services From 07/01/08 Through 10/31/0
8
6. Audited Medi-Cal Days of Service from 07/1/08 - 10/31/08 (excluding Administrative Days)
7. Audited Medi-Cal Cost Per Day for 07/01/08 - 10/31/08 (Line 5 X Line 6) $ 0
8. 10% Cost Reduction for 07/01/08 - 10/31/08 (Line 7 X 10%) $ 0
(To Schedule A, Ln 5)
10% REDUCTION FOR SERVICES FROM JULY 1, 2008 THROUGH OCTOBER 31, 2008
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
RURAL HEALTH HOSPITALS
AB 5
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STATE OF CALIFORNIA SCHEDULE 1
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009
Provider No.

ZZT30107G
REPORTED AUDITED
1. Net Cost of Covered Services Rendered to
Medi-Cal Patients (Schedule 3) $ 8,960,121 $ 8,991,725

2. Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0
3. Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ N/A
4. $0 $0
5. TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 8,960,121 $ 8,991,725
6. Interim Payments (Adj 29) $ (8,260,723) $ (8,481,358)
7. Balance Due Provider (State) $ 699,398 $ 510,367
8. Duplicate Payments (Adj ) $ $ 0

9. AB 5 $ (926,000) $ (898,972)

10. $0 $0
11. TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ (226,602) $ (388,605)
(To Summary of Findings)
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
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STATE OF CALIFORNIA SCHEDULE 2
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009
Provider No.
ZZT30107G
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1. Cost of Covered Services (Schedule 3) $ 9,043,166 $ 9,075,575

CHARGES FOR MEDI-CAL INPATIENT SERVICES
2. Inpatient Routine Service Charges (Adj 28) $ 10,287,523 $ 12,689,639
3. Inpatient Ancillary Service Charges (Adj 28) $ 25,001,239 $ 26,028,225
4. Total Charges - Medi-Cal Inpatient Services $ 35,288,762 $ 38,717,864
5. Excess of Customary Charges Over Reasonable Cost
(Line 4 minus Line 1) * $ 26,245,596 $ 29,642,289
6. Excess of Reasonable Cost Over Customary Charges
(Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
* If charges exceed reasonable cost, no further calculation necessary for this schedule.
COMPUTATION OF LESSER OF
MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
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STATE OF CALIFORNIA SCHEDULE 3
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009
Provider No.
ZZT30107G
REPORTED AUDITED
1. Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 4,634,401 $ 4,636,499
2. Medi-Cal Inpatient Routine Services (Schedule 4) $ 4,408,765 $ 4,439,076
3. Medi-Cal Inpatient Hospital Based Physician
for Intern and Resident Services (Sch ) $ 0 $ 0
4. $0 $0
5. $0 $0
6. SUBTOTAL (Sum of Lines 1 through 5) $ 9,043,166 $ 9,075,575
7. Medi-Cal Inpatient Hospital Based Physician
for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0

8. SUBTOTAL $ 9,043,166 $ 9,075,575
(To Schedule 2)
9. Coinsurance (Adj 29) $ (83,045) $ (9,129)
10. Patient and Third Party Liability (Adj 29) $ 0 $ (74,721)
11. Net Cost of Covered Services Rendered to Medi-Cal
Inpatients $ 8,960,121 $ 8,991,725
(To Schedule 1)
COMPUTATION OF
MEDI-CAL NET COSTS OF COVERED SERVICES
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STATE OF CALIFORNIA SCHEDULE 4
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009
Provider No.
ZZT30107G
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS
1. Total Inpatient Days (include private & swing-bed) (Adj 24) 34,331 35,518
2. Inpatient Days (include private, exclude swing-bed) 34,331 35,518
3. Private Room Days (exclude swing-bed private room) (Adj ) 0 0
4. Semi-Private Room Days (exclude swing-bed) (Adj ) 34,331 34,331
5. Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0
6. Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0
7. Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0
8. Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0
9. Medi-Cal Days (excluding swing-bed) (Adj 26) 3,884 4,001

SWING-BED ADJUSTMENT

17. Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 0.00 $ 0.00
18. Medicare NF Swing-Bed Rates after Dec 31(Adj ) $ 0.00 $ 0.00
19. Medi-Cal NF Swing-Bed Rates through July 31(Adj ) $ 0.00 $ 0.00
20. Medi-Cal NF Swing-Bed Rates after July 31(Adj ) $ 0.00 $ 0.00
21. Total Routine Serv Cost (Sch 8, Line 25, Col 27) $ 28,112,680 $ 27,321,085
22. Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0
23. Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0
24. Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0
25. Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0
26. Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0
27. Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 28,112,680 $ 27,321,085
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28. Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 115,992,479 $ 115,992,479
29. Private Room Charges (excluding swing-bed charges) $ 0 $ 0
30. Semi-Private Room Charges (excluding swing-bed charges) $ 115,992,479 $ 115,992,479
31. Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) $ 0.242366 $ 0.235542
32. Average Private Room Per Diem Charge (L 29 / L 3) $ 0.00 $ 0.00
33. Average Semi-Private Room Per Diem Charge (L 30 / L 4) $ 3,378.65 $ 3,378.65
34. Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 0.00 $ 0.00
35. Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 0.00 $ 0.00
36. Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0
37. Inpatient Rout Cost Net of Swing-Bed & Prvt Rm (L 27 minus L 36) $ 28,112,680 $ 27,321,085
PROGRAM INPATIENT OPERATING COST
38. Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) $ 818.87 $ 769.22
39. Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3,180,491 $ 3,077,649
40. Cost Applicable to Medi-Cal (Sch 4A) $ 1,228,274 $ 1,361,427
41. Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42. TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39,40 & 41) $ 4,408,765 $ 4,439,076
( To Schedule 3 )
MEDI-CAL INPATIENT ROUTINE SERVICE COST

COMPUTATION OF
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STATE OF CALIFORNIA SCHEDULE 4A
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009
Provider No.
ZZT30107G
SPECIAL CARE AND/OR NURSERY UNITS REPORTED AUDITED
NURSERY
1. Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) $ 2,462,658 $ 2,492,392
2. Total Inpatient Days (Adj 24) 6,834 6,440
3. Average Per Diem Cost $ 360.35 $ 387.02
4. Medi-Cal Inpatient Days (Adj 26) 3,291 3,390
5. Cost Applicable to Medi-Cal $ 1,185,912 $ 1,311,998
INTENSIVE CARE UNIT
6. Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) $ 6,634,315 $ 6,398,014
7. Total Inpatient Days (Adj 24) 3,602 3,508
8. Average Per Diem Cost $ 1,841.84 $ 1,823.84
9. Medi-Cal Inpatient Days (Adj 26) 23 26
10. Cost Applicable to Medi-Cal $ 42,362 $ 47,420

CORONARY CARE UNIT
11. Total Inpatient Routine Cost (Sch 8, Line 27, Col 27) $ 0 $ 0
12. Total Inpatient Days (Adj ) 0 0
13. Average Per Diem Cost $ 0.00 $ 0.00
14. Medi-Cal Inpatient Days (Adj ) 0 0
15. Cost Applicable to Medi-Cal $ 0 $ 0
NEONATAL INTENSIVE CARE UNIT

16. Total Inpatient Routine Cost (Sch 8, Line 28, Col 27) $ 0 $ 0
17. Total Inpatient Days (Adj ) 0 0
18. Average Per Diem Cost $ 0.00 $ 0.00
19. Medi-Cal Inpatient Days (Adj ) 0 0
20. Cost Applicable to Medi-Cal $ 0 $ 0

SURGICAL INTENSIVE CARE UNIT
21. Total Inpatient Routine Cost (Sch 8, Line 29, Col 27) $ 0 $ 0
22. Total Inpatient Days (Adj ) 0 0
23. Average Per Diem Cost $ 0.00 $ 0.00
24. Medi-Cal Inpatient Days (Adj ) 0 0
25. Cost Applicable to Medi-Cal $ 0 $ 0

ADMINISTRATIVE DAYS (JULY 1, 2008 THROUGH JULY 31, 2008)
26. Per Diem Rate (Adj 25) $ 0.00 $ 318.19
27. Medi-Cal Inpatient Days (Adj 25) 0 3
28. Cost Applicable to Medi-Cal $ 0 $ 955
ADMINISTRATIVE DAYS (AUGUST 1, 2008 THROUGH JUNE 30, 2009)
29. Per Diem Rate (Adj 25) $ 0.00 $ 351.26
30. Medi-Cal Inpatient Days (Adj 25) 0 3
31. Cost Applicable to Medi-Cal $ 0 $ 1,054
32. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,28,31) $ 1,228,274 $ 1,361,427
(To Schedule 4)
COMPUTATION OF
MEDI-CAL INPATIENT ROUTINE SERVICE COST
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STATE OF CALIFORNIA SCHEDULE 4B
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:

MARIAN MEDICAL CENTER JUNE 30, 2009

Provider No.
ZZT30107G
SPECIAL CARE UNITS REPORTED AUDITED

1. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
2. Total Inpatient Days (Adj ) 0 0
3. Average Per Diem Cost $ 0.00 $ 0.00
4. Medi-Cal Inpatient Days (Adj ) 0 0
5. Cost Applicable to Medi-Cal $ 0 $ 0


6. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
7. Total Inpatient Days (Adj ) 0 0
8. Average Per Diem Cost $ 0.00 $ 0.00
9. Medi-Cal Inpatient Days (Adj ) 0 0
10. Cost Applicable to Medi-Cal $ 0 $ 0

11. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
12. Total Inpatient Days (Adj ) 0 0
13. Average Per Diem Cost $ 0.00 $ 0.00
14. Medi-Cal Inpatient Days (Adj ) 0 0
15. Cost Applicable to Medi-Cal $ 0 $ 0

16. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
17. Total Inpatient Days (Adj ) 0 0
18. Average Per Diem Cost $ 0.00 $ 0.00
19. Medi-Cal Inpatient Days (Adj ) 0 0
20. Cost Applicable to Medi-Cal $ 0 $ 0

21. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
22. Total Inpatient Days (Adj ) 0 0
23. Average Per Diem Cost $ 0.00 $ 0.00
24. Medi-Cal Inpatient Days (Adj ) 0 0
25. Cost Applicable to Medi-Cal $ 0 $ 0

26. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
27. Total Inpatient Days (Adj ) 0 0
28. Average Per Diem Cost $ 0.00 $ 0.00
29. Medi-Cal Inpatient Days (Adj ) 0 0
30. Cost Applicable to Medi-Cal $ 0 $ 0
31. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 0 $ 0
(To Schedule 4)
COMPUTATION OF
MEDI-CAL INPATIENT ROUTINE SERVICE COST
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STATE OF CALIFORNIA SCHEDULE 5
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009
Provider No:
ZZT30107G
RATIO
COST TO
CHARGES
ANCILLARY COST CENTERS
37.00 Operating Room $ 11,051,806 $ 106,344,799 0.103924 $ 5,363,295 $ 557,377
37.01 Gastro Intestinal Service 443,025 1,170,465 0.378504 19,482 7,374

37.20 Cardicac Cath Lab 2,706,650 30,631,594 0.088361 198,769 17,564
38.00 Recovery Room 0 0 0.000000 0 0
39.00 Delivery Room and Labor Room 7,254,402 19,550,277 0.371064 6,684,146 2,480,245
40.00 Anesthesiology 346,015 36,937,085 0.009368 2,456,948 23,016
41.00 Radiology - Diagnostic 8,300,061 52,095,736 0.159323 202,086 32,197
41.01 CT Scan and MRI 1,870,488 36,694,158 0.050975 444,536 22,660
43.00 Radioisotope 1,777,070 16,706,218 0.106372 31,812 3,384
44.00 Laboratory 8,154,976 73,924,038 0.110316 2,888,211 318,615
44.01 Pathological Lab 0 0 0.000000 0 0
46.00 Whole Blood & Packed Red Blood 1,987,954 4,811,561 0.413162 256,179 105,843
47.00 Blood Storing and Processing 0 0 0.000000 0 0
48.00 Intravenous Therapy 180,685 625,923 0.288670 0 0
49.00 Respiratory Therapy 3,502,733 8,505,764 0.411807 62,023 25,542
50.00 Physical Therapy 2,800,043 10,407,977 0.269029 204,914 55,128
51.00 Occupational Therapy 1,235,588 4,038,475 0.305954 5,612 1,717
52.00 Speech Pathology 0 0 0.000000 0 0
53.00 Electrocardiology 2,533,069 11,279,552 0.224572 14,330 3,218
54.00 Electroencephalography 113,498 267,478 0.424326 2,812 1,193
55.00 Medical Supplies Charged to Patients 9,262,769 35,024,732 0.264464 1,168,432 309,008
55.01 Medical Supplies Chrg. Pat. - IMP 10,610,140 37,696,037 0.281466 148,654 41,841
56.00 Drugs Charged to Patients 8,085,390 79,938,761 0.101145 5,375,341 543,688
57.00 Renal Dialysis 381,009 655,266 0.581457 2,915 1,695
58.00 ASC (Non-Distinct Part) 0 0 0.000000 0 0
59.00 Ultrasound 694,280 7,805,337 0.088949 217,238 19,323
59.02 0 0 0.000000 0 0
59.03 0 0 0.000000 0 0
60.00 Clinic 1,793,163 4,012,970 0.446842 0 0
60.01 Other Clinic Services 0 0 0.000000 0 0
61.00 Emergency 10,105,355 43,030,654 0.234841 280,490 65,871
62.00 Observation Beds 0 1,747,028 0.000000 0 0

71.00 Home Health Agency 16,300,486 0 0.000000 0 0
89.00 Utilization Review 980,387 0 0.000000 0 0
93.00 Hospice 2,970,702 0 0.000000 0 0
0 0 0.000000 0 0
0 0 0.000000 0 0
0 0 0.000000 0 0
TOTAL $ 115,441,744 $ 623,901,885 $ 26,028,225 $ 4,636,499
(To Schedule 3)
* From Schedule 8, Column 27
ANCILLARY
MEDI-CAL
(Adj )
COSTCHARGES
(From Schedule 6)
MEDI-CAL
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
TOTAL
COST *
CHARGES
TOTAL ANCILLARY
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STATE OF CALIFORNIA SCHEDULE 6
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009
Provider No:
ZZT30107G
ANCILLARY CHARGES
37.00 Operating Room $ 5,144,446 $ 218,849 $ 5,363,295

37.01 Gastro Intestinal Service 17,965 1,517 19,482
37.20 Cardicac Cath Lab 176,410 22,359 198,769
38.00 Recovery Room 0
39.00 Delivery Room and Labor Room 6,573,360 110,786 6,684,146
40.00 Anesthesiology 2,376,637 80,311 2,456,948
41.00 Radiology - Diagnostic 189,731 12,355 202,086
41.01 CT Scan and MRI 424,407 20,129 444,536
43.00 Radioisotope 31,812 31,812
44.00 Laboratory 2,710,437 177,774 2,888,211
44.01 Pathological Lab 0
46.00 Whole Blood & Packed Red Blood 230,593 25,586 256,179
47.00 Blood Storing and Processing 0
48.00 Intravenous Therapy 0
49.00 Respiratory Therapy 59,233 2,790 62,023
50.00 Physical Therapy 199,864 5,050 204,914
51.00 Occupational Therapy 5,087 525 5,612
52.00 Speech Pathology 0
53.00 Electrocardiology 12,980 1,350 14,330
54.00 Electroencephalography 2,812 2,812
55.00
Medical Supplies Charged to Patients 1,114,072 54,360 1,168,432
55.01 Medical Supplies Chrg. Pat. - IMP 145,677 2,977 148,654
56.00 Drugs Charged to Patients 5,111,707 263,634 5,375,341
57.00 Renal Dialysis 2,915 2,915
58.00 ASC (Non-Distinct Part) 0
59.00 Ultrasound 197,001 20,237 217,238
59.02 0
59.03 0
60.00 Clinic 0
60.01 Other Clinic Services 0

61.00 Emergency 274,093 6,397 280,490
62.00 Observation Beds 0
71.00 Home Health Agency 0
89.00 Utilization Review 0
93.00 Hospice 0
0
0
0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 25,001,239 $ 1,026,986 $ 26,028,225
(To Schedule 5)
ADJUSTMENTS TO MEDI-CAL CHARGES
REPORTED ADJUSTMENTS AUDITED
(Adj 27)
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