john muir medical center - concord campus concord ...€¦ · 31-12-2007 · report on the cost...
TRANSCRIPT
REPORT ON THE
COST REPORT REVIEW
JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS CONCORD, CALIFORNIA
PROVIDER NUMBER: ZZR00496G AND NPI NUMBER: 1801821376
FISCAL PERIOD ENDED
DECEMBER 31, 2007
Audits Section - Richmond Financial Audits Branch
Audits and Investigations Department of Health Care Services
Section Chief: Louise Wong Audit Supervisor: David Mui Auditors: Mandy Lin and Tyler Zeng
State of California—Health and Human Services Agency
Department of Health Care Services
TOBY DOUGLAS EDMUND G. BROWN JR. DIRECTOR GOVERNOR
January 28, 2011 George Fan Reimbursement Director John Muir / Mt. Diablo Health System 1400 Treat Boulevard Walnut Creek, CA 94597-2142 PROVIDER: JOHN MUIR MEDICAL CENTER – CONCORD CAMPUS PROVIDER NO. ZZR00496G AND NPI NO. 1801821376 FISCAL PERIOD ENDED DECEMBER 31, 2007 We have examined the provider's Medi-Cal Cost Report for the above-referenced fiscal period. Our examination was made under the authority of Section 14170 of the Welfare and Institutions Code and, accordingly, included such tests of the accounting records and such other auditing procedures as we considered necessary in the circumstances. In our opinion, the audited settlement for the fiscal period due the provider in the amount of $3,889,824 presented in the Summary of Findings represent a proper determination in accordance with the reimbursement principles of the applicable program. This audit report includes the: 1. Summary of Findings 2. Computation of Audited Medi-Cal Reimbursement Settlement (NONCONTRACT
Schedules) 3. Audit Adjustments Schedule The audited settlement will be incorporated into a Statement of Account Status, which may reflect tentative retroactive adjustment determinations, payments from the provider, and other financial transactions initiated by the Department. The Statement of Account Status will be forwarded to the provider by the State's fiscal intermediary. Instructions regarding payment will be included with the Statement of Account Status.
850 Marina Bay Parkway, Building P, 2nd Floor, MS 2104, Richmond, CA 94804-6403 Telephone: (510) 620-3100 FAX: (510) 620-3111
Internet Address: www.dhcs.ca.gov
George Fan Page 2
Notwithstanding this audit report, overpayments to the provider are subject to recovery pursuant to Section 51458.1, Article 6 of Division 3, Title 22, California Code of Regulations. If you disagree with the decision of the Department, you may appeal by writing to: John Melton, Chief Office of Administrative Appeals and Hearings 1029 J Street, Suite 200 MS 0017 Sacramento, CA 95814 (916) 322-5603 The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter. A copy of this notice should be sent to: United States Postal Service (USPS) Courier (UPS, FedEx, etc.) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 P.O. Box 997413 1501 Capitol Avenue, Suite 71.5001 Sacramento, CA 95899-7413 Sacramento, CA 95814-5005 (916) 440-7700 The procedures that govern an appeal are contained in Welfare and Institutions Code, Section 14171, and California Code of Regulations, Title 22, Section 51016, et seq. If you have questions regarding this report, you may call the Audits Section—Richmond at (510) 620-3100. Original Signed by Louise Wong, Chief Audits Section—Richmond Financial Audits Branch Certified
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
SETTLEMENT COST
1. Medi-Cal Noncontract Settlement (SCHEDULE 1)Provider No. ZZR00496GReported $ 3,492,936
Net Change $ 396,888
Audited Amount Due Provider (State) $ 3,889,824
2. Subprovider I (SCHEDULE 1-1)Provider No. Reported $ 0
Net Change $ 0
Audited Amount Due Provider (State) $ 0
3. Subprovider II (SCHEDULE 1-2)Provider No. Reported $ 0
Net Change $ 0
Audited Amount Due Provider (State) $ 0
4. Medi-Cal Contract Cost (CONTRACT SCH 1)Provider No. Reported $ 0
Net Change $ 0
Audited Cost $ 0
Audited Amount Due Provider (State) $ 0
5. Distinct Part Nursing Facility (DPNF SCH 1)Provider No. Reported $ 0.00
Net Change $ 0.00
Audited Cost Per Day $ 0.00
Audited Amount Due Provider (State) $ 06. Distinct Part Nursing Facility (DPNF SCH 1-1)
Provider No. Reported $ 0.00
Net Change $ 0.00
Audited Cost Per Day $ 0.00
Audited Amount Due Provider (State) $ 07. Adult Subacute (ADULT SUBACUTE SCH 1)
Provider No. Reported $ 0.00
Net Change $ 0.00
Audited Cost Per Day $ 0.00
Audited Amount Due Provider (State) $ 0
8. Total Medi-Cal SettlementDue Provider (State) - (Lines 1 through 7) $ 3,889,824
9. Total Medi-Cal Cost $ 0
SUMMARY OF FINDINGS
SUMMARY OF FINDINGS
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
SETTLEMENT COST10. Subacute (SUBACUTE SCH 1-1)
Provider No. Reported $ 0.00
Net Change $ 0.00
Audited Cost Per Day $ 0.00
Audited Amount Due Provider (State) $ 011. Rural Health Clinic (RHC SCH 1)
Provider No. Reported $ 0
Net Change $ 0
Audited Amount Due Provider (State) $ 012. Rural Health Clinic (RHC 95-210 SCH 1)
Provider No. Reported $ 0
Net Change $ 0
Audited Amount Due Provider (State) $ 013. Rural Health Clinic (RHC 95-210 SCH 1-1)
Provider No. Reported $ 0
Net Change $ 0
Audited Amount Due Provider (State) $ 0
14. County Medical Services Program (CMSP SCH 1)Provider No. Reported $ 0
Net Change $ 0
Audited Amount Due Provider (State) $ 015. Transitional Care (TC SCH 1)
Provider No. Reported $ 0.00
Net Change $ 0.00
Audited Cost Per Day $ 0.00
Audited Amount Due Provider (State) $ 0
16. Total Other SettlementDue Provider - (Lines 10 through 15) $ 0
17. Total Combined Audited Settlement DueProvider (State/CMSP/RHC) - (Line 8 + Line 16) $ 3,889,824
STATE OF CALIFORNIA SCHEDULE 1PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
Provider No.ZZR00496G
REPORTED AUDITED
1. Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 11,963,293 $ 13,303,359
2. Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0
3. Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ N/A
4. Routine Reimnursement (Adj 26) $ 64,963 $ 0
5. TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 12,028,256 $ 13,303,359
6. Interim Payments (Adj 25) $ (8,535,320) $ (9,372,856)
7. Balance Due Provider (State) $ 3,492,936 $ 3,930,502
8. Routine Services - Late Billing Penalty Adjustment (Adj 27) $ 0 $ (16,739) 9. Medi-Cal Overpayments (Adj 28) $ 0 $ (23,939) 10. $ 0 $ 0
11. TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 3,492,936 $ 3,889,824(To Summary of Findings)
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
STATE OF CALIFORNIA SCHEDULE 2PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
Provider No.ZZR00496G
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1. Cost of Covered Services (Schedule 3) $ 12,174,155 $ 13,514,221
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2. Inpatient Routine Service Charges (Adj 24) $ 28,358,125 $ 31,718,272
3. Inpatient Ancillary Service Charges (Adj 24) $ 36,300,299 $ 40,254,125
4. Total Charges - Medi-Cal Inpatient Services $ 64,658,424 $ 71,972,397
5. Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) * $ 52,484,269 $ 58,458,176
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 OFMEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
STATE OF CALIFORNIA SCHEDULE 3PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
Provider No.ZZR00496G
REPORTED AUDITED
1. Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 5,999,700 $ 6,839,413
2. Medi-Cal Inpatient Routine Services (Schedule 4) $ 6,174,455 $ 6,649,038
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) $ 12,174,155 $ 13,488,451
7. Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 25,770
8. SUBTOTAL $ 12,174,155 $ 13,514,221(To Schedule 2)
9. Coinsurance (Adj ) $ (210,862) $ (210,862)
10. Patient and Third Party Liability (Adj ) $ 0 $ 0
11. Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 11,963,293 $ 13,303,359
(To Schedule 1)
COMPUTATION OFMEDI-CAL NET COSTS OF COVERED SERVICES
STATE OF CALIFORNIA SCHEDULE 4PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
Provider No.ZZR00496G
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1. Total Inpatient Days (include private & swing-bed) (Adj ) 43,554 43,554 2. Inpatient Days (include private, exclude swing-bed) 43,554 43,554 3. Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4. Semi-Private Room Days (exclude swing-bed) (Adj ) 43,554 43,554 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 21) 2,679 2,877 SWING-BED ADJUSTMENT17. Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 0.00 $ 0.0018. Medicare NF Swing-Bed Rates after Dec 31(Adj ) $ 0.00 $ 0.0019. Medi-Cal NF Swing-Bed Rates through July 31(Adj ) $ 0.00 $ 0.0020. Medi-Cal NF Swing-Bed Rates after July 31(Adj ) $ 0.00 $ 0.0021. Total Routine Serv Cost (Sch 8, Line 25, Col 27) $ 65,033,973 $ 62,505,89222. Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 023. Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 024. Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 025. Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 026. Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 027. Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 65,033,973 $ 62,505,892
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT28. Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 285,454,959 $ 285,454,95929. Private Room Charges (excluding swing-bed charges) $ 0 $ 030. Semi-Private Room Charges (excluding swing-bed charges) $ 285,454,959 $ 285,454,95931. Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) $ 0.227826 $ 0.21896932. Average Private Room Per Diem Charge (L 29 / L 3) $ 0.00 $ 0.0033. Average Semi-Private Room Per Diem Charge (L 30 / L 4) $ 6,554.05 $ 6,554.0534. Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 0.00 $ 0.0035. Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 0.00 $ 0.0036. Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 037. Inpatient Rout Cost Net of Swing-Bed & Prvt Rm (L 27 minus L 36) $ 65,033,973 $ 62,505,892
PROGRAM INPATIENT OPERATING COST 38. Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) $ 1,493.18 $ 1,435.1439. Program General Inpatient Routine Service Cost (L 9 x L 38) $ 4,000,229 $ 4,128,898
40. Cost Applicable to Medi-Cal (Sch 4A) $ 2,174,226 $ 2,518,66441. Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 1,476
42. TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39,40 & 41) $ 6,174,455 $ 6,649,038( To Schedule 3 )
COMPUTATION OFMEDI-CAL INPATIENT ROUTINE SERVICE COST
STATE OF CALIFORNIA SCHEDULE 4APROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
Provider No.ZZR00496G
SPECIAL CARE AND/OR NURSERY UNITS REPORTED AUDITEDNURSERY 1. Total Inpatient Routine Cost (Sch 8, Line 33, 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
INTENSIVE CARE UNIT 6. Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) $ 21,514,012 $ 19,911,508 7. Total Inpatient Days (Adj ) 7,352 7,352 8. Average Per Diem Cost $ 2,926.28 $ 2,708.31 9. Medi-Cal Inpatient Days (Adj 21) 743 90510. Cost Applicable to Medi-Cal $ 2,174,226 $ 2,451,021 CORONARY CARE UNIT11. Total Inpatient Routine Cost (Sch 8, Line 27, Col 27) $ 0 $ 012. Total Inpatient Days (Adj ) 0 013. Average Per Diem Cost $ 0.00 $ 0.0014. Medi-Cal Inpatient Days (Adj ) 0 015. Cost Applicable to Medi-Cal $ 0 $ 0
NEONATAL INTENSIVE CARE UNIT16. Total Inpatient Routine Cost (Sch 8, Line 28, Col 27) $ 0 $ 017. Total Inpatient Days (Adj ) 0 018. Average Per Diem Cost $ 0.00 $ 0.0019. Medi-Cal Inpatient Days (Adj ) 0 020. Cost Applicable to Medi-Cal $ 0 $ 0 SURGICAL INTENSIVE CARE UNIT21. Total Inpatient Routine Cost (Sch 8, Line 29, Col 27) $ 0 $ 022. Total Inpatient Days (Adj ) 0 023. Average Per Diem Cost $ 0.00 $ 0.0024. Medi-Cal Inpatient Days (Adj ) 0 025. Cost Applicable to Medi-Cal $ 0 $ 0 ADMINISTRATIVE DAYS26. Per Diem Rate (Adj 22) $ 0.00 $ 310.6827. Medi-Cal Inpatient Days (Adj 22) 0 18728. Cost Applicable to Medi-Cal $ 0 $ 58,097
ADMINISTRATIVE DAYS29. Per Diem Rate (Adj 22) $ 0.00 $ 318.1930. Medi-Cal Inpatient Days (Adj 22) 0 3031. Cost Applicable to Medi-Cal $ 0 $ 9,546
32. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,28,31) $ 2,174,226 $ 2,518,664(To Schedule 4)
MEDI-CAL INPATIENT ROUTINE SERVICE COSTCOMPUTATION OF
STATE OF CALIFORNIA SCHEDULE 4BPROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007 Provider No.ZZR00496G
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 ) 0 010. Cost Applicable to Medi-Cal $ 0 $ 0
11. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 012. Total Inpatient Days (Adj ) 0 013. Average Per Diem Cost $ 0.00 $ 0.0014. Medi-Cal Inpatient Days (Adj ) 0 015. Cost Applicable to Medi-Cal $ 0 $ 0
16. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 017. Total Inpatient Days (Adj ) 0 018. Average Per Diem Cost $ 0.00 $ 0.0019. Medi-Cal Inpatient Days (Adj ) 0 020. Cost Applicable to Medi-Cal $ 0 $ 0
ADMINISTRATIVE DAYS (BILLED LATE - REDUCED RATE @75%)21.22.23. Per Diem Rate (Adj 22) $ 0.00 $ 233.0124. Medi-Cal Inpatient Days (Adj 22) 0 525. Cost Applicable to Medi-Cal $ 0 $ 1,165
ADMINISTRATIVE DAYS (BILLED LATE - REDUCED RATE @50%)26.27.28. Per Diem Rate (Adj 22) $ 0.00 $ 155.3429. Medi-Cal Inpatient Days (Adj 22) 0 230. Cost Applicable to Medi-Cal $ 0 $ 311
31. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 0 $ 1,476(To Schedule 4)
COMPUTATION OFMEDI-CAL INPATIENT ROUTINE SERVICE COST
STATE OF CALIFORNIA SCHEDULE 5PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
Provider No:ZZR00496G
RATIOCOST TOCHARGES
ANCILLARY COST CENTERS37.00 Operating Room $ 16,140,991 $ 92,864,091 0.173813 $ 3,197,778 $ 555,81638.00 Recovery Room 5,650,768 13,573,990 0.416294 270,591 112,64539.00 Delivery Room and Labor Room 0 0 0.000000 0 040.00 Anesthesiology 2,326,690 17,673,749 0.131647 378,672 49,85141.00 Radiology - Diagnostic 9,337,027 40,787,763 0.228917 1,204,079 275,63541.01 CT Scanner 2,333,114 35,596,911 0.065543 1,241,632 81,38041.02 Ultrasound 2,006,820 12,937,174 0.155120 426,219 66,11542.01 Oncology 9,413,747 57,955,014 0.162432 0 043.00 Radioisotope 2,455,829 11,271,869 0.217872 436,852 95,17844.00 Laboratory 18,241,290 125,296,156 0.145585 7,647,165 1,113,31544.01 Pathological Lab 0 0 0.000000 0 046.00 Whole Blood 2,890,996 2,417,205 1.196008 258,098 308,68747.00 Blood Storing and Processing 0 0 0.000000 0 048.00 Intravenous Therapy 0 0 0.000000 0 049.00 Respiratory Therapy 5,632,661 23,304,396 0.241699 2,174,951 525,68550.00 Physical Therapy 6,179,530 10,622,492 0.581740 313,110 182,14851.00 Occupational Therapy 0 0 0.000000 0 052.00 Speech Pathology 0 0 0.000000 0 053.00 Electrocardiology 2,351,750 27,927,156 0.084210 377,112 31,75753.01 Cardiac Cath Lab 5,871,135 35,070,857 0.167408 1,656,318 277,28155.00 Medical Supplies Charged to Patients 27,372,047 111,732,001 0.244979 4,174,726 1,022,72256.00 Drugs Charged to Patients 21,276,694 181,745,127 0.117069 13,215,315 1,547,10257.00 Renal Dialysis 1,422,597 7,575,039 0.187801 854,963 160,56258.01 Short Stay 3,316,681 7,873,709 0.421235 0 059.00 Gastrointestinal Laboratory 4,844,648 17,821,141 0.271848 355,202 96,56159.01 0 0 0.000000 0 059.02 0 0 0.000000 0 059.03 0 0 0.000000 0 060.00 Clinic 412 0 0.000000 0 060.01 Diabetes Center 1,206,775 1,344,741 0.897403 0 060.03 Wound Care Center 313,504 434,769 0.721082 0 061.00 Emergency 14,305,136 87,932,318 0.162683 2,071,343 336,97362.00 Observation Beds 0 4,811,237 0.000000 0 0
0 0 0.000000 0 0 0 0 0.000000 0 0 0 0 0.000000 0 0 0 0 0.000000 0 0 0 0 0.000000 0 0
TOTAL $ 164,890,843 $ 928,568,905 $ 40,254,125 $ 6,839,413(To Schedule 3)
* From Schedule 8, Column 27
TOTAL ANCILLARY MEDI-CAL
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
TOTAL
COST *CHARGES
MEDI-CAL
(Adj )COSTCHARGES
(From Schedule 6)ANCILLARY
STATE OF CALIFORNIA SCHEDULE 6PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
Provider No:ZZR00496G
ANCILLARY CHARGES37.00 Operating Room $ 3,213,908 $ (16,130) $ 3,197,77838.00 Recovery Room 252,593 17,998 270,59139.00 Delivery Room and Labor Room 040.00 Anesthesiology 361,848 16,824 378,67241.00 Radiology - Diagnostic 1,039,004 165,075 1,204,07941.01 CT Scanner 1,155,967 85,665 1,241,63241.02 Ultrasound 392,229 33,990 426,21942.01 Oncology 043.00 Radioisotope 399,933 36,919 436,85244.00 Laboratory 6,854,279 792,886 7,647,16544.01 Pathological Lab 046.00 Whole Blood 253,972 4,126 258,09847.00 Blood Storing and Processing 048.00 Intravenous Therapy 049.00 Respiratory Therapy 1,887,717 287,234 2,174,95150.00 Physical Therapy 247,067 66,043 313,11051.00 Occupational Therapy 052.00 Speech Pathology 053.00 Electrocardiology 1,982,583 (1,605,472) 377,11253.01 Cardiac Cath Lab 1,656,318 1,656,31855.00 Medical Supplies Charged to Patients 3,827,224 347,502 4,174,72656.00 Drugs Charged to Patients 11,630,177 1,585,138 13,215,31557.00 Renal Dialysis 808,550 46,413 854,96358.01 Short Stay 059.00 Gastrointestinal Laboratory 0 355,202 355,20259.01 059.02 059.03 060.00 Clinic 060.01 Diabetes Center 060.03 Wound Care Center 061.00 Emergency 1,993,248 78,095 2,071,34362.00 Observation Beds 0
0 0 0 0 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 36,300,299 $ 3,953,826 $ 40,254,125(To Schedule 5)
(Adj 23)
ADJUSTMENTS TO MEDI-CAL CHARGES
REPORTED ADJUSTMENTS AUDITED
STATE OF CALIFORNIA SCHEDULE 7PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
Provider No: ZZR00496G
PROFESSIONALSERVICE
COST CENTERS
40.00 Anesthesiology $ 0 $ 0 0.000000 $ $ 042.01 Oncology 174,688 57,955,014 0.003014 0 044.00 Laboratory 265,835 125,296,156 0.002122 7,647,165 16,22549.00 Respiratory Therapy 54,245 23,304,396 0.002328 2,174,951 5,06353.00 Electrocardiology 331,945 27,927,156 0.011886 377,112 4,48254.00 Electroencephalography 0 0 0.000000 061.00 Emergency 0 0 0.000000 0
0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0
TOTAL $ 826,713 $ 234,482,722 $ 10,199,227 $ 25,770(To Schedule 3)
TO CHARGES(Adj 18) (Adj 19) (Adj 20)
PHYSICIAN'S REMUNERATION
TOTAL CHARGES TO ALL PATIENTS
MEDI-CAL MEDI-CALCOST
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CO
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00
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29,5
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44,9
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3,63
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22,8
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4,68
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4,63
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69,7
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21,9
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6,94
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30,0
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6,18
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0,98
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00
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5,66
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00
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5,22
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3,72
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74,5
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7,77
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7,06
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71,8
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65,4
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16,1
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3,56
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149,
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5,98
448
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2,95
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00
00
00
00
00
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485
105,
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152
173,
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5,16
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79,8
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7,02
543
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227,
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2,74
187
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21,2
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4,62
50
00
00
00
00
00
00
00
00
00
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00
00
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1,98
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00
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00
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03,
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00
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1,91
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14,8
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3,51
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22,0
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5,07
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540
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00
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00
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00
655,
593
9,04
8,69
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4,01
34,
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726
2,21
2,42
43,
325,
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03,
777,
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3,74
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19,
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3,47
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ST
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Pro
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ST
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Pro
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306
306
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441
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28,9
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222,
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222,
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2,76
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0,47
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151,
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151,
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00
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413,
574
413,
574
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816,
765
816,
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ST
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Pro
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3,60
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Ope
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105
STATE OF CALIFORNIA SCHEDULE 10
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
GENERAL SERVICE COST CENTERS1.00 Old Cap Rel Costs - Building and Fixtures $ 4,346,978 $ (2,957,515) $ 1,389,4632.00 Old Cap Rel Costs - Movable Equipment 1,087,902 0 1,087,9023.00 New Cap Rel Costs - Building and Fixtures 4,995,221 493,009 5,488,2304.00 New Cap Rel Costs - Movable Equipment 6,030,402 0 6,030,4024.01 0 04.02 0 04.03 0 04.04 0 04.05 0 04.06 0 04.07 0 04.08 0 05.00 Employee Benefits 42,970,869 (192,231) 42,778,6386.01 PBX 832,821 (17,935) 814,8866.02 Information System 8,706,715 (169,795) 8,536,9206.03 Purchasing/Receiving 732,518 0 732,5186.04 Patient Admitting 2,352,100 (45,870) 2,306,2306.05 Cashering 2,461,532 (48,004) 2,413,5286.06 0 06.07 0 06.08 0 06.06 Administrative and General 21,248,773 (233,208) 21,015,5657.00 Maintenance and Repairs 433,342 0 433,3428.00 Operation of Plant 6,406,282 0 6,406,2829.00 Laundry and Linen Service 459,917 0 459,917
10.00 Housekeeping 2,987,049 0 2,987,04911.00 Dietary 1,456,514 (199,904) 1,256,61012.00 Cafeteria 1,484,841 199,904 1,684,74513.00 Maintenance of Personnel 0 014.00 Nursing Administration 1,830,577 0 1,830,57715.00 Central Services and Supply 11,557,176 (9,415,021) 2,142,15516.00 Pharmacy 13,303,147 (7,778,830) 5,524,31717.00 Medical Records and Library 2,748,771 (53,605) 2,695,16618.00 Social Service 0 019.00 0 019.02 0 019.03 0 020.00 0 021.00 Nursing School 0 022.00 Intern and Res Service - Salary and Fringes 0 023.00 Intern and Res - Other Program 0 024.00 Paramedical Ed Program 98,908 0 98,908
INPATIENT ROUTINE COST CENTERS25.00 Adults and Pediatrics (Gen Routine) 32,240,584 45,086 32,285,67026.00 Intensive Care Unit 11,270,975 0 11,270,97527.00 Coronary Care Unit 0 028.00 Neonatal Intensive Care Unit 0 029.00 Surgical Intensive Care 0 030.00 Subprovider I 0 031.00 Subprovider II 0 032.00 0 033.00 Nursery 0 034.00 Medicare Certified Nursing Facility 0 035.00 Distinct Part Nursing Facility 0 036.00 Adult Subacute Care Unit 0 036.01 Subacute Care Unit II 0 036.02 Transitional Care Unit 0 0
REPORTED ADJUSTMENTS
TRIAL BALANCE OF EXPENSES
(From Sch 10A)AUDITED
STATE OF CALIFORNIA SCHEDULE 10
Provider Name: Fiscal Period Ended:JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS DECEMBER 31, 2007
REPORTED ADJUSTMENTS
TRIAL BALANCE OF EXPENSES
(From Sch 10A)AUDITED
ANCILLARY COST CENTERS37.00 Operating Room $ 9,823,900 $ (2,491,349) $ 7,332,55138.00 Recovery Room 2,692,195 171 2,692,36639.00 Delivery Room and Labor Room 0 040.00 Anesthesiology 829,883 0 829,88341.00 Radiology - Diagnostic 3,248,801 720,864 3,969,66541.01 CT Scanner 898,957 122,154 1,021,11141.02 Ultrasound 1,178,347 145 1,178,49242.01 Oncology 4,195,861 149,820 4,345,68143.00 Radioisotope 1,373,563 53,697 1,427,26044.00 Laboratory 9,934,772 (7,351) 9,927,42144.01 Pathological Lab 0 046.00 Whole Blood 2,582,227 0 2,582,22747.00 Blood Storing and Processing 0 048.00 Intravenous Therapy 0 049.00 Respiratory Therapy 3,030,424 207,679 3,238,10350.00 Physical Therapy 3,190,333 11,745 3,202,07851.00 Occupational Therapy 0 052.00 Speech Pathology 0 053.00 Electrocardiology 987,017 71,915 1,058,93253.01 Cardiac Cath Lab 5,223,981 (2,453,273) 2,770,70855.00 Medical Supplies Charged to Patients 1,009,059 20,115,329 21,124,38856.00 Drugs Charged to Patients 7,183,730 337,066 7,520,79657.00 Renal Dialysis 1,228,801 0 1,228,80158.01 Short Stay 1,809,213 141,331 1,950,54459.00 Gastrointestinal Laboratory 2,178,360 160,992 2,339,35259.01 0 059.02 0 059.03 0 060.00 Clinic 372 0 37260.01 Diabetes Center 620,648 (21,493) 599,15560.03 Wound Care Center 168,600 0 168,60061.00 Emergency 7,858,560 479 7,859,03962.00 Observation Beds 0 0
0 0 0 0 0 0 0 0 0 0 SUBTOTAL $ 253,291,518 $ (3,253,998) $ 250,037,520 NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop and Canteen 0 0 0 0
98.02 NRCC 0 0100.00 Fitness Center 276 0 276100.01 Clinical Trials 138,471 0 138,471100.02 Physician Services 0 0100.05 Foundation 125,444 0 125,444100.06 MOB - Pharmacy 2,193,929 0 2,193,929100.07 MOB - Pharmacy - Pavilion 0 0100.08 Volunteer Services 0 0100.09 Nonreimbursable Managed Care 966,217 0 966,217100.11 Home Health - JMMC 0 0100.12 Vacant Space 0 0100.13 Dietary Pavillion 525,846 0 525,846100.99 SUBTOTAL $ 3,950,183 $ 0 $ 3,950,183101 TOTAL $ 257,241,701 $ (3,253,998) $ 253,987,703
(To Schedule 8)
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rovi
der
Num
ber
28
Adj
.A
udit
Wor
kA
sIn
crea
seA
sN
o.R
epor
tS
heet
Par
tT
itle
Line
Col
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epor
ted
(Dec
reas
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djus
ted
Rep
ort R
efer
ence
sJO
HN
MU
IR M
ED
ICA
L C
EN
TE
R -
CO
NC
OR
D C
AM
PU
S
Ad
just
men
ts
Exp
lana
tion
of A
udit
Adj
ustm
ents
JAN
UA
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1, 2
007
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
007
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R00
496G
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EN
TS
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ME
DI-C
AL
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TT
LEM
EN
T D
AT
A -
NO
NC
ON
TR
AC
T
214
D-1
IX
IX9.
001
Med
i-Cal
Inpa
tient
Day
s -
Adu
lts a
nd P
edia
tric
s2,
679
198
2,87
74A
D-1
IIX
IX43
.00
4M
edi-C
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patie
nt D
ays
- In
tens
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nit
743
162
905
224A
Not
Rep
orte
dM
edi-C
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dmin
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ativ
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ays
(Jan
uary
1, 2
007
thro
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July
31,
200
7)0
187
187
4AN
ot R
epor
ted
Med
i-Cal
Adm
inis
trat
ive
Rat
e (J
anua
ry 1
, 200
7 th
roug
h Ju
ly 3
1, 2
007)
$0.0
0$3
10.6
8$3
10.6
84A
Not
Rep
orte
dM
edi-C
al A
dmin
istr
ativ
e D
ays
(Bill
ed L
ate)
05
54A
Not
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dM
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dmin
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ativ
e D
ays
(Bill
ed L
ate,
Red
uced
Rat
e @
75%
)$0
.00
$233
.01
$233
.01
4AN
ot R
epor
ted
Med
i-Cal
Adm
inis
trat
ive
Day
s (B
illed
Lat
e)0
22
4AN
ot R
epor
ted
Med
i-Cal
Adm
inis
trat
ive
Day
s (B
illed
Lat
e, R
educ
ed R
ate
@50
%)
$0.0
0$1
55.3
4$1
55.3
44A
Not
Rep
orte
dM
edi-C
al A
dmin
istr
ativ
e D
ays
(Aug
ust 1
, 200
7 th
roug
h D
ecem
ber
31, 2
007)
030
304A
Not
Rep
orte
dM
edi-C
al A
dmin
istr
ativ
e R
ate
(Aug
ust 1
, 200
7 th
roug
h D
ecem
ber
31, 2
007)
$0.0
0$3
18.1
9$3
18.1
9
236
D-4
XIX
37.0
02
Med
i-Cal
Anc
illar
y C
harg
es -
Ope
ratin
g R
oom
$3,2
13,9
08($
16,1
30)
$3,1
97,7
786
D-4
XIX
38.0
02
Med
i-Cal
Anc
illar
y C
harg
es -
Rec
over
y R
oom
252,
593
17,9
9827
0,59
16
D-4
XIX
40.0
02
Med
i-Cal
Anc
illar
y C
harg
es -
Ane
sthe
siol
ogy
361,
848
16,8
2437
8,67
26
D-4
XIX
41.0
02
Med
i-Cal
Anc
illar
y C
harg
es -
Rad
iolo
gy -
Dia
gnos
tic1,
039,
004
165,
075
1,20
4,07
96
D-4
XIX
41.0
12
Med
i-Cal
Anc
illar
y C
harg
es -
CA
T S
can
1,15
5,96
785
,665
1,24
1,63
26
D-4
XIX
41.0
22
Med
i-Cal
Anc
illar
y C
harg
es -
Ultr
asou
nd39
2,22
933
,990
426,
219
6D
-4X
IX43
.00
2M
edi-C
al A
ncill
ary
Cha
rges
- R
adio
isot
ope
399,
933
36,9
1943
6,85
26
D-4
XIX
44.0
02
Med
i-Cal
Anc
illar
y C
harg
es -
Lab
orat
ory
6,85
4,27
979
2,88
67,
647,
165
6D
-4X
IX46
.00
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edi-C
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ncill
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Cha
rges
- W
hole
Blo
od a
nd P
acke
d R
ed B
lood
Cel
ls25
3,97
24,
126
258,
098
6D
-4X
IX49
.00
2M
edi-C
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ncill
ary
Cha
rges
- R
espi
rato
ry T
hera
py1,
887,
717
287,
234
2,17
4,95
16
D-4
XIX
50.0
02
Med
i-Cal
Anc
illar
y C
harg
es -
Phy
sica
l The
rapy
247,
067
66,0
4331
3,11
06
D-4
XIX
53.0
02
Med
i-Cal
Anc
illar
y C
harg
es -
Ele
ctro
card
iolo
gy1,
982,
583
(1,6
05,4
72)
377,
112
6D
-4X
IX53
.01
2M
edi-C
al A
ncill
ary
Cha
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- C
ardi
ac C
aute
rizat
ion
Labo
rato
ry0
1,65
6,31
81,
656,
318
6D
-4X
IX55
.00
2M
edi-C
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ncill
ary
Cha
rges
- M
edic
al S
uppl
ies
Cha
rged
to P
atie
nts
3,82
7,22
434
7,50
24,
174,
726
6D
-4X
IX56
.00
2M
edi-C
al A
ncill
ary
Cha
rges
- D
rugs
Cha
rged
to P
atie
nts
11,6
30,1
771,
585,
138
13,2
15,3
156
D-4
XIX
57.0
02
Med
i-Cal
Anc
illar
y C
harg
es -
Ren
al D
ialy
sis
808,
550
46,4
1385
4,96
36
D-4
XIX
59.0
02
Med
i-Cal
Anc
illar
y C
harg
es -
Gas
troi
ntes
tinal
Lab
orat
ory
035
5,20
235
5,20
26
D-4
XIX
61.0
02
Med
i-Cal
Anc
illar
y C
harg
es -
Em
erge
ncy
1,99
3,24
878
,095
2,07
1,34
36
D-4
XIX
101.
002
Med
i-Cal
Anc
illar
y C
harg
es -
Tot
al36
,300
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3,95
3,82
640
,254
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tinue
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Pag
e8
Sta
te o
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alif
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are
Ser
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s
Pro
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Fis
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dP
rovi
der
Num
ber
28
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(Dec
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djus
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Rep
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sJO
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242
E-3
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11.0
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i-Cal
Anc
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3,95
3,82
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251
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To
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ED
S P
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9
Pay
men
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Jan
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1, 2
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June
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9
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Per
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Jan
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1, 2
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thro
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Dec
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r 31
, 200
7C
MS
Pub
. 15-
1, S
ectio
ns 2
304
and
2408
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CR
Titl
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, Sec
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5151
1
Pag
e9
Sta
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f C
alif
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tmen
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djus
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Rep
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R00
496G
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TM
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AT
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261
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cos
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det
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t rep
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CM
S P
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5-1,
Sec
tions
230
4 an
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08
271
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dR
outin
e S
ervi
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- La
te B
illin
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djus
tmen
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739
$16,
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*T
o in
clud
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low
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-line
adj
ustm
ent f
or la
te b
illin
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nalti
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to r
outin
e se
rvic
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W &
I C
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Sec
tion
1411
5C
CR
, Titl
e 22
, Sec
tion
5145
8.1
CM
S P
ub. 1
5-1,
Sec
tions
230
4 an
d 24
08
281
Not
Rep
orte
dM
edi-C
al O
verp
aym
ent
*$1
6,73
9$2
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8T
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corr
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MS
Pub
. 15-
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ectio
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and
2409
CC
R, T
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22, S
ectio
ns 5
0786
and
514
58.1
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ance
car
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forw
ard
from
prio
r/to
sub
sequ
ent a
djus
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age
10