STATE OF CALIFORNIA SCHEDULE 7 PROGRAM: NONCONTRACT COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED PHYSICIAN''''S REMUNERATION_part4 potx

STATE OF CALIFORNIA
Provider Name:
MARIAN MEDICAL CENTER
GENERAL SERVICE COST CENTERS
1.00 Old Cap Rel Costs-Bldg & Fixtures
2.00 Old Cap Rel Costs-Movable Equipment
3.00 New Cap Rel Costs-Bldg & Fixtures
4.00 New Cap Rel Costs-Movable Equipment
4.01
4.02
4.03
4.04
4.05
4.06
4.07
4.08
5.00 Employee Benefits
6.01 Non-Patient Telephones
6.02 Data Processing
6.03 Purchasing/Receiving
6.04 Patient Admitting
6.05 Patient 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 Neonatal Intensive Care Unit
29.00 Surgical Intensive Care
30.00 Subprovider I
31.00 Subprovider II
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 9.3
Fiscal Period Ended:
JUNE 30, 2009
STAT STAT NONPHY NURSE I&R-SAL I&R-PRG PARAMED
ANESTH SCHOOL & FRINGES COST EDUCAT
(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME)
19.02 19.03 20.00 21.00 22.00 23.00 24.00
(Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
(Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
STATISTICS FOR COST ALLOCATION (W/S B-1)
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STATE OF CALIFORNIA
Provider Name:
MARIAN MEDICAL CENTER
ANCILLARY COST CENTERS
37.00 Operating Room
37.01 Gastro Intestinal Service
37.20 Cardicac Cath Lab
38.00 Recovery Room
39.00 Delivery Room and Labor Room
40.00 Anesthesiology
41.00 Radiology - Diagnostic
41.01 CT Scan and MRI
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood & Packed Red Blood
47.00 Blood Storing and Processing

48.00 Intravenous Therapy
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
55.01 Medical Supplies Chrg. Pat. - IMP
56.00 Drugs Charged to Patients
57.00 Renal Dialysis
58.00 ASC (Non-Distinct Part)
59.00 Ultrasound
59.02
59.03
60.00 Clinic
60.01 Other Clinic Services
61.00 Emergency
62.00 Observation Beds
71.00 Home Health Agency
89.00 Utilization Review
93.00 Hospice



NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen
97.00 Research
98.00 Physicians' Private Office
99.00 Nonpaid Workers

99.01
99.02
99.03
99.04
99.05
100.00
100.01 Foundation
100.02
100.03 Community Relations
100.04
TOTAL
COST TO BE ALLOCATED
UNIT COST MULTIPLIER - SCH 8
SCHEDULE 9.3
Fiscal Period Ended:
JUNE 30, 2009
STAT STAT NONPHY NURSE I&R-SAL I&R-PRG PARAMED
ANESTH SCHOOL & FRINGES COST EDUCAT
(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME)
19.02 19.03 20.00 21.00 22.00 23.00 24.00
(Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
(Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
STATISTICS FOR COST ALLOCATION (W/S B-1)


0000000
0000000
0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000
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STATE OF CALIFORNIA SCHEDULE 10
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009

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 6,429,449 (1,969,656) 4,459,793
4.00 New Cap Rel Costs-Movable Equipment 5,342,064 1,633,874 6,975,938
4.01 00
4.02 00
4.03 00
4.04 00
4.05 00
4.06 00
4.07 00
4.08 00
5.00 Employee Benefits 23,297,357 (557,257) 22,740,100
6.01 Non-Patient Telephones 0 0
6.02 Data Processing 00
6.03 Purchasing/Receiving 0 0
6.04 Patient Admitting 00
6.05 Patient Business Office 0 0
6.06 00
6.07 00
6.08 00
6.00 Administrative and General 28,987,953 (5,894,764) 23,093,189
7.00 Maintenance and Repairs 4,854,230 (25) 4,854,205
8.00 Operation of Plant 2,605,898 (197,296) 2,408,602
9.00 Laundry and Linen Service 886,908 0 886,908

10.00 Housekeeping 2,165,800 0 2,165,800
11.00 Dietary 1,403,139 0 1,403,139
12.00 Cafeteria 1,369,291 106,572 1,475,863
13.00 Maintenance of Personnel 0 0
14.00 Nursing Administration 1,806,659 0 1,806,659
15.00 Central Services & Supply 402,079 (560) 401,519
16.00 Pharmacy 2,576,016 (180,254) 2,395,762
17.00 Medical Records and Library 1,132,829 0 1,132,829
18.00 Social Service 00
19.00 00
19.02 00
19.03 00
20.00 00
21.00 Nursing School 00
22.00 Intern & Res Service-Salary & Fringes 0 0
23.00 Intern & Res Other Program 0 0
24.00 Paramedical Ed Program 0 0
INPATIENT ROUTINE COST CENTERS
25.00 Adults & Pediatrics (Gen Routine) 13,791,449 (166,060) 13,625,389
26.00 Intensive Care Unit 3,454,404 (40,874) 3,413,530
27.00 Coronary Care Unit 0 0
28.00 Neonatal Intensive Care Unit 0 0
29.00 Surgical Intensive Care 0 0
30.00 Subprovider I 00
31.00 Subprovider II 00
32.00 00
33.00 Nursery 1,433,129 45,940 1,479,069
34.00 Medicare Certified Nursing Facility 4,705,466 (6,283) 4,699,183
35.00 Distinct Part Nursing Facility 0 0
36.00 Adult Subacute Care Unit 0 0

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
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STATE OF CALIFORNIA SCHEDULE 10
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009

REPORTED ADJUSTMENTS
TRIAL BALANCE OF EXPENSES
(From Sch 10A)
AUDITED
ANCILLARY COST CENTERS
37.00 Operating Room $ 4,955,402 $ (45,173) $ 4,910,229
37.01 Gastro Intestinal Service 212,687 (766) 211,921
37.20 Cardicac Cath Lab 1,117,357 (21,331) 1,096,026
38.00 Recovery Room 00
39.00 Delivery Room and Labor Room 4,136,680 (40,547) 4,096,133
40.00 Anesthesiology 146,802 (11,303) 135,499
41.00 Radiology - Diagnostic 3,328,053 (11,292) 3,316,761
41.01 CT Scan and MRI 516,039 (2,195) 513,844
43.00 Radioisotope 1,291,377 (4,371) 1,287,006
44.00 Laboratory 5,140,846 (12,720) 5,128,126
44.01 Pathological Lab 00
46.00 Whole Blood & Packed Red Blood 1,555,570 0 1,555,570
47.00 Blood Storing and Processing 0 0

48.00 Intravenous Therapy 103,855 0 103,855
49.00 Respiratory Therapy 1,854,927 (3) 1,854,924
50.00 Physical Therapy 1,686,912 (20) 1,686,892
51.00 Occupational Therapy 655,034 0 655,034
52.00 Speech Pathology 0 0
53.00 Electrocardiology 1,090,149 (542) 1,089,607
54.00 Electroencephalography 63,219 0 63,219
55.00 Medical Supplies Charged to Patients 6,334,741 449,446 6,784,187
55.01 Medical Supplies Chrg. Pat. - IMP 8,335,663 0 8,335,663
56.00 Drugs Charged to Patients 3,527,163 175,154 3,702,317
57.00 Renal Dialysis 290,849 (557) 290,292
58.00 ASC (Non-Distinct Part) 0 0
59.00 Ultrasound 345,883 (5,902) 339,981
59.02 00
59.03 00
60.00 Clinic 504,893 (816) 504,077
60.01 Other Clinic Services 0 0
61.00 Emergency 5,328,437 (118,512) 5,209,925
62.00 Observation Beds 0 0
71.00 Home Health Agency 10,130,828 0 10,130,828
89.00 Utilization Review 0 0
93.00 Hospice 2,138,604 0 2,138,604
00
00
00
SUBTOTAL $ 171,436,090 $ (6,878,093) $ 164,557,997
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen 0 0
97.00 Research 00
98.00 Physicians' Private Office 0 0

99.00 Nonpaid Workers 0 0
99.01 00
99.02 00
99.03 00
99.04 00
99.05 00
100.00 00
100.01 Foundation 00
100.02 00
100.03 Community Relations 1,133,607 1,111,595 2,245,202
100.04 00
100.99 SUBTOTAL $ 1,133,607 $ 1,111,595 $ 2,245,202
101 TOTAL $ 172,569,697 $ (5,766,498) $ 166,803,199
(To Schedule 8)
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STATE OF CALIFORNIA SCHEDULE 10A
Page 1
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009
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)6234578910111213
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
(1,969,656)
(53,218)
101,989
(1,818,188)
4.00
New Cap Rel Costs-Movable Equipment
1,633,874
1,633,874
4.01

0
4.02

0
4.03

0
4.04

0
4.05

0
4.06

0
4.07

0

4.08

0
5.00
Employee Benefits
(557,257)
(557,257)
6.01
Non-Patient Telephones
0
6.02
Data Processing
0
6.03
Purchasing/Receiving
0
6.04
Patient Admitting
0
6.05
Patient Business Office
0
6.06

0
6.07

0
6.08

0
6.00
Administrative and General
(5,894,764)
(434)
(290,976)
(47,737)
(80,760)
(5,474,857)
7.00
Maintenance and Repairs
(25)
(25)
8.00
Operation of Plant
(197,296)
(197,296)
9.00
Laundry and Linen Service
0
10.00
Housekeeping
0
11.00
Dietary
0
12.00
Cafeteria
106,572
106,572

13.00
Maintenance of Personnel
0
14.00
Nursing Administration
0
15.00
Central Services & Supply
(560)
(560)
16.00
Pharmacy
(180,254)
(5,116)
(175,138)
17.00
Medical Records and Library
0
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
0
23.00 Intern & Res Other Program 0
24.00 Paramedical Ed Program 0

INPATIENT ROUTINE COST CENTERS
25.00 Adults & Pediatrics (Gen Routine) (166,060) (116,521) (49,539)
26.00 Intensive Care Unit (40,874) (40,874)
27.00
Coronary Care Unit
0
28.00
Neonatal Intensive Care Unit
0
29.00 Surgical Intensive Care 0
30.00 Subprovider I 0
31.00 Subprovider II 0
32.00 0
33.00 Nursery 45,940 (3,583) 49,539 (16)
34.00 Medicare Certified Nursing Facility (6,283) (6,283)
35.00 Distinct Part Nursing Facility 0
36.00 Adult Subacute Care Unit 0
36.01
Subacute Care Unit II
0
36.02
Transitional Care Unit
0
ADJUSTMENTS TO REPORTED COSTS

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STATE OF CALIFORNIA SCHEDULE 10A
Page 1
Provider Name: Fiscal Period Ended:
MARIAN MEDICAL CENTER JUNE 30, 2009
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)6234578910111213
ADJUSTMENTS TO REPORTED COSTS
ANCILLARY COST CENTERS
37.00 Operating Room (45,173) (45,173)
37.01 Gastro Intestinal Service (766) (766)
37.20 Cardicac Cath Lab (21,331) (21,331)
38.00 Recovery Room 0
39.00 Delivery Room and Labor Room (40,547) (40,547)
40.00
A
nesthesiolog
y
(11,303) (11,303)
41.00 Radiology - Diagnostic (11,292) (11,292)
41.01 CT Scan and MRI (2,195) (2,195)
43.00 Radioisotope (4,371) (4,371)
44.00 Laborator
y
(12,720) (12,720)
44.01 Pathological Lab 0
46.00 Whole Blood & Packed Red Blood 0
47.00 Blood Storing and Processing 0
48.00 Intravenous Therapy 0

49.00 Respiratory Therapy (3) (3)
50.00 Physical Therapy (20) (20)
51.00 Occupational Therapy 0
52.00 Speech Pathology 0
53.00 Electrocardiolog
y
(542) (542)
54.00 Electroencephalograph
y
0
55.00 Medical Supplies Charged to Patients 449,446 449,446
55.01 Medical Supplies Chrg. Pat. - IMP 0
56.00 Drugs Charged to Patients 175,154 175,154
57.00 Renal Dialysis (557) (557)
58.00 ASC (Non-Distinct Part) 0
59.00 Ultrasound (5,902) (5,902)
59.02 0
59.03 0
60.00 Clinic (816) (816)
60.01 Other Clinic Services 0
61.00 Emergency (118,512) (118,512)
62.00 Observation Beds 0
71.00 Home Health Agenc
y
0
89.00 Utilization Review 0
93.00 Hospice 0
0
0
0

NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen 0
97.00 Research 0
98.00 Physicians' Private Office 0
99.00 Nonpaid Workers 0
99.01 0
99.02 0
99.03 0
99.04 0
99.05 0
100.00 0
100.01 Foundation 0
100.02 0
100.03 Community Relations 1,111,595 290,976 47,737 772,882
100.04 0
101.00 TOTAL ($5,766,498) 00000772,882106,572(197,296) (53,218) (80,760) (4,296,251) (1,818,188)
(To Sch 10)
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STATE OF CALIFORNIA
Provider Name:
MARIAN MEDICAL CENTER
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
4.00 New Cap Rel Costs-Movable Equipment
4.01
4.02
4.03

4.04
4.05
4.06
4.07
4.08
5.00 Employee Benefits
6.01 Non-Patient Telephones
6.02 Data Processing
6.03 Purchasing/Receiving
6.04 Patient Admitting
6.05 Patient 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
Neonatal Intensive Care Unit
29.00 Surgical Intensive Care
30.00 Subprovider I
31.00 Subprovider II
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:
JUNE 30, 2009
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
14
(200,239)
ADJUSTMENTS TO REPORTED COSTS
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STATE OF CALIFORNIA
Provider Name:
MARIAN MEDICAL CENTER
ANCILLARY COST CENTERS
37.00 Operating Room
37.01 Gastro Intestinal Service
37.20 Cardicac Cath Lab
38.00 Recovery Room
39.00 Delivery Room and Labor Room
40.00 Anesthesiology
41.00 Radiology - Diagnostic
41.01 CT Scan and MRI
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood & Packed Red Blood
47.00 Blood Storing and Processing
48.00 Intravenous Therapy
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
55.01 Medical Supplies Chrg. Pat. - IMP
56.00 Drugs Charged to Patients
57.00 Renal Dialysis
58.00 ASC (Non-Distinct Part)

59.00 Ultrasound
59.02
59.03
60.00 Clinic
60.01 Other Clinic Services
61.00 Emergency
62.00 Observation Beds
71.00 Home Health Agency
89.00 Utilization Review
93.00 Hospice



NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen
97.00 Research
98.00 Physicians' Private Office
99.00 Nonpaid Workers
99.01
99.02
99.03
99.04
99.05
100.00
100.01 Foundation
100.02
100.03 Community Relations
100.04
101.00 TOTAL
SCHEDULE 10A

Page 2
Fiscal Period Ended:
JUNE 30, 2009
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
14
ADJUSTMENTS TO REPORTED COSTS
(200,239) 0 0 0000000000
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
29
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
MEMORANDUM ADJUSTMENT
1 1 E-3 III XIX 50.00 1 AB5 Settlement Reductions $926,000 ($27,028) $898,972
The services provided to Medi-Cal inpatients in Noncontract acute
hospitals are subject to various reimbursement limitations identified in
AB 5.
W&I Code, Section 14105.245

Page 1
Report References
MARIAN MEDICAL CENTER
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H
Cost Report
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
29
Adj. Audit Work As Increase As
No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted
Report References
MARIAN MEDICAL CENTER
Adjustments
Explanation of Audit Adjustments
JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H
Cost Report
RECLASSIFICATIONS OF REPORTED COSTS

2 10A A 6.00 7 Administrative and General $28,987,953 ($290,976) $28,696,977 *
10A A 100.03 7 Community Relations 1,133,607 290,976 1,424,583 *
To reclassify public relation expenses for proper cost determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2304 and 2328

3 10A A 6.00 7 Administrative and General * 28,696,977 (47,737) 28,649,240 *
10A A 100.03 7 Community Relations * 1,424,583 47,737 1,472,320 *
To reclassify mission service expenses for proper cost determination.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2304 and 2328

4 10A A 25.00 7 Adults and Pediatrics 13,791,449 (49,539) 13,741,910 *
10A A 33.00 7 Nursery 1,433,129 49,539 1,482,668 *
To reclassify Adults and Pediatrics other costs to agree with
provider's supporting documents.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

5 10A A 16.00 7 Pharmacy 2,576,016 (175,138) 2,400,878 *
10A A 33.00 7 Nursery * 1,482,668 (16) 1,482,652 *
10A A 56.00 7 Drugs Charged to Patients 3,527,163 175,154 3,702,317
To reclassify IV solutions and pharmaceuticals for proper cost
determination.
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
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